Pediatric Dermoscopy, Trichoscopy and Onychoscopy Subrata Malakar, Surit Malakar, Harshal Ranglani, Seujee Das, Rashmi Agarwal
Page numbers followed f refer to figure, and t refer to table
Acanthosis nigricans 93
Achromatic lens 5
Acute cutaneous lupus erythematosus
dermoscopy of 90f
lesions of 90f
Alopecia areata 4, 94f, 102f, 106f, 108f, 109f, 110, 111, 112f, 113f, 115f, 116f, 123f, 128f, 129f, 164, 166
Alopecia totalis 112f
Amorphous globules 51f
Anagen effluvium 117, 117f
Androgenetic alopecia 102f
Angiofibromas 61
dermoscopy of 62, 62f
Angiokeratoma 82
circumscriptum 82
corporis diffusum 82
multiple 82
of Fordyce 82
of Mibelli 82
Anonychia 140, 140f
Antecubital fossa 21f, 23f
Aplasia cutis congenita 58, 126, 160
Arborizing vessels 67
Arthritis 84
Ash leaf macule 61, 68, 69, 70, 74f
dermoscopy of 69f
Atopic dermatitis 20, 21f, 22f, 29f
Atopy 43
Atypical pigment network 15, 16f
Aurora borealis pattern 142f
Auspitz sign 154
dermoscopic 31, 28
Autoimmune disorder 88
Autosomal dominant disorder 39
Ball and socket appearance 123
Bamboo hair 43, 123
Biopsy 42f
Björnstad and Crandall syndrome 125
Blaschko's lines 25f, 34, 35f, 63f, 70f
Blistering distal dactylitis 141
Block hair 106, 106f, 113, 163
Blue nevi 17, 18f
Blue-white veil 16, 17f
Branchial cyst 60f
Branchial fistula 59
Broken hair 106, 106f, 107f, 111, 114f, 116f, 121, 129f, 130f
multiple 114f
short 108f
Brooke-Spiegler syndrome 66
Burnt matchstick sign 114
Cadaverized hairs 128f
Calcineurin inhibitors 52f, 156
Calcinosis 84
Callus 50f
dermoscopy of 49f
Candidiasis 157
Cervical abscess 59
Cheilitis 20f
Chemotherapy alopecia 117f, 128
dermoscopy of 128
Chromonychia 146f
Chronic plaque psoriasis, dermoscopy of 28
Chrysalis structures 86
Circle hair 106, 117
Cobblestone 14f
Coiled hair 106, 107f, 113, 114f
Collar hypertrichosis 59
Collarette sign 35
Comma hair 107
Connective tissue disorders 84
Contact dermatitis 31f
Corkscrew hair 107, 107f
Corn 50f
Coudability hair 108, 109f, 111, 111f
Craters of moon
appearance 113f
sign 111
Crypts 62
Crystalline structures 15, 16f
Cutaneous lupus erythematosus 89
Cyclophosphamide 129f
Cystic hygroma 59
Cytarabine 129f
Darier's disease 39, 39f, 41, 41f, 155
dermoscopic dirty scalp of 41f
Dark lacunae 82
Dark-brown globules 41
Deep morphea 88
Demodex 52
Demodicosis 52, 156
Depigmented macule 69f
Dermal-epidermal junction 6
Dermatoglyphics, disruption of 48
Dermatomyositis 84f
Dermatophytosis 157
Dermlite dermoscopes 7
Dermogenius molemap 5
Dermoid cyst 59
Dermoscope 5, 6, 79
basic model of 5
over simple magnification lens, advantages of 5
types of 6, 7
Dermoscopic dirty scalp 39
Dirty warty papules 39f, 42f
Discoid lupus erythematosus 89, 103f, 105f
progression of 89
Discoid plaques 26f
Dissecting cellulitis 120
Distal nail plate onychoschizia 148f
Distorted pigment network 73f, 74f
Dorsum of hand, dermoscopy of 40f
Ectodermal dysplasias 125
Ectopic thyroid 59
Eczema 157
Eczematous eruptions 20
Empty follicles 117
Endocrine disorders 93
Epidermal hyperplasia 120f
Epidermal nevus syndrome 63
Epiluminescence microscope 5
Erythema annulare centrifugum 36
Erythematous lunula 146f
Erythematous papulosquamous lesions 90f
Erythematous patch, asymptomatic 88f
Erythematous rash 156
mild 52f
Escherichia coli 148
Etoposide 129f
Exclamation mark hair 108, 111, 111f, 128f
