Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 1 Dermoscopic Characteristics of Cutaneous Lupus Erythematosus According to Subtype, Lesion Location, Lesion Duration, and CLASI Score Yıldız Gürsel Ürün1, Mustafa Ürün1, Mehmet Şerif Danişman1 1 Departments of Dermatology and Venereology, Faculty of Medicine, Trakya University, Edirne, Turkey Key words: discoid lupus erythematosus, dermoscopy, lupus erythematosus tumidus, cutaneous lupus erythematosus disease area and severity index Citation: Gürsel Ürün Y, Ürün M, Danişman MS. Dermoscopic Characteristics of Cutaneous Lupus Erythematosus According to Subtype, Lesion Location, Lesion Duration, and CLASI Score. Dermatol Pract Concept. 2024;14(1):e2024040. DOI: https://doi.org/10.5826 /dpc.1401a40 Accepted: June 9, 2023; Published: January 2024 Copyright: ©2024 Gürsel Ürün 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: Dr. Yıldız Gürsel Ürün, Department of Dermatology and Venereology, Faculty of Medicine, Trakya University, Edirne/Turkey. Tel: +90 284 235 7641 / +90 505 537 30 63 Email: yildizgurselurun@trakya.edu.tr Introduction: Dermoscopic findings are used to diagnose and evaluate disease activity in patients with cutaneous lupus erythematosus (CLE). Objectives: This study aimed to characterize the dermoscopic features of discoid LE (DLE) and LE tumidus (LET) by lesion duration and CLE Disease Area and Severity Index (CLASI) scores and to examine the dermoscopic findings of lesions in different locations in DLE patients. Methods: Dermoscopic findings (follicular features, perifollicular surface, interfollicular features, and vessel pattern) were assessed and lesion duration (≤12 and >12 months) and CLASI scores (grouped as mild or moderate) were calculated. DLE lesion locations were categorized as, non-scalp, scalp and lip. Results: Forty-eight dermoscopic images from 35 DLE and 4 LET patients were analyzed. The most common dermoscopic findings in non-scalp DLE were follicular keratotic plugs (82.8%) and white scales (69%). In scalp DLE (n=9), the most common findings were absent follicular openings (77.8%), white structureless areas (77.8%), and perifollicular scaling (66.7%). All LET patients had pink-white background and linear vessels. Follicular plugs, peripheral pigmentation, and polymorphous vessels were lower in patients with mild CLASI activity than moderate activity (P = 0.036, 0.039, and 0.019, respectively). Fibrotic white dots, honeycomb pigment pattern, and blue-gray dots/globules were lower in those with mild CLASI damage scores than moderate damage (P = 0.010, 0.010, and 0.020, respec- tively). Peripheral pigmentation was more common in patients with lesion duration ≤12 months, while blue-gray dots/globules were more common with lesion durations >12 months. Conclusions: Certain dermoscopic features may facilitate the differential diagnosis of DLE and LET. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 Introduction Discoid lupus erythematosus (DLE) is the most common type of cutaneous lupus erythematosus (CLE) [1]. DLE is defined as a subtype of chronic CLE (CCLE) and is cate- gorized as one of the specific skin manifestations of lupus erythematosus [2,3]. Lupus erythematosus tumidus (LET), the most photosensitive type of lupus erythematosus, was recently classified separately as intermittent CLE (ICLE) [4]. DLE heals with scarring and dyspigmentation, and se- vere inflammatory DLE impacts patients’ quality of life [5-7]. The differential diagnosis of DLE includes many dis- eases, and early treatment leads to complete clearance of active lesions [8,9]. For patients with CLE, using the CLE Disease Area and Severity Index (CLASI) is recommended at baseline, while monitoring treatment response, and in the as- sessment of the disease impact on quality of life [7,8]. CLASI is used in most CLE patients, with the exception of a few rare subtypes [10]. Dermoscopy of inflammatory dermatoses, also known as inflammascopy, has become an important tool not only for diagnosis but also for evaluating disease activity [11]. Au- thors recommend using dermoscopic findings from inflam- mascopy examination along with a patient’s history, clinical picture, and macroscopic features [12]. In this respect, it is important to know the dermoscopic characteristics in differ- ent locations. Objectives This