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ARTICLE IN PRESS
doi:
10.25259/IJDVL_1047_20

Named signs and metaphoric terminologies in dermoscopy: A compilation

Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
Department of Dermatology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra, India
Department of Dermatology, North DMC Medical College and Hindu Rao Hospital, New Delhi, India
Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India
Department of Dermatology, Katihar Medical College, Katihar, Bihar, India
Department of Dermatology, All India Institute of Medical Sciences, Patna, Bihar, India
Corresponding author: Dr. Deepak Jakhar, Department of Dermatology, North DMC Medical College and Hindu Rao Hospital, New Delhi. dr.deepakjakhar@yahoo.in
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This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Das A, Madke B, Jakhar D, Neema S, Kaur I, Kumar P, et al. Named signs and metaphoric terminologies in dermoscopy: A compilation. Indian J Dermatol Venereol Leprol, doi: 10.25259/IJDVL_1047_20.

Introduction

Dermoscopy is one of the most fascinating aspects of modern dermatology. It is a non-invasive bedside technique which facilitates the diagnosis of many common and uncommon dermatological conditions. Being an evolving technique, the dermoscopic features of various dermatoses have been traditionally described using multiple metaphoric terminologies and named signs. These metaphors and signs were intended to help memorize the newly introduced dermoscopic features. This article intends to enumerate and briefly describe the named signs and appearances in dermoscopy which will benefit the residents. To simplify, we have classified dermatoses as nevi, malignancies, infections and infestations (entomodermoscopy), pigmentary disorders, vascular disorders, papulosquamous disorders, hair (trichoscopy) and nail (onychoscopy) disorders.

Dermoscopic Signs in Nevi and Malignancies

Dermoscopy has remarkable diagnostic accuracy for benign and malignant skin tumours. Lesional dermoscopic examination may be helpful in avoiding unnecessary intervention. Melanocytic and non-melanocytic tumours show a specific pattern recognized by dermoscopy [Figures 1-4]. Some patterns such as “maple leaf appearance” and “blue-gray ovoid nests” are specific while others remain indicative. Dermoscopic signs should be clinically correlated to reach a final diagnosis. Metaphoric terminologies may help in the easy recall of signs associated with a particular disease, however, it may also mislead the physician as similar dermoscopic appearances have been reported in multiple diseases. Table 1 describes the signs and patterns observed in various benign and malignant skin tumours.

