Section 5 Miscellaneous

#### **Chapter 6**

## Dermatoscopic Findings in Palmoplantar Dermatoses

*Tubanur Çetinarslan, Ece Gökyayla and Aylin Türel Ermertcan*

#### **Abstract**

Dermatoscopy is a useful, non-invasive method in the diagnosis of various dermatological diseases. Dermatoscopy of non-pigmented skin lesions shows additional morphologic features, such as cutaneous vascular pattern, scale color and scale distribution pattern, and background color. Dermatoscopy can be useful tool in differential diagnosis in palmoplantar dermatoses. The most specific dermatoscopic features of hand eczema include yellowish-orange globules, yellowish scales and yellowish crusts. Light red background color, regular vascular distribution pattern, dotted vessels and white scale color have been reported in previous studies as dermatoscopic features of palmoplantar psoriasis. Dotted vessels can be seen in various dermatoses, such as psoriasis, eczema, lichen planus, porokeratosis and keratodermas. The distribution pattern and color of the scales are also important in the differential diagnosis of palmoplantar dermatoses. Previous studies have shown that scales are mainly localized in skin furrows in patients with tinea manum. Patchy distributed, homogeneous, structureless, orange areas were reported in palmar keratoderma due to pityriasis rubra pilaris. Amber scales, white-to-pinkish background; sparse whitish scales were reported in palmar keratoderma due to mycosis fungoides. Dermatoscopical findings of palmoplantar area can help in the differential diagnosis of various dermatoses.

**Keywords:** dermatoscopy, palmoplantar, eczema, psoriasis, tinea manuum

#### **1. Introduction**

Dermatoscopy is a useful, non-invasive and cost-effective diagnostic tool for benign and malignant skin tumors; it is also important in the clinical diagnosis of pigmentary disorders, hair-nail disorders, inflammatory and infectious diseases [1].

Palmoplantar dermatoses include a wide range of skin conditions. Dermatological diseases involving palmoplantar region are a common question when consulted in dermatological practice. The correct diagnosis is often easy on the basis of typical clinical characteristics, but could be difficult when several entities occur at the same time or overlap.

Many dermatological diseases can involve palmoplantar region; such as inflammatory dermatoses, infections and palmoplantar keratodermas (PPKs). In particular, differential diagnosis of inflammatory dermatoses such as eczema, psoriasis, pityriasis rubra pilaris (PRP), lichen planus may be more difficult in patients with isolated involvement of the palmoplantar region.

#### **2. Dermatoscopic findings in palmoplantar dermatoses**

#### **2.1 Inflammatory dermatoses**

Dermatoscopy has been shown to be a useful supportive tool to assist the diagnosis of inflammatory skin diseases [2–10].

In this section, dermatoscopical findings in inflammatory dermatoses localized in the palmoplantar region will be discussed.

#### *2.1.1 Psoriasis vulgaris*

Psoriasis is a common skin disorder that can affect people of all ages. Chronic plaque psoriasis (psoriasis vulgaris) is the most common form of the disease, and accounts for about 90% of cases [11]. Psoriasis can affect any skin site. Palmoplantar plaque psoriasis is a manifestation of plaque psoriasis which affects the palms and soles [12]. It could present as isolated palmoplantar involvement or may be associated with generalized psoriasis vulgaris [13, 14].

There are few studies in the literature regarding the use of dermatoscopy in palmoplantar psoriasis [2–4]. Dermatoscopy of palmoplantar plaque psoriasis shows a characteristic pattern consisting of diffuse white scales and symmetrically, regularly distributed dotted vessels on a light or dull red background [1–6]. It has been reported that the scale distribution pattern is rarely central or patchy [2, 5].

Although dotted vessels are a hallmark of trunk and extremity plaque psoriasis [6], as well as palmoplantar involvement [2], it should be remarked that this finding is not specific for psoriasis vulgaris. It could also be seen in eczema [2, 3], Bowen's disease [7], lichen nitidus [8], lichen simplex chronicus [15] and PRP [5, 9, 16]. Based on these findings, it can be suggested that dotted vessels may not be useful to distinguish psoriasis from other dermatoses, but the vascular distribution pattern may be beneficial in the differential diagnosis [2, 3, 17, 18].

Regular dotted vessels are the most common vascular distribution pattern in palmoplantar psoriasis [2, 3, 18]. Yu et al. found that beaded distributed dotted vessels along the sulci cutis is important new finding in psoriasis. It has been suggested that this finding, which is not seen in palmoplantar eczema, may be useful in differential diagnosis [4]. **Figure 1a** shows clinical view of palmar psoriasis vulgaris and **Figure 1b** shows regular dotted vessels on light red background.

