Dermatology: Practical and Conceptual Review | Dermatol Pract Concept. 2024;14(2):e2024125 1 A Systematic Review of Diagnoses with Rosettes Under Dermoscopy May Alorainy1, Kendall Buchanan2, Tyler Nussinow3, Judy B. Rabinowitz4, Peggy Cyr5,6, Elizabeth V. Seiverling1 1 Tufts University School of Medicine, Department of Dermatology, Boston, Massachusetts, USA 2 Medical College of Georgia at Augusta University, Department of Dermatology, Augusta, Georgia, USA 3 University of New England College of Osteopathic Medicine, Biddeford, Maine, USA 4 Hirsh Health Science Library, Tufts University, Boston, Massachusetts, USA 5 Maine Medical Center, Department of Family Medicine, Boston, Massachusetts, USA 6 Tufts University School of Medicine, Department of Family Medicine, Boston, Massachusetts, USA Key words: rosettes, four dot, dermoscopy, shiny white structures, systematic review Citation: Alorainy M, Buchanan K, Nussinow T, Rabinowitz JB, Cyr P, Seiverling EV. A Systematic Review of Diagnoses With Rosettes Under Dermoscopy. Dermatol Pract Concept. 2024;14(2):e2024125. DOI: https://doi.org/10.5826/dpc.1402a125 Accepted: January 17, 2024; Published: April 2024 Copyright: ©2024 Alorainy 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: Dr. Seiverling is a consultant for Melatech and for DermaSensor. Dr. Buchanan is a consultant for DermaSensor and SkinVest. Dr. Cyr is a consultant for DermaSensor. The rest of the authors have no conflict of interest to declare. Authorship: All authors have contributed significantly to this publication. May Alorainy and Kendall Buchanan: first co-authors who contributed equally to this manuscript. Corresponding Author: Elizabeth V. Seiverling MD, Tufts Medical Center 800 Washington Street Boston MA, 02111. Tel: 617-636-0156 Fax: 617-636-8316 E-mail: vseiverling@gmail.com Introduction: Rosettes are a cluster of shiny white dots in the shape of a four-leaf clover seen under polarized dermoscopic light. Historically, rosettes were primarily reported in actinic keratoses and squamous cell carcinoma. However, rosettes have also been reported in other conditions. Objectives: The objective of this systematic review to elucidate the breadth of diagnoses exhibiting this unique dermoscopic phenomenon. Methods: A review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Literature searches were performed in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science, as well as a manual search of the reference lists of screened articles. Results: A total of 73 articles met the inclusion criteria. Out of these, 47 distinct diagnoses with rosette were identified. Among neoplastic conditions, keratinizing neoplasms had the highest num- ber of articles reported (N = 19). Discoid lupus was the most commonly reported diagnosis within the inflammatory category (N = 6). Molluscum contagiosum was the predominant diagnosis among infectious entities (N = 3), while acroangiodermatitis was the sole diagnosis reported in the vascular category (N = 1). ABSTRACT 2 Review | Dermatol Pract Concept. 2024;14(2):e2024125 Introduction Under dermoscopy, rosettes are a distinct type of white shiny structures characterized by a cluster of shiny white dots in the shape of a four-leaf clover. They are created by the pres- ence of scale in the follicular ostia and can only be observed under dermoscopy when using polarized light [1]. Histori- cally, rosettes were primarily reported as a finding in actinic keratoses (AKs) and squamous cell carcinoma (SCC) [2]. However, several reports demonstrated that rosettes are not specific to keratinocytic neoplasms and are rather encoun- tered in many other conditions [3]. Objectives The goal of this systematic review was to