Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2023;13(3):e2023147 1 Dermoscopic and Cytological Findings in Scleromyxedema Tuğba Tehçi1, Elif Burcu Şenyurt2, Murat Durdu3, Enzo Errichetti4 1 Department of Dermatology, University of Health Sciences -Adana Health Practice and Research Center, Adana, Turkey 2 Department of Pathology, University of Health Sciences -Adana Health Practice and Research Center, Adana, Turkey 3 Department of Dermatology, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Application and Research Center, Adana, Turkey 4 Department of Dermatology, University Hospital “Santa Maria della Misericordia”, Udine, Italy Citation: Tehçi T, Şenyurt EB, Durdu M, Errichetti E. Dermoscopic and Cytological Findings in Scleromyxedema. Dermatol Pract Concept. 2023;13(3):e2023147. DOI: https://doi.org/10.5826/dpc.1303a147 Accepted: December 4, 2022; Published: July 2023 Copyright: ©2023 Tehçi 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: Murat Durdu, Department of Dermatology, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Application and Research Center, Adana, Turkey. Tel: +90 2422406710 Fax: +90 2422496040 Email: sivandr@hotmail.com Case Presentation A 63-year-old male presented with pruritic, firm, dome- shaped, skin-colored/whitish papules mainly located over the forehead, neck, elbows, hands and feet (Figure 1A) that had progressively increased in number over the last year; skin induration of the trunk without papular lesions was also evident on palpation. Dermoscopic  examination of the papules showed round/oval, homogenous, white-ivory structureless areas similar to “rice grains” with no vessels (Figure 1B) [1], while cytological assessment of slit-skin smear taken from the lesions revealed round fibrotic colla- gen structures and mucinous materials (Figures 1, C and D). Based on clinical, dermoscopic and cytological findings, a possible diagnosis of scleromyxedema was made, and a bi- opsy was taken for histological examination, that confirmed this hypothesis by revealing fibroblast proliferation, collagen deposition, perivascular lymphoplasmocytic infiltration, and mucin  deposition in the dermis (Figures 1, E and F). Lab- oratory tests showed monoclonal gammopathy, while no systemic involvement was detected on further examination. Intravenous immunoglobulin therapy (2 g/kg dose for 5 con- secutive days per month) was started, with significant im- provement after three cycles of treatment. Teaching Point Scleromyxedema is a form skin mucinosis with possible extra-cutaneous involvement, including neurological, re- nal, hematological, and rheumatological, that may carry a poor prognosis if not treated timely [2]. Diagnosis is gen- erally clinical, yet in initial phases/incomplete instances it may be challenging to differentiate from similar condi- tions (eg lichen planus, lichen amyloidosis, papular lichen simplex chronicus, papular granuloma annulare, multiple follicular adnexal tumors) that, however, show a different 2 Image Letter | Dermatol Pract Concept. 2023;13(3):e2023147 Figure 1. (A) Dome-shaped, firm, small papules on the nape are similar as seen on clinical examination. (B) Dermoscopy reveals round and oval-shaped white-ivory homogenous areas similar to rice grains (magnification x10) [1]. (C,D) Cytology shows round fibrotic collagen structures and mucinous materials (May-Grünwald Giemsa x1000). (E) Histopathological examination displays increased mucin deposition in the superficial dermis and stellated fibroblasts between collagen fibers (H&E x200). (F) Fragmented elastic fibers are also evident (Alcian blue stain x200). Image Letter | Dermatol Pract Concept. 2023;13(3):e2023147 3 dermoscopic and cytological patterns [3]. Therefore, the use of such techniques may increase the index of suspicion for scleromyxedema with consequent prompt treatment. References 1. Mendes Bastos P, Borges AS, Cardoso JC, Oliveira A. Dermos- copy and reflectance confocal microscopy for the diagnosis of scleromyxedema. JAAD Case Rep. 2019;5(5):451-453. Pub- lished 2019 May 8. doi:10.1016/j.jdcr.2019.03.005 2. Ferreli C, Gasparini G, Parodi A, Cozzani E, Rongioletti F, At- zori L. Cutaneous Manifestations of Scleroderma and Sclero- derma-Like Disorders: a Comprehensive Review. Clin Rev Allergy Immunol. 2017;53(3):306-336. DOI: 10.1007/s12016 -017-8625-4. PMID: 28712039. 3. Lallas A, Errichetti E, Ioannides D. Dermoscopy in General Dermatology. CRC Press, Boca Raton, FL, 2018.