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Through the Dermoscope

Dermoscopy of Salt and Pepper Pigmentation

Bains, Anupama; Rajagopal, S. Varun; Lahoria, Utkrist

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Indian Dermatology Online Journal: Jul–Aug 2022 - Volume 13 - Issue 4 - p 548-550
doi: 10.4103/idoj.IDOJ_333_20
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Sir,

We wish to describe dermoscopic features of salt and pepper pigmentation in systemic scleroses.

Case 1

A 30-year-old female, known case of diffuse systemic scleroses, had salt and pepper pigmentation over extensor aspect of extremities [Figure 1a and b]. Dermoscopic examination of lesions showed white homogeneous areas with perifollicular pigment [Figures 2 and 3]. Dermoscopy of smaller lesions at the periphery of main lesion over forearm showed multiple regularly arranged brown dots around small white homogeneous areas [Figure 4].

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Figure 1:
(a) Salt and pepper pigmentation over forearm in case 1. (b) Salt and pepper pigmentation over leg in case 1
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Figure 2:
Dermoscopy (Dermlite™ DL4, 3Gen Inc., San Juan Capistrano, CA; 10× magnification; polarized mode) of lesions over forearm shows irregularly shaped white homogenous areas with perifollicular pigment (Black arrow) in case 1
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Figure 3:
Dermoscopy (Dermlite™ DL4, 3Gen Inc., San Juan Capistrano, CA; 10× magnification; polarized mode) of lesions over leg shows depigmented area with perifollicular pigment (Black arrow) in case 1
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Figure 4:
Dermoscopy (Dermlite™ DL4, 3Gen Inc., San Juan Capistrano, CA; 10× magnification; polarized mode) of smaller lesions present at the periphery of main lesion over forearm shows multiple regularly arranged brown dots (Red arrow) around small white homogenous areas and perifollicular pigment (Black arrow) in the centre of lesion in case 1

Case 2

A 23-year-old female, known case of diffuse systemic scleroses, had multiple asymptomatic grouped irregularly shaped depigmented macules over extensor aspect of forearms [Figure 5a]. Dermoscopic examination of these lesions revealed central irregularly shaped white homogeneous areas with periphery showing pale area with multiple regularly arranged brown dots [Figure 5b].

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Figure 5:
(a) Multiple grouped irregularly shaped depigmented macules over forearm in case 2. (b) Dermoscopy (Dermlite™ DL4, 3Gen Inc., San Juan Capistrano, CA; 10× magnification; polarized mode) shows central irregularly shaped white homogenous areas (Black arrow) with periphery showing pale area with multiple regularly arranged brown dots (Blue arrow) in case 2

Salt and pepper pigmentation clinically manifests as vitiligo-like depigmentation with perifollicular pigmentary retention.[1] Clinically lesions can be confused with vitiligo, idiopathic guttate hypomelanoses (IGH) and lichen sclerosus et atrophicus (LSA). However, dermoscopy can easily differentiate between these conditions. Dermoscopy of vitiligo shows depigmented area, leukotrichia, and sometimes polka dot appearance.[2] Perifollicular, marginal, and reticular pigmentation can be seen in repigmenting vitiligo.[34] IGH has characteristic dermoscopic patterns, i.e., nebuloid, petaloid, feathery, and amoeboid.[5] In LSA, there were white structureless areas, perilesional erythematous halo, and follicular plugging.[2] Recently, one case has described whitish perifollicular halo as a dermoscopic finding in salt and pepper pigmentation in systemic scleroses.[6] Histopathology of salt and pepper pigmentation shows scattered clear cells without pigment in basal layer alternating with areas containing normal pigment. Dermis contains melanophages below the area of normal pigmentation.[7] Brown dots at periphery of smaller new lesions may represent dermal melanophages suggesting the progression of inflammatory process. However, it warrants further research and histopathological confirmation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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2. Al-Refu K Dermoscopy is a new diagnostic tool in diagnosis of common hypopigmented macular disease:A descriptive study Dermatol Reports 2018 11 7916
3. Jha AK, Sonthalia S, Lallas A Dermoscopy as an evolving tool to assess vitiligo activity J Am Acad Dermatol 2018 78 1017–9
4. Chandrashekhar L Dermoscopy:A tool to assess stability in Vitiligo Khopkar U Dermoscopy and Trichoscopy in Diseases of the Brown Skin:Atlas and Short Text New Delhi, India Jaypee Brothers Medical Publishers 2012 112–3
5. Ankad BS, Beergouder SL Dermoscopic evaluation of idiopathic guttate hypomelanosis:A preliminary observation Indian Dermatol Online J 2015 6 164–7
6. Hernandez Collazo A, Quinones Venegas R Whitish perifollicular halo in dermoscopy of salt and pepper appearance in diagnosis of systemic sclerosis and pulmonary fibrosis Available from: https://www.wcd2019milan-dl.org/abstract-book/documents/abstracts/11-dermoscopy-skin-imaging/whitish-perifollicular-halo-in-dermoscopy-2408.pdf [Last accessed on 2020 Jul 29]
7. Sanchez JL, Vazquez M, Sanchez NP Vitiligo like macules in systemic scleroderma Arch Dermatol 1983 119 129–33
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