Figure 1:: Blue-white veil (red star) in melanoma showing confluent blue pigmentation with an overlying white “ground-glass” haze (Dermlite DL4;×10;polarising)
Figure 2:: Maple leaf (red arrow) and blue-gray ovoid nest (yellow circle) in basal cell carcinoma showing discrete, bulbous extensions connected to base and forming a leaf-like pattern (Dermlite DL4;×10;polarising)
Figure 3:: Pore sign (yellow arrow) in epidermal cyst showing the barely visible punctum (Dermlite DL4;×10;polarising)
Figure 4:: Sulci (yellow arrow) and gyri (blue arrow) in seborrheic keratosis showing cerebriform pattern (red circle) (Dermlite DL4;×10;non-polarising)
Table 1:: Signs and patterns in melanocytic and non-melanocytic disorders
S. No. Dermoscopic sign Disease Description
Melanocytic lesions
1 Beauty and the beast sign1 Melanoma Dermoscopy of benign melanocytic lesions is placed into nine categories and it generally fits into one of them and is considered “beauty.” Melanoma symbolized by the “beast” is a melanocytic lesion that derives from one of the malignant patterns or deviates from benign pattern
2 Blue-white veil Melanoma Described as confluent blue pigmentation with an overlying white “ground-glass” haze [Figure 1]
3 Honeycomb-like pigment network Junctional nevus A regular homogeneous honeycomb-like pigment network thinning out at the periphery
4 Isobar sign2 Lentigo maligna melanoma The hair follicle openings show central black dot apart from granular pigment around the follicle known as annular granular pattern
5 Little red riding hood sign1 Amelanotic or hypomelanotic melanoma This sign comes from a fairy tale in which the wolf disguises himself as the grandmother but can be still be recognized by his enormous teeth. It is used to describe an individual lesion that at first glance looks benign, but on closer inspection with dermoscopy shows features of a melanoma
6 Micro-Hutchinson sign3 Subungual melanoma Visible pigment on cuticle in case of melanonychia
7 Pseudo-micro-Hutchinson sign4 Congenital nevi Dark nail plate pigmentation is visible through the transparent nail fold specially in children
8 Starburst pattern5 Spitz nevus A hyperpigmented macule with regular peripheral pigmented streaks with central homogeneous pigmentation
Non-melanocytic lesion
1 Arborizing telangiectasia BCC, other benign lesions Multiple branching blood vessels in a tree-like pattern. More easily visualised in the non-pigmented BCC
2 Blink sign6 Actinic keratosis Some dermoscopic structures are more prominent with non-polarised dermoscopy while others with polarised dermoscopy.1,2The hybrid dermoscope allows the user to toggle between polarised and non-polarised light result in “blink sign.”
3 Chrysalis structures Basal cell carcinoma, dermatofibroma, scars White shiny linear streaks seen under polarised microscopy
4 Comedo-like opening Seborrheic keratoses Dark brown, gray- or black-coloured round to oval clefts containing keratin plug
5 Double edge sign7 Bowen’s disease Two parallel pigmented edges at the periphery of the lesion
6 Finger print-like structures Lentigo or early seborrheic keratosis Thin light brown lines that do not interconnect to form a meshwork pattern
7 Jelly sign8 Solar lentigo/flat seborrheic keratosis Smudging of pigment in some areas on contact dermoscopy is called as jelly sign
8 Large blue-gray ovoid nests Basal cell carcinoma Well-circumscribed, pigmented ovoid or elongated areas that are not connected to the pigmented tumour body
9 Leaf-like areas or Maple leaf-like areas9 Basal cell carcinoma Discrete, bulbous extensions connected to base and forming a leaf-like pattern [Figure 2]
10 Milia-like cysts (stars in the sky appearance)10 Seborrheic keratosis, congenital nevi Round circumscribed, white to yellow structure better visualized on non-polarised dermoscopy
11 Mobility sign11 Epidermal cyst In contact dermoscopy, when plate is shifted back and forth on the lesion with a slight pressure, nodular part of the lesion remains immobile while the overlying skin moves in same direction with the dermoscope plate
12 Moth eaten border12 Solar lentigo/flat seborrheic keratosis Concave invaginations at the border of the lesion
13 Pore sign11 Epidermal cyst Highlights the barely visible punctum [Figure 3]
14 Ridges and fissures (cerebriform structures) Seborrheic keratoses Brain-like or cerebriform appearance with the grooves resembling “sulci” and the intervening ridges resembling surface “gyri” [Figure 4]
15 Rosette sign Actinic keratosis, basal cell carcinoma, melanoma, discoid lupus erythematosus, molluscum Four white points arranged as four-leaf clover. Non-specific, initially described in AK but seen in many conditions
16 Spoke wheel-like structures Basal cell carcinoma Radial projections surrounding a central darker point
17 Strawberry pattern13 Actinic keratosis Background erythema interrupted by multiple small keratin filled follicular ostia

Dermoscopic Signs in Infections and Infestations

Recently, dermoscopy is being utilized to diagnose infections and infestations (entomodermoscopy) [Figures 5 and 6]. The classical “Delta wing-jet with contrail sign” is the hallmark of scabies, while newer signs and terminologies have been described to identify several bacterial, viral, fungal and other parasitic infections [Table 2].