**Figure 1.** *(a) Palmar psoriasis vulgaris. (b) Regular dotted vessels on a light red background.*

#### *Dermatoscopic Findings in Palmoplantar Dermatoses DOI: http://dx.doi.org/10.5772/intechopen.99746*

Vazquez-Lopez et al. described the vascular pattern that they specifically named "red globular rings" in plaque psoriasis lesions [19]. Lacarrubba et al. reported this pattern is a less common, but specific vascular pattern in plaque psoriasis lesions [20]. We showed red globular ring vessels in psoriasis also in palmoplantar lesions. Rarely, other vessel types have been reported in palmoplantar region [2].

Micali et al. showed dilated/tortuous "bushy" capillaries in all of the patients with palmar and/or plantar psoriasis by using videodermatoscopy. On the other hand, this pattern was not detected in patients with palmar and/or plantar eczema. Normal capillary pattern or dilated capillaries without tortuous or "bushy" appearance were showed in eczema [21].

The background color of the lesion, scale color and scale distribution pattern are useful findings to differentiate inflammatory dermatoses [2–10, 22].

Diffuse white scale is the most common scale distribution pattern in both the body and palmoplantar psoriasis lesions. The presence of diffuse white scales in psoriasis could explain with the dry and hyperkeratotic nature of plaque psoriasis [1, 15, 23]. Central and peripheral scale distribution patterns are very rare in psoriasis [2]. **Figure 2a** shows clinical view of palmar psoriasis and **Figure 1b** shows diffuse white scales along with the skin furrows. **Figure 3a** shows diffuse white scales in palmar plaque psoriasis.

It is recommended to examine the vascular structures after the scale is removed because of difficulty to show the vascular structures in palmoplantar region due to the presence of hyperkeratosis [3, 6, 24, 25]. In addition, it is suggested to use a fluid interface to reduce the scaling [6].

Lallas et al. examined the background color of the lesions in patients with plaque psoriasis, eczema, pityriasis rosea and lichen planus affecting the trunk and /or upper or lower extremities. They found that the most common background color was light red in psoriasis and, white versus yellow scales along with regular versus patchy distribution of dotted vessels may represent a valuable clue in the differential diagnosis of plaque psoriasis and nummular eczema [22]. Similarly, we found that light red is the most common background color in patients with palmoplantar psoriasis [2].

**Figure 2.** *(a) Palmar psoriasis vulgaris. (b) Diffuse white scales along with the skin furrows.*

**Figure 3.** *(a) Diffuse white scales in palmar psoriasis. (b) Yellowish background and patchy yellow scales in eczema.*

Specific clues can also be used in the differential diagnosis of inflammatory dermatoses. Palmar papular psoriasis can be differentiated from porokeratosis, with the absence of peripheral annular whitish keratotic track [26], and lichen planus, which is characterized by the detection of Wickham striae [26, 27].

In a recent study, Yu et al. investigated 26 patients with palmoplantar psoriasis and 31 patients with palmoplantar eczema. The most common dermatoscopic appearance of psoriasis was a red background, white scales, and dotted/globular/ hairpin type vessels in a regular arrangement, while the presence of pink background, yellow scales, and atypical blood vessels in an irregular arrangement were observed in eczema. The most specific dermatoscopical finding in psoriasis was hairpin type vessels (100%), and followed by regular arrangement of blood vessels (93.55%), red background color (87.1%), dotted or globular vessels (77.42%), and white scales (54.84%). They suggested that regular arrangement of vessels was the most valuable finding for the diagnosis of palmoplantar psoriasis and they reported that dotted vessels in beaded distribution pattern along the sulci cutis that cannot always be shown was very specific for psoriasis. They suggested that the most characteristic dermatoscopical finding of psoriasis is the regular distributed hairpin/ dots/globular vessels. It is assumed that the appearance of these vascular structures changes according to the position of the dermatoscope. When dermatoscope is perpendicular to dilated capillaries dotted/globular type vessels could be seen, ring/ hairpin type vessels could be seen when viewed with angle. Yu et al. showed hairpin type vessels in 34.6% of PP patients. However, they suggested that hairpin type vessels show a high diagnostic specificity for psoriasis. They also reported that, unlike in other studies [2, 3], the color of the scales was not significant in the differential diagnosis of eczema and psoriasis in the palmoplantar region [4].

Lallas et al. investigated 22 palmoplantar psoriasis lesions (14 on palms and 8 on soles) under dermatoscopy. They showed diffuse white scales and regular dotted vessels. Dotted vessels were seen in 90% of lesions, this ratio was the lowest compared to other body parts. They explained this finding by the thickness of the epidermis of palmoplantar region, which possibly impedes the visualization. They showed white scales in all palmoplantar lesions [6].

We examined dermatoscopic findings of 90 patients, 35 palmoplantar pustular psoriasis and 55 palmoplantar hyperkeratotic eczema. Similar to other studies, we showed red background color, regular vascular distribution pattern, red globular ring vessels and white scale color in psoriasis in our study [2].