study aimed to evaluate the dermoscopic findings of patients with DLE and LET and summarize the dermoscopic features of DLE lesions in various anatomical locations. We also aimed to evaluate differences in the dermoscopic find- ings of patients with CLE according to lesion duration and CLASI scores. Thus, having more detailed knowledge of der- moscopic findings will guide clinicians in the diagnosis and follow-up of patients with DLE and LET. Methods This study was planned as a retrospective cohort study in- cluding patients diagnosed with DLE and LET who pre- sented to the Skin and Venereal Diseases outpatient clinic of Trakya University between 2018 and 2022. Approval was obtained from the Trakya University Faculty of Medicine Ethics Committee (2023/69). Patients diagnosed with DLE or LET whose medical re- cords contained complete clinical, histopathological, and di- rect immunofluorescence data were included in the study. The patients sociodemographic and clinical characteristics (age, sex, tobacco and alcohol use, family history, CLE subtype, age at onset, duration and location of lesions, Fitzpatrick skin type, topical and systemic treatments received, and an- tinuclear antibody [ANA] positivity) were retrospectively screened by an independent dermatologist (MŞD). Exclusion criteria were: 1) age younger than 18 years, 2) lack of de- finitive diagnosis, 3) diagnosis of overlap syndrome/mixed connective tissue disease, and 4) receiving topical and/or sys- temic treatment in the last 3 months [13,14]. Cutaneous Lupus Erythematosus Disease Area and Sever- ity Index Activity (CLASI-A) and CLASI Damage (CLASI-D) scores were calculated at initial presentation by a different der- matologist (MÜ). Clinical and dermoscopic lesion locations were determined according to the CLASI classification [15]. CLASI-A scores were grouped into disease activity levels of mild (0-9), moderate (10-20), and severe (21-70) as recom- mended by Klein et al [16]. CLASI-D scores were grouped into disease severity levels of mild (0-5), moderate (6-16), and severe (≥17) [17]. Dermoscopic images were divided into three regions (non-scalp, scalp, and lip [cutaneous and/or mucosal]) by an independent dermatologist (MÜ). Lesions on the rest of the face, ears, back, nose, chest, arms were included in the non- scalp category [18]. CLASI-A and D scores were calculated separately for each location (non-scalp, scalp, and lip). All dermoscopic findings were evaluated at 20X mag- nification with a video dermoscope (FotoFinder Systems GmbH) by the same dermatologist (YGÜ), who was blinded to the patients macroscopic photographs and lesion loca- tions. Both “dry” (without immersion fluid) and “wet” (with ultrasound gel) dermoscopy was performed. During the pro- cedures, minimal pressure was applied for better visualiza- tion of blood vessels. Using a review by Zychowska et al. as a reference, der- moscopic images were examined under four main headings: : 1) follicular features (Figure 1A-I), 2) interfollicular features (Figure 2A-F, Figure 3A-D), 3) perifollicular surface (Figure 4A-D), and 4) vessel pattern (Figure 5A-E) [18]. In this study, the appearance of arborizing vessels was described as similar to the dermoscopic appearance of vessels in basal cell carci- noma but thicker and irregular. The study by Lallas et al was used for the description of thin and linear vessels (with and without bends or branches) [19]. The vessel patterns in our study were evaluated as recommended by Lallas et al. The standardized dermoscopic terms for non-neoplastic derma- toses published by Errichetti et al were used to describe the dermoscopic images [20]. Statistical Analysis The data were analyzed using SPSS (Statistical Package for Social Sciences) version 18.0. In descriptive analyses, fre- quency data were expressed as number (N) and percentage (%), and numerical data were presented as mean, standard Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 3 deviation (SD), and range (minimum-maximum). The dis- tribution of categorical data was analyzed using the Fisher exact test. Level of statistical significance was accepted as p<0.05 for all tests. Results Demographic and Clinical Characteristics A total of 39 CLE patients with 48 dermoscopic images were included in the study. The mean age of the patients was 43.95 ± 12.61 years and 71.8% (N = 28) were women. CLE type was DLE in 35 patients (89.7%) and LET in 4 patients (10.3%). Most CLE lesions were located on the rest of the face (58.9%) and on the scalp (23%). Lip location was most fre- quently associated with lesions on the rest of the face (N = 4); isolated lip location was observed in only one patient. In the LET group, dermoscopic images were obtained from the back in 3 patients and the chest in 1 patient. Thirty (76.9%) of the patients received topical corticosteroids and 36 (92.3%) received hydroxychloroquine therapy (Table S1). Distribution of Dermoscopic Images The dermoscopic images were most commonly from the rest of the face (45.8%, N = 22 images), scalp (18.7%, N = 9 images), lips (12.5%, N = 6 images), and ears (8.3%, N = 4 images) (Table S2). CLASI Scores The mean CLASI-A score was 5.23 ± 3.44 and the mean CLASI-D score was 2.52 ± 2.83 (Table S1). Dermoscopic Findings The most common dermoscopic findings in DLE patients were white structureless areas (70.5% of images), follicular plugs (65.9%), white scales (63.6%), pink-white background (56.8%), and linear vessels (50%). In patients with LET, the most common dermoscopic findings were pink-white background (100%) and linear vessels (100%). Among DLE patients with scalp location, the most common dermo- scopic findings were absence of follicular openings (77.8%) white structureless areas (77.8%), and perifollicular scaling (66.7%). The most common vessel patterns observed in all pa- tients were linear vessels (54.2%, N = 26 of images) and dotted vessels (33.7%, N = 18 of images). Follicular plugs were observed in 69.6% (N = 32) of all lesions but were not detected in any of the lesions involving the lips. White struc- tureless areas and hairpin vessels were present in all lesions involving the lips and were less frequent in the other groups. Perifollicular scaling and perifollicular pigmentation were not detected in any of the lesions involving the lips but were observed at high rates in the other groups (Table 1). Distributions of dermoscopic features according to lesion locations in patients with DLE are compared in Table 2. Pa- tients with scalp DLE had significantly higher rates of absence of follicular openings and perifollicular scaling compared to patients with non-scalp DLE (P values <0.001 and 0.009, respectively). Dermoscopic images with follicular plugs (P < 0.001) and perifollicular white color (P = 0.027) were statistically less common in DLE patients with lip location than in patients with non-scalp location. In the lip location group, yellow (scales and crusts) (P = 0.016) and hairpin vessels (P < 0.001) were more common while dotted vessels (P =  0.022) and linear vessels (P = 0.019) were less com- mon compared to patients with non-scalp location ( Table 2). When grouped and compared according to CLASI-A scores, patients with mild disease activity had significantly lower rates of follicular plugs, peripheral pigmentation, and poly- morphous vessels compared to those with moderate disease activity (P values 0.036, 0.039, and 0.019, respectively). There was no statistical difference in the distribution of other dermoscopic features between the mild and moderate activity groups (P > 0.05) (Table 3). When grouped and compared according to CLASI-D scores, rates of fibrotic white dots, honeycomb pigment pat- tern, and blue-gray dots/globules were found to be signifi- cantly lower in patients with mild disease severity compared to those with moderate disease severity (P values 0.010, 0.010, and 0.020, respectively). There was no statistical dif- ference in the distribution of other dermoscopic features be- tween the disease severity groups (P > 0.05) (Table 4). When differences in the dermoscopic findings of pa- tients with CLE were evaluated according to lesion duration (≤12 versus. >12 months), we observed that blue-gray dots/ globules, and dotted vessels were more common dermoscopic findings in patients with lesion duration over 12 months (P values 0.018 and 0.021, respectively) (Table 5). Conclusions The sociodemographic characteristics of our study sample (age, sex, age at onset) were similar to those in other studies [7]. Fredeau et al reported that 73% of patients had a Fitzpatrick skin type between I and IV [21]. In our study, Fitzpatrick skin