Dermatology: Practical and Conceptual Original article | Dermatol Pract Concept. 2023;13(3):e2023174 1 Dermatoscopy of Cutaneous Lichen Planus – Attempt to Translate Metaphoric Terminology Into Descriptive Terminology Agata Szykut-Badaczewska1, Mariusz Sikora2, Lidia Rudnicka3, Harald Kittler4 1 Department of Dermatology and Venereology, State Hospital Klagenfurt, Klagenfurt am Wörthersee, Austria 2 National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland 3 Department of Dermatology, Medical University of Warsaw, Warsaw, Poland 4 Department of Dermatology, Medical University of Vienna, Vienna, Austria Key words: dermatoscopy, dermoscopy, descriptive terminology, inflammoscopy, lichen planus Citation: Szykut-Badaczewska A, Sikora M, Rudnicka L, Kittler H. Dermatoscopy of Cutaneous Lichen Planus – Attempt to Translate Metaphoric Terminology into Descriptive Terminology. Dermatol Pract Concept. 2023;13(3):e2023174. DOI: https://doi.org/10.5826/dpc.1303a174 Accepted: February 26, 2022; Published: July 2023 Copyright: ©2023 Szykut-Badaczewska 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: HK reports royalties or licenses from Casio, Barco and MetaOptima, speaker honoraria from FotoFinder, and receipt of equipment for testing from FotoFinder, 3Gen, DermaMedicalSystems, Heine and Casio; all outside the submitted work. The other authors have no conflicts of interest to disclose. Authorship: All authors have contributed significantly to this publication. Corresponding author: Agata Szykut-Badaczewska, Department of Dermatology and Venereology, State Hospital Klagenfurt, Klagenfurt am Wörthersee , Austria, Tel. +43 463 538-32603, E-mail: agata.szykut-badaczewska@kabeg.at Introduction: Dermatoscopy is gaining appreciation in assisting the diagnosis of inflammatory dermatoses (inflammoscopy). Lichen planus (LP) is a common inflammatory skin disease with charac- teristic dermatoscopic features. Over the last few years, numerous articles were published on the der- matoscopy of LP and a high number of terms have been used to describe the dermatoscopic features of this disease. Objectives: The objective of this study was to review the literature on the dermatoscopy of LP and to re-evaluate the published descriptions in the light of the 2019 expert consensus on the terminology of dermatoscopy for non-neoplastic skin diseases. Methods: We searched the PubMed database using the keywords ‘lichen planus and dermatoscopy’, ‘lichen planus and dermoscopy’, ‘lichen planus and epiluminescence microscopy’, and ‘lichen planus and inflammoscopy’. ABSTRACT 2 Original article | Dermatol Pract Concept. 2023;13(3):e2023174 Introduction Dermatoscopy is a non-invasive diagnostic technique that is widely used for in vivo examinations of skin lesions. It improves the diagnostic accuracy for pigmented and non-pigmented cutaneous proliferations and enables users to detect criteria that are invisible with the unaided eye. Application of dermatoscopy is straightforward and fast and can be easily incorporated into clinical routine [1-3]. An in- creasing number of publications on alternative applications of dermatoscopy suggests that dermatoscopy is gaining ap- preciation for the diagnosis of non-neoplastic skin diseases, such as inflammatory skin diseases and skin infections and infestations [2-4]. Due to its broader scope, the vocabulary of dermatoscopy expanded significantly over the last few years [2]. Dermatoscopic terms used in the literature are nu- merous and often incomprehensible, which prevents a sys- tematic analytic approach [2-3,5]. In 2019, the International Dermoscopy Society (IDS) published a consensus paper on standardization of dermo- scopic terminology in non-neoplastic dermatoses [5]. A set of the following 5 dermoscopic parameters was proposed as a basic guide to use in general dermatology: (I) vessels (in- cluding morphology and distribution); (II) scales (including colour and distribution); (III) follicular findings; (IV) ‘other structures’ (structures other than vessels/scales; including co- lour and morphology); and (V) ‘specific clues’ (features that, when present, are strongly suggestive of only 1 diagnosis due to a strict dermoscopic-pathological correlation) [3]. Lichen planus (LP) is an inflammatory skin disorder, often with a chronic course [6]. The term LP was coined by Eras- mus Wilson in 1869 [7]. Data on the epidemiology of LP are scarce but it is believed to be common [8]. The disease com- monly affects middle-aged adults, between 30 and 60 years of age. The skin (cutaneous LP) and oral cavity (oral LP) are the most frequently involved areas. Other mucous membranes, including the genitalia (penile or vulvar LP), esophagus, conjunctiva, and skin appendages may also be affected [6,8- 9]. The typical primary lesion of cutaneous LP is a papular eruption characterized by the development of flat-topped, violaceous papules on the skin [6,8]. In 1895, Wickham noted the characteristic reticulate white lines on the surface of LP papules now recognized as Wickham striae [10]. Often, a mnemonic (‘4 P’s’ or ‘5 P’s’) is used  to describe the skin lesions associated with LP, which includes planar, polygonal, pruritic, purple papules or plaques [8,10]. Approximately 50% of patients with active LP may show an isomorphic re- sponse (the development of lesions of LP in sites of trauma, commonly as a result of scratching) [6,8]. The predilection sites of LP include the extensor surfaces of the lower legs and the volar aspect of the wrists and forearms, trunk and the lumbar region [6]. LP is mainly a self-limited dermatosis. The mean duration of the disease is estimated at about 1–2 years but longer and chronically recurrent courses are possible [6]. Lesions tend to heal with significant post-inflammatory hy- perpigmentation especially in individuals with dark skin tone [8]. In addition to the classic variant of cutaneous LP, other multiple clinical presentations of the disease have been described. Combinations of morphological variants are pos- sible in the individual case [6,8]. Examples of variants of LP are given in Table 1 [6,8,11]. In many cases, the diagnosis of cutaneous LP can be made clinically. In doubtful cases a skin biopsy is useful to confirm the diagnosis [8]. Occasionally, direct and indirect methods for immunofluorescence may be helpful in the diagnostic process of LP [6,12]. Objectives The main aims of this study were (1) to retrieve and analyse the dermatoscopy terminology of cutaneous LP and (2) to revaluate the published descriptions in the light of the IDS consensus 2019. Results: Of 408 articles retrieved, we selected 67 articles for full-text review and finally included 58 articles, mostly case reports or small case series, comprising 572 patients with LP. We identified 118 different terms or short descriptions that were used to characterize the dermatoscopy of LP and redescribed them according to International Dermoscopy Society consensus paper. Frequently, au- thors applied various terms or descriptions to variants of the same feature. Although reported under different designations, Wickham striae were the most consistent dermatoscopic feature of LP. Other characteristics of LP, such as vascular patterns, pigmented structures and follicular findings were less consistent or depended on skin type, anatomic site, disease stage and applied treatment. Conclusions: While Wickham striae are the single most important clue for the diagnosis, other derma- toscopic characteristics of LP are less consistent. Based on the descriptions published in the literature we established a dictionary of useful terms for the description of LP that is consistent with the termi- nology suggested by the recent consensus conference. Original article | Dermatol Pract Concept. 2023;13(3):e2023174 3 Methods We conducted a systematic literature review searching the PubMed database according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guide- lines [13]. We searched for relevant articles in English using the keywords ‘lichen planus dermatoscopy’, ‘lichen planus dermoscopy’, ‘lichen planus epiluminescence microscopy’ and ‘lichen planus inflammoscopy’ and identified 401 publi- cations. The titles and abstracts were screened and 51 articles were selected for full-text review. Publications on hair, nail and mucous membrane involvement were excluded. A man- ual search was also carried out by analysing the reference sections of all relevant articles about dermatoscopy of cuta- neous LP. In total, 58 articles were selected for full-text-re- view, including 34 case reports and case series, 9 reviews