Extensive broom hairs 163
Eyelashes 122f
Eyelid dermatitis 29f
Fabry's disease 82
Facial angiofibromas, multiple 62f
Fibrotic beams 88
Fibrotic white patches 119
Fibrous cephalic plaque 62f
Fingernails, sand-paper appearance of 147f
Flame hair 107, 113, 114f, 115f
multiple 114f
Follicular openings, absence of 119
Follicular pattern 102
Follicular plugging 89
Folliculitis decalvans 120
Fotofinder 9f
dermoscope 5
Fractured hairs 128f
Friar tuck sign 114
Fungal infections 45
Genodermatoses 61
Globules 15
Golf tee hair 123f
Gottron's papule 84, 84f, 85
dermoscopy of 84, 85f
Granuloma annulare 36, 95
Gray granular pigmentation 26
Grayish papillary appearance 65f
Guttate lichen sclerosus et atrophicus 87f
Guttate psoriasis 154
cast 104, 104f
disorder 4
loss 89
disorders 122
ectoparasites of 107f
patterns 106
Halo nevus 17, 18f
Handheld video dermoscopes 9
Heine dermoscopes 7
Heliotrope rash 84f
Hematopoietic stem cell transplantation 128
Hemorrhagic crusts 82
Henderson-Paterson bodies 50
Herpes virus infection 141
nails 138
pattern 139
Homogeneous blue pigmentation 15f
Honeycomb pigment network 105
Human papilloma virus 47
infections 47
Hutchinson's sign 136
Hybrid demoscopes 7
Hyperkeratosis 120f, 140f
subungual 40f, 41f
Hyperkeratotic papules 40f
Hyperpigmented border 41
Hyperpigmented macules 33f
Hypertrichosis 14f
Hypertrophic lichen planus 32f, 34
Hypomelanosis of Ito 68, 69, 70, 70f, 71f
diagnosis of 70
Hyponychium 136
Hypopigmentary disorders 69t
congenital 68, 68t
Hypopigmented lesions 68
Hypopigmented macule 61, 61f
Hypopigmented papules 37f
Hypopyon 80, 81
I hair 107, 113
Ichthyosis linearis circumflexa 43
Ichthyosis vulgaris 105, 105f
Ifosfamide 129f
Infantile hemangioma precursors 75, 75f, 76t
Infections 45, 141
Infestations 45, 52
Inflammatory linear verrucous epidermal nevus 25
Inflammatory nail disorders 143
Interfollicular patterns 104
Interfollicular scales 105, 105f
Itchy lesions 31f, 161
Juvenile dermatomyositis 84
Juvenile xanthogranuloma 96
follicularis 39
spinulosa decalvans 119
spinulosa 23
Keratotic follicular plugs 121
Keratotic halo 48
Keratotic plugs 103
Lesions, frogspawn appearance of 81f
Leukemia 129f
Leukonychia 138, 138f
Leukotrichia 72f, 129f, 130f
Lichen nitidus 36, 38, 38f, 87f, 158
Lichen planopilaris 119, 167
early 119f
hallmark of 119f
Lichen planus 31, 33f
diagnosis of 31
Lichen sclerosus 36, 38
et atrophicus 86, 158
Lichen spinulosus 23, 24f
histopathology of 24f
Lichen striatus 24, 25f, 37f
Light-emitting diodes 5
Linear atrophic bands 94, 94f
Linear branching vessels 86, 88
Linear crista cutis 93, 93f
dermoscopic features of 94
Linear lichen nitidus 37f
recent reports of 36
Linear nail bed dyschromia 146f
Linear vessels 88
Lipodystrophy 84
Lobular capillary hemangioma 76
Lobulated verrucous plaques 65f
Loose anagen 126f
hair syndrome 125
Lymphadenopathy 59
Lymphangioma 80
circumscriptum 80, 81f
Lymphatic malformations, congenital 80
Mace hair 113, 114f, 115f
Macular erythematous stain 75f
Macule, dermoscopy of 61f
Malar rash 84, 90f
Match-stick hair 123f
defect 43, 44f
Medulloblastoma 130f
activation 136
proliferation 136
Melanocytic lesions 13
Melanocytic nevi
acquired 17
congenital 13
Melanoma 19
malignant 136
Melanonychia 135
benign 136
longitudinal 135
Menkes syndrome 125