types ranged from II to IV. Although it is known that the in- cidence of LE is higher in Asian and black ethnic groups than in whites, ethnic background was not evaluated in our study. Insawang et al reported that the most common lesion lo- cations in patients with DLE were the face and scalp [22]. Between 25% and 90% of patients with DLE are photosen- sitive, and apoptosis and other immunological mechanisms induced by UV light lead to more frequent manifestations of 4 Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 perifollicular white color, and white scales [18,19,24]. Our dermoscopic findings are similar to those of other studies. Lallas et al reported that telangiectasias were the most common vessel pattern in DLE [19]. In another study, the most the disease in sun-exposed areas [23]. Our findings in this study are consistent with this. The most common dermoscopic findings in DLE pa- tients with non-scalp lesion locations are follicular plugs, Table 1. Dermoscopic characteristics in all patients and according to disease subtype and lesion locations. Dermoscopic features All (N = 48) DLEa (N = 44) LET (N = 4) Scalp DLE (N = 9) Lips DLE (N = 6) Follicular features, N (%) Follicular plugs 30 (62.5) 29 (65.9) 1 (25.0) 5 (55.6) 0 (0.0) Absence of follicular openings 9 (18.8) 9 (20.5) 0 (0.0) 7 (77.8) 0 (0.0) Reduced number of follicular openings 3 (6.3) 3 (6.8) 0 (0.0) 0 (0.0) 0 (0.0) Fibrotic white dots 8 (16.7) 8 (18.2) 0 (0.0) 4 (44.4) 0 (0.0) Pinpoint white dots 6 (12.5) 6 (13.6) 0 (0.0) 0 (0.0) 0 (0.0) Follicular red dots 5 (10.4) 5 (11.3) 0 (0.0) 3 (33.3) 0 (0.0) Yellow dots 2 (4.2) 2 (4.5) 0 (0.0) 0 (0.0) 0 (0.0) Black dots 4 (8.3) 4 (9.1) 0 (0.0) 2 (22.2) 0 (0.0) Red spider on a yellow dot 1 (2.1) 0 (0.0) 1 (25.0) 0 (0.0) 0 (0.0) Dilated follicles 3 (6.3) 3 (6.8) 0 (0.0) 1 (11.1) 0 (0.0) Perifollicular surface, N (%) Perifollicular white color 19 (39.6) 19 (43.2) 0 (0.0) 4 (44.4) 0 (0.0) Perifollicular scaling 13 (27.1) 11 (25.0) 0 (0.0) 6 (66.7) 0 (0.0) Perifollicular erythema 3 (6.3) 3 (6.8) 0 (0.0) 0 (0.0) 0 (0.0) Perifollicular pigmentation 13 (27.1) 13 (29.6) 0 (0.0) 3 (33.3) 0 (0.0) Interfollicular features, N (%) White structureless areas 32 (66.7) 31 (70.5) 1 (25.0) 7 (77.8) 6 (100.0) Pink-white background 29 (60.4) 25 (56.8) 4 (100.0) 2 (22.2) 4 (66.7) Speckled brown pigmentation 14 (29.2) 14 (31.8) 0 (0.0) 2 (22.2) 0 (0.0) Honeycomb pigment pattern 3 (6.3) 3 (6.8) 0 (0.0) 1 (11.1) 0 (0.0) Peripheral pigmentation 11 (22.9) 11 (25.0) 0 (0.0) 1 (11.1) 0 (0.0) White scales 30 (62.5) 28 (63.6) 2 (50.0) 3 (33.3) 5 (83.3) Yellow (scales and crusts) 10 (20.8) 10 (22.7) 0 (0.0) 3 (33.3) 4 (66.7) White rosettes 7 (14.6) 7 (15.9) 0 (0.0) 1 (11.1) 1 (16.7) Shiny white lines 9 (18.8) 8 (18.2) 1 (25.0) 0 (0.0) 3 (50.0) Blue-gray dots/globules 9 (18.8) 9 (20.5) 0 (0.0) 0 (0.0) 0 (0.0) Blue-white veil 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Erosions/ulcerations 10 (20.8) 10 (22.7) 0 (0.0) 2 (22.2) 3 (50.0) Vessel pattern, N (%) Thick arborizing vessels 9 (18.8) 9 (20.5) 0 (0.0) 4 (44.4) 0 (0.0) Dotted vessels 18 (33.7) 16 (36.3) 2 (50.0) 0 (0.0) 0 (0.0) Hairpin vessels 8 (16.7) 8 (18.2) 0 (0.0) 0 (0.0) 6 (100.0) Linear vessels 26 (54.2) 22 (50.0) 4 (100.0) 5 (55.6) 0 (0.0) Coiled vessels 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) Polymorphous vessels 2 (4.2) 2 (4.5) 0 (0.0) 0 (0.0) 0 (0.0) DLE = Discoid lupus erythematosus; LET = Lupus erythematosus tumidus. a The DLE category includes dermoscopic images obtained from patients clinically and histopathologically diagnosed with DLE who presented with non-scalp (rest of the face, ears, back, nose, chest, arms), scalp, and lip location. Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 5 openings, and perifollicular scaling [18,33] The prevalence of these findings was significantly higher for patients with scalp lesion locations compared to patients with non-scalp lesion locations [18]. Our findings are consistent with the lit- erature. Absent follicular openings and perifollicular scaling in particular should be kept in mind as important dermo- scopic findings in DLE scalp location. common vessel pattern in patients with DLE was reported to be polymorphous, linear and linear curved vessels [25]. Thus, considering the literature and our study, linear vessels are more common in DLE