#### *2.1.2 Pustular psoriasis*

Palmoplantar pustular psoriasis (PPP) is a chronic immune-mediated skin disease that mainly affects women in the fourth to seventh decade of life. It is a debilitating disease of the palms and/or soles and show high resistance to treatment [28]; in addition has a high impact on health-related life quality [29]. PPP is characterized by eruptive, sterile intraepidermal pustules on the palms and soles, with psoriasis vulgaris-like erythematous and desquamating lesions [14].

Pustular psoriasis shows yellow globules correspond to non-follicular superficial pustules; and regularly distributed dotted vessels correspond to papillary dermal vessels dilatation. In addition, white or yellow scales or crusts may also occur [5, 10, 15, 30].

Although pustules are not visible on clinical examination, yellow globules may be seen with dermatoscopy even at initial stages [30–32].

Palmoplantar pustulosis, or pustulosis palmaris et plantaris, is a chronic inflammatory and recurrent skin disease with clinical findings of erythema, scales and pustules on the palms and soles. In the advanced stage, the lesions consist of numerous pustules on an erythematous-squamous base [33]. To the our knowledge, there is no previous report about dermatoscopical findings in palmoplantar pustulosis. We showed white scales, yellow globules and regular dotted vessels similar to palmoplantar pustular psoriasis. **Figure 4a** shows clinical view of palmoplantar pustulosis and **Figure 4b** shows yellow globules, white scales and regular dotted vessels.

#### **2.2 Eczema**

Chronic hand eczema (CHE) clinically presents with sharply demarcated areas of thick scaling or hyperkeratosis on the proximal or middle aspect of the palms [34]. Eczematous dermatitis shows some differences according to the disease stage. Acute exudative lesions represent yellow scales/crusts and chronic lesions demonstrate patched distributed dotted vessels with scaling [15, 22, 35].

The characteristic dermatoscopic findings of CHE include yellowish scales, brownish-orange dots/globules, and yellowish-orange crusts [3, 5]. **Figure 3b** shows yellowish background and patchy yellow scales in eczema.

Patchy dotted vessels with yellow scales are indicative of eczema in body and extremity lesions [22]. Errichetti et al. suggested that dermatoscopic features of CHE is similar to eczematous dermatitis localized on other sites. Dermatoscopic features of CHE includes yellowish scaling with or without white scales, yellowish crusts and focal dotted vessels [1, 15, 23]. Similar to previous studies [18, 22], patchy vascular distribution pattern and dotted vessels have also been demonstrated in the palmoplantar region of eczema patients [2, 3]. Glomerular, linear and hairpin vessels have been rarely reported in CHE [2, 3].

Errichetti et al. reported dermatoscopic findings of 10 patients with palmar psoriasis and 11 patients with CHE. Yellowish scales, brownish-orange dots/ globules and yellowish-orange crusts have been shown in CHE. It was suggested that the presence of brownish-orange dots/globules corresponds to tiny spongiotic vesicles. Palmoplantar spongiotic vesicles have a higher resistance to rupture compared with other areas because of the increased thickness of the keratin layer at these sites [3]. Similarly, we showed yellow-orange crusts, patchy vascular distribution pattern, brownish-orange globules, yellow scale color and dull red background color in CHE in our study [2]. Yu et al. found that brown-orangeyellow dots are significant for the diagnosis of palmoplantar eczema [4]. Yellowish scales, brownish orange dots/globules and yellowish-orange crusts show the spongiotic nature of CHE [1, 3].

**Figure 5a** shows clinical view of dyshidrotic eczema and **Figure 5b** shows yellowish background, brownish-orange globules and yellow scales in dyshidrotic eczema.

We also observed globule structures with pale center and dark peripheral rim only in patients with CHE, which was thought due to spongiosis progressing to vesicle formation that suggesting eczema. Dark peripheral rim may be associated with hyperkeratotic foci around vesicles [2]. **Figure 6a** shows globule structures with pale center and dark peripheral rim in CHE. **Figure 6b** shows yellowish background, brownish-orange globules and yellow scales in CHE.

**Figure 5.** *(a) Dyshidrotic eczema. (b) Yellowish background, brownish-orange globules and yellow scales in dyshidrotic eczema.*

*Dermatoscopic Findings in Palmoplantar Dermatoses DOI: http://dx.doi.org/10.5772/intechopen.99746*

#### **Figure 6.**

*(a) Globule structures with pale center and dark peripheral rim in chronic hand eczema. (b) Yellowish background, brownish-orange globules and yellow scales in chronic hand eczema.*

Errichetti et al. noticed a higher prevalence of scaling than vessels compared to other studies. This difference could be explained by the use of an interface fluid in the previous studies which improved the visualization of the vessels [6].

