Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2022;12(2):e2022048 1 Dermoscopic and Reflectance Confocal Microscopy Features of Superficial Morphea on Preexisting Atrophoderma of Pasini and Pierini Chun-Xiao Song1, Yu-Ting Zhang1, Cheng Tan1 1 Department of Dermatology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China Key words: morphea, atrophoderma, hyperpigmentation, hypopigmentation, dermatology Citation: Song CX, Zhang YT, Tan C. Dermoscopic and reflectance confocal microscopy features of superficial morphea on preexisting atrophoderma of Pasini and Pierini. Dermatol Pract Concept. 2022;12(2):e2022048. DOI: https://doi.org/10.5826/dpc.1202a48 Accepted: July 28, 2021; Published: April, 2022 Copyright: ©2022 Song et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License 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: Cheng Tan, MD, Department of Dermatology, Affiliated Hospital of Nanjing University of Chinese Medicine, 155 Hanzhong Road, Nanjing, China, 210029. E-mail: tancheng@yeah.net Introduction Superficial morphea (SM) is a distinct new variant of local- ized scleroderma with the collagen proliferated and deposited in the papillary and upper reticular dermis [1]. We present a case of SM developed on a primary lesion of atrophoderma of Pasini and Pierini (APP), and describe related dermoscopic and reflectance confocal microscopy (RCM) features. Case Presentation A 26-year-old Chinese woman presented with a seven-year-history of large hyperpigmented patches on the right leg. On examination, larger hyperpigmented patches were distributed in a zosteriform pattern. It spread from the right groin area, down the medial portions of the thigh, and finally to the popliteal fossa region. Furthermore, multiple 2 to 3  mm depigmented macules were disseminated within these hyperpigmented patches (Figure 1). Dermoscopic ex- amination of the white spots showed whitish fibrotic beams Figure 1. Large hyperpigmented patches were distributed in a zos- teriform pattern on the right groin area, and the thigh. Lesions were atrophic and slightly depressed without induration. Multiple 2 to 3 mm depigmented macules speckled within the hyperpigmented patch are shown. 2 Research Letter | Dermatol Pract Concept. 2022;12(2):e2022048 Figure 2. Dermoscopic examination of the white spots showed whitish fibrotic beams and linear arborizing vessels (green arrows). (A,B) The pigment network is irregularly distributed with a storiform pattern (red oval circles) in some speckled hypopigmented macule (blue oval circles). (C) RCM mosaic shows marked hyperreflective areas with decreased appendageal structures. Histological examination of this hypopigmented macule displayed decreased epidermal thickness with flattened rete pegs. (D) mild superficial perivascular lymphocytic infil- trate and pronounce dense clumping and homogenization of collagen bundles, compared to the neighboring area’s unaltered collagen. (E,F) Discrete, highly reflective clouds in the “coffee-bean” pattern under RCM, which might be corresponding to the clumps of collagen under the microscope. and linear arborizing vessels. The pigment network was irregularly distributed with a storiform pattern in some speckled hypopigmented macules. Histological examination of a hypopigmented macule displayed decreased epidermal thickness with flattened rete pegs. There were mild superfi- cial perivascular lymphocytic infiltrate and pronounce dense clumping and homogenization of collagen bundles, com- pared to the neighboring area’s unaltered collagen. Discrete, highly-reflective clouds were in the “coffee-bean” pattern under RCM, which might be corresponding to the clumps of collagen in histopathology (Figure 2). These findings were consistent with the diagnosis of SM (over APP), and the application of 1% pimecrolimus ointment for 4 months showed no improvement. Discussion SM is typically presented with symmetric hypopigmented to hyperpigmented patches at intertriginous sites. Histologically, there are flattened rete ridges. The collagen fibers in the up- per reticular dermis become thickened or homogenized, with the deeper dermis’s invariable sparing. Perivascular lympho- cytic infiltration is present in the superficial dermis with oc- casional plasma cells [2]. Dermoscopic examination of the white spots in our patient showed whitish fibrotic beams and linear arborizing vessels. The pigment network is irregularly distributed with a storiform pattern in some speckled hy- popigmented macules. RCM mosaic shows marked hyperre- flective areas with decreased appendageal structures. Divergent opinions about the relationship between SM and APP are present in literature. Some authors believe that SM is not identical to APP considering the clinical de- pression of “cliff sign” and older age of onset in APP. SM differs itself from APP with thickened collagen in upper reticular dermis. Others believe SM and APP belong to the same entity mainly considering both share a chronic be- nign course and a favorable prognosis that usually needs no treatment [3,4]. Besides, APP and SM may coexist as separate entities in the same patient or association with classical morphea or systemic scleroderma, and therefore APP can be considered an abortive type of scleroderma without sclerosis [4]. Research Letter | Dermatol Pract Concept. 2022;12(2):e2022048 3 phenomenon. Am J Dermatopathol. 1999;21(4):315–3199. DOI: 10.1097/00000372-199908000-00001. PMID: 10446770. 2. Mosbeh AS, Aboeldahab S, El-Khalawany M. Superficial Morphea: Clinicopathological Characteristics and a Novel Therapeutic Outcome to Excimer Light Therapy. Dermatol Res Pract. 2019;2019:1967674. DOI: 10.1155/2019/1967674. PMID: 31641348. PMCID: PMC6770326. 3. Ling X, Shi X. Idiopathic atrophoderma of Pasini-Pierini associ- ated with morphea: the same disease spectrum? G Ital Dermatol Venereol. 2016;151(1):127–128. PMID: 26373865. 4. Amano H, Nagai Y, Ishikawa O. Multiple morphea coexistent with atrophoderma of Pasini-Pierini (APP): APP could be abor- tive morphea. J Eur Acad Dermatol Venereol. 2007;21(9):1254– 1256. DOI: 10.1111/j.1468-3083.2006.02131.x. PMID: 17894716. Conclusions The presence of discrete hypopigmented macules of SM within the primary lesion of APP adds another evidence that SM and APP are part of the same spectrum of disease. The marked hyperreflective areas with discrete, highly reflective clumped as white coffee beans. Dermoscopy and RCM can be applied as an ancillary diagnostic technique in SM. References 1. McNiff JM, Glusac EJ, Lazova RZ, Carroll CB. Morphea limited to the superficial reticular dermis: an underrecognized histologic