Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2022;12(2):e2022055 1 Dermoscopy of Viral Folliculitis of the Beard: Report of Two Cases Biswanath Behera1, Rashmi Kumari2, Debasis Gochhait3, Pavithra Ayyanar4 1 Department of Dermatology, and Venereology, AIIMS, Bhubaneswar, India 2 Department of Dermatology, Venereology and Leprology, JIPMER, Puducherry, India 3 Department of Pathology, JIPMER, Puducherry, India 4 Department of Pathology, AIIMS, Bhubaneswar, India Key words: dermoscopy, folliculitis, molluscum contagiosum, papilloma Citation: Behera B, Kumari R, Gochhait D, Ayyanar P. Dermoscopy of viral folliculitis of the beard: report of two cases. Dermatol Pract Concept. 2022;12(2):e2022055. DOI: https://doi.org/10.5826/dpc.1202a55 Accepted: September 1, 2021; Published: April 2022 Copyright: ©2022 Behera et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication Corresponding author: Rashmi Kumari, M.D., Associate Professor, Dept. of Dermatology, Venereology and Leprology, JIPMER, Puducherry, India Pin-605006. E-mail: rashmi.sreerag@gmail.com Introduction Differentiating human papillomavirus (HPV) folliculitis from molluscum contagiosum (MC) folliculitis over the beard area can be clinically challenging. Both can present as asymptomatic follicle-based papules, and the verrucous morphology of HPV infection and punctum of MC may not be appreciable in all cases. Case presentation The first case is a 26-year-old male who presented with a history of multiple asymptomatic lesions on the beard for 4 months.. Cutaneous examination showed multiple folli- cle-based skin-colored to pearly-white papules (Figure 1A). Dermoscopic examination under nonpolarized mode showed perifollicular pearly white clods (Figure 1B). Histology of a papule showed lobular epidermal acanthosis with prominent intracytoplasmic Henderson-Patterson bodies, consistent with a diagnosis of MC folliculitis (Figure 1C). The second case is A 33-year-old male who had multi- ple asymptomatic skin lesions over the beard for the last 6 months. He denied any history of recent cosmetic procedures. Cutaneous examination revealed multiple follicle-based skin- colored flat-topped (2 mm X 3 mm) papules (Figure 2A). Dermoscopy showed a perifollicular mosaic pattern compris- ing a variable-shaped white knob-like area with or without central dotted and hairpin vessels (Figure 2B). Histology of a papule showed basket weave hyperkeratosis, hypergranu- losis, moderate acanthosis, and koilocytes in upper stratum spinosum and granulosum, consistent with the diagnosis of verruca plana/HPV folliculitis (Figure 2C). In both the patients, all the investigations, including HIV 1 and 2 serology, to rule out immunosuppression were negative. 2 Research Letter | Dermatol Pract Concept. 2022;12(2):e2022055 Conclusions MC folliculitis is rare and usually occurs in patients with either acquired or iatrogenic immunosuppression. The pres- ence of flesh-colored to erythematous papules with or with- out central umbilication is the common presentation. HPV can spread from infected materials during cos- metic procedures, resulting in cosmetic warts. It can also spread along the line of the trauma due to pseudo-Koebner- ization of preexisting warts [2]. The case in the discussion was unique. Each of the flat-topped papules over the beard area was follicle-based compared to the clustered or linear arrangement described for cosmetic warts or pseudo-Koeb- nerization, respectively. Under dermoscope, MC characteristically demonstrates a variable-shaped white clod and crown vessels with or with- out a central punctum. Other features described are rosette, dotted and radial vessels [1,2]. Verruca vulgaris demonstrates grouped papillae with dotted and hairpin vessels surrounded by a whitish halo. In contrast, the verruca plana can have dotted vessels on a yellowish background [1]. We observed a mosaic pattern comprising a white knob-like area with or without a central hairpin or dotted vessel in the HPV folliculitis. The dermoscopic features described for other infectious folliculitis are the following: dotted vessels in Malassezia folliculitis; broken hairs, corkscrew hairs, black dots, zigzag hairs, and morse code hairs in dermatophytic folliculitis; central round pustule with peripheral sparse dotted vessels in staphylococcal folliculitis; and Demodex tails, and Demodex follicular openings in Demodex folliculitis. Another com- mon mimicker, pseudo-olliculitis, demonstrates a U-shaped in-growing hair under a dermoscope [1,2]. In conclusion, we report dermoscopic features of 2 rare cases of viral folliculitis on the beard. The dermoscopic ex- amination can help differentiate between MC folliculitis Figure 1. (A) Multiple follicle-based skin-colored to pearly-white (arrow) papules. (B) Dermoscopic examination (Heine Delta20®, 10X magnification) showing perifollicular pearly white clods. (C) Histology shows endophytic epithelial hyperplasia containing molluscum bodies (H & E, X50). Figure 2. (A) Multiple follicle-based skin-colored verrucous flat-topped papules. (B) Dermoscopy (Heine Delta20®, 10X magnification) shows a perifollicular mosaic pattern comprising of a variable-shaped white knob-like area with or without central dotted and hairpin vessels. (C) Histology shows basket weave hyperkeratosis, hypergranulosis, moderate acanthosis, and koilocytes in upper stratum spino- sum and granulosum (H & E, X50). Inset showing koilocytes (H & E, X400). Research Letter | Dermatol Pract Concept. 2022;12(2):e2022055 3 from HPV folliculitis, with the former characterized by white clod and the latter by a mosaic pattern. References 1. Piccolo V. Update on Dermoscopy and Infectious Skin Diseases. Dermatol Pract Concept. 2019;10(1):e2020003. DOI: 10.5826/ dpc.1001a03. PMID: 31921490. PMCID: PMC6936624. 2. Durdu M, Errichetti E, Eskiocak AH, Ilkit M. High accuracy of recognition of common forms of folliculitis by dermoscopy: An observational study. 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