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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 13  |  Issue : 3  |  Page : 103-108

Dermoscopic features of cutaneous leishmaniasis lesions


1 Department of Dermatology, Şanlıurfa Training and Research Hospital, Şanlıurfa, Turkey
2 Department of Dermatology, Harran University Medical Faculty, Şanlıurfa, Turkey

Date of Submission08-Apr-2019
Date of Decision12-Jun-2019
Date of Acceptance12-Jun-2019
Date of Web Publication17-Oct-2019

Correspondence Address:
Dr. Isa An
Department of Dermatology, Sanliurfa Training and Research Hospital, Sanliurfa
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJD.TJD_9_19

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  Abstract 

Objective: This study aimed at determining the dermoscopic characteristics of cutaneous leishmaniasis (CL) and comparing these characteristics to the previous results. Materials and Methods: The prospective study included a total of 225 lesions from 69 patients with the ages between 1 and 70 years who were admitted to our dermatology clinic between March 1, 2016, and August 1, 2016, diagnosed with CL using smears of skin lesions, and did not receive any previous antileishmanial treatment. Results: When the lesions were dermoscopically examined for their general characteristics, the most common findings were erythema (100%), teardrop-like structures (59.1%), and hyperkeratosis (53.3%). The most common vascular structures in the lesions were linear vessels (50.2%), dotted vessels (39.6%), and hairpin-like vessels (32.9%). Conclusion: Our data were comparable to those of the previous studies in literature. Although there is no specific dermoscopic feature specific to CL, we presume that dermoscopic findings may contribute to differential diagnosis in the presence of clinically similar cutaneous lesions.

Keywords: Cutaneous leishmaniasis, dermoscopy, linear vessels, teardrop-like structures


How to cite this article:
Eroglu N, An I, Aksoy M. Dermoscopic features of cutaneous leishmaniasis lesions. Turk J Dermatol 2019;13:103-8

How to cite this URL:
Eroglu N, An I, Aksoy M. Dermoscopic features of cutaneous leishmaniasis lesions. Turk J Dermatol [serial online] 2019 [cited 2019 Nov 20];13:103-8. Available from: http://www.tjdonline.org/text.asp?2019/13/3/103/269502




  Introduction Top


Leishmaniasis is a vector-borne, common infection affecting 12 millions of individuals in 98 countries including Turkey, with >350 million people being at risk. Cutaneous leishmaniasis (CL) is the most common form of the disease.[1],[2],[3],[4] The definitive diagnosis of CL is made by laboratory methods including microscopic examination of the Giemsa-stained smears, histopathologic examination, culture, or polymerase chain reaction.[5],[6],[7],[8],[9] Dermoscopy is a noninvasivein vivo diagnostic technique that facilitates the examination of epidermis and superficial dermis. Today, dermoscopy is highly important for the diagnosis and treatment monitorization in almost all fields of dermatology including infectious and inflammatory dermatoses, mainly early diagnosis of melanoma.[10],[11],[12],[13],[14] This study aimed at determining the dermoscopic characteristics of CL, comparing these characteristics to the previously published studies, and demonstrating whether dermoscopy is a valuable technique for the diagnosis of CL.


  Materials and Methods Top


The prospective study included a total of 225 lesions from 69 patients with the ages between 1 and 70 years who were admitted to our dermatology clinic between March 1, 2016, and August 1, 2016, diagnosed with CL using smears of skin lesions, and did not receive any previous antileishmanial treatment.

Dermoscopic findings and clinical characteristics of the lesion were noted before initiating antileishmanial treatment in all patients. All the included lesions were individually examined and assessed. Macroscopic and dermoscopic images were taken. DermLite photo equipment (3Gen Inc. 31521 Rancho Viejo Road, Suite 104 San Juan Capistrano, CA 92675 USA) was used as the dermoscope, (Canon inc, shimomaruko, 3-chumo, Ohta-ku, Tokyo, Japan) was used as the camera, and Canon EF 50 mm f/1.8 II was used as the lens. All information was noted. At least three dermoscopic images were taken from each lesion. While taking images by the dermoscope, lesions were wiped using 60% alcohol to obtain more quality images, to view deeper regions, and to prevent light reflection. Minimal pressure was applied using the dermoscope to protect the main vascular structure and prevent vascular collapse. The examination was performed after all patients and lesions were collected.