It has been suggested that the color of scales (white vs. yellow) is the most useful clue for distinguishing psoriasis and eczematous dermatitis in body localizations [1, 15, 23]. In previous studies, yellow is the main scale color in palmoplantar eczema [2, 3]. The histopathological reason for this color is irregular hyperplasia of the spinous layer, spongiotic edema, and serous exudation of the cuticle layer [4].

Unlike other studies, Yu et al. suggested that scale color in palmoplantar psoriasis is similar to eczema because of the topical drug usage and the presence of a thicker corneous layer. They also showed atypical vessels and dark red stasis around cracks in palmoplantar eczema. This finding could be explained by itch-provoked excoriations [4]. **Figure 4a** shows globule structures with pale center and dark peripheral rim in chronic hand eczema and **Figure 4b** shows yellowish background, brownish-orange globules and yellow scales in CHE.

#### **2.3 Keratodermas**

Palmoplantar keratodermas (PPKs) are diverse group of disorders that are characterized by abnormal thickening of the skin on the palms and soles. PPKs may be divided into acquired and genetic types [36].

Acquired PPKs lesions have a wide range of clinical appearances: diffuse, focal, and punctate. There are many causes of acquired PPKs [37].

In this section, dermatoscopic findings of PPKs will be discussed. There are a few publications on dermatoscopy of PPKs in the literature.

#### *2.3.1 Keratoderma due to pityriasis rubra pilaris*

PRP is an inflammatory skin disease, and its most common presentation is characterized by follicular and palmoplantar hyperkeratosis and orange-red scaling plaques [38].

Papular lesions of classic PRP usually reveal round/oval yellowish areas surrounded by vessels of mixed morphology (i.e., linear and dotted) and often centered by central keratin plugs on body lesions [10, 15, 25, 39]. It has been suggested

#### *Dermatoscopy*

that orange-colored areas in PRP-related acquired keratoderma is compatible with the clinical finding of such a tint in PRP [25, 40, 41].

There is only one report in the literature reporting dermatoscopic findings in palmar keratoderma due to PRP. Errichetti et al. reported dermatoscopic findings in four palmar acquired keratoderma patients (1 psoriasis, 1 eczema, 1 PRP, 1 mycosis fungoides (MF)) in their study. They reported monomorphous aspect consisting of whitish scaling with patchy distributed, homogeneous, structureless, orange areas presenting with different sizes in palmar acquired keratoderma due to PRP. Non-specific dermatoscopic structures, including whitish scaling and reddish fissures could be seen [25].

#### *2.3.2 Keratoderma due to mycosis fungoides*

Mycosis fungoides (MF), the most common cutaneous T-cell lymphoma, typically presents with inflammatory erythematous patches or plaques in its early stage. There is only one publication in the literature reporting dermatoscopic findings in palmar acquired keratoderma due to MF. It has been observed relatively large, amber scales over a white-to-pinkish background; sparse whitish scales and several non-specific reddish fissures in palmar acquired keratoderma due to MF [25].

They concluded that the presence of large amber scales and a pale background in MF-related acquired keratoderma might be due to the marked/compact hyperkeratosis/ acanthosis [25, 40, 42].

#### *2.3.3 Aquagenic syringeal acrokeratoderma*

Aquagenic syringeal acrokeratoderma (ASA) is a rare acquired condition characterized by translucent papules and plaques with apparent eccrine duct openings. The lesions appear only after a 2- to 4-minute exposure to water. ASA is more common on palmar surface, although the dorsal surfaces of the hands and plantar region could also be involved [43].

Fernández-Crehuet et al. investigated four patients with ASA and, observed the presence of well-defined yellowish globules not affecting dermatoglyphics in all of their patients. They suggested that these structures could be due to widening of the excretory ducts of eccrine sweat glands [44].

Sezer et al. found larger sweat duct pores compared with normal palmar region, reflecting the dilated and tortuous acrosyringium [45].

Lacarrubba et al. showed a hypertrophic stratum corneum with deepening of normal dermatoglyphics and a marked dilatation of eccrine ostia, both configuring a gruyere-like aspect in a 19-year-old woman with cystic fibrosis [46].

#### **2.4 Lichen planus**

Palmoplantar lichen planus (LP) is an uncommon localized variant of lichen planus [47].

Errichetti et al. reported that palmar LP is characterized by roundish yellowish areas often having peripheral projections that may create a star-like appearance; a purplish background is sometimes visible [5].

Wickham striae are typically white, they could also appear yellow on palmoplantar areas [5, 10, 15].

**Figure 7a** shows clinical view of palmoplantar LP. **Figure 7b** shows brownish areas and Wickham stria on a purplish background.

