Dermatology: Practical and Conceptual 328 Letter | Dermatol Pract Concept 2018;8(4):17 DERMATOLOGY PRACTICAL & CONCEPTUAL www.derm101.com Introduction Primary cutaneous lymphomas are a diverse group of neo- plasms with different clinical presentation, histopathology, and prognosis [1,2]. Dermoscopy is a noninvasive, low-cost method that allows assessment of colors, patterns, and vascular structures, and today we know very well that dermoscopy cor- responds well with histopathology. The importance of dermos- copy for the differential diagnosis of pink nodules has already been established and in case of the presence of the pink-yellow structureless areas and polymorphous vessels, the possibility of lymphoma should be taken into consideration [3]. Discussion The dermoscopic pattern for early patch stage mycosis fun- goides (MF) lesions characteristically consists of fine, short, linear vessels; orange-yellow patchy areas; and spermatozoa- like vascular structures [1]. In a recently published report of a pilot study of primary cutaneous lymphomas, comedo-like openings were observed in folliculotropic MF, likely reflecting follicular plugging and loss of normal hair follicle architecture. The authors describe the dermoscopic perifollicular accen- tuation presumably reflecting the atypical lymphoid infiltrate within/adjacent to the hair follicle [2]. Patients with the classic clinical and dermoscopic picture of MF do not exhibit fol- licular changes, and follicles are not usually dermoscopically observed in MF lesions. In dermoscopy, follicles are usually seen if there are some changes in arrangement of melanocytic cells (as in lentigo maligna) or in some diseases in which the follicle is affected (such as discoid lupus, actinic keratosis). In our patients with patch stage MF (Figure 1a), der- moscopy revealed perifollicular accentuation described as a white halo around the follicles (Figure 2). Folliculotropism Early dermoscopic sign of folliculotropism in patients with mycosis fungoides Ruzica Jurakic Toncic1, Daniela Ledic Drvar1, Mirna Bradamante1, Jaka Rados1, Sandra Jerkovic-Gulin2, Stefano Caccavale3, Giuseppe Argenziano4 1 Department of Dermatology and Venereology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia 2 Department of Dermatology and Venereology, General Hospital Sibenik, Sibenik, Croatia 3 Dermatology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania Luigi Vanvitelli, Naples, Italy 4 Dermatology Unit, University of Campania, Nuovo Policlinico, Naples, Italy Key words: dermoscopy, primary cutaneous lymphoma, mycosis fungoides, folliculotropism, folliculotropic mycosis fungoides Citation: Jurakic Toncic R, Ledic Drvar D, Bradamante M, Rados J, Jerkovic-Gulin S, Caccavale S, Argenziano G. Early dermoscopic sign of folliculotropism in patients with mycosis fungoides. Dermatol Pract Concept. 2018;8(4):328-329. DOI: https://doi.org/10.5826/ dpc.0804a17 Received: February 20, 2018; Accepted: May 22, 2018; Published: October 31, 2018 Copyright: ©2018 Jurakic Toncic et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: None. Competing interests: The authors have no conflicts of interest to disclose. All authors have contributed significantly to this publication. Corresponding author: Ruzica Jurakic Toncic, MD, University Department of Dermatology and Venerology, University Hospital Centre Zagreb, University of Zagreb, School of Medicine, Salata 4, Zagreb 10000, Croatia. Email: rjtoncic@gmail.com Letter | Dermatol Pract Concept 2018;8(4):17 329 ers to standard PUVA and re-PUVA treatment, and this group can benefit from additional therapy, such as radiotherapy. Conclusions Accentuation of the follicle is an easily recognized dermo- scopic sign that can be found in patients who do not exhibit clinical signs of folliculotropic MF. It represents a very early sign that allows us to choose a proper biopsy site, predict histology even at an early stage of MF, select more complex treatment and, finally, to predict the group of MF patients who will have a poor response to the standard treatment References 1. Lallas A, Apalla Z, Lefaki I, et al. Dermoscopy of early stage myco- sis fungoides. J Eur Acad Dermatol Venereol. 2013;27(5):617-621. 2. Ghahramani GK,  Goetz KE,  Liu V. Dermoscopic character- ization of cutaneous lymphomas: a pilot survey. Int J Derma- tol. 2018;57(3):339-343. 3. Uzuncakmak TK, Akdeniz N, Karadag, et al. Primary cutaneous CD 30 (+) ALK (−) anaplastic large cell lymphoma with dermoscopic findings: a case report. Dermatol Pract Concept. 2017;7(1): 59-61. was confirmed by histopathology (Figure 1b). Perifollicular accentuation made follicles visible (Figure 2). This accentua- tion depends on the amount of lymphoid infiltrate; therefore, white halos present with different sizes. Perifollicular accen- tuation can be seen using handheld dermoscopy, but in lesions that do not clinically exhibit criteria for folliculotropism these changes of follicles can be discrete, and we observed that using greater enlargement on the digital dermoscopy device and a nonpolarized camera allows better visualization of the effect on the follicle. Of note, we did not observe accentuation of the follicle in patients with MF without folliculotropism in histopathology. Therefore, we believe this is a very early sign of folliculotropism. This finding is clinically useful and can be used as a marker for choosing the adequate site of biopsy. Therefore, we suggest using dermoscopy to examine all MF lesions, and especially, if possible, we recommend using greater enlarge- ment of the digital dermoscopic device (30×), as it allows for visualization of more discrete changes in the follicle. This is even more important in light of the clinical observation that patients with folliculotropism may not respond as well as oth- Figure 1. (a) Clinical findings: erythematous patch on the right side of a forehead, with site of biopsy. (b) Histopathological findings: irregular psoriasiform hyperplasia of the epidermis with parakera- tosis, heavy lymphocytic infiltrate in the dermis with signs of follicu- lotropism with some mucin deposits (hematoxylin and eosin, ×4). [Copyright: ©2018 Jurakic Toncic et al.] Figure  2. (a,b) Dermoscopic view: perifollicular accentuation seen as a white halo around the follicles. [Copyright: ©2018 Jurakic Ton- cic et al.]