Based on the dermoscopic appearance of the lesions, features including erythema, hyperkeratosis, crust, teardrop-like structures, milia-like cyst, white-starburst pattern, ulceration, scar, and orange areas were assessed. Vascular structures in the lesions were assessed based on morphology including dotted vessels, hairpin-like vessels, linear vessels, comma-like vessels, and arborizing vessels.

Written consent was taken from the patients. The study was approved by the local ethics committee of Faculty of Medicine, Harran University (date: March 01, 2016, number: 8).

Statistical analysis

Statistical analyses were performed using the SPSS 15.0 for Windows (SPSS Inc., Chicago, IL, USA) package software. Percentage was used for descriptive statistics, and Chi-square test was used for pair-wise analyses. P < 0.05 was considered to be statistically significant.


  Results Top


Out of 69 patients included in the study, 32 (46.4%) were female and 37 (53.6%) were male, with a total of 225 lesions being examined. The patients' ages were between 1 and 70 years. Thirty-four (49.2%) patients were symptomatic. The number of patients with itching was 27 (39.1%), with pain was 6 (8.7%), and with burning sensation was 2 (3%). Ninety-five lesions (42.2%) were on the face, 7 (3.1%) were on the neck, 98 (42.7%) were on the upper extremity, and 25 (11.1%) were on the lower extremity [Table 1]. One hundred and forty lesions (62.2%) were papules, 54 (24%) were plaques, 23 (10.2%) were nodules, and 8 (3.6%) were noduloulcerative.
Table 1: Anatomic locations of cutaneous leishmaniasis lesions (n=225)

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When the lesions were dermoscopically examined for their general characteristics, the most common findings were erythema (100%), teardrop-like structures (59.1%), and hyperkeratosis (53.3%), and the least common findings were scar (8.9%) and ulceration (3.5%). The most common vascular structures in the lesions were linear vessels (50.2%), dotted vessels (39.6%), and hairpin-like vessels (32.9%) [Table 2] and [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Table 2: Dermoscopic features of cutaneous leishmaniasis

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Figure 1: (a) At the center of the lesion, there are crusts and hyperkeratosis (blue arrow), and in the periphery, there are reticular branching and linear vessels (red arrow). (b) Crust and hyperkeratosis (blue arrow) at the center of the lesion; in the periphery, tear-shaped structures (red arrow) with reticular branching and some with targetoid appearance are seen

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Figure 2: (a) At the center of the lesion, there are ulcer, scar areas, and dotted vessels (blue arrow); in the periphery, there are some ellipse or round tear structures (red arrow). (b) At the center of the lesion, there are crusts and hyperkeratosis (blue arrow), and in the periphery, there are reticular branching (red arrow) and linear vessels (yellow arrow)

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Figure 3: (a) The dermoscopic examination of the lesion shows orange areas (blue arrow). (b) At the center of the lesion, dotted vessels (red arrow) are seen

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Figure 4: (a) The dermoscopic examination of the lesion shows arborizing vessels (blue arrow) and milia-like cysts (red arrow). (b) The dermoscopic examination of the lesion shows hairpin-like vessels (blue arrow)

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Figure 5: (a) The dermoscopic examination of the lesion shows starburst pattern (blue arrow). (b) The dermoscopic examination of the lesion shows dotted vessels (blue arrow)