and overviews, 3 retrospective studies and 12 prospective stud- ies (Figure 1). One of the authors made a list of terms and phrases that were used to describe the dermatoscopy of LP. We excluded phrases and terms that could be understood outside the context of dermatoscopy (e.g. crusting, erosions). The final list consists of 118 terms and phrases (Table 2). Results Wickham striae (WS) are the dermatoscopic hallmark of LP. WS most often appear as white lines but occasionally may be yellow or, rarely, even blue, for example in palmo-plantar le- sions of patients with darker skin tone [3,14]. The most com- mon arrangement of WS is the reticular pattern [14] (Figure 2). Less commonly, WS may not be arranged in a reticular fashion. These variations in the arrangement of WS have been described in the literature as annular, circular, round, arboriform, perpendicular, veil-like, ‘leaf venation’, ‘starry sky’ or structureless, polymorphic and combined [11,14-25]. In scarring or resolving lesions of dermatoses other than LP (e.g. discoid lupus erythematosus, prurigo nodularis), a network-like white structure similar to Wickham striae may be seen. These structures, which result from dermal fibro- sis, are defined as pseudo-Wickham striae [3,11]. Additional features of active LP frequently reported in the literature are peripheral dotted or linear vessels; structureless backgrounds of various colours including violet, reddish, pink, brown or yellow; white or yellow dots, and pigmented structures (dots, globules and/or reticular or cloud-like areas) [14]. Palmar LP is characterized by roundish yellowish areas with peripheral projections that may create a star-like ap- pearance [14], which may correspond to the specific man- ifestation of Wickham striae in palmar skin. Madke et al described black colored patches on the palms for which the term ‘hem-like pattern’ was coined. It corresponds to pig- ment distribution along the ridges [26]. Dermatoscopy of a plantar lichen planus, presented in another article published by Madke et al, showed scaling and a reticular pattern [7] (Figure 3). Dermatoscopy of hypertrophic LP lesions is typified by a rippled surface, comedo-like structures filled with yel- low keratinous plugs, round structures (‘corn pearls’) and blue-gray globules (Figure 4). Less common features include non-specific vascular findings (red globules, linear and dot- ted vessels), white structureless areas, scaling and central hyperpigmentation [14]. WS are often invisible in hypertro- phic LP, as they are covered by the overlying hyperkeratosis [3,22,27]. The main dermatoscopic patterns of LP pigmentosus in- clude a diffuse, structureless, brownish pigmentation, gray, blue or brown dots (‘peppering’) or globules (clods). Other findings such as perifollicular pigmentation and white dots are less common [14,28-29]. In LP pigmentosus WS are typ- ically absent [30]. It is worth mentioning that a special form of lichen planopilaris - frontal fibrosing alopecia - may coex- ist with lichen planus pigmentosus. It was firstly reported by Dlova in 2013 [31-32]. Lichen planus pigmentosus-inversus (LPPI), a rare subvariant of lichen planus pigmentosus, first described by Table 1. Clinical variants of cutaneous lichen planus. Clinical variants Classic LP Hypertrophic LP Annular LP Bullous LP Erythrodermic LP LP pemphigoides Lichen planus-lupus erythematosus overlap syndrome LP actinicus LP pigmentosus LP pigmentosus-inversus Atrophic LP Follicular LP (Lichen planopilaris) LP follicularis decalvans Regressive lichen planus Acute generalized lichen planus Ulcerative LP Linear LP Nail LP Oral LP Genital LP Esophageal LP Otic LP LP = lichen planus. 4 Original article | Dermatol Pract Concept. 2023;13(3):e2023174 but with time, they form reticular, linear, and cobblestone patterns. In some instances of LPPIs more than one pattern can be found dermatoscopically. The white dots described in LPPI result from the lack of pigmentation of the follicular Pock in 2001, is characterized by hyperpigmented macules or plaques located in the intertriginous and flexural areas [8,33]. The dermatoscopy in LPPI is typified by brown structureless areas and gray dots and clods. Initially gray dots are grouped, Figure 1. PRISMA flow diagram of study selection for inclusion in the systematic review. Figure 2. Lichen planus. (A) Clinical image. (B) Dermatoscopy shows classic Wickham striae (white lines in reticular arrangement), keratin plugs that appear as yellow clods and vessels as dots. Scale is also present but this is not a typical feature of lichen planus. Original article | Dermatol Pract Concept. 