conduct a thor- ough examination of all reported entities with rosettes to elucidate the breadth of diagnoses exhibiting this unique dermoscopic phenomenon. Through our analysis, we aim to equip clinicians with the knowledge necessary to harness the diagnostic potential of rosettes in the evaluation of skin le- sions and cutaneous eruptions. Methods A review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guide- lines [4]. Literature searches were performed in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science, through April 24, 2023, as well as a manual search of the reference lists of full-text-screened articles. Key- words and subject heading terms used were: dermoscopy, dermatoscopy, trichoscopy, epiluminescence/skin surface microscopy, rosettes, four dot and four clod. Conference ab- stracts, studies based on reflectance confocal microscopy alone were excluded. No studies were excluded based on language, publication date, or patient age. Two reviewers independently performed data screening and extraction (MA and KB). Con- flicts were resolved by discussion with a third reviewer (ES). The full MEDLINE search was conducted as detailed below: Ovid MEDLINE(R) ALL <1946 to April 24, 2023> 1 exp Dermoscopy/ 2 dermoscop*.mp. 3 dermatoscop*.mp. 4 trichoscop*.mp. 5 (microscope or microscopes or microscopy or micros- copies).mp. 6 exp Microscopy/ 7 5 or 6 8 skin surface.mp. 9 epiluminescen*.mp. 10 8 or 9 11 7 and 10 12 1 or 2 or 3 or 4 or 11 13 rosett*.mp. 14 Four Dot.mp. 15 4 dot.mp. 16 four clod.mp. 17 4 clod.mp. 18 13 or 14 or 15 or 16 or 17 19 12 and 18 Results A total of 73 articles met the inclusion criteria (Figure 1). The majority were case reports (N = 33), followed by ob- servational cohort studies (N = 29), case series (N = 7), re- view articles (N = 3) and a single randomized controlled trial (N = 1). Out of these 73 articles, 47 distinct diagno- ses were reported (Table 1). The diagnoses were categorized into four main groups: neoplastic processes accounted for 51.9% of the diagnoses, inflammatory conditions comprised 39.0%, infectious conditions made up 7.8%, and vascular conditions represented 1.30%. Among neoplastic cases, ke- ratinizing neoplasms had the highest frequency of number of articles reported, these predominantly included AKs and SCC (N = 12) followed by basal cell carcinoma (BCC) (N = 6) and one report of basosquamous carcinoma (n=1). Within the inflammatory category, discoid lupus erythematosus (DLE) was the most commonly reported entity (N = 6). Mol- luscum contagiosum was the predominant diagnosis among infectious entities (N = 3), while acroangiodermatitis was the sole diagnosis reported in the vascular category (N = 1). Conclusions This systematic review identified a wide range of skin conditions which manifest rosettes under dermoscopy. As Conclusions: These findings confirm rosettes are not specific to keratinocytic growths and are ob- served in a wide range of conditions. Knowledge of the breadth of conditions with rosettes may aid clinicians when developing a differential diagnosis of a growth or an eruption with rosettes under dermoscopy. Review | Dermatol Pract Concept. 