*Dermatoscopic Findings in Palmoplantar Dermatoses DOI: http://dx.doi.org/10.5772/intechopen.99746*

**Figure 7.** *(a) Palmar lichen planus. (b) Brownish areas and Wickham stria on a purplish background.*

#### **2.5 Lichen nitidus**

Lichen nitidus is a relatively uncommon chronic inflammatory disease which is presented with 1–2 mm, shiny, flat-topped, pale to skin-colored, clustered papules. The lesions mostly seen over the penis, lower abdomen, medial surface of the thighs, dorsal hands, forearms and buttocks [48]. It can be seen on palmoplantar region, nail and mucosa uncommonly [49].

Qian et al. reported well-defined depressions with fewer, thinner scales, surrounded with obvious ring-shaped, silvery-white scales on the palmoplantar sites. They suggested that the variation of pit patterns on palmoplantar area under dermatoscopy depends on epidermal hyperkeratosis, persistent mechanical stress, and thickness of stratum corneum. On the other hand, dermatoscopical findings of lichen nitidus on other localizations showed round, elevated, shiny and smooth surface without scales in their study [50].

#### **3. Infectious diseases**

Dermatoscopy is a helpful tool in the diagnosis of various infectious diseases. In this section, dermatoscopic findings reported on infectious diseases involving the palmoplantar region will be discussed.

#### **3.1 Tinea manuum**

Tinea manuum is a superficial mycosis of the palm, dorsum, or interdigital folds of one or both hands. It is usually caused by dermatophytes [41].

Errichetti et al. reported that whitish scaling mainly located in the furrows is specific for tinea manuum. They explained this finding with the localization of dermatophytes to proliferate in moist environment, such as palmar furrows [13].

#### *Dermatoscopy*

Jakhar et al. also reported that dotted vessels only in the skin furrows is another dermatoscopic finding in tinea manuum. They explained this vascular finding with the reactionary vasodilatation of vessels in response to inflammatory process induced by dermatophytes [5, 51, 52].

#### **3.2 Tinea nigra**

Tinea nigra (TN) is a rare superficial cutaneous mycosis caused by Hortaea werneckii. Dermatoscopy is a fast and effective tool for the diagnostic suspicion of TN. Multiple light brown thin lines that cross forming a weave is characteristic dermatoscopic finding in TN [53]. Navarrete et al. also defined hyperchromic patch with a regular distribution of the pigmentation and the spicules on the edges [54]. Guarenti et al. examined an 11-year-old girl with TN and demonstrated a homogeneous nonmelanocytic pigmented pattern with spicules [55]. The pigmentation in TN does not follow the parallel ridges pattern described for melanomas [39]. However, there are some reported cases contrary to this information [56, 57].

#### **3.3 Palmar syphiloderm**

Syphilis is a chronic, systemic infection that mimics many dermatological diseases. Secondary syphilis is classically characterized by a copper- colored maculopapular rash with sharply delineated margins typically present on the palmar and plantar surfaces [13].

Errichetti et al. showed an orangish background and a thin, whitish, annular, scaling edge progressing in an outward direction and often surrounded by an erythematous halo in palmar syphiloderm [27].

It has been suggested that the presence of an orangish background corresponds to hemosiderin deposits in the dermis as a consequence of extravasation of erythrocytes, typical for secondary syphilitic lesions [5]. Palmar syphilis lesions may be confused with palmar papular psoriasis. Palmar papular psoriasis shows no orangish areas/ background and, this has been emphasized as an important finding in differential diagnosis. The diffuse/regular distributed dotted vessels may be seen in both psoriasis and palmar syphiloderm, consequently it may not be useful in the differential diagnosis [58].

Tognetti et al. showed a circular, thin, scaling edge progressing in an outward direction and surrounded by an erythematous halo (the so-called Biett's collarette) as a diagnostic indicator, even in clinically non-scaling lesions in palmar syphiloderm [58]. Errichetti et al. reported thicker scaling ring and lacking of erythematous halo [3, 6, 25].

#### **3.4 Pitted keratolysis**

Pitted keratolysis is a bacterial infection of plantar region which caused by Gram-positive bacteria, especially *Corynebacterium spp* [59]*.* Hyperhidrosis, long standing occlusion and increased skin pH are predisposing factors. In an appropriate environment, bacteria proliferate and secrete keratin-degrading enzymes which are responsible for pitted appearance. Patients usually present with irritated, malodored, hyperhidrotic soles with small, multiple pits on them. Lockwood et al. identified dermatoscopy of pitted keratolysis in a case report as irregularly distributed pits with heterogeneously architecture pit walls [60].