Metherton syndrome 123
Methotrexate 129f
Microhemorrhages 85f
Micro-Hutchinson's sign 136
Microsporum canis 107f
Molluscum bodies 50
Molluscum contagiosum 50, 51, 51f, 162
classical vascular pattern of 51f
Monilethrix 112f, 122, 122f, 123f
Morphea 88
Mosaic wart 49f
Multicomponent vascular pattern 89
Multiple palmar pits 40f
Nail 89
changes 155
dermoscopy of 4
disorders 135
lichen planus 145147
melanoma 135
hyperkeratosis of 140f
nonpolarizing dermoscopy of 144f
psoriasis 143
salient onychoscopic features of 143t
Nailfold capillaroscopy 84, 85f, 91f
Netherton's syndrome 4, 43, 43f, 44f
anemicus 69
depigmentosus 6972
lesion of 72f
sebaceous 65
of Jadassohn 65
simplex 80
spilus 18
Non-scarring alopecias 103f, 111
Normal scalp
vasculature 105
vessels 105f
Nummular eczema 26, 36
Onycholysis 142f, 145f, 149
proximal border of 141f
Onychomycosis 138f, 141, 142f
Onychophagia 148
Onychorrhexis 145f, 146f, 147f
Onychoscopy 41f, 133, 141, 144f, 149f
Opaque trachyonychia 147f
Optics in dermoscopy 6
Oral mucosal lichen planus 33f
Pachyonychia congenita 139
Palatal ulcers 90f
Palisading granuloma 95
Palmar lesions, dermoscopy of 90f
Papillomatosis 47
Papular lesion, dermoscopy of 66f
Parallel pigmentation 16f
Parasitic infections 52
acute 141
chronic 141
Patchy alopecia 115f, 165
Patchy hair loss 116f
Patchy nonscarring alopecia 89
Patchy scarring alopecia 89
dermoscopy 1, 3
longitudinal melanonychia 135
melanocytic lesions 13
melanocytic nevi 13
nail diseases, dermoscopy of 135
onychoscopy 135
scabies 54
trichology 101
Pediculosis capitis 53
Pediculus humanus var capitis 53
Perifollicular collar scaling 119f
Perifollicular patterns 104
Perifollicular pigment 72, 73f
Perifollicular scales 104, 104f, 119
Perifollicular whitish halo 89
Peripheral erythema 82, 90f
Peripheral globular pattern 17f
Peripheral scales 36f
Peripilar casts 119
Peripilar sign 38, 104, 104f, 117, 118
Photosensitivity rash 90f
Pili annulati 125, 125f
Pili torti 124, 125f
lichenoides chronica 154
rosea 34, 35f
versicolor 45
Plantar wart 48, 49, 49f
Pohl-Pinkus constrictions 107, 108f, 111, 117
formation of 112f
Poikiloderma 84
Polarized trichoscopy 101
Polymorphic light eruption 38, 161
Popliteal fossae 21f
Porokeratosis 36, 41
Port-wine stain 75, 78, 79f
Potassium hydroxide 45
Prominent erythematous nail bed 146f
Prominent linear vessels 80
Proximal erythematous band 144f
Proximal muscle weakness 84
Proximal nail
fold 136
plate 136f
Pseudocomedones 39f, 40f, 41
Pseudo-Hutchinson sign 136, 137, 137f
Pseudohyperkeratosis 140f
Pseudoleukonychia 138, 138f
Pseudomonilethrix 123f
Pseudo-nail plate 140f
Psoriasis 28, 28f, 29f, 30f, 36, 155, 157
Psoriatic erythroderma 140f
Psoriatic onycholysis 144f
Punctate keratosis 40f
Pyogenic granuloma 76, 77f, 78f
lesion of 77f
P4 pattern of 78f
P5 pattern of 78f
shiny red nodule of 78f
Question mark hair 113, 114f
Radial streaming pattern 31
Red blood cells 80
Red globular ring 28
Red lacunae 82
Red linear vessels 76
Red round globular vessels 76
Red starburst pattern 89
Salivary tissue 59
Salmon patch 80f
dermoscopy of 80f
Sand-blasted nails 147
Scabetic mite 55f
Scabies 54, 54f
Scalp 59, 84, 89
dysesthesia 163
erythema 121
psoriasis 105, 105f
trichoscopy of 85, 86f, 126
Scarring alopecias 119
Seborrheic dermatitis 36, 105, 105f
