Dermoscopic norms for the face in skin of colour: A reference for detecting abnormal findings

Facial dermatoses, including infectious, inflammatory, and neoplastic conditions, are common in clinical practice, and their morphological overlap requires histopathological confirmation. However, cosmetic concerns often limit the use of a facial biopsy.

Dermoscopy is crucial for facial assessment, enabling a rapid and non-invasive evaluation. The face poses unique challenges in dermoscopic interpretation due to its dense vascular supply and high adnexal density, making an understanding of normal facial patterns essential for recognizing disease. However, data on the dermoscopic features of normal facial skin across phototypes, age groups, and genders remain scarce. In this context, the study by Agrawal et al. is both timely and significant¹. By systematically characterising dermoscopic patterns of the normal face in 200 healthy Indian participants (1,320 facial sites), the authors address a critical gap that has limited accurate interpretation of facial dermoscopy in skin of colour.¹ Their comparison of seven predefined facial sites across gender and age strata provides a robust baseline map of physiological variation, particularly valuable in darker skin types in which pigmentation-related findings may mimic pathology. Notably, 78% of participants had Fitzpatrick skin types V–VI, a group historically underrepresented in dermoscopic literature. The authors demonstrate both overlapping normal features, such as a uniform pseudonetwork, and site-specific differences across facial regions. The findings reported by Agrawal et al., together with the recent standardisation of dermoscopic criteria for both non-neoplastic and neoplastic dermatoses in skin of colour by the International Dermoscopy society, are expected to further enhance diagnostic consistency and accuracy.^2,3

The nose is an outlier, lacking a background pseudo-network while showing widely spaced follicular openings, brown circles around adnexal openings, follicular plugs, and white reticular lines. These findings have clear clinical implications, as misinterpreting such variants as pathological may result in unwarranted biopsies or interventions. Follicular plugs, classically considered a hallmark feature of discoid lupus erythematosus, and white reticular (shiny white) lines, reported across neoplastic and inflammatory conditions, warrant particular caution in interpretation when confined to the nose.⁴

Features such as follicular brown pigmentation, brown circles around adnexal openings, and dot-in-circle morphology were frequently observed in healthy facial skin, particularly on the cheeks and zygoma, and exhibited site- and age-related variations. These observations overlap with conditions such as lichen planus pigmentosus, post-inflammatory hyperpigmentation, and maturational hyperpigmentation, underscoring the need to understand the clinical context before labelling subtle facial pigmentation as pathological. In contrast, asymmetric perifollicular pigmentation and circles should continue to raise concern for underlying disease, including melanoma.

The documentation of unfocused linear vessels, particularly on the cheeks and in older patients, establishes an important normative reference, while the complete absence of dotted or sharply focused vessels across all sites reinforces the diagnostic weight of these vascular patterns in inflammatory or neoplastic facial lesions. The age-related increase in accentuated patchy pseudonetwork, follicular plugs, vessel visibility, and white reticular lines likely reflect cumulative photodamage in darker phototypes, in whom such changes may otherwise be clinically subtle or under-recognized.

Despite its strengths, the study included a relatively small number of elderly subjects and individuals with lighter phototypes, which limited the generalizability of some age- and phototype-related observations. Future work should expand cohorts across the full Fitzpatrick spectrum to capture the complete range of normal facial dermoscopic features in both fair- and dark-skinned individuals. Incorporating high-resolution video-dermoscopy or digital dermoscopy could enable a quantitative assessment of adnexal density, vessel calibre, and pigment architecture, while histopathological correlation would be valuable in understanding ambiguous patterns, such as dot-in-circle structures. Longitudinal studies examining the impact of cumulative sun exposure, cosmeceutical use, and hormonal influences on dermoscopic ageing of the face in skin of colour would further enrich this normative framework.

The data presented by Agrawal et al. meaningfully extend the concept of “normal limits” for facial pigmentation, vascularity, and adnexal patterns in skin of colour, and are likely to improve clinician confidence in dermoscopic diagnosis while reducing misdiagnosis and unnecessary biopsies.¹ The schematic representations of site-specific facial patterns provided by the authors constitute an especially useful educational tool for postgraduate training and dermoscopy teaching.