2024;14(2):e2024125 3 previously reported, rosettes are commonly found in ke- ratinocytic neoplasms with most of the articles devoted to actinic keratosis and squamous cell carcinoma. Rosettes are also frequently present in BCC [5] and accounted for approximately 30% of articles on keratinizing neoplasms. Therefore, BCC should be considered when encountering ro- settes in neoplastic processes. In addition to AK, SCC and BCC, this review identi- fied articles on rosettes in autoimmune diseases, sarcomas, skin infections, rosacea, scars and cysts. Of the autoimmune conditions with rosettes, DLE was the most common. No- tably, SCC may develop within DLE lesions, therefore it is imperative to seek additional dermoscopic indicators of SCC beyond the presence of scale and rosettes [6]. The breadth of diagnoses with rosettes supports the lack of specificity of this dermoscopic finding. Furthermore, this review identified three reports on rosettes in molluscum contagiosum. A sub- sequent report on a child who had two fleshy papules with rosettes raised concerns about SCC, which led to the deci- sion to perform skin biopsies. The biopsies ultimately con- firmed the presence of molluscum contangiosum instead [7]. Increased awareness of the presence of rosettes in infectious conditions, such as molluscum, has the potential to improve diagnostic accuracy and reduce the number of biopsies per- formed in pediatric patients. The study main limitation is that most of the reports in- cluded were single case reports restricting the generalizability of rosettes as a universal finding for all cases of each diagnosis. Lastly, in this review we did not attempt to characterize rosettes based on quantity, distribution, or location. Most ar- ticles were case reports featuring single entities, with limited dermoscopic images and lacked descriptive details necessary for further characterization of rosettes. In our own obser- vations, rosettes are commonly diffuse in actinic keratoses, but are few and randomly arranged in entities such as scars and molluscum contagiosum [7]. Additionally, knowledge of hair follicle size and distribution in different body sites could provide further insight into the distribution and appearance of rosettes in different entities. For example, Otberg et al reported the forehead has the highest follicular density com- pared to the trunk and extremities, and the calf showed the largest hair follicle diameter [8]. Expanding this insight may help explain the differences in the distribution, quantity, and size of rosettes on dermoscopy. In sum, this study identified the breadth of conditions with rosettes and may aid clinicians when developing a differential diagnosis of a growth or an eruption with rosettes. Given the wide range of conditions which can exhibit rosettes, it is im- portant to look for additional clinical and dermoscopic clues before rendering a diagnosis or deciding to pursue a skin biopsy. Figure 1. Flow diagram of literature screening using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 4 Review | Dermatol Pract Concept. 2024;14(2):e2024125 Table 1. All Diagnostic Entities Reported to Exhibit Rosettesa. Diagnostic Entity Total Number of Reports Study Type CR CS O/C R RCT AKs/SCCIS/SCC [9,10,19,20,11–18] 12 2 8 1 1 BCC [5,21–25] 6 1 4 1 Basosquamous carcinoma [26] 1 1 Melanoma [27] 1 LPLK/Lentigo [28] 1 1 Macular seborrheic keratosis [29] 1 1 Blue nevus [30] 1 1 Warty dyskeratoma [31] 1 1 Syringocystadenoma papilliferum [32] 1 1 Trichilemmal cyst [33,34] 2 2 Milium-like cysts [35] 1 1 Trichoepithelioma [36] 1 1 Juvenile xanthogranuloma [37] 1 1 Lymphomatoid papulosis [38] 1 1 Mycosis fungoides [39] 1 1 T-cell pseudolymphoma [40] 1 1 Kaposi sarcoma [41] 1 Acroangiodermatitis [42] 1 1 Molluscum contangiosum [43–45] 3 2 1 Leprosy [46,47] 2 2 Lupus vulgaris [48] 1 1 Scars (including cicatricial alopecia) [49–51] 3 3 Keloid [52] 1 COVID-19 associated chilblain lesions [53,54] 2 2 Lichen planus [55,56] 2 2 Lichen sclerosis [57,58] 2 1 1 Rosacea [59,60] 2 2 DLE [61–66] 6 1 1 4 Acute CLE [67] 1 1 Chronic CLE [68] 1 1 CLE (all types) [69] 1 1 Comedonal lupus [70] 1 1 Chilblain lupus [71] 1 1 Granuloma annulare [72] 1 1 Lichen amyloidosis [73] 1 1 Pigmented purpura [74] 1 1 Epidermolysis