2023;13(3):e2023174 5 Table 2. Lichen planus metaphoric presented in literature vs. suggested descriptive terminology. Suggested terminology Terms and phrases found in literature References # (where described) Wickham striae (specific clue) White or gray peripheral parallel lines and structureless in the centre peripheral striations with pearly white areas (or milky-white structures at the centre and grayish strands arranged peripherally) 27 White circles and white branched or curved lines annular and arboriform whitish line 37 White reticular lines reticular pearly white areas 35 Blue, gray reticular lines reticular pigmentation with blue-gray WS 35 Branched or curved lines WS: arboriform or arborizing 24 Lines WS: linear 41 Reticular lines WS: reticular 41 Reticular lines network of whitish striae 42 Reticular lines reticular streaks 16 Radial lines white linear streaks arranged in a radial manner (starburst pattern) 43 White reticular lines white crossing lines 36 White reticular lines white crossing streaks 39 Branched lines, connected to a common base at one side, linked together on the other side WS: leaf venation pattern (mimics snow crystal; ‘fern leaf’ aspect) 21 Perpendicular lines WS: perpendicular 11 Reticular lines WS: cross-linked 16 White radial lines WS: white streaming lines 24 Radial lines WS: radial streaming 11 Parallel lines WS: projections, thin spikes (comb-like appearance) 25 Branched or curved thin or thick lines WS: thin or broad arboriform projections, ramifications 25 Yellow reticular or branched lines yellowish structures (in a lacy network), lacy network pattern 37 White straight lines WS: longitudinal pearly-whitish lines 23 Reticular lines lacy reticular striae 7 Parallel lines WS ‘brush-like’ 47 Clods globules WS: globular 16,20,37 Circle WS: round 17,23,41 Circle WS: circular 17,20,24,37 Circle WS: annular 1,15,37 White circles white streaks of annular pattern 24 White circle between brown diffuse dots invisible WS 11 White circles with white lines annular crystalline white striae 15 White structureless zone PWS=pearly white structures 19 Structureless zone WS: structureless 16,43 More than 1 type, undefined WS: combined morphology 11 More than 1 type, undefined WS: polymorphic pearly whitish structure 25 Structureless zone WS: veil-like 16,20 White structureless zone WS: homogeneous pearly-whitish configuration 18 White structureless zone WS: homogeneous crystalline white (striae) 24 Table2 continues 6 Original article | Dermatol Pract Concept. 2023;13(3):e2023174 Suggested terminology Terms and phrases found in literature References # (where described) Lines Pigmented lines linear pigment pattern 11 Reticular lines reticular pigment pattern 11 Brown, blue, gray straight lines brownish to bluish-gray rods 44 Angulated or polygonal lines rhomboidal structures 45 Fragmented angulated lines broken lines, semi-arcuate structures (Chinese letters) 46 Reticular lines lacy reticular pattern 7 Radial lines parallel to white lines pigment streaming lines, pigmented lines streaming around a waned WS 24 Globules and dots Follicular plugs follicular plugging 27 Blue, gray, brown, black globules bluish-gray, brownish-black, brown globules 27,44,45 Blue, gray globules arranged randomly, around white structureless zones blue-gray globules arranged in diffuse structureless pattern interspersed in pearly white areas 37 Brown, yellow or orange (rarely black) globules or simply ‘keratin plugs’ comedo-like openings, comedo-like structures (resembling oil drops) 22,48,49 White globules or dots milia-like cysts 33,48 Pigmented globules pigmented globules, pigment globules 16,24 Pigmented polygonal globules cobblestone pigment pattern 11,12,16 Yellow polygonal globules roundish yellow areas often having peripheral projections (star-like appearance) 14 Globules (rounded, corned structures) round corneal structures ‘corn pearls’ 14 White or black globules comedones 33 Gray, blue, brown globules and dots