ORIGINAL ARTICLE

Dermoscopy for differentiation of palmoplantar psoriasis and

hyperkeratotic hand-foot eczema: a descriptive study

Arun Achar, MD 1 Background: Palmoplantar psoriasis (PPP) and hyperkeratotic

Loknath Ghoshal, MD 2 eczema (HPKE) are common and troublesome entities affecting the
Smriti Chowdhury, MD 3 palms and soles. The diagnosis is made clinically, but differentiation
is difficult; histopathology helps but is often impossible in
Samiran Bisai, PhD 4*
daily practice. Dermoscopy is increasingly utilized to diagnose
inflammatory disorders and has been used to differentiate PPP
1. Department of Dermatology, NRS
from HPKE. The present study was carried out to evaluate the
Medical College, Kolkata, West
Bengal, India
role of dermoscopy in the differentiation of PPP and HPKE in a
2. Department of Dermatology, Malda tertiary care center of eastern India.
Medical College, Malda, West Methods: This hospital-based observational study included
Bengal, India 20 patients with each of clinically diagnosed PPP and HPKE.
3. Raghunathpur SSH, Raghunathpur,
Dermoscopy examinations were done, and the results were
Purulia, West Bengal, India
tabulated and summarized. Fisher’s exact test was employed to
4. Department of Anthropology & TS,
assess statistical significances in differences.
Sidho Kanho Birsha University,
Purulia, West Bengal, India Results: Diffuse white and yellow scales were found in both
PPP and HPKE without any significant difference. Brown orange
*Corresponding author: globules, clustered dotted vessels, yellow, orange crusts, and
Samiran Bisai, PhD perilesional scaling were found more in HPKE (P < 0.05). On the
Department of Anthropology & TS,
other hand, uniformly dotted vessels and background erythema
Public Health & Nutrition Research
were more characteristic of PPP (P < 0.05). The results of the
Unit, Sidho Kanho Birsha University,
Purulia, West Bengal, India
current study had deviations from the results of studies done
Email: [email protected] abroad, which can be ascribed to differences in skin color.
Conclusion: Dermoscopy is a valuable tool to sort out diagnostic
dilemmas in cases of PPP and HPKE. It should be used more
commonly to gain more experience and information in the
diagnosis of inflammatory dermatoses.
Keywords: palmoplantar psoriasis, hyperkeratotic eczema, dermoscopy,
India

Iran J Dermatol 2021; 24: 214-219

Received: 30 July 2020
Accepted: 26 September 2020 DOI: 10.22034/ijd.2020.241867.1181

lesions elsewhere. Typically, psoriasis lesions are

INTRODUCTION well defined, scaly, and come with the frequent
The hands and feet are essential parts of the presence of fissures 1. The diffuse hyperkeratotic
body, mediating our interactions with the external variety is of primary interest in the present study.
environment. Consequently, involvement of these On the other hand, hyperkeratotic eczema
areas in chronic disease results in serious difficulties (HPKE)/tylotic eczema is another chronic condition
in daily activity. affecting the hands and feet 2. Clinical findings
Palmoplantar psoriasis (PPP) is a form of psoriasis include well-defined hyperkeratotic plaques on the
that may present alone or in the presence of psoriatic palms and on the palmar aspects of the fingers,