Figure 5:: Contrast halo sign in a case of hypopigmented pityriasis versicolor showing a ring of increased pigmentation (yellow arrow) around the primary hypopigmented (red star) lesion (Dino-lite AM4115ZT;×50;polarising)
Figure 6:: Morse code-like hair in tinea capitis showing multiple horizontal bands (alternating red and yellow arrows) of fungal invasion in vellus hairs by masses of arthroconidia formed at intervals (Dermlite DL4;×10;polarising)
Table 2:: Signs and patterns in infections
S. No. Dermoscopic sign Disease Description
1 Bird’s feet-like structures and thorn crown14 Myiasis Here, the posterior segment of the larva appears as creamy-white body with central bird’s feet-like structures which correspond the breathing spiracles. The white structures are surrounded by black dots in the periphery, appearing as thorn crown
2 Contrast halo sign15 Pityriasis versicolor A halo of contrast to the central primary lesion of pityriasis versicolor. In hypopigmented variant, this contrast halo is a ring of increased pigmentation while in the hyperpigmented variant, the primary area of increased pigmentary network is surrounded by a halo of hypopigmentation [Figure 5]
3 Delta-wing jet with contrail sign16 Scabies It presents as a white S-shaped line (contrail) corresponding to the irregular burrow excavated by the mite, whose anterior part of the body is appreciated as a brown triangle resembling a delta wing jet
4 Demodex tail17,18 Demodicidosis
Demodex dermatitis
Spinulosis of face
Pityriasis folliculorum
Rosacea-like demodicidosis
Granulomatous rosacea
Gelatinous, whitish-creamy 1–3mm long thread-like structure protruding out of the follicular opening. This feature signifies the presence of the mite and can be appreciated in more abundance in spinulosis of the face or pityriasis folliculorum, than other types of demodicidosis
5 Frog spawn appearance19,20 Common wart Multiple densely packed papillae with a central red dot or loop surrounded by a whitish halo giving it an appearance of frog spawn
6 Hang glider sign/triangular head16,19,21 Scabies It appears as a brown triangle that corresponds to the anterior section of the mite which includes the head and the two anterior pairs of legs of the mite
7 Mite-Gallery Unit (MGU)22 Scabies MGU is divided into three parts: The head hosting the mite; the body which represents what is clinically defined as the burrow containing the eggs and feces of the parasite; and the tail at the end of the tunnel which provides an incomplete structure as it is without a roof but is made of keratin collarettes
8 Morse code hair23 Tinea incognito
Tinea capitis
Multiple horizontal bands of fungal invasion invellus hairs by masses of arthroconidia formed at intervals. The masses of arthroconidia are separated by thinner fragments of hyphae [Figure 6]
9 Mosaic pattern19] Genital wart Presence of groups of dotted or glomerular vessels at centre with a surrounding whitish network
10 Noodle sign24 Norwegian scabies It represents an accumulation of hundreds of burrows
11 Red corona/corona-like vessels25,26 Molluscum contagiosum A central pore or umbilication with polylobular white to yellow amorphous structures surrounded by linear, fine telangiectatic vessels
12 Reniform and hairpin loop structures27 Myiasis These represent the larva which appear as multiple, mobile, creamy white structures with reniform centers. Each reniform centre consists of three pairs of hairpin loop-like structures
13 Rosettes/4-leaf-clover-like appearance28,29 Early molluscum Four white points arranged as 4-leaf clover, mainly located around the follicular openings. This appearance is seen on polarized dermoscopy, and it is also seen in other conditions such as actinic keratosis, discoid lupus erythematosus and squamous cell carcinoma
14 White jade coin pendant sign30,31 Talaromyces marneffeiinfection It is seen as a circular or quasi-circular whitish amorphous structure with a central keratin plug or a haemorrhage
15 White starburst-like pattern32-34 Leishmaniasis White halo surrounding a central eroded area which may correspond to parakeratosis and hyperkeratosis surrounding the erosion
16 Yellow tears33,35 Leishmaniasis
cutaneous sporotrichosis
Yellowish structures with an oval and/or tear drop shape. This feature attributes to the follicular plugs due to the lateral compression of follicular openings

Dermoscopic Signs in Pigmentation Disorders

Dermoscopy is immensely helpful for diagnosing pigmentary disorders (both hypopigmentary and hyperpigmentary conditions) as most conditions are difficult to differentiate clinically, and biopsy is not feasible due to patient reluctance for fear of post-inflammatory hyperpigmentation [Figures 7 and 8]. Some of the important signs in hyperpigmentary and hypopigmentary disorders are summarised in Table 3.