bullosa [75] 1 1 Progressive vitiligo [76] 1 1 Photo-contact dermatitis [77] 1 1 Apocrine hidrocystoma [77] 1 1 Urticarial dermatitis [1] 1 1 Dermatofibroma [1] 1 1 Melanocytic nevus [1] 1 1 Dilated pore [1] 1 1 Cyst [1] 1 1 aThe total number of articles differs from the total number of diagnoses as some articles reported on multiple entities with rosettes. AKs = actinic keratoses; BCC = basal cell carcinoma; CLE = cutaneous lupus erythematosus; COVID-19 = coronavirus disease-2019; CR = case report; CS = case series; DLE = discoid lupus erythematosus; LPLK = lichen planus-like keratosis; O/C = observational/cohort; R = review article; RCT = randomized controlled trial; SCC = squamous cell carcinoma; SCCIS = squamous cell carcinoma in situ. Review | Dermatol Pract Concept. 2024;14(2):e2024125 5 pattern. J Eur Acad Dermatology Venereol. 2018;32(1):48–52. DOI: 10.1111/jdv.14474. PMID: 28707711. 15. Jin Q, Li W, Wu W, Zhang H, Zhao F, Zhang Q, et al. Assessment of 5-Aminolaevulinic Acid Photodynamic Therapy (ALA-PDT) in Chinese patients with actinic keratosis: Correlation of der- moscopic features with histopathology. Australas J Derma- tol. 2020;61(3):e339–343. DOI: 10.1111/ajd.13289. PMID: 32424840. J 16. Sgouros D, Theofili M, Zafeiropoulou T, et al. Dermos- copy of Actinic Keratosis: Is There a True Differentiation be- tween Non-Pigmented and Pigmented Lesions? J Clin Med. 2023;12(3):30. DOI: 10.3390/jcm12031063. PMID: 36769711. PMCID: PMC9917853. 17. Gouda G, Pyne J, Dicker T. Pigmented Macules on the Head and Neck: A Systematic Review of Dermoscopy Features. Dermatol Pract Concept. 2022;12(4):e2022194. DOI: 10.5826 /dpc.1204a194. PMID: 36534577. PMCID: PMC9681183. 18. Peralta R, Salerni G, Sabban EC, Marin MB, Cabo H. Dermoscopy of a Squamous Cell Carcinoma of the Lower Lip Showing Multiple Rosettes. Dermatol Pract Concept. 2020; 10(1):e2020022. DOI: 10.5826/dpc.1001a22. PMID: 31921509. PMCID: PMC6936628. 19. Uzuncakmak TK, Karadag AS, Koska MC, Akay BN, Heper AO, Simsek BC. Collision tumour of actinic keratosis and basal cell carcinoma with different dermoscopic features. Hong Kong J Dermatology Venereol. 2019;27(4):185–191. Available from: https://www.embase.com/records?subaction=viewrecord&id =L2017557431. Accessed on April 24, 2023. 20. Sadeghinia A, Dastmalchi DA, Kianfar N, et al. Efficacy and safety of hydrogen peroxide topical solution in treating actinic keratosis: a randomized controlled trial. Dermatol Ther. 2021;34(5):e15097. DOI: 10.1111/dth.15097. PMID: 34392573. S 21. Liebman TN, Jaimes-Lopez N, Balagula Y, et al. Dermoscopic features of basal cell carcinomas: differences in appearance under non-polarized and polarized light. Dermatologic Surg. 2012;38(3):392–399. DOI: 10.1111/j.1524-4725.2011.02205.x. PMID: 22093161. 22. Navarrete-Dechent C, Bajaj S, Marchetti MA, Rabinovitz H, Dusza SW, Marghoob AA. Association of Shiny White Blotches and Strands With Nonpigmented Basal Cell Carcinoma: Evaluation of an Additional Dermoscopic Diagnostic Criterion. JAMA Der- matology. 2016;152(5):546–552. DOI: 10.1001/jamadermatol .2015.5731. PMID: 26792406. PMCID: PMC5037958. 23. Popadic M. Statistical evaluation of dermoscopic features in basal cell carcinomas. Dermatologic Surg. 2014;40(7):718–724. DOI: 10.1111/dsu.0000000000000031. PMID: 25111342. 24. Suppa M, Micantonio T, Di Stefani A, et al. Dermoscopic vari- ability of basal cell carcinoma according to clinical type and an- atomic location. J Eur Acad Dermatology Venereol. 2015;29(9): 1732–1741. DOI: 10.1111/jdv.12980. PMID: 25627865. 25. Salerni G, Alonso C, Bussy RF. Crystalline structures as the only dermoscopic clue for the diagnosis of basal cell carcinoma. Arch Dermatol. 