214 Iranian Journal of Dermatology © 2021 Iranian Society of Dermatology

Dermoscopy for differentiation of psoriasis and eczema

easily confused with PPP. The incidence of atopy findings and photography were examined and
or psoriasis in these patients is not increased as compared by an investigator (AA) blinded to the
compared to the general population 3. clinical diagnosis.
Both these conditions are recurring in nature The information from each patient was recorded
and interfere with daily activities. Histological into individual case record sheets before being
examination is often indicated to reach a compiled in a Microsoft Excel 2013 spreadsheet.
definitive diagnosis but is not possible routinely 4. Data were analyzed using descriptive statistics.
Differentiation between these two entities is Fisher’s exact test was employed to assess statistical
challenging in clinical practice but is necessary significance. A P-value < 0.05 was considered to
because of differences in prognosis, preventive be significant.
measures, and therapy 1.
The utility of dermoscopy (dermatoscopy) has
RESULTS
been expanding and has received recognition
in the field of inflammatory skin disorders The current study was conducted with 40
(inflammoscopy) 5-8. Dermoscopy has been utilized clinically diagnosed patients, including 20 PPP
as a handy tool in the differentiation of PPP from cases and 20 HPKE cases. The mean age of the
HPKE 9,10 and may serve to reduce the need for PPP group was 35 years (range: 25-65 years), while
biopsies 11,12. that of the HPKE group was 46 years (range: 35-
There is a dearth of data regarding the application 67 years). Males outnumbered females in both
of dermoscopy in cases of inflammatory dermatoses, groups; there were 12 males in the PPP group and
especially in its utility in the differentiation of 13 males patients in the HPKE group. The duration
PPP from HPKE. Thus, a study in this regard of disease was 19 months and 14 months in the
was found necessary. The aims and objectives of PPP and HPKE groups, respectively (Table 1).
the study were to evaluate the diagnostic utility Each patient was subjected to dermoscopy by
of dermoscopy in cases of PPP and HPKE of the one of the authors (AA), who was kept unaware of
palms and soles. the clinical diagnosis. The findings of dermoscopy
were tabulated on individual case sheets; the results
are presented in Table 2.
MATERIALS AND METHODS
The dermoscopy features most commonly found
The present study was hospital-based and in PPP (Figure 1) were background erythema and
observational in nature. Subjects were selected diffuse white scales (both present in 80% of patients),
randomly from those patients attending the hospital followed by the appearance of uniform dotted
clinic after being diagnosed clinically with PPP or vessels (60%). The most prevalent dermoscopy
HPKE over a period of one year. Exclusion criteria features of HPKE (Figure 2) were perilesional skin
consisted of topical or systemic therapy within the scaling (100%), followed by clusters of dotted vessels
last month. The study was conducted according to (70%) and brown-orange globules (65%). Diffuse
the Helsinki Declaration, and verbal consent was white scaling was present in both PPP and HPKE
obtained from the patients after being thoroughly (in 80% and 50% of patients, respectively). Brown-
informed about the study. orange globules were absent in PPP, while uniform
For examination, a dry digital polarized self- dotted vessels were absent in HPKE. Also, while
illuminating dermatoscope (Dino-Lite®) with uniform dotted vessels were exclusively found in
1.3 Megapixel resolution and magnification of
20x, 50x, and 200x was used. The dermatoscope Table 1. Age and sex characteristics of the patients
was connected to the USB port of the computer PPP HPKE
and switched on. It was held on the center of (n = 20) (n = 20)
the lesion and adjusted into focus. We used the Age range (year) 25 - 65 35 - 65
non-polarized mode to visualize surface findings, Average age (year) 35 46
Male to female ratio 12:8 13:7
while the polarized mode was used to note deeper
Duration of disease (month) 19 14
findings. The images were captured and transferred
Abbreviations: HPK, hyperkeratotic eczema; PPP, palmoplantar
to a computer via a USB cable. The dermoscopy psoriasis.

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Achar et al.

Table 2. Dermoscopy findings of the patients

PPP (n = 20) HPKE (n = 20)
Dermoscopy findings P-value
n (%) n ( %)
Diffuse white scales 16 (80) 10 (50) 0.0958
Yellowish scales 4 (20) 10 (50) 0.0958
Brown-orange globules 0 (0) 13 (65) <0.05
Uniform dotted vessels 12 (60) 0 (0) <0.05
Clusters of dotted vessels 2 (10) 14 (70) <0.05
Background erythema 16 (80) 4 (20) <0.05
Yellow-orange crusts 1 (5) 9 (45) <0.05
Increased scaling in surrounding skin 1 (5) 20 (100) <0.05
Abbreviations: HPK, hyperkeratotic eczema; PPP, palmoplantar psoriasis.