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When dermoscopic characteristics were assessed by body regions, the most common characteristics were teardrop-like structures (71.7%), linear vessels (58.7), and arborizing vessels (48.9%) on the face; teardrop-like structures (85.6%) and dotted vessels (71.4%) on the neck; dotted vessels (51.0%), white-starburst pattern (46.9%), and teardrop-like structures (44.8%) on the upper extremities; and teardrop-like structures (62.5%) and dotted vessels (58.3%) on the lower extremities [Table 3] and [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Table 3: Results of dermoscopic features by localization in cutaneous leishmaniasis

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When dermoscopic characteristics were assessed by lesion types, erythema was the most common finding for all lesion types. Other most common findings were teardrop-like structures and linear vessels in papular lesions; hyperkeratosis and teardrop-like structures in plaque lesions; crust, hyperkeratosis, teardrop-like structures, and pustules in nodular lesions; and teardrop-like structures and linear vessels in noduloulcerative lesions [Table 4] and [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Table 4: Results of dermoscopic features by type of lesion in cutaneous leishmaniasis

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  Discussion Top


There are four previous studies investigating the dermoscopic characteristics of CL.[15],[16],[17],[18] First, Llambrich et al. assessed 26 lesions of 25 CL patients using dermoscopy and observed teardrop-like structures in 53%.[18] In their study, Ayhan et al. detected teardrop-like structures in 42.5% of the lesions, and teardrop-like structures were detected only in lesions located on the face and the posterior and lateral sides of the neck, however, nowhere else on the body.[16] In their study, Yücel et al. observed teardrop-like structures in 40% of the lesions, and these structures were most frequently observed in nodular lesions.[15] Teardrop-like structures were observed in 59.1% of the lesions in our study. These structures were particularly observed in nonchronic, crustless, new papular lesions (60%, P = 0.728).

Histopathologically, teardrop-like structures were considered to be follicular fillings plugged with keratin formed due to pressure on the hair follicle from the sides.[15] Keratin-plugged follicular fillings can also be seen in nonpigmented actinic keratosis, which lead to a strawberry pattern.[19] In the strawberry pattern in nonpigmented actinic keratosis, keratin plugs are not inside the structure but around the pseudoweb with a large erythema. No ulcer or crust is found at the center.[19],[20] Differences like this may help with the dermoscopic differential diagnosis of CL.

White starburst-like patterns were first described by Llambrich et al. in CL lesions and were thought to be caused by parakeratotic hyperkeratosis. This finding was found in 38% of the lesions diagnosed with CL.[18] In their study, Taheri et al. detected this finding in 60.4% of the lesions, mainly in nodular lesions on the upper extremities.[17] In their study, Yücel et al. detected this finding in 19% of the lesions, especially in noduloulcerative lesions.[15] In our study, white starburst-like patterns were detected in 33.8% of the lesions, most commonly in papular lesions on the neck. As white starburst-like patterns were not detected in dermatological lesions previously, it can be considered an important criterion for the dermoscopic assessment of CL lesions.

Arborizing vessels were first found to be useful for the diagnosis of basal-cell carcinoma (BCC) in 1990.[21] In their study, Ayhan et al. observed arborizing vessels in 38.6% of the patients diagnosed with CL, most commonly in lesions on the face.[16] In their study, Yücel et al. observed arborizing vessels in 36.6% of the lesions, most commonly in papular lesions.[15] In our study, arborizing vessels were observed in 31.1% of all patients and in 27.1% of papular lesions (P = 0.099), with most of these lesions (48.9%) being placed on the face (P = 0.000). The presence of arborizing vessels and follicular fillings indicates CL diagnosis.