Setting sun appearance 96, 96f
Shagreen patch 62, 62f
dermoscopy of 63
Short anagen hair syndrome 126
Short regrowing hair 108, 117
Skin 93
scrapings 53f
surface microscope 5
Snell's law 6f
Solitary angiokeratomas 82
Splinter hemorrhages 41f
Staphylococcus aureus 141
Starburst hyperplasia pattern 120
Starburst pigmentation 16f
Starry sky pattern 31
Sticky fiber sign 42f
Stratum corneum 142f
Striae distensae 94, 94f
Subpapillary plexus 80
Sulcus cutis 93, 93f
Superficial morphea 88
Sweat glands 43
Systemic lupus erythematosus 89, 91f
Tapering hair 108, 111, 117
Telangiectasia 94, 94f
periungual 84
Telangiectatic structures 89
Telogen effluvium 89, 117
Terminal hair 108, 109f, 116f
Thyroglossal cyst 59
Tinea capitis 4, 105, 105f–108f
trichoscopic hallmark of 107f
Tinea corporis 36
Tinea pedis 28f
Topical steroid 156
Toxic epidermal necrolysis 140f
Trachyonychia 147
Traumatic onycholysis 149
onychoscopy of 149f
Triangular alopecia, congenital 4, 115, 116f, 126, 126f
Trichoepithelioma 66, 66f, 67
multiple familial 66
Trichoptilosis 113
Trichorrhexis invaginata 43, 123
Trichorrhexis nodosa 124, 124f, 163
Trichoscopy 4, 53, 85, 86f, 99, 101, 102, 111f
Trichoteiromania 129f
Trichothiodystrophy 124
Trichotillomania 4, 102f, 106f–108f, 112f, 113, 114f–116f, 164, 165
typical chaotic multicomponent pattern of 114f
Tuberous sclerosis 61f, 68
complex 61
Tufted hair 108
Tulip hair 108, 113, 115f, 117
Tumors 65
Twenty-nail dystrophy 147
Ulceration 84
Ultraviolet light 9
V hair 114f
V sign 113
Vascular lesions 75
Vascular patterns 77
Vascular structures 77
Vellus hair 108, 108f, 109, 111, 112f, 116f, 129f, 130f
absence of 119
short 116f
Verruca plana, fleshy skin-colored macules of 48f
Verruca plantaris 48
Verruca vulgaris 47, 47f
Verrucous epidermal nevus 63
Video dermoscopes 8, 9
Viral infection 47
Vitiligo 46f, 69
Volar fat-pad of distal phalanx, localized infection of 141
Wart 50f
common 47
on finger 48f
onychoscopy of 142
periungual 142, 142f
White amorphous globular structures 91f
White blood cells 80
White fibrotic beam 88
White patches 105
White scales 28, 89
White track
appearance 42f
structure 41
Whitish keratotic halo 47
Whitish-yellow lobular appearance 65f
Wickham's striae 31, 32f, 33f
Yellow clod sign 26
Z hair 109, 110f
Zig-zag hair 110f
Zosteriform lichen planus 33f
Chapter Notes

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1Pediatric Dermoscopy
  • Pediatric Dermoscopy: Introduction
  • Instrument2

Pediatric Dermoscopy: IntroductionCHAPTER 1

Seujee Das,
Rashmi Agarwal
Dermoscopy, considered as the dermatologist's stethoscope in recent times, is an ex vivo noninvasive method which enables us to look beyond what our naked eyes cannot perceive. It helps in examining the subsurface features of the skin and in appreciating the epidermal and superficial dermal features of a lesion at a greater magnitude by decreasing the scattering of light and increasing transillumination, either through polarized light or through usage of a linkage fluid. Therefore, it serves as an important diagnostic aid in the practice of dermatology.
There are three ways to perform dermoscopy:
  1. Nonpolarized dermoscopy—requires direct contact with the skin surface in addition to a liquid interface (mineral oil or alcohol) placed between the dermoscope and the skin.