Figure 7:: Cristae (red star) and sulci (yellow arrow) pattern in acanthosis nigricans showing presence of grooves, furrows, ridges and crests along with hyperpigmented globules (green arrow) (Dino-lite AM4115ZT;×50;polarising)
Figure 8:: Polka dot appearance (red circle) in unstable vitiligo showing multiple depigmented macules (blue arrow)[Dinolite AM4115ZT;50×;polarising]
Table 3:: Signs and patterns in pigmentation disorders
S. No. Dermoscopic sign Disease Description
Hyperpigmentation
1 Cristae and sulci pattern36 Acanthosis nigricans Presence of grooves, furrows, ridges and crests along with hyperpigmented dots [Figure 7]
2 Hill and valley pattern36 Acanthosis nigricans This is seen in severe cases of AN and appears as ridges (hills) and grooves (valleys)
3 Hub and spoke pattern37 Macular amyloidosis Brown clods and radiating brown lines from the clod
4 Reticuloglobular pattern38 Melasma Peripheral reticular pigmentation with central globules
5 Wagyu beef-like appearance39 Erythema dyschromicum perstans Pigmentation in crista cutis and presence of small brown dots
6 Worm-like structures40 Exogenous ochronosis Short, stout, curvilinear, “banana-shaped,” ochre-coloured fibres of varying thickness in the papillary and upper dermis
Hypopigmentation
1 Ameboid pattern41 Idiopathic guttate hypomelanosis,vitiligo Relatively well-defined margins of the depigmented patch sending out pseudopod-like extensions
2 Cloudy sky-like pattern (cloudy pattern)42 Idiopathic guttate hypomelanosis Multiple small areas coalescing into irregular/polycyclic macules with several white shades and both well- and ill-defined edges, surrounded by patchy hyperpigmented network
3 Comet tail43 Unstablevitiligo Depigmented patch with koebnerization in a comet tail pattern
4 Manchurian gravy sign44 Vitiligo post-skin grafting After 2–3 months of micropunch grafting, grafts insituappear as homogeneous dark brown well-circumscribed pigmented structures with lighter brown-coloured areas emerging centrifugally from the darker structures
5 Nebulous pattern41 Vitiligo Dense white depigmentation with ill-defined margins that merges indistinctly with the surrounding.
6 Petaloid pattern45 Idiopathic guttate hypomelanosis A well-defined depigmented macule with pigmented polycyclic margins
7 Polka dot appearance41 Unstablevitiligo Depigmented macules in a polka dot appearance [Figure 8]
8 Reversed pigmentary network pattern46 Evolving vitiligo Net-like pigmentary network formed by homogeneous white lines separated by pigmented areas in between (opposite to that of normal reticulate pigmentary network)
9 Tapioca sago appearance43 Unstablevitiligo Satellite lesions appearing as small white blotches around the main patch of vitiligo
10 Trichrome pattern47 Vitiligo Zone of normal pigmentation surrounding a hypopigmented rim around depigmented patch
11 White chrysalis like structures48 Extragenital lichen sclerosus White-yellowish structureless areas, without any sharp margin to differentiate the hypopigmented patch from the surrounding skin

Dermoscopic Signs in Vascular Disorders

Dermatologists frequently encounter various vascular lesions (benign and malignant) and most of them are superficially distributed [Figure 9]. Dermoscopy of vascular lesions can highlight their vascular pattern and arrangement of blood vessels. Table 4 highlights the important dermoscopic signs and patterns observed in cutaneous vascular lesions.

Figure 9:: White rail lines (black arrow) in pyogenic granuloma showing whitish streaks that intersect the lesion [Dermlite DL4;10×;polarising]
Table 4:: Signs and patterns in vascular disorders
S. No. Dermoscopic sign Disease Description
1 Collarette sign49 Kaposi sarcoma Four types of collarette signs have been described: white, brown, scaly and mixed. The pathological correlation of collarette sign was areas of epidermal invagination, where acanthosis and hyperkeratosis are prominent
2 Hypopyon sign50,51 Lymphangioma circumscriptum Presence of lacunae (often multicoloured). The lacunae has different amount of blood and lymphatic content owing to the presence of micro-shunts between lymphatic channels and small blood vessels. The extravasated cellular element of blood (erythrocytes) lies at the bottom and serum on the upper part giving rise to a “hypopyon sign” or 2-tone lacunae (as a result a half blood-filled lacunae resembling the hypopyon in the eye). it is a reliable feature to distinguish between LC and hemangioma
3 Rainbow pattern sign52 Kaposi sarcoma Presence of multicoloured areas similar to the spectrum of a rainbow. The pattern is predominantly seen in vascular lumen-rich histological subtype of KS and is not observed in the vascular lumen-poor subtype
4 White rail lines53 Pyogenic granuloma Whitish streaks or bands that intersect the lesion through and through [Figure 9]

Dermoscopic Signs of Papulosquamous Disorders

Skin disorders such as psoriasis, lichen planus, pityriasis rosea and subacute lupus erythematosus have a common morphologic appearance as scaly plaques [Figures 10-12]. Clinical differentiation may be difficult occasionally, thereby requiring histopathological confirmation. Dermoscopic magnification of surface structures and sub-surface features may aid in correct diagnosis by revealing disease-specific diagnostic features [Table 5].