with non-scalp lesion locations [18,24,26,27]. The most common dermoscopic findings in scalp DLE include white structureless areas, absence of follicular Table 2. Comparison of dermoscopic findings according to non-scalp, scalp and lip location in patients with discoid lupus erythematosus (N = 35 patients, 44 images). Dermoscopic features DLE DLE Non-scalpa (N = 29) Scalp (N = 9) P valueb Non-scalpa (N = 29) Lip (N = 6) P valueb Follicular features, N (%) Follicular plugs 24 (82.8) 5 (55.6) 0.174 24 (82.8) 0 (0) ˂0.001 Absence of follicular openings 2 (6.9) 7 (77.8) ˂0.001 2 (6.9) 0 (0) 1.000 Reduced number of follicular openings 3 (10.3) 0 (0) 1.000 3 (10.3) 0 (0) 1.000 Fibrotic white dots 4 (13.8) 4 (44.4) 0.071 4 (13.8) 0 (0) 1.000 Pinpoint white dots 6 (20.7) 0 (0) 0.303 6 (20.7) 0 (0) 0.561 Follicular red dots 2 (6.9) 3 (33.3) 0.075 2 (6.9) 0 (0) 1.000 Yellow dots 1 (3.4) 0 (0) 1.000 1 (3.4) 1 (16.7) 0.318 Black dots 2 (6.9) 2 (22.2) 0.233 2 (6.9) 0 (0) 1.000 Dilated follicles 2 (6.9) 1 (11.1) 1.000 2 (6.9) 0 (0) 1.000 Perifollicular surface, N (%) Perifollicular white color 15 (51.7) 4 (44.4) 1.000 15 (51.7) 0 (0) 0.027 Perifollicular scaling 5 (17.2) 6 (66.7) 0.009 5 (17.2) 0 (0) 0.561 Perifollicular erythema 3 (10.3) 0 (0) 1.000 3 (10.3) 0 (0) 1.000 Perifollicular pigmentation 10 (34.5) 3 (33.3) 1.000 10 (34.5) 0 (0) 0.152 Interfollicular features, N (%) White structureless areas 18 (62.1) 7 (77.8) 0.456 18 (62.1) 6 (100.0) 0.146 Pink-white background 19 (65.5) 2 (22.2) 0.051 19 (65.5) 4 (66.7) 1.000 Speckled brown pigmentation 12 (41.4) 2 (22.2) 0.438 12 (41.4) 0 (0) 0.074 Honeycomb pigment pattern 2 (6.9) 1 (11.1) 1.000 2 (6.9) 0 (0) 1.000 Peripheral pigmentation 10 (34.5) 1 (11.1) 0.237 10 (34.5) 0 (0) 0.152 White scales 20 (69) 3 (33.3) 0.115 20 (69) 5 (83.3) 0.649 Yellow (scales and crusts) 4 (13.8) 3 (33.3) 0.322 4 (13.8) 4(66.7) 0.016 White rosettes 5 (17.2) 1 (11.1) 1.000 5 (17.2) 1 (16.7) 1.000 Shiny white lines 6 (20.7) 0 (0) 0.303 6 (20.7) 3 (50.0) 0.602 Blue-gray dots/globules 9 (31) 0 (0) 0.082 9 (31) 0 (0) 0.304 Erosions/ulcerations 6 (20.7) 2 (22.2) 1.000 6 (20.7) 3 (50.0) 0.602 Vessel pattern, N (%) Thick arborizing vessels 6 (20.7) 3 (33.3) 0.655 7 (24.1) 0 (0) 0.311 Dotted vessels 16 (55.2) 0 (0) 0.005 16 (55.2) 0 (0) 0.022 Hairpin vessels 3 (10.3) 0 (0) 1.000 3 (10.3) 6 (100.0) 0.001 Linear vessels 17 (58.6) 5 (55.6) 1.000 17 (58.6) 0 (0) 0.019 Polymorphous vessels 2 (6.9) 0 (0) 1.000 2 (6.9) 0 (0) 1.000 DLE= Discoid lupus erythematosus. a Dermoscopic images of the rest of the face, ears, nose, chest, back, and arms were included in the non-scalp group. b Fisher exact test. 6 Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 Table 3. Dermoscopic characteristics according to CLASI activity score groups. Dermoscopic features CLASI activity score Mild (N = 41) Moderate (N = 7) P valuea Follicular features, N (%) Follicular plugs 26 (56.1) 7 (100.0) 0.036 Absence of follicular openings 8 (19.5) 1 (14.3) 1.000 Reduced number of follicular openings 3 (7.3) 0 (0.0) 1.000 Fibrotic white dots 7 (17.1) 1 (14.3) 1.000 Pinpoint white dots 5 (12.2) 1 (14.3) 1.000 Follicular red dots 3 (7.3) 2 (28.6) 0.148 Yellow dots 2 (4.9) 0 (0.0) 1.000 Black dots 4 (9.8) 0 (0.0) 1.000 Red spider on a yellow dot 1 (2.4) 0 (0.0) 1.000 Dilated follicles 2 (4.9) 1 (14.3) 0.384 Perifollicular surface, N (%) Perifollicular white color 14 (34.1) 5 (71.4) 0.097 Perifollicular scaling 11 (26.8) 2 (28.6) 1.000 Perifollicular erythema 2 (4.9) 1 (14.3) 0.384 Perifollicular pigmentation 10 (24.4) 3 (42.9) 0.370 Interfollicular features, N (%) White structureless areas 26 (63.4) 6 (85.7) 0.398 Pink-white background 23 (56.1) 6 (85.7) 0.219 Speckled brown pigmentation 11 (26.8) 3 (42.9) 0.400 Honeycomb pigment pattern 1 (2.4) 2 (28.6) 0.052 Peripheral pigmentation 7 (17.1) 4 (57.1) 0.039 White scales 25 (61.0) 5 (71.4) 0.696 Yellow (scales and crusts) 7 (17.1) 3 (42.9) 0.147 White rosettes 6 (14.6) 1 (14.3) 1.000 Shiny white lines 7 (17.1) 2 (28.6) 0.601 Blue-gray dots/globules 6 (14.6) 3 (42.9) 0.111 Erosions/ulcerations 10 (24.4) 0 (0.0) 0.318 Vessel pattern, N (%) Thick Arborizing vessels 7 (17.1) 2 (28.6) 0.601 Dotted vessels 16 (39.0) 4 (57.1) 0.429 Hairpin vessels 6 (14.6) 2 (28.6) 0.330 Linear vessels 22 (53.7) 4 (57.1) 1.000 Polymorphous vessels 0 (0.0) 2 (28.6) 