Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2024;14(2):e2024077 1 Could Conventional, Ultraviolet-Induced Fluorescence and Sub-Ultraviolet Reflectance Dermatoscopy Assist the Diagnosis of Cutaneous Collagenous Vasculopathy? A Case Report Paweł Pietkiewicz1, 2, Adarsha Adhikari3, Katarzyna Kowalska4, Agnieszka Malińska4, Monika Bowszyc-Dmochowska5 1 Dermatology Private Practice, Poznań, Poland 2 Polish Dermatoscopy Group, Poznań, Poland 3 Gandaki Medical College, Pokhara, Nepal  4 Histology and Embryology Department, Poznan University of Medical Sciences, Poznan, Poland 5 Cutaneous Histopathology and Immunopathology Section, Department of Dermatology, Poznań University of Medical Sciences, Pozna, Poland Key words: ultraviolet radiation, dermoscopy, telangiectasia, endothelial damage, imaging Citation: Pietkiewicz P, Adhikari A, Kowalska K, Malińska A, Bowszyc-Dmochowska M. Could Conventional, Ultraviolet-Induced Fluorescence and Sub-Ultraviolet Reflectance Dermatoscopy Assist the Diagnosis of Cutaneous Collagenous Vasculopathy? A Case Report. Dermatol Pract Concept. 2024;14(2):e2024077. DOI: https://doi.org/10.5826/dpc.1402a77 Accepted: October 29, 2023; Published: April 2024 Copyright: ©2024 Pietkiewicz 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: Paweł Pietkiewicz, Centrum Medyczne Zwierzyniecka, Zwierzyniecka Street 30/28, Poznań 60-814. Telephone: +48 602 133 503 Email: pietkiewicz.pp@gmail.com Introduction Cutaneous collagenous vasculopathy (CCV) is an uncom- mon yet likely underreported idiopathic microangiopathy, first described in 2000 [1]. The disorder is characterized by progressive, asymptomatic cutaneous telangiectasias as- sociated with collagen IV deposition around the affected vessels in the superficial dermis [1]. CCV may mimic other telangiectatic disorders, particularly generalized essential tel- angiectasia (GET) or pigmented purpuric dermatoses. Case Presentation A 50-year-old male presented with progressive patchy erythematous/telangiectatic non-atrophic macules sym- metrically distributed over extensor aspects of arms and forearms that had developed over the previous three years (Figure 1A, B). He had no history of sunburns, occupational sun exposure, radiation, topical glucocorticosteroid applica- tion, hypertension, alcohol abuse, or of taking any medica- tions. However, he has been a car parts reseller and thus, 2 Research Letter | Dermatol Pract Concept. 2024;14(2):e2024077 Figure 1. Clinical presentation of erythematotelangiectatic macules distributed over extensor surfaces of the arms and forearms in 50-year- old male (A, B).  Contact polarized dermatoscopic image (DL5, Dermlite, US) of the lesion displays a vascular pattern of thick linear serpentine vessels with alternating regions of constrictions and dilations (a sausage-string appearance) of reticular/polygonal arrangement (better seen in the box) (C). Ultraviolet-induced fluorescence dermatoscopy (365nm) (DL5, Dermlite, US) demonstrates vascular constrictions and dilations (a sausage- string appearance) of reticular/polygonal arrangement along with darkening of perivascular structureless areas (higher absorption of UV spectrum by hemoglobin) suggestive of underlying endothelial dysfunction and erythrocyte extravasation  (better seen in the box) (D). Sub-ultraviolet reflectance dermatoscopy (405nm)(DZ-D100, Casio, Japan) exhibits hyporeflective linear serpentine reticular/polygonal ves- sels with indistinct contours (higher absorption of UV spectrum by hemoglobin) suggestive of underlying endothelial dysfunction and eryth- rocyte extravasation (better seen in the box) (E). Pathology displays thinned epidermis with reduced papillomatosis, numerous dilated vessels of the superficial vascular plexus (no perivas- cular infiltrate noted), and fragmented elastin fibers in the upper dermis that could support the diagnosis of both generalized essential tel- angiectasia and cutaneous collagenous vasculopathy (F), but thickened hyalinized walls of the vessels support the diagnosis of the CCV (G). Research Letter | Dermatol Pract Concept. 