Figure 10:: Collerette sign (black arrow) in pityriasis rosea showing the characteristic peripheral white scale [Dinolite AM4115ZT;50×; polarising]
Figure 11:: White track (between the black lines) of porokeratosis coronoid lamella appearing as well-defined, thin, white-yellowish, annular peripheral hyperkeratotic structure which resembles outlines of a volcanic crater (red arrow) seen from a high point. [Dinolite AM4115ZT;50×;polarising]
Figure 12:: Dermoscopic Auspitz sign in psoriasis showing characteristic pattern consisting of diffuse white scales (blue arrow) at periphery and symmetrically and regularly distributed dotted vessels (yellow arrow) on a light or dull red background [Dinolite AM4115ZT;50×;polarising]
Table 5:: Signs and patterns in papulosquamous disorders
S. No. Dermoscopic sign Disease Description
1 Collarette sign54,55 Pityriasis rosea The characteristic peripheral whitish scaling seen in both herald patch and other lesions [Figure 10]
2 Cornoid lamella (white track sign)56,57 Porokeratosis A well-defined, thin, white-yellowish, annular peripheral hyperkeratotic structure (“white track”) which resembles outlines of a volcanic crater seen from a high point corresponds to cornoid lamella [Figure 11]
3 Dermoscopic Auspitz sign58 Plaque psoriasis In presence of marked hyperkeratosis after removal of scales, dermoscopy shows characteristic pattern consisting of diffuse white scales and symmetrically and regularly distributed dotted vessels and tiny red blood drops on a light or dull red background suggestive of dermoscopic Auspitz sign [Figure 12]
4 Rail-like appearance59 Asteatotic eczema Asteatotic eczema on dermoscopy is seen as white scales having a double free edge giving “rail-like” appearance
5 Red globular ring pattern60 Plaque psoriasis Typical pattern of vessels in psoriasis described as uniformly distributed “dotted,” “pinpoint” capillaries and coiled (or glomerular) vessels. The same pattern of blood vessels in psoriasis also described as red dots (for vessels with diameters up to 0.1 mm) or “red globules” terms
6 Spermatozoon-like structures61 Patch stage of mycosis fungoides A peculiar vascular pattern (composed of a dotted and a short curved linear vessel) resembles spermatozoa
7 Sunburst appearance62 Lichen nitidus Lichen nitidus is characterised by shiny elevated surface with absence of dermatoglyphics over the lesions along with radial ridges and central circular depression. The radial ridges are seen to be radiating from the edges of central depression giving a “sunburst appearance.” It is classically seen on non-polarised dermoscopy
8 Trizonal concentric pattern59 Acquired reactive perforating collagenosis Central round brownish-greenish/yellowish-brown structureless area surrounded by a white keratotic collarette and an erythematous halo with or without dotted vessels
9 White starburst pattern63 Prurigo Nodularis Both hyperkeratotic and excoriated lesions of prurigo nodularis show arranged whitish lines or peripheral whitish halo with some centrifugal coarse projections on a brownish and/or reddish background
10 Wickham’s striae64,65(polymorphic pearly whitish structures)
Patterns:
Reticular pattern, circular pattern, radial streaming, leaf venation
starry sky pattern
Lichen planus Leaf venation pattern of WS-delicate secondary striae branching from the centered WS venation, linked together at either end, resembling the crystal structure of snow
Starry sky pattern: Clustered, follicular white dots

Dermoscopic Signs of Scalp and Hair Disorders

Trichoscopy is a valuable tool for not only diagnosing different hair and scalp disorders including alopecias but may be used additionally for assessing prognosis and monitoring treatment response [Figures 13 and 14]. It involves detailed observation of hair follicle openings, perifollicular and interfollicular scalp epidermis, dermal vasculature and hair shafts. A careful analysis of these findings is necessary for diagnosis. Over years, various trichoscopic signs have been documented and established. Some of these signs are non-specific, but are helpful in assessment of different alopecias, while other specific signs facilitate a quick diagnosis.1,2We have compiled both non-specific and specific trichoscopic signs in Table 6.