fine/coarse, gray-blue/brown dots or globules 14 Brown clustered globules and dots mottled pattern 23 Globules and dots located centrally in the lesion ashy holes 23,50 Brown globules, dots brown punctate areas 51 Four white dots, 4-dot globule rosettes 41 White clustered dots and gray dots starry sky, starry sky pattern 14,16,17,21,24 White follicular clustered dots starry sky/white dots 14,16,21,24 Black dots black pepper-like pattern 12 Gray dots peppered pigment, peppering pigment pattern 16,24 Brown diffuse dots peppering, diffuse 52 Gray dots and circles annular-granular pattern 16 Globules and dots arranged in lines hem-like pigment pattern, hem-like pattern 25 Gray, blue dots gray, blue-gray granules 19,53 Gray, brown dots granular gray-brown dots 50,54 Brown dots in the centre of hypopigmented globules targetoid lesion, owl eye appearance 46 Globules and dots arranged in lines that are connected at an angle dots and globules in arcuate pattern 55 Circles Circle pigmentation: follicular 56 Gray, brown, blue circles, or dots arranged in circles, or dots periappendageal, perifollicular, peri-eccrine gray to brown/gray blue pigment deposition 56 Table 2. Lichen planus metaphoric presented in literature vs. suggested descriptive terminology. Original article | Dermatol Pract Concept. 2023;13(3):e2023174 7 Suggested terminology Terms and phrases found in literature References # (where described) Concentric circles hair follicles with central black dots (isobar sign) 52 Incomplete circles areas with gray, blue-gray dots arranged in circles 57 White circles ring-form whitish striae 58,59 Gray, brown, blue circles circular pigment pattern 11 Structureless Polychromatic structureless zone rainbow pattern 41 Brown structureless zone brown patches 48,54 Gray structureless zone gray patches 48 Gray and brown structureless zone mix of gray and brown 48 Brown or gray dots with brown structureless zones mixed pigmented pattern 21,60 White and blue structureless zone blue-white veil 24 White and blue structureless zone homogeneous white-bluish pattern 33 White and blue structureless zone blue and white curtain structure 61 White or yellow structureless zone yellowish or white non-structured pattern 16 Yellow and brown structureless zone yellow-brown pigmentation 61 Brown, gray, blue structureless zone diffuse hyperpigmentation 16 Structureless zone obliteration of the pigmentary network 55 Structureless zone homogeneous cloud like pattern, homogenous cloud like pattern 16 Brown structureless zone diffuse brown background, diffuse brown (brownish) areas, diffuse brown colour, diffuse brownish pigmentation 21,30,56,62 Structureless zone diffuse pigmentation 29,56 Gray, blue structureless zone gray-blue background 47 Brown structureless zone interrupted by follicular openings pseudonetwork, pseudoreticular pigmentary network, pseudoreticular pigment network, pseudoreticular pigmentary network pattern 31,55,56 Blue, gray structureless zone interrupted by follicular openings blue-gray pigmentation around asymmetrically distributed follicular openings 45 Gray structureless zone gray blotch 30 White structureless zone chalk-white structureless areas 14,22 Brown, gray, black structureless zone dark-coloured blotches 63 Red, brown structureless zone brown and erythematous homogeneous areas 12 WS = Wickham striae commonly seen in Middle East, India and east Africa. Sites of involvement include sun-exposed areas [8]. Güngör Ş et al analysed 255 lesions of active and regres- sive LP and found that the course of the disease has an im- pact on the dermatoscopic appearance. WS are less common in acute lichen planus. Furthermore, acute LP is typified by the presence of vascular patterns and the absence of pig- ment patterns [11]. They also found that in regressive LP WS and vascular patterns were absent while pigment patterns were frequently seen. The different variants of pigmentation were described as peripheral dots, diffuse dots, perifollicular -annular pigmenta tion, peripheral peppering, diffuse of annular lichen planus, this variant may occur in other regions as well. Dermatoscopic features of annular lichen planus may include circular WS, structureless zones with different pigmentation, which has been described as ‘cloud- like’, perifollicular-annu lar pigmentation, diffuse reticu lar pigmentation, as well as peripheral red dots on a pink back- ground or erythema, which has been described as homo- geneous vascular pattern [8,11,34]. The dermatoscopic features of another type of LP, LP actinicus, also known as LP tropicus, include diffuse pep- pering pigment pattern on a brown background, without WS or vascular patterns [8,11]. The skin lesions are most 8 Original article | Dermatol Pract Concept. 