Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2024;14(1):e2024022 1 Dermoscopy in Necrolytic Acral Erythema: A Case Report Shivani Bansal1, Parul Chojer1, Sushama Sushama1, Manjit Kaur Rana2 1 Department of dermatology, AIIMS, Bathinda, India 2 Department of Pathology, AIIMS, Bathinda, India Key words: necrolytic, acral, erythema, dermoscopy, seronegative, Citation: Bansal S, Chojer P, Sushama S, Rana MK. Dermoscopy in Necrolytic Acral Erythema: A Case Report. Dermatol Pract Concept. 2024;14(1):e2024022. DOI: https://doi.org/10.5826/dpc.1401a22 Accepted: August 1, 2023; Published: January 2024 Copyright: ©2024 Bansal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial 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 Sushama, Department of dermatology, AIIMS, Bathinda, Dabwali road, India. Phone numbers: +919958719382 Email address: singh.sushama@gmail.com Introduction Necrolytic acral erythema (NAE) is characterized by erythema, blisters or erosion in the acute stage to well-defined, hyperkeratotic plaques on the dorsum of feet and toes in the chronic stage [1]. We present a dermoscopy of a case of NAE which may help in the diagnosis. Case Presentation A 32-year-old female presented with hyperpigmented plaques on the dorsum of her feet, predominantly on the medial aspect (Figure 1A). Erythematous macules, plaques of irregular shape and size varying from 0.5 cm2 to 4 cm2 in diameter were present on bilateral lower legs interspersed with follicular or non-follicular pustules, erosions and ulcers superimposed with yellowish crust (Figure 1B). Differential diagnosis of allergic contact dermatitis, psoriasis, pellagra and necrolytic acral erythema was kept. Dermoscopic ex- amination (Illuco IDS 1100, 10x magnification, polarized mode) of the acute lesions revealed multiple perifollicular white globules on intense red- violaceous background inter- spersed with short linear vessels (Figure 2A). Dermoscopy of the ulcer showed yellow globules with radial white striations surrounded by brown dots and patches in polarized mode and dirty yellow scales and white globules in non-polarized mode (Figure 2, B and C). Raw areas revealed uniformly dis- tributed red dots and globules with peripheral white scales in polarized dermoscopy (Figure 2, D and E). Dermoscopy of chronic hyperkeratotic hyperpigmented plaques presented a mixture of gray-brown pigmentation along with dirty white scales and red globules (Figure 2F). Few resolved areas reveal whitish striations in a branching pattern with brown patches and linear red vessels on a white background (Figure  2, G and H). Her viral markers were non-reactive and patch test with Indian standard and footwear series was negative. However, serum albumin and serum zinc level were borderline low. Skin biopsy from the hyperkeratotic plaque revealed psori- asiform dermatitis (Figure 2I). She was prescribed a tablet 2 Research Letter | Dermatol Pract Concept. 2024;14(1):e2024022 Figure 1. (A) Clinical image of a 32-year-old seronegative female of necrolytic acral erythema showing bilaterally symmetrical hyper- pigmented verrucous plaques present over dorsum of legs and feet. (B) Clinical image of acute lesions of the patient showing erythem- atous macules and plaques of irregular shape and sizes with ulcers and erosions interspersed with pustulation. Figure 2. (A) Dermoscopy (polarized) showing multiple perifollicular white globules (black arrow) on intense red- violaceous background (brown arrow) interspersed with white structureless areas (green star) and short linear vessels (blue arrow). (B) Polarized dermoscopy of ulcer shows yellow globules (black arrow) with radial white striations (brown arrow) surrounded by brown dots and patches (blue arrow). (C) Dermoscopy on non-polarized mode reveals white globule (black arrow) and dirty yellow crust (brown arrow) suggestive of dried serum on red background. (D) Dermoscopic examination reveal red background (brown star) with uniform red dots (blue arrow), few red globules (green arrow) and peripheral dirty white scales (gray arrow) and brown patches (purple arrow). (E) Dermoscopy on polarized mode, red dots in uniform pattern (black