Hairpin-like vessels are mostly seen in seborrheic keratosis, keratoacanthoma (KA), and nonmelanocytic tumors such as squamous cell carcinoma (SCC), usually accompanied by a white halo surrounding the lesion.[22],[23],[24] Hairpin-like vessels were detected in 19% of CL patients in the study by Llambrich et al.[18] and in 17.2% of the cases in the study by Yücel et al.[15] These vessels were commonly observed in lesions on the lower extremities in both studies.[15],[18] Hairpin-like vessels were observed in 37.5% and 39.4% of the lesions in the studies by Taheri et al. and Ayhan et al., respectively. These vessels were commonly detected in lesions on the upper extremities.[16],[17] Hairpin-like vessels were detected in 32.9% of the lesions in our study. In our study, hairpin-like vessels were more common in nodular lesions. Teardrop-like structures existing in the absence of white irregular area, white halo, and central keratin plug were more commonly observed at the center; being observed less commonly and found in larger ulcers, hairpin-like vessels were detected more in the lesions on the neck. These might help in the differential diagnosis of KA and SCC from CL.

Linear vessels are in various sizes with a single fold.[25] Zalaudek et al. detected linear vessels in 70.8% of the CL lesions on the face and in 17.9% of the SCC lesions.[20] Yücel et al. detected linear vessels in 53.4% of the CL patients,[15] Ayhan et al.[16] in 26%, and Taheri et al.[17] in 30.6%. These vessels were frequently observed on the face.[15],[16],[17]

In our study, linear vessels were observed in 50.2% of the lesions, and these lesions were more commonly detected in noduloulcerative lesions (52.2%, P = 0.843) and on the face (58.7%, P = 0.034). As linear vessels may also be observed in KA and SCC, a careful differential diagnosis should be made.

Dotted vessels are observed due to placement of short and vertical capillaries around the lesion.[26] They can be seen in verruca vulgaris, actinic keratosis, seborrheic keratosis, Bowen's disease, and also in many small keratinized tumors such as SCC.[27] In their study, Ayhan et al. observed dotted vessels in 24.4% of the CL lesions. These vessels were mostly observed in the lesions on the upper extremities.[16] In their study, Taheri et al. observed dotted vessels in 61.1% of the CL lesions, and these vessels were mostly observed in ulcerative plaques on the lower extremities.[17] Dotted vessels were observed in 39.6% of the lesions in our study. Dotted vessels were mostly observed on the neck area (71.4%, P = 0.174) and in noduloulcerative lesions (47.8%, P = 0.392).

Comma-like vessels are slightly curved vessels with a diameter of ≥1 mm. They can be observed in lesions including melanoma,[27] dermal nevus,[28] dermatofibroma,[29] and BCC.[23],[24] Studies on CL patients have found comma-like vessels in 73%,[18] 4.1%,[15] 19.7%,[16] and 29.9%[17] of the lesions. While these vessels were most commonly observed on the face in the study by Ayhan et al.,[16] they were most commonly observed on the lower extremities in the study by Taheri et al.[17] In their study, Yücel et al. observed comma-like vessels most commonly in nodules and ulcerative lesions.[15] Comma-like vessels were observed in 21.8% of the lesions in our study. Comma-like vessels were most commonly observed in plaque lesions (25.9%, P = 0.394) and on the neck (57.1%, P = 0.021).

Lupus vulgaris is one of the granulomatous diseases which can be confused with CL. Orange areas are also known as salmon-colored ovoids.[15] Arborizing vessels and orange areas mostly accompany each other, and these structures are mostly observed in lesions of leishmaniasis recidivans. Therefore, orange areas are considered to be a sign of chronification.[16] In a study by Yücel et al., orange areas were observed in 13.1% of the lesions.[15] They were observed in 15.7% of the lesions in the study by Ayhan et al.[16] and in 43.8% in the study by Taheri et al.[17] In our study, the combination of arborizing vessels and orange areas was observed in 34.2% of the lesions.


  Conclusion Top


In our study, the vascular and nonvascular structures of the CL lesions were assessed using dermoscopy. The most common morphology of the vascular structures was linear vessels and dotted vessels and of the nonvascular structures were erythema, hyperkeratosis, crust, and teardrop-like structures. Although there is no specific dermoscopic feature specific to CL, we presume that dermoscopic findings may contribute to the differential diagnosis in the presence of clinically similar cutaneous lesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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