Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2022;12(2):e2022051 1 Dermatology Practical & Conceptual Introduction Rhinofacial entomophthoromycosis or zygomycosis is a rare infection, caused by Conidiobolus corononatus involving the nasal cavity, paranasal sinuses, and soft tissues of the face. It initially starts as a painless swelling of the rhinofacial region which is locally invasive and can lead to facial disfigurement over time [1]. The disease tends to involve immunocompe- tent males, usually involved in agriculture between the age of 20-50 years. The diagnosis is established through histopatho- logical and mycological examination. Special stains like pe- riodic acid schiff and silver methanamine can help in the visualization of fungal hyphae and confirmation of diagnosis. Herein, we present a case of rhinofacial entomophthoromyco- sis and describe the dermoscopic findings seen in the patient. Case Presentation A 19-year-old male, a farmer by occupation from the Hi- malayan region of north India, presented with diffuse fa- cial swelling which initially started as nasal mass, gradually progressing to involve the upper half of the face including nose, cheeks, and forehead with significant facial disfigure- ment for 8 months. There were no other symptoms associ- ated with the swelling. The patient had taken multiple short courses of antibiotics and antifungals without improvement. General physical and systemic examination of the patient was normal. Upon mucocutaneous examination, diffuse skin-col- ored to erythematous, slight scaly, woody hard, lobulated sub- cutaneous swelling was present over the nose extending to involve the center of forehead, upper part of both the cheeks, inner canthus of the eye, and infraorbital area restricting the patient’ vision (Figure 1A). Laboratory examination including blood count and blood chemistry were within normal limits. ELISA assays for detection of Human immunodeficiency vi- rus and hepatitis B surface antigen were negative. Computed tomography scan revealed heterogeneously enhancing soft tis- sue mass in the left nasal cavity arising from inferior turbinate extending into the soft tissue of nasal septum. Dermoscopic examination (x10, polarized non-contact mode) was done which revealed focal yellowish-orange structureless area, dot- ted and linear vessels over a background of diffuse erythema Dermoscopy of Rhinofacial Entomophthoromycosis in Skin of Color: First Report Payal Chauhan1, Rashmi Jindal2, Nadia Shirazi3 1 Department of Dermatology, All India Institute of Medical Sciences (AIIMS), Himachal Pradesh, India 2 Department of Dermatology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand 3 Department of Pathology, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand Key words: Dermoscopy, subcutaneous mycoses, deep mycosis, rhinofacial entomophthoromycosis Citation: Chauhan P, Jindal R, Shirazi N. Dermoscopy of rhinofacial entomophthoromycosis in skin of colour: first report. Dermatol Pract Concept. 2022;12(2):e2022051. DOI: https://doi.org/10.5826/dpc.1202a51 Accepted: August 11, 2021; Published: April 2022 Copyright: ©2022 Chauhan 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: Payal Chauhan, Assistant Professor, Department of Dermatology, All India Institute of Medical Sciences (AIIMS), Himachal Pradesh, India E-mail: chauhanpayal89@gmail.com 2 Research Letter | Dermatol Pract Concept. 2022;12(2):e2022051 (Figure 1, B and C). Few white areas, scaling, and yellow fol- licular plugs seen as yellow dots were also appreciated. Histopathological examination was done from the skin and underlying nasal mass. Skin biopsy revealed epidermal acanthosis, follicular plugs, and multiple epithelioid granu- lomas in the dermis with eosinophilic infiltrate (Figure 2, A and B). The nasal biopsy displayed amorphous eosinophilic material around fungal hyphae along with acute inflamma- tory infiltrate (Figure 2C). Gomori methanamine silver stain performed on the nasal biopsy sample demonstrated broad, aseptate fungal hyphae, a few branching at the right angle (Figure 2, D and E). No organism could be grown on tissue culture. A final diagnosis of rhinofacial entomophthoromy- cosis was made. The patient was started on itraconazole 200 mg twice a day and potassium iodide five drops 3 times a day. Discussion The clinical appearance of rhinofacial entomorphthoro- mycosis can mimic neoplasms like subcutaneous malig- nant, lymphatic oedema, tuberculosis. Dermoscopy-based differential diagnosis of the present case include cutaneous tuberculosis, other deep mycosis like cutaneous sporo- trichosis, though clinical appearance can help distinguish rhinofacial entomophthoromycosis from the latter. Timely diagnosis of this rare disorder is important to initiate early intervention and thus reduce patient morbidity. Application of dermoscopy has lately expanded to the diagnosis of deep fungal infections, though available literature is still limited [2]. To the best of our knowledge, dermoscopy of rhinofacial entomorphthoromycosis has not been previously described. Generalized erythema, yellowish structureless area, presence of vessels, and white scar-like areas have been seen to be common dermoscopic features of deep mycosis [2]. The yel- low follicular plugs appreciated in the dermoscopy of the present case are akin to yellow tears described in cutaneous leishmaniasis and cutaneous sporotrichosis The presence of yellowish-orange areas on dermoscopy reflect the underlying granulomas, yellow dots correspond to dilated infundibulum present on histopathology, whereas white areas represent dermal fibrosis, with generalized erythema and vessels sec- ondary to the dermal inflammation and neoangiogenesis. Figure 1. (A) Diffuse skin colored to erythematous, slight scaly, subcutaneous swelling involving nose, forehead, inner canthus of eye, upper part of both cheeks. (B) Dermoscopy of the swelling over infraorbital area (represented by blue star in clinical image) displays fo- cal yellowish-orange structureless area (black star), multiple dotted vessels (black circle) over a background of diffuse erythema. Yellow dots (blue circle) and scattered yellow-brown scales also appreciated. (C) Focal yellowish-orange structureless area (black star), white areas (blue star), linear (black arrow) and dotted vessels seen from dermoscopy of the swelling over nose (represented by black star in clinical image). Research Letter | Dermatol Pract Concept. 2022;12(2):e2022051 3 Conclusions Dermoscopic findings of rhinofacial entomophthoromycosi in- clude yellowish-ornage structureless areas, erythematous back- ground, white areas, follicular plus, scaling, linear and dotted vessels. Dermoscopy can act as a useful tool in the diagnosis of this rare disfiguring deep mycosis and further work is needed in this field to corroborate findings seen in the present case. References 1. Bhalla S, Srivastava VK, Gupta RK. Rhinofacial entomophthora- mycosis: A rare fungal infection in an adolescent boy. Indian J Pathol Microbiol. 2015;58(3):402-403. DOI: 10.4103/0377- 4929.162933. PMID: 26275280.  2. Dabas G, Kaur H, Vinay K, et al. Dermoscopy in disseminated spo- rotrichosis. J Eur Acad Dermatol Venereol. 2019;33(1):e33-e35. DOI: 10.1111/jdv.15152. Epub 2018 Jul 18. PMID: 29953691. Figure 2. (A) Histopathology of the skin over infraorbital area showing follicular plugs, epidermal acanthosis, multiple gran- ulomas in the dermis (H&E, original magnification x4). (B) Dermal granuloma formed of epithelioid cells, lymphocytes, plasma, and acute inflammatory infiltrate (H&E, original magnification x40). (C) Histopathology of nasal mass demonstrat- ing amorphous eosinophilic infiltrate surrounding fungal hyphae with dense acute inflammatory infiltrate (H&E, original magnification x20). (D) Gomori methanamine silver stain showing multiple scattered broad, aseptate fungal hyphae (original magnification x 200). (E) Another section showing broad, aseptate fungal hyphae with branching at right angle seen in silver methanamine stain (original magnification x 400).