#### **3.5 Verruca plantaris**

Verruca plantaris is a common human papilloma virus (HPV) infection which presents with solitary or multiple slightly elevated hyperkeratotic papules/plaques on soles. Due to plantar region's anatomical features, warts located in this area tend to ingrown. So far, HPV-1, −2, −3, −4, −27, −29, −57, −60, −63, −65, −66, and − 69 are isolated from verruca plantaris [61]. Although we can see tiny black dots which represent thrombosed, dilated capillaries on these hyperkeratotic papules with naked eye on occasion, in some cases it can not be seen and dermatoscopic examination is beneficial in these patients without paring the lesion. Lee el al. reported dermatoscopy of verruca plantaris as black and red dots on hyperkeratotic papilliform surface under polarized light [62].

### **4. Traumatic changes**

#### **4.1 Callus**

Callus is localized hyperkeratosis of epidermis as a reaction of chronic irregular pressure or friction. It is mostly recognizable with naked eye, however in some cases clinicians have to make differential diagnosis between verruca and callus. Bae et al. showed homogenous opacity is diagnostic for callus and easily distinguishable from verruca under polarized light dermatoscopy [63].

#### **4.2 Subcorneal hemorrhage**

Subcorneal hemorrhage is a pigmented macule mainly located on palms and soles after trauma. By the reason of its similarity to acral melanocytic lesions and sometimes patient could not remember the history of trauma, it is important to

**Figure 8.** *(a) Subcorneal hemorrhage. (b) Red-black satellite globules on a red-brown background.*

distinguish. Complete or partial removal of pigmentation under scratch test is indicative for subcorneal hemorrhage. Zalaudek et al. reported sharp-dermarcated red-black homogeneous area with satellite globules in subcorneal hemorrhage [64]. **Figure 8a** shows subcorneal hemorrhage on toe and **Figure 8b** shows red-black satellite globules on a red-brown background.

#### **5. Other diseases**

#### **5.1 Circumscribed palmar hypokeratosis**

Circumscribed palmar hypokeratosis (CPH) is a rare epidermal malformation described by Perez in 2002 [65]. It is characterized by a localized reduction of the stratum corneum and typically presents as an isolated, well-circumscribed, atrophic, annular erythematous plaque with a slightly raised scaly border on the palmar surface, most commonly on the thenar or hypothenar eminence [66]. The exact mechanism of CPH is unknown, but it has been suggested that it may be due to local micro-trauma because of late onset and localization of lesions [66].

There are few studies in the literature describing the dermatoscopic findings of CPH. Ishiko et al. described that characteristic features of palmar hypokeratosis are stair-like desquamation and a homogeneous erythema with regularly distributed whitish spot (without jelly; erythema with stair-like desquamation with jelly; structureless erythema with regularly distributed whitish spots) [67]. Nishimura et al. confirmed stair-like desquamation and well-demarcated erythema scattered with white spots. They showed small reddish dots in the erythema that show the congestive capillaries in the papillary dermis [68].

Vilas Boas da Silva et al. showed dotted vessels over an erythematous background, along with and a vertical interruption and a moth-eaten profile in three women [66]. They also described the whitish streaks as another dermatoscopical finding of CPH for the first time [66]. It has been suggested that the white spots represent acrosyringium and correspond to marked hypokeratosis. The whitish streaks indicates furrows that are deeper on the hypothenar eminence. The reasons of the erythematous background might be the chronic inflammatory infiltrate, congestive capillaries, and thinned horny layer [68].

Considering the dermatoscopical and clinical findings of CPH, the main differential diagnoses are Bowen's disease and Mibelli porokeratosis. The characteristic dermatoscopical findings of Bowen's disease are clustered glomerular vessels, dry scales, small brown globules and structureless gray to brown pigmentation [66, 69]. Red spots shown in CPH may be confused with glomerular vessels seen in Bowen's disease. Asymmetric and clustered distribution of vessels seen in Bowen's disease can be helpful differentiating it from CPH. Porokeratosis shows a double rim of scale, however the characteristic stair-like desquamation rim is present in CPH. The central part of porokeratosis is usually hypopigmented and reveals dotted vessels. CPH shows white dots and whitish streaks which are not seen in porokeratosis may help in differentiating of these two diseases [66].

#### **Conflict of interest**

No conflict of interest.

*Dermatoscopic Findings in Palmoplantar Dermatoses DOI: http://dx.doi.org/10.5772/intechopen.99746*

#### **Author details**

Tubanur Çetinarslan1 \*, Ece Gökyayla<sup>2</sup> and Aylin Türel Ermertcan2

1 Dermatology Clinic, Kırıkkale Yüksek İhtisas Hospital, Kırıkkale, Turkey

2 Department of Dermatology, Manisa Celal Bayar University, Manisa, Turkey

\*Address all correspondence to: t\_sarmis@windowslive.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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*Dermatoscopic Findings in Palmoplantar Dermatoses DOI: http://dx.doi.org/10.5772/intechopen.99746*

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[21] 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 2008; 9: 119-122.

[22] Lallas A, Kyrgidis A, Tzellos TG, et al. Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea. Br J Dermatol 2012; 166: 1198-1205.