0.019 CLASI = Cutaneous Lupus Erythematosus Disease Area and Severity Index. aFisher exact test Distinguishing between scalp DLE and lichen planopi- laris can be difficult in clinical practice [32]. According to Shim et al., the main criterion distinguishing DLE is the presence of follicular plugs [35]. In our study, the prevalence of follicular plugs was 55.6%, similar to the literature. Al- though the dermoscopic finding of follicular plugs is not as common in scalp DLE as in non-scalp DLE patients, it is highly diagnostic [33]. The term “thick arborizing vessels” is used more often when evaluating dermoscopic findings in DLE patients with scalp location [27-30]. Gomez-Quispe et al. suggested that the term “thick vessels” should be evaluated relative to the thick- ness of the hair shaft [31]. The second most common vessel pattern in scalp DLE patients in our study was “thick arboriz- ing vessels”. However, we did not evaluate the vessels relative to the thickness of the hair shaft. It is clear that there is still a Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 7 Table 4. Dermoscopic characteristics according to CLASI damage score groups. Dermoscopic features CLASI damage score Mild (N = 37) Moderate (N = 11) P valuea Follicular features, N (%) Follicular plugs 21 (56.8) 9 (81.8) 0.171 Absence of follicular openings 5 (13.5) 4 (36.4) 0.180 Reduced number of follicular openings 1 (2.7) 2 (18.2) 0.127 Fibrotic white dots 3 (8.1) 5 (45.5) 0.010 Pinpoint white dots 4 (10.8) 2 (18.2) 0.609 Follicular red dots 2 (5.4) 3 (27.3) 0.072 Yellow dots 2 (5.4) 0 (0.0) 1.000 Black dots 3 (8.1) 1 (9.1) 1.000 Red spider on a yellow dot 1 (2.7) 0 (0.0) 1.000 Dilated follicles 2 (5.4) 1 (9.1) 0.551 Perifollicular surface; N (%) Perifollicular white color 13 (35.1) 6 (54.5) 0.304 Perifollicular scaling 10 (27.0) 3 (27.3) 1.000 Perifollicular erythema 2 (5.4) 1 (9.1) 0.551 Perifollicular pigmentation 9 (24.3) 4 (36.4) 0.458 Interfollicular features, N (%) White structureless areas 22 (59.5) 10 (90.9) 0.073 Pink-white background 24 (64.9) 5 (45.5) 0.304 Speckled brown pigmentation 10 (27.0) 4 (36.4) 0.708 Honeycomb pigment pattern 0 (0.0) 3 (27.3) 0.010 Peripheral pigmentation 9 (24.3) 2 (18.2) 1.000 White scales 23 (62.2) 7 (63.6) 1.000 Yellow (scales and crusts) 7 (18.9) 3 (27.3) 0.675 White rosettes 5 (13.5) 2 (18.2) 0.653 Shiny white lines 7 (18.9) 2 (18.2) 1.000 Blue-gray dots/globules 4 (10.8) 5 (45.5) 0.020 Erosions/ulcerations 7 (18.9) 3 (27.3) 0.675 Vessel pattern, N (%) Thick Arborizing vessels 6 (16.2) 3 (27.3) 0.409 Dotted vessels 14 (37.8) 6 (54.5) 0.488 Hairpin vessels 7 (18.9) 1 (9.1) 0.661 Linear vessels 20 (54.1) 6 (54.5) 1.000 Polymorphous vessels 1 (2.7) 1 (9.1) 0.410 CLASI = Cutaneous Lupus Erythematosus Disease Area and Severity Index. aFisher exact test lack of standardization for dermoscopic terms used to describe vessel patterns, and further studies on this subject are needed. The dermoscopic appearance of “white perifollicular color” has rarely been reported in DLE patients with scalp location [28,36]. Golińska et al emphasized that this dermo- scopic finding had 100% specificity for DLE with scalp lo- cation [32]. In our study, it was observed in 44.4% of scalp lesions. This dermoscopic finding demonstrates perifollicular fibrosis and although it can be seen in both scalp and non- scalp location, it aids in the diagnosis of scalp DLE. In our study, the second most common vessel pattern observed in patients with non-scalp DLE was observed to be “dotted vessels.” Non-follicular red dots are considered “dotted vessels” [18]. The dotted vessel pattern is mostly seen in subacute cutaneous lupus (SCLE) [25]. While it has been reported that the dotted vessel pattern in DLE is mostly 8 Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 dermoscopic findings were pink-red background and linear vessels, while follicular plugs were relatively less common [13]. Similar dermoscopic findings were also observed in our study. Due to the clinical course and good prognosis of LET, it is important to differentiate it from classical DLE [36]. Larger studies including the dermoscopic findings of LET are warranted. It was previously reported that the dermoscopic findings of scalp DLE included “arborizing vessels overlying large observed in scalp DLE [18], it was found more