arrow) can be better appreciated with whitish scales (brown arrow). (F) Dermoscopy of chronic hyperkeratotic hyperpigmented plaques presented mixture of gray brown pigmentation (black arrow) along with dirty white scales (brown arrow) and red globules (blue arrow). (G) Resolved areas reveal whitish striations in a branching pattern (black arrow) with brown patches (blue star) on dermoscopy. (H) Linear vessels (black arrow) on white background (blue star) and whitish striations (red arrow) on dermoscopic examina- tion of these resolved areas. (I) Histopathology of the section shows mild hyperkeratosis, regular acanthosis in epidermis, numerous dilated capillaries in dermal papilla along with mild perivascular inflammatory infiltrate composed of lymphocytes and histiocytes (H&E stain; 40X). (J) Clinical image of the patient shows resolution of acute and chronic lesions at 4 months follow-up. zinc acetate 100 mg three times a day for 3 months to which the erythematous lesions, ulceration and edema responded well in 2 weeks. Topical super potent steroid was given for the hyperkeratotic lesions. There is no relapse at 3 months follow-up (Figure 2J). The clinical, dermoscopic and histo- pathologic findings along with supportive investigations and substantial improvement with oral zinc supplementation confirmed our diagnosis of NAE. Conclusions Although NAE has been associated with HCV infection, there have been few HCV seronegative case reports [2,3]. Our patient was also seronegative for HCV infection. Clinically, patients with NAE are systemically well and have a typical acral distribution which helps in ruling out causes of other acral erythemas such as pellagra, biotin and fatty acid deficiency [1]. Chronic lesions of NAE have to be differentiated from psoriasis, hyperkeratotic eczema and hypertrophic lichen planus. Our findings of dermos- copy of the lesions may assist in diagnosing both acute and chronic manifestations of NAE (Table 1). We could find only a single study on dermoscopy of necrolytic acral erythema [1]. Research Letter | Dermatol Pract Concept. 2024;14(1):e2024022 3 One should have a good suspicion of NAE even if the patient is seronegative for HCV and has innocuous- appearing psoriasiform or eczematous lesions with normal serum zinc levels. Dermoscopy may be of great assistance for the same, however, more studies on dermoscopic findings of this disease need to be done. References 1. Inamadar AC, Shivanna R, Ankad BS. Necrolytic Acral Erythema: Current Insights. Clin Cosmet Investig Dermatol. 2020;13:275- 281 DOI: 10.2147/CCID.S189175. PMID: 32308461. PMCID: PMC7147628. Table 1. Clinical-dermoscopic-histopathological correlation of a 32-year-old seronegative female patient of necrolytic acral erythema. Stage of lesions Clinical features Dermoscopic findings Corresponding histopathological features Acute lesions Erythematous macules and plaques with Peri-lesional hyperpigmentation Red background and Uniform Red dots Dilated capillary loops in regularly elongated dermal papillae Brown dots and patches Epidermal melanin Ulcers with yellowish crust White perifollicular globules Neutrophil collection, suggestive of acute infection over lesions Yellow globules Dried serous fluid Chronic lesions Hyperkeratotic plaques Dirty white scales loosely adherent scales Hyperkeratosis Hyperpigmented plaques Brown dots and patches Epidermal melanin Red globules Haemorrhages Resolved lesions Whitish to violaceous lesions Radial whitish striations Dermal fibrosis 2. Pandit VS, Inamadar AC, Palit A. Seronegative necrolytic acral erythema: A report of two cases and literature review. Indian Dermatol Online J. 2016;7(4):304-307. DOI: 10.4103/2229 -5178.185464. PMID: 27559510; PMCID: PMC4976414. 3. Das A, Kumar P, Gharami RC. Necrolytic acral erythema in the absence of hepatitis C virus infection. Indian J Dermatol. 2016;61(1):96-99. DOI: 10.4103/0019-5154.174047. PMID: 26955109. PMCID: PMC4763711. 4. Bentley D, Andea A, Holzer A, Elewski B. Lack of classic histol- ogy should not prevent diagnosis of necrolytic acral erythema. J Am Acad Dermatol. 2009;60(3):504–507. DOI: 10.1016/j .jaad.2008.08.046. PMID: 18992966. PMCID: PMC2708073.