2012;148(6):776. PMID: 22710474. 26. Akay BN, Saral S, Heper AO, Erdem C, Rosendahl C. Basosqua- mous carcinoma: Dermoscopic clues to diagnosis. J Dermatol. 2017;44(2):127–134. DOI: 10.1111/1346-8138.13563. PMID: 27570202. A 27. Gonzalez-Alvarez T, Armengot-Carbo M, Barreiro A, et al. Der- moscopic rosettes as a clue for pigmented incipient melanoma. Dermatology. 2014;228(1):31–33. DOI: 10.1159/000356822. PMID: 24356536. References 1. Haspeslagh M, Noë M, De Wispelaere I, et al. Rosettes and other white shiny structures in polarized dermoscopy: histo- logical correlate and optical explanation. J Eur Acad Dermatol Venereol. 2016;30(2):311–313. DOI: 10.1111/jdv.13080. PMID: 25786770. 2. Liebman T, Marghoob A, Rabinovitz H, Dusza S. White shiny structures: Morphologic evaluation under polarized dermos- copy. J Am Acad Dermatol. 2012;66(4):AB148. DOI: 10.1016 /j.jaad.2011.11.625. 3. Liebman TN, Scope A, Rabinovitz H, Braun RP, Marghoob AA. Rosettes may be observed in a range of conditions. Arch Derma- tol. 2011;147(12):1468. DOI: 10.1001/archdermatol.2011.312. PMID: 22184782. 4. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372(71). DOI: 10.1136/bmj.n71. PMID: 33782057. PMCID: PMC8005924. 5. Reiter O, Mimouni I, Dusza S, Halpern AC, Leshem YA, Marghoob AA. Dermoscopic features of basal cell carcinoma and its subtypes: A systematic review. J Am Acad Dermatol. 2021;85(3):653–664. DOI: 10.1016/j.jaad.2019.11.008. PMID: 31706938. PMCID: PMC9366765. 6. Zaalberg A, Moradi Tuchayi S, Ameri AH, et al. Chronic in- flammation promotes skin carcinogenesis in cancer-prone dis- coid lupus erythematosus. J Invest Dermatol. 2019;139(1):62. DOI: 10.1016/j.jid.2018.06.185. PMID: 30030152. PMCID: PMC6309656. 7. Gellatly ZS, Seiverling EV CP. Fleshy Papules on Arm.Cutis. Submitted. 8. Otberg N, Richter H, Schaefer H, Blume-Peytavi U, Sterry W, Lademann J. Variations of hair follicle size and distribution in different body sites. J Invest Dermatol. 2004;122(1):14–19. DOI: 10.1046/j.0022-202X.2003.22110.x. PMID: 14962084. 9. Ertop Dogan P, Akay BN, Okcu Heper A, Rosendahl C, Erdem  C. Dermatoscopic findings and dermatopathological correlates in clinical variants of actinic keratosis, Bowen’s dis- ease, keratoacanthoma, and squamous cell carcinoma. Derma- tol Ther. 2021;34(3): e14877. DOI: 10.1111/dth.14877. PMID: 33583118. 10. Kelati A, Baybay H, Moscarella E, Argenziano G, Gallouj S, Mernissi FZ. Dermoscopy of Pigmented Actinic Keratosis of the Face: A Study of 232 Cases. Actas Dermosifiliogr. 2017;108(9):844–851. DOI: 10.1016/j.ad.2017.05.002. PMID: 28705516. K 11. Lee DW, Kim DY, Hong JH, Seo SH, Kye YC, Ahn HH. Cor- relations between histopathologic and dermoscopic findings in Korean actinic keratosis. Microsc Res Tech. 2019;82(1):12–17. DOI: 10.1002/jemt.23043. PMID: 29676831. 12. Lee JH, Won CY, Kim GM, Kim SY. Dermoscopic features of actinic keratosis and follow up with dermoscopy: a pilot study. J Dermatol. 2014;41(6):487–493. DOI: 10.1111/1346- 8138.12282. PMID: 25032251. 13. Li W, Zhang C. The investigation of dermoscopy in differen- tial diagnosis of facial actinic keratosis. J Invest Dermatol. 2017;137(5):S31. DOI: 10.1016/j.jid.2017.02.195. 14. Lozano-Masdemont B, Polimon-Olabarrieta I, Marinero- Escobedo S, Gutierrez-Pecharroman A, Rodriguez-Lomba E. Rosettes in ac- tinic keratosis and squamous cell carcinoma: distribution, asso- ciation to other dermoscopic signs and description of the rosette 6 Review | Dermatol Pract Concept. 2024;14(2):e2024125 43. Meza-Romero R, Navarrete-Dechent C, Downey C. Molluscum contagiosum: an update and review of new perspectives in eti- ology, diagnosis, and treatment. Clin Cosmet Investig Derma- tol. 2019;12:373-381. DOI: 10.2147/CCID.S187224. PMID: 31239742. PMCID: PMC6553952. 