[23] Lallas A, Zalaudek I, Argenziano G, et al. Dermoscopy in general dermatology. Dermatol Clin 2013; 31: 679-694.

[24] Calonje JE, Brenn T, Lazar AJF, et al. Spongiotic, psoriasiform and pustular dermatoses. In: Calonje JE, Brenn T, Lazar AJF, McKee PH, eds. McKees Pathology of the Skin, 4th edn. Philadelphia, PA: Elsevier Saunders: 2012. p. 183-184.

[25] Errichetti E, Stinco G. Dermoscopy as a supportive instrument in the differentiation of the main types of acquired keratoderma due to dermatological disorders. J Eur Acad Dermatol Venereol. 2016; 30(12): 229-231.

[26] Calonje E, Neill S, Bunker C, et al. Diseases of the anogenital skin. In: Calonje E, Brenn T, Lazar A, et al. (eds) McKee's pathology of the skin, 4th ed. Edinburgh, United Kingdom: Elsevier Saunders, 2012. p. 465-472.

[27] Errichetti E, Stinco G. Dermoscopy in differentiating palmar syphiloderm from palmar papular psoriasis. Int J STD AIDS. 2017; 28(14): 1461-1463.

[28] Mrowietz U. Pustular eruptions of palms and soles. In: Goldsmith, ed. Fitzpatrick's Dermatology in General Medicine. New York: McGraw-Hill; 2012. p. 252-259.

[29] Meier M, Sheth PB. Clinical spectrum and severity of psoriasis. Curr Probl Dermatol. 2009; 38:1-20.

[30] Lallas A, Errichetti E. Papulosquamous disorders. In: Lallas A, Errichetti E, Ioannides D, eds. Dermatoscopy in General Dermatology. Boca Raton, FL: CRC Press; 2018. p. 2-51

[31] Errichetti E, Pegolo E, Stinco G. Dermatoscopy as an auxiliary tool in the early differential diagnosis of acute generalized exanthematous pustulosis (AGEP) and exanthematous (morbilliform) drug eruption. J Am Acad Dermatol 2016; 74: 29-31.

[32] Errichetti E, Stinco G. Dermatoscopy in life-threatening and severe acute rashes. Clin Dermatol. 2020; 38(1): 113-121.

[33] M. Uehara, S. Ofuji, The morphogenesis of pustulosis palmaris et plantaris, Arch. Dermatol. 1974; 109 (4): 518-520.

[34] Hersle K, Mobacken H. Hyperkeratotic dermatitis of the palms. Br J Dermatol. 1982; 107: 195-202.

[35] Errichetti E, Piccirillo A, Stinco G. Dermoscopy as an auxiliary tool in the differentiation of the main types of erythroderma due to dermatological disorders. Int J Dermatol 2016; 55: 616-618.

[36] Braun-Falco M. Hereditary palmoplantar keratodermas. J Dtsch Dermatol Ges 2009; 7: 971-984; quiz 84-5.

[37] Schiller S, Seebode C, Hennies HC, et al. Palmoplantar keratoderma (PPK): acquired and genetic causes of a not so rare disease. JDDG: Journal Der Deutschen Dermatologischen Gesellschaft 2014; 12(9): 781-788.

[38] Roenneberg S, Biedermann T. Pityriasis rubra pilaris: algorithms for diagnosis and treatment. J Eur Acad Dermatol Venereol. 2018; 32(6): 889-898.

[39] Giordano LMC, De la Fuente LA, Lorca JMB, et al. Tinea nigra: Report of three pediatrics cases. Rev Chil Pediatr. 2018; 89(4): 506-510.

[40] Aram H, Zeidenbaum M. Palmoplantar hyperkeratosis in mycosis fungoides. J Am Acad Dermatol 1985; 13: 897-899.

[41] Elewski BE, Greer DL. Hendersonula toruloidea and Scytalidium hyalinum. Review and update. Arch Dermatol. 1991; 127(7): 1041-1044.

[42] Goodlad J, Calonje E. Cutaneous lymphoproliferative diseases and related disorders. In: Calonje JE, Brenn T, Lazar AJF, McKee PH, eds. McKee's Pathology of the Skin, 4th edn. Elsevier Saunders, Philadelphia, 2012. p. 1313-1340.

[43] Yan AC, Aasi SZ, Alms WJ, et al. Aquagenic palmoplantar keratoderma. J Am Acad Dermatol 2001; 44: 696-699.

[44] Fernández-Crehuet P, Ruiz-Villaverde R. Dermoscopic features of aquagenic syringeal acrokeratoderma. Int J Dermatol. 2016; 55(7): 407-408.

[45] Sezer E, Erkek E, Duman D, et al. Dermatoscopy as an adjunctive diagnostic tool in aquagenic syringeal acrokeratoderma. Dermatology. 2012; 225(2): 97-99.