PPP, clusters of dotted vessels were found more scales (P > 0.05). The dermoscopy features that
in HPKE (70%) patients. favored the diagnosis of PPP rather than HPKE were
Statistically, the presence of white/whitish scales uniform dotted vessels (P < 0.05) and background
was not significantly different between the groups erythema (P < 0.05). On the other hand, findings
(P > 0.05). The same was true regarding yellow like brown-orange globules (P < 0.05), dotted vessels

b
Figure 1. (a, b). Dermatoscopic image of chronic plaque psoriasis. Red arrows represent uniformly distributed dotted vessels. Blue
arrows represent white scales distributed all over the lesion. Black arrows point out diffuse background erythema. Yellow arrows depict
yellowish scales and crusts.

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Dermoscopy for differentiation of psoriasis and eczema

c
Figure 2. (a, b, c). Dermatoscopic pictures of chronic hand and foot eczema. Blue arrows point at white scales throughout the lesion
and around the lesion. Black arrows represent erythema in the background. White arrows point at brown-orange globules. Red arrows
point at dotted vessels more prominent in (c).

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Achar et al.

in clusters (P < 0.05), yellow-orange crusts, and either by Lallas et al. 8 or by us. Thus, this may
increased scaling in surrounding skin were more be considered another reliable diagnostic feature
suggestive of HPKE rather than PPP (P < 0.05). present in PPP but not in HPKE.
The Errichetti and Stinco 9 study also revealed
brownish-orange globules and yellowish scales to be
DISCUSSION
present more in chronic eczema, and the difference
This study was conducted to assess the utility of was significant (P < 0.001). The current study holds
dermoscopy in differentiating between two often a similar observation and corroborates well with
confused entities involving the palms and soles, its predecessor. Thus, it may be speculated that
namely PPP and HPKE. the presence of yellow-orange crusts and yellow
Diffuse white scaling was found at a similar rate scales are dermoscopic features in favor of HPKE.
in both study groups (PPP and HPKE). The scales To the best of our knowledge, the present study
in PPP were white in color while they were yellow- is among the first studies to assess the utility of
orange in HPKE. This finding corroborates with the dermoscopy in differentiating PPP from chronic
findings of Errichetti and Stinco 9, who found diffuse palmoplantar eczema (HPKE). The presence of
scaling in both conditions. Lallas 8 also observed surrounding scales merging imperceptibly into
white scales in PPP and yellowish scales in HPKE normal skin is a feature that the present study
in diffuse distribution. Thus, the scales’ color can strongly suggests to indicate HPKE. This is a
be considered a useful dermoscopic variable for reflection of the rather ill-defined boundary of
differentiating between the two conditions. HPKE that we find clinically. The presence of
Dotted vessels were found in a uniform background erythema along with uniform dotted
distribution in our study in PPP, while they were vessels (the basis of the Auspitz sign) is suggestive
seen in clusters in HPKE. This former finding of PPP. The presence of diffuse scale smay indicate
agrees with the results of Errichetti and Stinco 9 and PPP or HPKE, but yellowish scales support the
Lallas et al. 8, both of whom found dotted vessels diagnosis of HPKE while white scales support
in 40% and 100% of cases, respectively. The latter PPP. The detection of abundant white scales
finding in the current study is corroborative with in dermoscopy is a reflection of the micaceous
the findings of Lallas et al. 8, who found vessels in scales classically seen in psoriasis. The presence
the patchy distribution in 59% of cases. Errichetti of yellowish scales, brown-orange globules, and
and Stinco 9, however, did not comment about the dotted vessels in clusters supports the diagnosis
vessels or their pattern in HPKE. It may hence be of HPKE. These features are a reflection of the
safely inferred that the finding of dotted vessels combination of hyperkeratosis and spongiosis
is fairly specific for PPP. seen histopathologically. A comparison of current
Background erythema was another common study findings with available literature is presented
feature (80%) found only in PPP cases in our study. in Table 3. The limitations of the investigation
This feature was also noted by Lallas et al. 8, who are that video-dermoscopy was not done and
found a ‘light red color’ in the background in histopathologic confirmation of diagnoses was
41% of PPP cases. This was not noted in HPKE not made.