44. Pradhan S, Ran X, Xu X, Yang Y, Lei S, Ran Y. Image Gallery: Dermoscopy of perianal molluscum contagiosum in a child caused by molluscum contagiosum virus subtype I. Br J Der- matol. 2019;180(3):e68–e68. DOI: 10.1111/bjd.17401. PMID: 30821395. P 45. Malakar S, Mukherjee S. Rosette: An additional in vivo dermo- scopic finding in molluscum contagiosum. Indian J Paediatr Der- matology. 2019;20(4):349–349. DOI:10.4103/ijpd.IJPD_89_17. 46. Laamari K, Bombay H, Jroundi C, et al. Lepromatous Leprosy with Rosette. Austin J Dermatolog. 2020;7(1):1089. Available from: https://austinpublishinggroup.com/dermatology/fulltext/ ajd-v7-id1089.php. Accessed on October 23, 2023. 47. Ankad BS, Drago NR, Koti VR, Nikam BP. White rosettes in borderline lepromatous leprosy: a new observation. J Eur Acad Dermatol Venereol. 2020;34(7):e329–e331. DOI: 10.1111/ jdv.16295. PMID: 32058644. 48. Ankad BS, Adya KA, Gaikwad SS, Inamadar AC, Manjula R. Lu- pus Vulgaris in Darker Skin: Dermoscopic and Histopathologic Incongruity. Indian Dermatol Online J. 2020;11(6):948–952. DOI: 10.4103/idoj.IDOJ_100_20. PMID: 33344345. PMCID: PMC7734991. 49. Antoniolli LP, Escobar GF. Be aware: rosettes may be a tran- sitory dermoscopic finding in scars. Australas J Dermatol. 2020;61(3):282–283. DOI: 10.1111/ajd.13305 PMID: 32338376. 50. Perez-Perez L, Garcia-Gavin J, Allegue F, Zulaica A. The rainbow pattern and rosettes in cutaneous scars. Actas Dermosifiliogr. 2014;105(1):96–97. DOI: 10.1016/j.ad.2012.12.017. PMID: 23608557. 51. Soto-García D, Couselo-Rodríguez C, Gónzalez-Sixto B, Flórez Á. An unexpected dermoscopy finding: Rosettes in a scar. Piel. 2022;37(10):e32–33. DOI: 10.1016/j.piel.2022.02.002. 52. Di Meo N, Corneli P, Vichi S, Del MF, Retrosi C, Zalaudek I. Treat- ment of keloid-scar under polarized dermoscopy. Ital J Derma- tology Venereol. 2021;156(6):1–2. DOI: 10.23736/S2784-8671 .18.06102-3. PMID: 29998715. 53. Discepolo V, Catzola A, Pierri L, et al. Bilateral Chilblain-like Lesions of the Toes Characterized by Microvascular Remodeling in Adolescents During the COVID-19 Pandemic. JAMA Netw Open. 2021;4(6):e2111369. DOI: 10.1001/jamanetworko- pen.2021.11369. PMID: 34110396. PMCID: PMC8193438. 54. Fabbrocini G, Vastarella M, Nappa P, et al. A new dermoscopic pattern for chilblain-COVID-19-like skin lesions in adolescents. JAAD Case Reports. 2020;6(12):1271–1274. DOI: 10.1016/j. jdcr.2020.09.024. PMID: 33020736. PMCID: PMC7527790. 55. Dash S, Behera B, Palit A, Sethy M, Nayak AK, Ayyanar P. An unusual dermoscopic presentation of eruptive lichen planus dominated by rosettes and blink sign. Australas J Dermatol. 2021;62(1):72–75. DOI: 10.1111/ajd.13398. PMID: 32757289. 56. Cymerman RM, Penn L, Meehan S, Polsky D. Polarized light der- moscopy to aid in the diagnosis of new pink lesions in an amelanotic melanoma survivor. J Am Acad Dermatol. 2015;73(6):e197–e199. DOI: 10.1016/j.jaad.2015.08.048. PMID: 26568348. l 57. Mahajan SA, Dave JS. Dermoscopic Evaluation of Extragen- ital Lichen Sclerosus et Atrophicus. Dermatol Pract Concept. 2022;12(3):e2022125. DOI: 10.5826/dpc.1203a125. PMID: 36159134. PMCID: PMC9464556. 28. Nagrani N, Jaimes N, Oliviero MC, Rabinovitz HS. Lichen planus-like keratosis: clinical applicability of in vivo reflectance confocal microscopy for an indeterminate cutaneous lesion. Dermatol Pract Concept. 2018;8(3):180–183. DOI: 10.5826 /dpc.0803a06. PMID: 30116660. PMCID: PMC6092072. 29. Ma Marques-da-Costa J, Campos-do-Carmo G, Ormiga P, Ishida CE, Cuzzi T, Ramos-e-Silva M. Rosette sign in dermatoscopy: a polarized finding. Skinmed. 2011;9(6):392. PMID: 22256632. 