frequently in non-scalp DLE in our study and a study by Ankad et al [34]. When defining dermoscopic red dot structures, follicular and non-follicular placement should be considered. In ad- dition, as dotted vessels can often be seen in inflammatory dermatoses, the clinician should look for specific clues for diagnosis [35]. Few studies have examined the dermoscopic findings of LET. Zychowska et al reported that the most common Table 5. Analysis of differences in dermoscopic findings according to lesion duration in patients with cutaneous lupus erythematosus. Dermoscopic features Lesion duration Pa12 ≤ months 12 > months Follicular features, N (%) Follicular keratotic plugs 9 (50) 21 (70) 0.166 Absence of follicular openings 1 (5.6) 8 (26.7) 0.125 Reduced number of follicular openings 0 (0) 3 (10) 0.282 Fibrotic white dots 1 (5.6) 7 (23.3) 0.229 Pinpoint white dots 1 (5.6) 5 (16.7) 0.388 Follicular red dots 1 (5.6) 4 (13.3) 0.637 Yellow dots 2 (11.1) 0 (0) 0.136 Black dots 2 (11.1) 2 (6.7) 0.624 Dilated follicles 1 (5.6) 2 (6.7) 1.000 Perifollicular surface, N (%) Perifollicular white color 8 (44.4) 11 (36.7) 0.594 Perifollicular scaling 3 (16.7) 10 (33.3) 0.317 Perifollicular erythema 2 (11.1) 1 (3.3) 0.547 Perifollicular pigmentation 11 (42.3) 2 (6.7) 0.032 Interfollicular features, N (%) White structureless areas 10 (55.6) 22 (73.3) 0.206 Pink-white background 12 (66.7) 17 (56.7) 0.493 Speckled brown pigmentation 4 (22.2) 10 (33.3) 0.412 Honeycomb pigment pattern 1 (5.6) 2 (6.7) 1.000 Peripheral pigmentation 4 (22.2) 7 (23.3) 1.000 White scales 13 (72.2) 17 (56.7) 0.281 Yellow (scales and crusts) 4 (22.2) 6 (20) 1.000 White rosettes 3 (16.7) 4 (13.3) 1.000 Shiny white lines 4 (22.2) 5 (16.7) 0.711 Blue-gray dots/globules 0 (0.0) 9 (30.0) 0.018 Erosions/ulcerations 3 (16.7) 7 (23.3) 0.722 Vessel pattern, N (%) Thick Arborizing vessels 3 (16.7) 6 (20) 1.000 Dotted vessels 3 (16.7) 15 (50) 0.021 Hairpin vessels 5 (27.8) 3 (10) 0.132 Linear vessels 7 (38.9) 19 (63.3) 0.100 Polymorphous vessels 2 (11.1) 0 (0) 0.136 a Pearson Chi-Square, Fisher Exact test. Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 9 Figure 1. Dermoscopic presentation of follicular features. (A) Follicular plugs. (B) Absence of follicular openings. (C) Reduced number of follicular openings. (D) Fibrotic white dots. (E) Follicular red dots. (F) Yellow dots. (G) Black dots. (H) Dilated follicles. Figure 2. Dermoscopic features of interfollicular features-part I. (A) White structureless areas. (B) Pink-white background (black arrow) and peripheral pigmentation (w hite arrow). (C) Speckled brown pigmentation. (D) Honeycomb pigment pattern. (E) White scales. (F) Yellow scales and crusts. 10 Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 The dermoscopic appearance of “white perifollicular color” has rarely been reported in DLE patients with scalp location [29,39]. The clinical presentation of DLE with lip location can be confused with premalignant lesions such as actinic cheilitis and lip location of inflammatory skin dis- eases. Yellow scales and crust formations are among the der- moscopic findings of DLE with lip location and are reported yellow dots,” which was highly specific for inactive DLE le- sions [28]. In our study, this finding was observed in a pa- tient with LET. Histopathologically, LET is characterized by minimal epidermal changes (epidermal atrophy, vacuolar de- generation of basal cells, hyperkeratosis) and minimal follic- ular plugging [37]. In this respect, it should not be forgotten that follicular changes may be observed on dermoscopy. Figure 3. Dermoscopic features of interfollicular features-part II. (A) White rosettes. (B) Shiny white lines. (C) Blue-gray dots/globules. (D) Erosions/ulcer ations. Figure 4. Dermoscopic features of perifollicular surface. (A) Perifollicular white color. (B) Perifollic- ular scaling. (C) Perifollicular erythema. (D) Perifollicular pigmenta tion. Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 11 to CLASI-A were not seen in patients with LET, these der- moscopic features were attributed to DLE activity. Although studies have recommended the use of CLASI in patients with LET, CLASI activity and damage scores have been found to be lower than in other CLE subtypes [42]. In this study, we were unable to compare dermoscopic findings in patients with LET according to CLASI activity for reasons such as the small number of patients and the fact that the edema seen in LET patients is not taken into account in the CLASI scoring system. Fibrotic white dots, honeycomb pigment pattern, blue- gray dots/globules were detected more frequently in patients with a high CLASI-D score. Our data support previous studies indicating that fibrotic white dots are a precursor of white structureless areas [18], and white structureless areas are associated with late DLE [19,32]. As DLE lesions expand and grow, squamae and pigmentation begin to appear at the periphery of the lesion [41]. In the literature, it was reported that “branching vessels” were more common in late scalp DLE lesions [1,43]. In the present study, no such difference was observed according to CLASI-D score. This may be because CLASI-D does not evaluate vessel patterns. Patients with discoid LE present distinct pigmentation findings on dermoscopy such as honeycomb pigment pat- tern, speckled pigmentation, perifollicular pigmentation, pe- ripheral pigmentation, and blue-gray dots/globules [34]. In the literature, different results have been reported regarding the relationship between pigmentation findings and DLE ac- tivity. Gomez-Quispe et al. reported a higher incidence of incontinentia pigmenti (scattered brown discoloration and to be statistically more common than in the aforementioned diseases [25]. According to a 2018 study, telangiectatic ves- sels and scales were most common in lip DLE, but scales subtyping was not performed [1]. In another study, the most common vessel pattern in lip DLE was reported to be the hairpin pattern (71.4%) [18]. Scales and hairpin vessels were also among the most common findings in our study. Although the dermoscopic appearance of “shiny white lines” is mostly seen in scalp DLE [32], it was also detected in 50.0% of patients with lip location in our study. Ayhan et al observed a 20.4% rate of yellowish-white streaks in dermo- scopic imaging of the labial mucosa in healthy people [40]. Therefore, comparing involved and uninvolved labial areas in the same patients may enable a clearer evaluation of our study data. It has been shown in the literature and in our study that follicular plugs are more common in patients with high CLASI-A scores, in parallel with disease activity [1,19]. As DLE lesions expand and grow, squamae and pigmentation begin to appear at the periphery of the lesion [41]. The pe- ripheral hyperpigmentation associated with high CLASI-A score seen in our study may be an indicator that DLE lesions are growing and have not progressed to the destructive phase. In our study, findings of polymorphous vessels were more common in the dermoscopic images of patients with high CLASI-A scores. It is known that erythema, one of the CLASI-A components, is associated with the hyperemia that accompanies inflammation [10]. We believe that the more frequent observation of vessels may be related to this in- flammation. Since significant dermoscopic findings related Figure 5. Dermosc opic findings in vessel pattern. (A) Thick arborizing vessels. (B) Dotted vessels. (C) Hairpin vessels. (D) linear vessels. (E) Polymorphous vessels. 12 Original Article | Dermatol Pract Concept. 2024;14(1):e2024040 findings. 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When our results are interpreted in the light of the literature, it can be concluded that peripheral pigmentation is seen in active disease and short-term lesions, while blue-gray dots are seen in the damage period and in long-term lesions. CLE variants are not always easily distinguishable from one an- other. For example, early inflammatory DLE that has not developed scarring is clinically very similar to SCLE [26]. Dermoscopic findings in SCLE are accompanied by whitish scales and a polymorphous vessel pattern on a pinkish-red- dish background [26,35]. Although these dermoscopic findings are seen in all cases of CLE [26], the differential di- agnosis is aided by the presence of follicular keratotic plugs, white perifollicular halo, and linear vessels, which are among the dermoscopic findings of DLE as seen in our study. How- ever, it should be noted that follicular keratotic plugs may be common in acute CLE [45]. 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