Table 3. Comparison of current study findings with previous research

Author Findings in PPP Findings in HPKE
Errichetti & Stinco, 2016 9 White scales (100%) Yellow scales (90%)
Dotted vessels (40%) Yellow-orange crusts (63.6%)
White scales in patches (45.5%)
Lallas et al., 2014 8 White diffuse scales (70%) Patchy scale distribution (66%)
Regular vessel pattern (88%) Yellow scales (20%)
Dotted vessels (100%) Patchy pattern of vessels (59%)
Background light-red color (41%)
Current study Diffuse white scales (80%) Scaly surrounding skin (100%)
Uniform dotted vessels (60%) Dotted vessels in clusters (70%)
Background erythema (80%) Yellow-orange crusts and yellow scale (50%)
Abbreviations: HPK, hyperkeratotic eczema; PPP, palmoplantar psoriasis.

218 Iranian Journal of Dermatology © 2021 Iranian Society of Dermatology

Dermoscopy for differentiation of psoriasis and eczema

J Dermatol Venereol Leprol. 2012;78(5):569-82.

CONCLUSION
3. Simpson EL. Thompson MM, Hanifin JM. Prevalence
Regardless of the confinements of the current and morphology of hand eczema in patients with atopic
dermatitis. Dermatitis. 2006;17(3):123-7.
investigation, it may be concluded that dermoscopy
4. Jackson SM, Nesbitt LT. The diagnosis. In: Jackson
is a valuable and convenient apparatus for SM, Nesbitt LT (Eds). Differential diagnosis for the
distinguishing between instances of PPP and dermatologist. New York: Springer; 2012.
HPKE in the clinic. It should be used more often 5. Lallas A, Giacomel J, Argenziano G, et al. Dermoscopy in
to make confident diagnoses and gain experience general dermatology: practical tips for the clinician. Br J
Dermatol. 2014; 170(3):514–26.
in the diagnosis of inflammatory dermatoses
(inflammoscopy). 6. Errichetti E, Stinco G. The practical usefulness of
dermoscopy in general dermatology. G Ital Dermatol
Venereol. 2015;150(5):533–46.

Source of funding: Borne by investigators. 7. Micali G, Lacarrubba F, Massimino D, et al.

Dermatoscopy: alternative uses in daily clinical practice. J
Am Acad Dermatol. 2011;64(6):1135–46.
Conflict of interest: None declared. 8. Lallas A, Apalla Z, Argenziano G, et al. Dermoscopic
pattern of psoriatic lesions on specific body sites.
Dermatology. 2014;228(3):250–4.
Author contributions
9. Errichetti E, Stinco G. Dermoscopy in differential diagnosis
of palmar psoriasis and chronic hand eczema. J Dermatol.
Study design & conceptualization: AA, LG, SB. 2016;43(4):423-5
Data collection: AA, LG, SC, Formal analysis: SB. 10. Errichetti E, Lacarrubba F, Micali G, et al. Differentiation
Manuscript drafting: AA, LG, SC. Review & final of pityriasis lichenoides chronica from guttate psoriasis by
dermoscopy. Clin Exp Dermatol. 2015;40(7):804–6.
editing: AA, LG, SB.
11. Micali G, Nardone B, Scuderi A, et al. Videodermatoscopy
enhances diagnostic capability in some forms of
palmar and/or plantar psoriasis. Am J Clin Dermatol.
REFERENCES 2008;9(2):119–22.
1. Rao A, Khandpur S, Kalaivani M. A study of the 12. Calonje JE, Brenn T, Lazar AJF, et al. Spongiotic,
histopathology of palmo-plantar psoriasis and psoriasiform and pustular dermatoses. In: Calonje JE,
hyperkeratotic palmo-plantar dermatitis. Indian J Dermatol Brenn T, Lazar AJF, McKee PH (Eds). McKees pathology
Venereol Leprol. 2018;84(1):27-33. of the skin. Philadelphia, PA: Elsevier Saunders; 2012.
2. Lakshmi C, Srinivas CR. Hand eczema: An update. Indian

Iranian Journal of Dermatology, Vol 24, No 3, September 2021 219