30. Salas-Callo CI, Riera-Monroig J, Podlipnik S, Puig S. Blue Nevus With Rosettes on Polarized Light Dermoscopy. Dermatol Pract Concept. 2020;10(1):e2020017. DOI: 10.5826/dpc.1001a17. PMID: 31921504. PMCID: PMC6936647. 31. Ingordo V, Ferrara G, Ingordo I, Argenziano G. A case of post- inflammatory warty dyskeratoma of the chest: Other dermoscopic features. Dermatology Reports. 2020;12(2):8791. DOI: 10.4081 /dr.2020.8791. PMID: 33408834. In PMCID: PMC7772768. 32. Dash S, Nayak AK, Sethy M, Palit A, Behera B. Dermoscopic findings of de novo syringocystadenoma papilliferum. Indian J Dermatol Venereol Leprol. 2021;87(2):278–280. DOI: 10.25259 /IJDVL_575_20. PMID: 33769726. 33. Bazzacco G, Zelin E, Maronese CA, et al. Rosette-like Structure: A Main Dermoscopic Feature in a Small Trichilemmal Cyst. Dermatol Pract Concept. 2022;12(1):e2022021. DOI: 10.5826/ dpc.1201a21. PMID: 35223166. B PMCID: PMC8824671. 34. Ramírez-Lluch M, Aldea Manrique B, Álvarez-Salafranca M, Sánchez-Bernal J. Rosettes in proliferating trichilemmal cyst: A new dermoscopic observation. Piel. 2021;36(4):275–277. DOI: 10.1016/j.piel.2020.05.011. 35. Giacaman A, Del Pozo LJ, Corral-Magaña O, Antón E. Milia in a multicolored tattoo: Dermoscopic findings. Med Cutan Ibero Lat Am. 2017;45(1):72–74. Available from: https://www.medi graphic.com/cgi-bin/new/resumenI.cgi?IDARTICULO=73090. Accessed on April 24, 2023. 36. Navarrete-Dechent C, Bajaj S, Marghoob AA, Gonzalez S, Munoz D. Multiple familial trichoepithelioma: confirmation via dermos- copy. Dermatol Pract Concept. 2016;6(3):51–54. DOI: 10.5826 /dpc.0603a10. PMID: 27648384. PMCID: PMC5006553. 37. Peruilh-Bagolini L, Silva-Astorga M, Hernández San Martín MJ, et al. Dermoscopy of Juvenile Xanthogranuloma. Dermatol- ogy. 2021;237(6):946–951. DOI: 10.1159/000510265. PMID: 33075787. 38. Ali AA, Shabani-Rad MT, Chia JC. Solitary pink papule in an el- derly man. JAAD Case Reports. 2022;24:48–51. DOI: 10.1016/j. jdcr.2022.04.004. PMID: 35600569. PMCID: PMC9120047. 39. Nakamura M, Huerta T, Williams K, Hristov AC, Tejasvi T. Dermoscopic Features of Mycosis Fungoides and Its Variants in Patients with Skin of Color: A Retrospective Analysis. Der- matol Pract Concept. 2021;11(3):e2021048. DOI: 10.5826/ dpc.1103a48. PMID: 34123556. PMCID: PMC8172036. 40. Alves RG, Ogawa PM, Enokihara M, Hirata SH. Rosettes in T-cell pseudolymphoma: a new dermoscopic finding. An Bras Dermatol. 2021;96(1):68–71. DOI: 10.1016/j.abd.2020.05.010. PMID: 33288369. PMCID: PMC7838094. 41. Erturk Yilmaz T, Akay BN, Okcu Heper A. Dermoscopic find- ings of Kaposi sarcoma and dermatopathological correlations. Australas J Dermatol. 2020;61(1):e46–5e3. DOI: 10.1111 /ajd.13150. PMID: 31495914. 42. Adya KA, Inamadar AC, Palit A. Shiny white lines and rosettes: New dermoscopic observations in acroangiodermatitis. Indian Dermatol Online J. 2020;12(4):660-662. DOI: 10.4103/idoj.IDOJ _101_20. PMID: 34430493. PMCID: PMC8354391. Review | Dermatol Pract Concept. 2024;14(2):e2024125 7 68. Zychowska M, Reich A. Dermoscopic Features of Acute, Sub- acute, Chronic and Intermittent Subtypes of Cutaneous Lupus Erythematosus in Caucasians. J Clin Med. 2022;11(14): 14. DOI: 10.3390/jcm11144088. PMID: 35887849. PMCID: PMC9321208. 69. Apalla Z, Papadimitriou I, Iordanidis D, et al. The dermatoscopic spectrum of cutaneous lupus erythematosus: A retrospective analysis by clinical subtype with clinicopathological correlation. Dermatol Ther. 2020;33(6):e14514. DOI: 10.1111/dth.14514. PMID: 33166029. 70. El Gaitibi FA, Belcadi J, Ali SO, Znati K, Senouci K, Ismaili N. Comedonal plaque on the scalp. JAAD Case Reports. 2021;11: 90–92. DOI: 10.1016/j.jdcr.2021.03.030. PMID: 33948465. PMCID: PMC8079957. 