Figure 13:: Comma (blue arrow) and corkscrew hairs (red arrow) showing fractured, c-shaped hair shafts of homogeneous thickness and pigmentation; and short, spiral shaped hairs [Dermlite DL4;10×;polarising]
Figure 14:: Peripilar cast in folliculitis decalvans showing concentric layers of scales around the emerging hair shaft (red circle) [Dermlite DL4;10×;polarising]
Table 6:: Signs and patterns in scalp and hair disorders
S. No. Dermoscopic sign Disease Description
Scalp related
1 “Cherry blossom” vascular pattern66 Seborrheic dermatitis Arborizing vessels surrounded by glomerular and comma-shaped vessels
2 Dandelion vascular conglomerate66 Seborrheic dermatitis Yellow dot surrounded by glomerular and comma-shaped vessels. This appears like seed head of dandelion (Taraxacumgenus) plants
3 Flambeau sign67 Traction alopecia Multiple linear white tracks (mimicking the shape of flame or lit torch) in the direction of traction on hairs. These white tracks are particularly noted posterior to fringe of hairs left (fringe sign) at the hair line
4 Honeycomb network68,69 Sun exposure Bald scalp shows increased pigmentation in a fine reticular pattern. It may be lost in various scarring alopecia
5 Peripilar sign70,71 Androgenetic alopecia Depressed brown halo around the hair follicle, represents perifollicular inflammation
6 Peripilar white halo68,70 Central cicatricial scarring alopecia Gray-white halo surrounding follicular openings
7 Red starburst sign70,71 Discoid lupus erythematosus Seen as circular, follicular erythema. Represents dilated follicular openings surrounded by dilated blood vessels
Hair shaft related
1 Bamboo hair72,73 Trichorrhexis invaginata Invagination of the distal portion of the hair shaft into its proximal portion forming a “ball in cup” appearance
2 Bent hairs74 Tinea capitis Hair shaft with a single bend at sharp angle
3 Broom fibres sign75 Lichen simplex chronicus of scalp Hair shaft gets broken longitudinally into two or more fragments and mimics broom fibres
4 Burnt matchstick hair76 Trichotillomania Hair with dark bulbar proximal tip with a linear stem of variable length
5 Coudability sign77 Alopecia areata Proximal narrowing (and subsequent kinking) of hair shafts
6 Coiled hairs78 Trichotillomania Broken (terminal) hairs that curl back
7 Comma hairs74 Tinea capitis
Sometimes, alopecia areata and trichotillomania
Fractured, c-shaped hair shafts of homogeneous thickness and pigmentation [Figure 13]
8 Corkscrew hairs74 Tinea capitis Short, spiral-shaped hairs [Figure 13]
9 Crawling snake appearance79 Woolly hair syndrome Short wavy cycles in the hair shaft resembling a crawling snake
10 Exclamation mark hairs77 Alopecia areata Broken hair shafts have a darker, thicker tip while the proximal portion is thinner and pale. Indicate active disease process
11 Flame hairs77 Alopecia areata, trichotillomania, anagen effluvium Semi-transparent, wavy or cone shaped, pigmented structure resembling flame. Represents pigmented hair cast
12 Golf tee hairs72,73 Trichorrhexis invaginata The cupped proximal end of hair shaft remains while the distal end fractures and fall off
13 Hair dust/hair powder78 Trichotillomania Small fragments of broken hair visible on the scalp
14 i-hairs80,81 Tinea capitis
alopecia areata, trichotillomania
Short hair with an accentuated distal end and a thin hypopigmented shaft just beneath the darker distal end, resembling the alphabet “i”
15 Mace hair82 Trichotillomania Distal end of the hair shaft is bulbous and the hair shaft is hyperpigmented throughout its length and the upper half is rough in texture due to pulling and playing action with hair
16 Matchstick hairs83 Trichorrhexis invaginata Short hair shafts with bulging tips
17 Morse code (bar code) like hairs74 Tinea capitis Hair shafts with irregular horizontal white bands. Correlates with zone of ectothrix. Hair shafts may get bent at this zone.
18 Peripilar cast68-70 Lichen planus pilaris,
also in discoid lupus erythematosus, folliculitis decalvans
Concentric layers of scales around the emerging hair shaft. Peripilar cast encircling 2–3 or more hairs is very suggestive of LPP [Figure 14]
Thicker peripilar casts encircling six or more hairs is suggestive of folliculitis decalvans
19 Pigtail hairs (circle hairs)77,78 Androgenetic alopecia, anagen effluvium, tinea capitis, Trichotillomania Thin, curved, regrowing (vellus) hairs appear circular or coiled
Correlates with hair regrowth
20 Pohl-pinkusconstrictions68,69 Alopecia areata, anagen effluvium, cicatricial alopecia, telogen effluvium Refers to zones of decreased hair shaft thickness
21 Question mark hair78 Trichotillomania The distal portion of the hair shaft is curved and appears like question mark. Unlike exclamation mark hairs, the proximal portion of hair shaft is not tapered
22 Regularly bended ribbon sign84 Monilethrix Bended regularly at multiple locations with tendency to curve in different directions, giving it an appearance of a regularly bended ribbon
23 Starburst pattern hyperplasia85 Folliculitis decalvans Perifollicular erythema arranged in a pattern of lines radiating from a centre (it results from fibrosis)
24 Tulip bulb hairs78 Trichotillomania Short hairs with tulip bulb-shaped ends
25 V sign or V-hairs78 Trichotillomania Two (or more) hairs emerging from same follicular opening get broken at similar level/height and give an impression of “V”
26 Zigzag hairs74 Tinea capitis Hair shafts bent at multiple sharp angles along the length. Hair shafts appear like letter “Z”