  2. Polarized contact dermoscopy.
  3. Polarized noncontact dermoscopy.
Polarized dermoscopy has the advantage of eliminating the reflected light from the skin surface by using cross-polarized filters, thus allowing the reflected light from deeper layers to reach the observer's retina, making visualization of structures below the stratum corneum possible.
A few extra minutes is what the dermoscope demands and henceforth the clinical examination stands complete. Apart from enhancing the subtle clinical features, the dermoscope gives an insight into the pigment network as well as the vascular pattern of the skin. Any alteration in them can be very well-detected through a dermoscope, thereby, contributing to the diagnosis. Dermoscopy improves the clinician's diagnostic accuracy and can help correctly classify numerous skin lesions based on the presence or absence of specific dermoscopic structures. Dermoscopy also helps in monitoring the response to treatment and in predicting the prognosis of a disease.
The wide array of colors that we see through a dermoscope actually corroborates to the histology of the normal or diseased skin. Pin-point white dots represent eccrine gland/hair follicles openings while white patches, white shiny structures denote fibrosis. Red color denotes cutaneous vessels and extravasated blood. Superficial cutaneous vessels that form hair pin loops and are perpendicular to the skin appear as dots and globules while the subpapillary plexus which is parallel to the skin appear as red linear structures. Black, light to dark brown, grey, and blue relate to melanin at different depths in the skin. Therefore, the color concept, the different size and shapes in which the colors are configured give rise to various patterns. A constellation of these features contribute to the dermoscopic diagnosis of various skin diseases. For example, the arrangement of red dots in a lesion can differentiate psoriasis from lichen planus and eczema, which actually corresponds to the morphology of different vascular arrangement histologically.
Even the inflammatory infiltrate gives rise to different colors. Orange-yellow background or structures on dermoscopy points toward a granulomatous infiltrate while a violaceous hue usually corresponds to a lichenoid infiltrate.
The pediatric population constitutes a special population in our society with very specific needs. The practice of pediatric dermatology differs greatly from general dermatology since the challenges faced are diverse ranging from inability of the child to correctly specify their problems to handling them in a hospital setup. Handling parental queries and anxieties also form one of the corner stones of pediatric practice. As dermoscopy is a noninvasive and painless tool, it is very well accepted by children and their parents. The ease with which it can be handled and the minimum time required for examination of lesions under a dermoscope, makes it an ideal tool for examining pediatric skin lesions in day-to-day practice. Dermoscopy definitely contributes to the overall satisfaction of the parents as4 it imparts the idea in their mind that a proper thorough examination of their child has been carried out and this in turn improves the doctor-patient relationship as well as compliance.
It is very difficult to perform biopsies in a child because of their low-pain threshold and is often very restless. Moreover, even the parents are hesitant to let their child undergo such invasive procedures. Therefore, it is always better to avoid such procedures in a child and this is where dermoscopy come into play.
Hair disorder in children is very common and raises substantial amount of concern in the parents as well as children. The most common sign is alopecia and can be either due to congenital or acquired causes and the pathology can involve either the hair itself or the scalp skin. Trichoscopy is considered to be as reliable as microscopy in the detection of most hair shaft diseases and thus assist in the diagnosis of multiple genetic disorders, such as trichorrhexis invaginata, trichorrhexis nodosa, monilethrix, pili torti, and pili annulati. Prompt diagnosis of these features with the help of dermoscopy can give the clinician an insight into a broader syndrome, for example, the presence of trichorrhexis invaginata points toward the diagnosis of Netherton's syndrome. Presence of corkscrew and comma hair, exclamation mark hair, flame hairs, and carpet of vellus hair can point toward the diagnosis of tinea capitis, alopecia areata, trichotillomania, and congenital triangular alopecia respectively in cases of patchy hair loss. Trichoscopy is a practical, painless, and tolerable method for examining various hair disorders, obviating the need for plucking or cutting the hair for microscopic examination.
Many dermatological diseases involve the nails in children. Dermoscopy of the nail, i.e., onychoscopy, helps in differentiating onychomycosis from nail psoriasis and nail lichen planus. Visualization of the nail fold capillaries helps in the diagnosis and prognostication of various connective tissue diseases in children.
Dermoscopy is indeed a revelation in the practice of pediatric dermatology. With the ever increasing horizons of dermoscopy literature we are soon progressing to a stage where many skin conditions can be diagnosed with a dermoscope, thus obviating the need for histopathological examination and making it an indispensable tool in our daily practice.