71. Jaworek AK, Szepietowski JC, Dyduch G, Hałubiec P, Iwaniec T, Wojas-Pelc A. Untypical presentation of cutaneous lupus in a young patient following COVID-19: Differentiation of COVID toes. Polish Arch Intern Med. 2021;131(7–8):732–734. DOI: 10.20452/pamw.16022. PMID: 34060777. 72. Errichetti E, Lallas A, Apalla Z, Di Stefani A, Stinco G. Der- moscopy of Granuloma Annulare: A Clinical and Histological Correlation Study. Dermatology. 2017;233(1):74–79. DOI: 10.1159/000454857. PMID: 28099955. 73. Madarkar MS, Koti VR. FotoFinder Dermoscopy Analysis and His- topathological Correlation in Primary Localized Cutaneous Am- yloidosis. Dermatol Pract Concept. 2021;11(3):e2021057. DOI: 10.5826/dpc.1103a57. PMID: 34123561. PMCID: PMC8172053. 74. Metin MS, Elmas OF. Dermoscopic profile of pigmented purpu- ric dermatosis: new observations. Postep Dermatologii I Alergol. 2019;36(6):687–691. DOI: 10.5114/ada.2019.91419. PMID: 31997996. PMCID: PMC6986287. 75. Narkhede ND, Nikham B, Jamale V, Hussain A, Kale M. Eval- uation of Dermoscopic Patterns of Vesiculobullous Disor- ders. Indian J Dermatol. 2021;66(4):445. DOI: 10.4103/ijd. IJD_294_20. PMID: 34759418. PMCID: PMC8530039. 76. Yanfei LI, Qiri MU. Progressive vitiligo with rosette sign under der- matoscope: a case report. Diagnosis Ther J Dermato-Venereology. 2022;29(1):53–56. DOI: 10.3969/j.issn.1674-8468.2022.01.013. 77. Jindal R, Chauhan P, Shirazi N. Rosette or Four Dot Signs in Dermoscopy: a Non-specific Observation. Dermatol Pract Concept. 2022;12(2): e2022069. DOI: 10.5826/dpc.1202a69. PMID: 35646433. PMCID: PMC9116560. 58. Ederaine SA, Harvey JA, Swanson DL. A case report: The der- matoscopic finding of rosettes on extragenital lichen sclero- sus. JAAD Case Reports. 2023;32:21–22. DOI: 10.1016/j.jdcr .2021.12.039. PMID: 36620498. PMCID: PMC9813475. 59. Aqil N, Nassiri A, Moustaide K, Gallouj S MF. Rosettes within rosacea. Our Dermatology Online. 2019;10(3):313–314. DOI:10.7241/OURD.20193.29. 60. Rubegni P, Tataranno DR, Nami N, Fimiani M. Rosettes: optical effects and not dermoscopic patterns related to skin neoplasms. Australas J Dermatol. 2013;54(4):271–272. DOI: 10.1111/ajd .12024. PMID: 23841852. 61. Al-Refu K. The role of dermoscopy in assessment of the activity and scarring response in discoid lupus erythematosus. Open Dermatol J. 2018;12(1):99–111. DOI: 10.2174/1874372201812010099. 62. Ankad B, Gupta A, Nikam B, Smitha S, Rangappa M. Implica- tions of Dermoscopy and Histopathological Correlation in Dis- coid Lupus Erythematosus in Skin of Color. Indian J Dermatol. 2022;67(1):5. DOI: 10.4103/ijd.ijd_591_21. PMID: 35656275. PMCID: PMC9154128. 63. Fathy H, Ghanim BM, Refat S, Awad A. Dermoscopic criteria of discoid lupus erythematosus: An observational cross- sectional study of 28 patients. Indian J Dermatol Venereol Leprol. 2022;88(3):360–366. DOI: 10.25259/IJDVL_207_19. PMID: 35138063. 64. Salah E. Clinical and dermoscopic spectrum of discoid lupus erythematosus: novel observations from lips and oral mucosa. Int J Dermatol. 2018;57(7):830–836. DOI: 10.1111/ijd.14015. PMID: 29700807. 65. Ankad BS, Shah SD, Adya KA. White rosettes in discoid lupus erythematosus: a new dermoscopic observation. Dermatol Pract Concept. 2017;7(4):9–11. DOI: 10.5826/dpc.0704a03. PMID: 29214102. PMCID: PMC5718119. 66. Manoharan K, Manoharan D, Kumar NA, Salam A. A Case of Facial Discoid Lupus Erythematosus (LE) with Oral Lichen Pla- nus (LP): A Dig into Co-existence and LE-LP Overlap. J Clin Diagnostic Res. 2022;16(3):WD01–3. DOI:10.7860/JCDR /2022/52554.16050. 67. Zhou F, Chen S. White Rosettes as a New Dermoscopic Find- ing in Acute Cutaneous Lupus Erythematosus Patient With Unilateral Erythema. Dermatol Pract Concept. 2022;12(4): e2022205. DOI: 10.5826/dpc.1204a205. PMID: 36534554. PMCID: PMC9681162.