Dermoscopic Signs of Nail Disorders

Nail disorders are often complicated by dubious clinical diagnoses. Moreover, histopathological confirmation is difficult due to the tedious process of nail biopsy. The evolution of onychoscopy is one of the most significant contributions of dermoscope [Figures 15 and 16]. Some of the important onychoscopic signs are tabulated in Table 7.

Figure 15:: Dendritic pattern (yellow circle) of endonyx appearing as the haphazard proliferation and branching of fungal elements in the nail plate. [Dinolite AM4115ZT;50×;polarising]
Figure 16:: Ruin pattern (blue box) of onychomycosis appearing as indented areas on the subungual keratosis and distal pulverisation [Dinolite AM4115ZT;50×;polarising]
Table 7:: Signs and patterns in nail disorders
S. No. Dermoscopic sign Disease Description
1 Aurora borealis pattern86 Onychomycosis Parallel bands of different colours in the onycholytic nail plate
2 Chick-pea flour pattern87 White superficial onychomycosis Yellowish-white, opaque and friable debris on the nail plate, concentrated near the proximal nail fold
3 Dendritic pattern88 Endonyx The haphazard proliferation and branching of fungal elements in the nail plate [Figure 15]
4 Grid pattern87 Superficial white onychomycosis Interconnected linear striae progressing from proximal to distal end
5 Irregular pattern of LPB3 Malignant melanonychia longitudinal lines that are irregular in colour, spacing, thickness and parallelism
6 Mirror sign89 Onychomatricoma Intraoperative dermoscopy sign: Symmetry of the lesion through a perpendicular axis in the proximal nail fold with the digitations (finger-like extensions of the tumour above the lunula) within the tumour being mirrored by the crypts within the nail plate
7 Pink glow sign90 Subungual glomus tumour Ultraviolet light dermoscopy glow of the glomus tumour due to its vascular nature
8 Pseudo-fibre sign91 Nail psoriasis Red and black filamentous structures under the distal-free edge of nail plate
9 Regular pattern of longitudinal pigmentary bands3 Benign melanonychia Parallel longitudinal lines are homogeneous in colour, spacing, thickness and orientation
11 Ruin pattern91 Onychomycosis Indented areas on the subungual keratosis and distal pulverisation [Figure 16]
12 Sagrada Familia sign89 Onychomatricoma Intraoperative dermoscopy sign: Multiple, regularly spaced and arranged, hyperbolic cavities in the ventral aspect of the nail plate

Conclusion

Metaphoric language is a part of our cognitive development and is commonly used to comprehend new knowledge by comparing with already learned knowledge. The use of metaphoric language in dermoscopy has been both supported and opposed. Its use in dermatology (including dermoscopy) has been criticized for lacking a clear definition and specificity. A metaphor should be well defined and clearly pictured (descriptive terminology may be used), useful (help the student understand a new concept which is otherwise difficult and/or complex), straight forward and commonplace (easily recognized and remembered) and resemble the described dermoscopic feature.92 The aforementioned parameters must be kept in mind, while proposing a novel metaphoric term so as to minimize inter-observer variability and confusion in its interpretation. If a metaphor fails to satisfy these criteria, it may become difficult for the readers to interpret and remember them. Therefore, it is prudent to strike a balance between both metaphoric and descriptive angles, while coining the dermoscopic appearances.93 Our attempt to compile the named signs and metaphoric language will be useful for the learners of dermoscopy and will make it interesting.

Declaration of patient consent

Patients’ consent is not required as the patients’ identities are not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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