Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2024;14(1):e2024021 1 Super-High Magnification Entodermoscopy: The New Era of Dermoscopy in the Field of Skin Parasitoses Luca Di Bartolomeo1, Federico Vaccaro2, Francesco Borgia3, Laura Macca3, Stefano Portuese3, Mario Vaccaro3 1 Dermatology, ASL Salerno, Salerno, Italy 2 Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy 3 Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, Messina, Italy Key words: entodermoscopy, super-high magnification dermoscopy, scabies, pediculus, pthirus Citation: Di Bartolomeo L, Vaccaro F, Borgia F, Macca L, Portuese S, Vaccaro M. Super-High Magnification Entodermoscopy: The New Era of Dermoscopy in the Field of Skin Parasitoses. Dermatol Pract Concept. 2024;14(1):e2024021. DOI: https://doi.org/10.5826 /dpc.1401a21 Accepted: June 8, 2023; Published: January 2024 Copyright: ©2024 Di Bartolomeo 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: Luca Di Bartolomeo, Viale della Repubblica, 23 – 84047 Capaccio-Paestum, Salerno, Italy; E-mail: lucadibartolomeo@live.it Introduction Super-high magnification dermoscopy (SHMD) is dermos- copy at 400x magnification. Its use in the study of skin par- asitoses is still limited to scabies and demodicosis [1,2]. We report four cases of skin parasitoses studied with SHMD, including infestations by Pthirus pubis and Pediculus capitis. Case Presentation Three patients presented 2-weeks history of persistent itch. The patients were respectively a 50-year-old man, an 8-year- old child and a 40-year-old man. In the first patient, the itch was diffuse on all body and clinical examination revealed only isolated reddish-gray spots on the trunk. The child suffered from scalp itching and his mother said that other children in his school suffered from similar condition. The last patient presented itchy skin bumps, mainly located on inguinal folds and proximal lower limbs, some of which are centered by linear escoriations. Dermoscopy at 20x magnification and SHMD with the videodermoscope Foto- finder Medicam 1000 (Fotofinder System, Bad Birnbach) al- lowed us to recognize infestation by Pthirus pubis in the first patient, by Pediculus capitis in the second and by Sarcoptes scabiei in the third (Figure 1 and Figure 2, A and B). In addi- tion to traditional dermoscopy, SHMD allowed us to study all body parts of lice and to recognize scabies mites in nod- ular scabies lesions where no traditional dermoscopic signs were visible. We report also a case of a 65-year-old female with a two year history of facial erythema. Clinical examina- tion showed erythema and telangiectasia of the left cheek, on which follicular spicules are barely noticeable to the naked eye. Super-high magnification dermoscopy revealed several elongated white structures emerging from dilated hair follicles, suggesting the presence of Demodex mites (Figure 2, B and C). 2 Research Letter | Dermatol Pract Concept. 2024;14(1):e2024021 Figure 1. (A) Pthirus pubis observed by SHMD (videodermoscope Fotofinder Medicam 1000, Fotofinder System, Bad Birnbach); the red letters indicate the components of louse body: M, mouthparts with antennae; D, the digestive system; S, spiracles; TC, terminal claws; H, hair on the dorsal surface; T, air tubes; (B) Close-up of terminal claws attached to patient body’s hair; (C) A second stage nymph of Pediculus capitis observed by SHMD; the red letters indicate the components of louse body: A, antennae; M, mouthparts; E, eyes; D, digestive tract, L, legs; (D): vital nit presenting the dome-shaped operculum (O). Figure 2. (A) Excoriated nodules of nodular scabies visible on inner thigh of the patient; (B) Dorsal view of Sarcoptes scabiei mite with mouthparts and anterior legs, spines on abdomen and posterior legs visible through transparent body; (C) Barely noticeable follicular spicules with erythema and telangiectasia on the left cheek of the patient; (D) Demodex folliculorum tails emerging from dilated follicle as elongated white structures (videodermoscope Fotofinder Medicam 1000, Fotofinder System, Bad Birnbach). Research Letter | Dermatol Pract Concept. 2024;14(1):e2024021 3 Conclusions For over 20 years, dermoscopy has proven its usefulness in the diagnosis of parasitoses and in the distinction between various species of lice, based on body features, which has been improved by the use of SHMD [3,4]. Moreover, SHMD allows us the study of parasite vitality by dynamic observa- tions of peristaltic activity based on blood movements inside the digestive tract of adult lice and by the visualization of the operculum on the end of the eggs, which is absent in empty nits [5]. Moreover, the study of operculum shape may distinguish the different lice species: Pthirus pubis presents a conoidal operculum, while Pediculus capitis a dome-shaped operculum [4], as in our patient. SMDH has been already used to assess the vitality of sca- bies mites and the effectiveness of treatments. It is useful in cases where traditional dermoscopy fails to distinguish frag- ments of mites from viable mites [1,6]. Moreover, as in our patient, SHMD may be useful in cases of scabies difficult to diagnoses as nodular scabies, in which the burrows are not clinically evident, so the dermoscopic “delta wing jet with contrail” sign is not clearly detected. As already demonstrated by Cinotti et al, SHMD may avoid skin biopsies on the face where traditional dermos- copy fails to detect Demodex. Moreover, SHMD may allow a measurement of the degree of parasitosis based on the amount of mites found. We report a study of lice infestation by SHMD, in ad- dition to our experience in other skin parasitoses. SHMD allows to view more details than traditional 20x dermoscopy and can be useful for several purposes in skin infestation study, such as the detection of parasites or determination of parasite vitality and efficacy of therapy [1,6]. SHMD can be considered a kind of in vivo microscopy and implementing its use in clinical practice could help us to better understand our skin. References 1. Winkler JK, Toberer F, Enk AH, Haenssle HA. Super-high magnification dermatoscopy for in-vivo imaging of scabies mites. J Dtsch Dermatol Ges. 2022;20(2):216-217. DOI: 10.1111 /ddg.14651. PMID: 34914169. 2. Cinotti E, Bertello M, Donelli C et al. Super-high magnification dermoscopy can detect Demodex folliculorum. J Eur Acad Der- matol Venereol. 2023;37(1):e96-e97. DOI: 10.1111/jdv.18496. PMID: 35964306. 3. Argenziano G, Fabbrocini G, Delfino M. Epiluminescence micros- copy. A new approach to in vivo detection of Sarcoptes scabiei. Arch Dermatol. 1997;133(6):751-3. DOI: 10.1001/archderm. 133.6.751. PMID: 9197830. 4. Scanni G. Human phthiriasis. Can dermoscopy really help dermatologists? Entodermoscopy: a new dermatological dis- cipline on the edge of entomology. G Ital Dermatol Venereol. 2012;147(1):111-7. PMID: 22370575. 5. Scanni G., Bonifazi E. Viability of the head louse eggs in pe- diculosis capitis. A dermoscopy study. Eur J Pediat Dermatol. 2006;16:201-204. 6. Di Bartolomeo L, Argenziano G, Borgia F, Vaccaro F, Vaccaro M. Efficacy evaluation of scabies treatment through super high mag nification dermoscopy. Ital J Dermatol Venerol. 2023;158(2):161-162. DOI: 10.23736/S2784-8671.22.07447-3. PMID: 37153952.