2023;13(3):e2023174 Annular LP is another rare variant of LP. Typically, the centre of the lesion is atrophic. Friedman and Hashimoto reported that the annular and central atrophy results from elastolytic activity of inflammatory cells. Although the geni- tal and intertriginous areas are common sites of involvement openings. The furrows of the skin (skin markings) are not ex- posed to friction, which could be the reason for the absence of pigmentation in skin furrows in LPPI patients [11,12]. Clinical and dermatoscopic images of LP pigmentosus are shown in Figure 5. Figure 3. Plantar lichen planus. (A) Clinical presentation. (B) Dermatoscopic picture with typical reticular pattern and white scaling. Figure 4. Hypertrophic lichen planus. (A) Clinical (A) and (B) dermatoscopic images showing comedo-like structures filled with yellow keratinous plugs. Figure 5. Lichen planus pigmentosus. (A) Lichen planus pigmentosus in the groin of a patient with dark skin tone, clinical image. (B) Dermatoscopy shows brown dots in different arrangements. Wickham striae are absent. Original article | Dermatol Pract Concept. 2023;13(3):e2023174 9 basic elements lines, circles or ‘structureless’ if absence of basic elements. Due to the distinctiveness of the vocabulary describing vascular structures and limited vocabulary for de- scribing scaling, we have listed terms and phrases describing vessels and scaling in a separate table (Table 3). This paper also demonstrates that the morphology of li- chen planus varies according to skin tone, duration, variants and anatomic site. Clinical and dermatoscopic images of LP in different stages in a patient with dark skin tone are shown in Figure 6. The most consistent dermatoscopic feature of lichen pla- nus are WS. WS correspond to wedge-shaped hypergranu- losis in dermatopathology. They are mainly seen in active lesions of LP and can be regarded as an activation marker of LP. WS may disappear after treatment, whereas pigment patterns resist treatment. In this regard it is important to emphasise the correlation between the dermatoscopic pat- terns and the histological features of LP. Knowledge of histopathology and its correlation with dermatoscopy in- creases the understanding of dermatoscopy and allows a significant level of interpretation of dermatoscopic patterns and clues [40]. Pigment patterns on dermatoscopic examination corre- spond to dermal melanophages and pigment incontinence and are a sign of regressing LP. It comes as no surprise that pigment patterns can be resistant to anti-inflammatory ther- apy (e.g. topical steroids) due to the absence of the inflam- matory cells [11]. Dermatoscopy of LP may be used to assess the likelihood of the persistence of post-inflammatory hyperpigmentation. Struc- tureless light brown areas devoid of dots (granularity) are asso- ciated with a shorter duration and granular pigmentation being associated with a longer course. Furthermore, the dermatoscopy enables monitoring the evolution of lesions after therapy [3]. All those observations indicate the dynamic course of LP and magnify the importance and the advantages of der- matoscopy. It can be helpful not only for the diagnosis but also for treatment decisions and prognosis. A limitation of this paper is that we did not include dermatoscopic fea- tures of non-cutaneous LP (nails, hair, mucosa), which have their own descriptions. According to the level of evidence majority of works are level 4 (case series, low-quality co- hort or case-control studies) or 5 (expert opinions based on non-systematic reviews of results or mechanistic studies). The intent of this critical paper is not to discourage researchers from making new observations and describing them in their own words. On the contrary, we want to support researchers by giving them a framework in which their astute observa- tions can be described in a