2024;14(2):e2024077 3 Figure 2. Electron microscopy reveals focally disrupted hemidesmosomal internal/external plates in the basal layer (yellow arrowheads) with focal multiplication of basal lamina (green arrowhead) (A, B), mild dilation of superficial dermal vessels exhibiting multi-laminated and focally deformed basal laminas (suggestive for cutaneous collagenous vasculopathy) (red arrowheads) (C), and in- creased activity of endothelial cells. Perivascular lymphocytes and single extravasated erythrocytes can be noted (white arrowhead) (D). Focal abnormally banded (long-spaced) collagen (Luse-like bod- ies) in the vicinity of sensory receptors is suggestive for the diagnosis of CCV (blue arrowhead) (E). reportedly frequently used lacquer thinner (toluene-acetone solution) and vehicle paint. Based on the clinical presentation, GET (bilateral nev- oid variant), telangiectasia macularis eruptiva perstans, and CCV were considered as possible differentials. Complete blood count, ESR, aminotransferases, fast- ing glucose, lipid profile, serum tryptase levels, thyroid hormones, estrogen and progesterone levels, and abdominal ultrasound were within the normal limits. Contact polarized conventional, ultraviolet-induced fluorescence (UVFD) and sub-ultraviolet reflectance der- matoscopic (sUVRD) imaging were performed (Figure 1C). Diagnostic biopsy was evaluated with pathology (Figure 1D, E) and electron microscopy (Figure 1F, G). 4 Research Letter | Dermatol Pract Concept. 2024;14(2):e2024077 Discussion There is a certain clinical and pathological overlap between CCV and GET. Thus, the diagnosis can only be made with electron microscopy (CCV featuring multiplication and defor- mation of vascular basal lamina and the presence of Luse-like bodies) [1, 3], as was in our case. Here we describe a der- matoscopic pattern of alternated vascular constrictions and dilations (sausage-like appearance) which has not yet been observed in CCV [1, 4] and which may hint at endothelial instability [2]. Although non-contact polarized dermatoscopy is a gold standard in inflammoscopy, contact mode with 70% alcohol solution produced a crisper image of the vessels in all dermatoscopy subtypes due to the reduction of stratum corneum reflection. Although there were no dermatoscopic or histopathologic clues to erythrocyte extravasation, UVFD and sUVRD could support it with perivascular hyporeflective areas, which was confirmed with electron microscopy. We hy- pothesize that disruption of vascular integrity in the reported patient could possibly result from prolonged exposure to ar- omatic volatile organic chemical compounds present in paint thinners, especially toluene. This substance, constituting 80% of paint thinner, has been reported to upregulate TNFα levels [5] responsible for the production of reactive oxygen species. Abrupt cutoff of telangiectatic macules sparing the hands was likely associated with the use of protective gloves. Conclusions CCV is a clinically challenging entity associated with endo- thelial damage. Even though the diagnosis can be reached with electron microscopic studies, it is possible that it may present characteristic dermatoscopic, UVFD, and sUVRD clues that may aid the diagnosis and make it technically eas- ier and affordable. References 1. Sartori DS, Almeida Jr. HL de, Dorn TV, Ruas CP. Cutaneous collagenous vasculopathy: light and transmission electron mi- croscopy. An Bras Dermatol. 2019;94(2):211–3. 2. Jacobsen JC, Beierholm U, Mikkelsen R, Gustafsson F, Alstrøm P, Holstein-Rathlou NH. “Sausage-string” appearance of arteries and arterioles can be caused by an instability of the blood vessel wall. Am J Physiol Regul Integr Comp Physiol. 2002;283(5):R1118-30. doi: 10.1152/ajpregu.00006.2002. PMID: 12376405. 3. Salama SS. Cutaneous collagenous vasculopathy: a new case series with clinicopathologic and ultrastructural correlation, literature review, and insight into the pathogenesis. Am J Derma- topathol. 2015 May;37(5):368-75. doi: 10.1097/DAD.000000 0000000194. PMID: 25079204 4. Knöpfel N, Martín-Santiago A, Saus C, Escudero-Góngora MM, Del Pozo LJ, Gómez C. Extensive Acquired Telangiectasias: Com- parison of Generalized Essential Telangiectasia and Cutaneous Col- lagenous Vasculopathy. Actas Dermosifiliogr. 2017;108(3):e21-e26. English, Spanish. doi: 10.1016/j.ad.2016.02.020. PMID: 27663404. 5. Abouee-Mehrizi A, Rasoulzadeh Y, Kazemi T, Mehdipour A, Mesgari-Abbasi M. Toxicopathological changes induced by com- bined exposure to noise and toluene in New Zealand White rab- bits. Arh Hig Rada Toksikol. 2022;73(1):31-42. doi: 10.2478/ aiht-2022-73-3602.