Dermoscopy in viral infections: An observational study

Background: Viral infections can be diagnosed and treated accordingly. Atypical presentation or sometimes presenting with other dermatological condition can be difficult for diagnosis. Dermoscopy provide rapid diagnostic aid for diagnosis. Aim: To evaluate dermoscopic patterns in viral infections. Materials and Methods: This study was conducted in dermatology department in tertiary hospital. Ethical clearance and informed consent was obtained. Patients with viral infection were subjected to dermoscopy. DermLite4 with 10x magnification, attached to a smartphone was employed for dermoscopy. Results: 106 patients were enrolled. Dermoscopy of Pityriasis rosea (n=10, 9.43%) showed brown dots and red dots in patients (100%). Light pink back ground in 80% patients. Molluscum (n=9, 8.49%) showed whitish structure in poly lobulated pattern (40%). In chicken pox (n=08. 7.54%), erythematous background (100%) and brown dots (100%). All the warts (n=48, 45.28%) showed red or blackish red dots (100%). Grouped red dots with white halo, finger-like projection with hairpin vessel surrounding white halo, knob like structure with hairpin like vessels were observed in common, filiform, genital warts respectively. Black dots in plantar and periungual warts. In herpes labialis (n=10, 9.43%) 3 zones, centre brown pigmentation, white colour and peripheral erythema. Cloudy white polyglobular structure with central brown dots in Herpes Zoster (n=8, 7.43%). Yellowish/brown pigmentation, brown dots, brown globules and crusting in Hand Foot Mouth Disease (n=5, 4.71%). Bluish globules and whitish area in Orf nodule (n=1, 0.94%). Conclusion: Dermoscopy is gaining importance in the realm of dermatology. In this study, dermoscopic patterns in viral infections were correlated clinically. © 2020 Published by Innovative Publication. This is an open access article under the CC BY-NC license (https://creativecommons.org/licenses/by-nc/4.0/)


Introduction
Various virus infections can be easily diagnosed and treated. Some cases can be atypical in presentation, making it difficult to proceed to diagnosis. Many of the infections when present in immunocompromised state can be difficult to diagnose because of its atypical presentation. Sometimes they can present with other dermatological condition, overlapping each-others clinical features. Thus, clinical diagnosis can be challenging. There can be delay in the diagnosis and treatment. Even the skin type (dark skin type) can contribute for such delay.
Histopathology is the gold standard for the diagnosis, but it is an invasive cumbersome and time consuming process. Whereas, dermoscopy is accurate non-invasive, easier, technique which can be used for diagnosis within a short period. 1 Dermoscopy is very useful auxiliary tool. It helps in diagnosing different dermatological condition by magnifying both surface and sub-surface features, which are not appreciated by unaided eye. 2 In this report, we sought to provide various dermoscopic features in various viral infection which may assist in clinical diagnosis.

Objective
To evaluate dermoscopic patterns in viral infections.

Materials and Methods
The ethical clearance for the study was obtained by the Institutional Ethical Committee. Written informed consent was taken from the patients. This study was carried out on 106 patients, out of which 85 were men and 21 were female attending the department of dermatology in a tertiary care hospital. Ages of the patients were between 6 years to 80 years. It was an observational study and patients were selected randomly. Handheld contact dermoscope, Derm Lite 4 was employed in the study. A smart phone was attached to the dermoscope to save images.

Pityriasis rosea (PR)
In our study most common background was light pink (80%), as compared to study (65%) which was yellow. 3 The reason can be due to darker skin type in our study. In a study, 3 50% of the background was dull red in

Molluscum contagiosum
In our study all the patients had whitish structure. (44.45%)patients had erosion and poly lobulated structure (44.45%). Central umbilication was seen in only 11.12 % patients. Polylobulated structure was seen in all cases in the study, 7 while in our study it was 40% of patients. Polylobular structure is due to lobular hyperplasia. As mentioned in the literature, 8 vascular structure like crown (72.34), radial (54.25), dotted vessels (20.21%) and flower pattern (19.68) were not noticed in our study, due to skin typeIV. Our study also showed 4-leaf-clover-like appearance similar to Piccolo V. 9 According to him young lesions showed 4-leaf -clover -like appearance. Similar structure was seen in the study, 10 due to optical effect by horny material. Ianhez M et al described yellowish material at the centre of lesion. 8 but our study showed whitish structure.

Chicken pox
Dermoscopically there was presence of erythematous background (100%), brown dots (100%), central erosion (25%) and vesicles presented with well-defined to illdefined border. Similar findings were seen in the study. 7 With erythematous background and brown dots in 100% of the patients. In addition, we were also able to appreciate central umbilication (25%). Brown dots represent multinucleated giant cell. 7 But due to lack of literature on dermoscopy of chicken pox, we could not compare our study.

Wart
On dermoscopy all types of common warts show brown to blackish dots, which represent vascular pattern. We appreciated grouped red dots with white halo. These were mentioned as tadpole like structures in the study. 7 There was presence of black dots in plantar and periungual wart. We also observed finger like projection in filiform wart similar to described in the study. 7 These finger like projections were described as more pronounced papillae than that one seen in common wart in the literature. 9 In our patient with filiform wart we observed hairpin vessel with white halo. Knob like structure and hairpin like vessels were seen in genital wart. 11,12 As compared to the study, 13 mosaic pattern (grouped dotted vessels in centre surrounded by whitish network) was similar to our study. There was presence of tiny small brown to blackish red dots in plane warts in our study. Similarly, red dots in light brown background were described by Papakonstantinou E. 14

Herpes labialis
It is caused by herpes simplex virus-1. 15 In a study, 7 dermoscopy showed erythematous background and brown dots in all the patients. We noticed 3 zones, central brown pigmentation, surrounded by white colour representing ballooning degeneration and peripheral erythema in 80% patients. 20% patients showed erythematous background, erosions and brown dots. Due to lack of literature on dermoscopy of Herpes labialis, we could not compare with other studies.

Herpes zoster
According to the literature, 7 herpes zoster showed multiple confluent round cloudy white polyglobular structures. Similarly, we were able to appreciate it in 80% of our patients.Central brown dots (53%) as present in their study, 7 were also seen in our study (80%). We were also able to appreciate erythematous background in 100 % of our patients. There was also presence of grey to black centrally placed dots (30%) in our study which was not described in the study. 7 In a study, 16 dermoscopy showed erythematous area and dilated vessels. These patterns were not similar to our study, due to early presentation of herpes zoster.
Our findings of herpes and the ones mentioned in literature were similar. But, again due to inadequate dermoscopic studies on herpes infection, we were unable to compare our findings.

Hand foot mouth disease
Hand foot mouth disease, very common in children, caused by Coxsackievirus. 17 Dermoscopy shows yellowish/brown pigmentation in all the patients. Brown dots, globules present in 60%, crusting in 40 % and whitish hue. Due to lack of literature, we could not compare with other studies.

Orf nodule
According to the study, 18 dermoscopy of orf nodule showed yellow white ring, crust, greyish white streak and yellow white area. Vascular structures like erythema, dot vessels, glomerular vessels, and milky red globule were noticed. Similarly, our study shows bluish globules and whitish area. No vascular structures were appreciated in our study. As we had only one case, various dermoscopic features of Orf nodule was unable to study. Due to paucity of article we could not compare our study with other article.

Conclusion
Clinically similar conditions can be distinguished with the help of dermoscopy. It can help to proceed to diagnosis within short time, in case of atypical presentation. It is gaining wide spread importance in realm of dermatology.

Source of Funding
None.

Conflict of Interest
None.