meaningful and repeatable way so that others can benefit maximally from their findings. It should be noted that in many cases of LP the diagnosis can be established easily with the unaided eye. However, if peppering, linear pig mentation, cobblestone pigmentation, reticu lar pigmentation, circular pigmentation, peripheral homogeneous cloud-like pigmentation, and diffuse homo- geneous cloud-like pigmentation. Furthermore, brown and yellow background colours were also observed [11]. Conclusions The increased use of dermatoscopy for inflammatory skin diseases resulted in an expansion of publications which caused the dermatoscopic vocabulary to grow substantially. LP is a particularly interesting example because it is equally common among all ethnic groups and has a variable course. The dermatoscopic features of LP vary significantly depend- ing on skin tone, course, variant, and anatomic site. These idiosyncratic features of LP led researchers to use different terms for the same structures, which is confusing and dimin- ishes the comparability between studies. Natural language is expansive in nature and constantly creates new terms and phrases, but this may not be desirable in science. Technical languages in- and outside of medicine typically limit their vo- cabulary to a few, well defined standard terms. The same ap- proach is recommended in dermatoscopy. The standardized terminology and standardized description suggested in the two consensus papers on dermatoscopic terminology [2,5] will prevent the undesirable growth of terms. The first main idea is to narrow down descriptions of dermatoscopic struc- tures to 3 basic elements: ‘lines’, ‘dots or clods’ and ‘circles’. If none of these basic elements is present, the term ‘structure- less’ can be applied [2]. This approach is sufficient to describe even complex dermatoscopic structures [2]. The second idea is to use a standardized way to describe non-neoplastic le- sions including vessels, scales, follicular findings, other struc- tures and specific clues as put forward by Errichetti et al [5]. Many articles included in this paper were published before the consensus on dermatoscopic terminology for non-neoplastic skin diseases. Lack of guidelines resulted it in a wild growth of terminology for a single disease. We were able to identify 118 terms and phrases for LP. This is clearly too much. Some terms and phrases describe the same struc- tures in different words, for example ‘white crossing lines’, ‘cross-linked WS’, ‘white crossing streaks’, ‘reticular pearly white areas’ [2,16,35-39]. These abundant number of terms for basically the same structure have no additional value and it is better to use just one term, either reticular white lines or simply Wickham striae – a specific clue [2]. The largest numbers of terms and phrases used for der- matoscopic features of LP were those addressing manifesta- tions of patterns formed by Wickham striae and clods and dots. We have summarized the terms found in the literature in Table 2. Here, we also tried to translate the remaining terms or phrases into a standardized terminology using the 10 Original article | Dermatol Pract Concept. 2023;13(3):e2023174 Table 3. Lichen planus metaphoris presented in literature vs. suggested descriptive terminology (scaling and vessels). Descriptive terminology Metaphoric terminology References # (where mentioned) Scaling White scale chalk-like scale 22,27 White scale white scales; distribution: diffuse, patchy, peripheral 20,39,48,56 White scale with a central distribution whitish scaly plaques 17 White scale overlying white scales 24 White reticular scaly lines a lacy network of white scales 7 Yellow scale yellowish scales 36,39,43 VESSELS Red structureless zone peripheral homogen vascular pattern 11 Clustered vessels pattern of vessels: patchy, peripheral; patchy vessels 39, 48 Pink structureless zone or simply erythema light red background 47 Figure 6. Lichen planus in different stages. (A) Lichen planus in a patient with dark skin tone, clinical image (A). (B) Dermatoscopy shows prominent white lines (Wickham striae) and keratin plugs that appear as yellow clods. The flat pigmented lesions are older lesions with pigmented dots, circles, lines and dots ranged in circles. 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