[46] Lacarrubba F, Verzì AE, Leonardi S, et al. Palmar wrinkling: Identification of a peculiar pattern at incident light dermoscopy with confocal microscopy correlation. J Am Acad Dermatol. 2016; 75(4): 143-145.

[47] Landis M, Bohyer C, Bahrami S, et al. Palmoplantar lichen planus: A rare presentation of a common disease. J Dermatol Case Rep. 2008; 2:8-10.

[48] James WD, Elston DM, Berger TG. Clinical Dermatology. 11th ed. United Kingdom: Saunders Elsevier; 2011. p. 222-223.

[49] Park SH, Kim SW, Noh TW, et al. A Case of Palmar Lichen Nitidus Presenting as a Clinical Feature of Pompholyx. Ann Dermatol. 2010; 22: 235-237.

[50] Qian G, Wang H, Wu J, et al. Different dermoscopic patterns of palmoplantar and nonpalmoplantar lichen nitidus. J Am Acad Dermatol. 2015; 73(3): 101-103.

[51] Errichetti E, Stinco G. Dermoscopy in tinea manuum. An Bras Dermatol. 2018; 93(3): 447-448.

[52] Jakhar D, Kaur I, Sonthalia S. Dermoscopy of Tinea Manuum. Indian Dermatol Online J. 2019; 10(2): 210-211.

[53] Cabo H. Dermatoscopia, Segunda edición, Buenos Aires 2016, Ediciones Journal, 14 p. 328.

[54] Navarrete M, Castillo A, Sánchez A, et al. Dermatología CMQ 2012; 10(3): 205-211.

[55] Guarenti IM, Almeida HL Jr, Leitão AH, et al. Scanning electron microscopy of tinea nigra. An Bras Dermatol. 2014; 89(2): 334-336.

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[57] Nazzaro G, Ponziani A, Cavicchini S. Tinea nigra: A diagnostic pitfall. J Am Acad Dermatol 2016; 75: 219-220.

[58] Tognetti L, Sbano P, Fimiani M, et al. Dermoscopy of Biett's sign and differential diagnosis with annular maculo-papular rashes with scaling. Indian J Dermatol Venereol Leprol 2017; 83: 270-273.

[59] Bristow IR, Lee YL. Pitted keratolysis: a clinical review. J Am Podiatr Med Assoc. 2014; 104(2): 177-182.

[60] Lockwood LL, Gehrke S, Navarini AA. Dermoscopy of Pitted Keratolysis. Case Rep Dermatol. 2010; 2(2):146-148.

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#### **Chapter 7**

## Precautions on Contact Dermatoscopy and Other Practices in the Pandemic of COVID-19

*Walid Al-Zyoud and Dana Erekat*

#### **Abstract**

In the age of the pandemic of COVID-19, there is a considerable need for hospitals that triggers many challenges for health care providers to keep themselves and their patients protected from any nosocomial infections, including viral, fungal and bacterial infections. Among health care providers, dermatologists play a vital role in performing dermatoscopy free from *Staphylococcus epidermidis*, *Micrococcus*, and *Corynebacterium* species reported to be identified on the dermoscopic lenses and their adaptors. There is also a possibility for SARS-CoV-2, a member of coronaviruses, to be transmissible from patient to a physician or vice versa or even from a physician to one of her or his family members. SARS-CoV-2 can be transferred through the mucus membranes of the human eyes. This chapter will flag the importance of having a detailed list of precautions for dermatologists and patients to make clinical practice as safe as possible.

**Keywords:** dermatoscopy, COVID-19, nosocomial, precautions, dermatology

#### **1. Introduction**

The novel coronavirus (SARS-CoV-2 or 2019-nCoV) originated in Wuhan, China, in December 2019 and caused deadly acute respiratory syndrome and hence the pandemic COVID-19 [1] with an exponential increase in the number of infected persons. It is well-known that the pandemic of COVID-19 has affected everyone and every sector we are involved in, either physically mentally or even economically. One of the most affected sectors is the sector of public health. The health care providers represent the front line defence and the most critical components of any healthcare system across the globe. The pandemic of COVID-19 has put an unprecedented challenge on the healthcare providers, including dermatologists [2, 3] to cope with such an outbreak. Many studies have reported that SARS-CoV-2 can stay on inanimate surfaces such as stainless steel, copper, plastics, and papers [4–6]. Our contact with lifeless surfaces might represent a source of infection if we contact a living tissue or mucus of suspected or confirmed cases of COVID-19; this was our motivation to write this chapter to summarise precautions from the literature on how dermatologists can apply some contact practices when dealing with expected infections. This chapter has been divided into five sections: the first section of the introduction; section two about consent and precaution; section three about aesthetic procedure protection, section four about general principles, and the last section about dermatoscopy procedures. The chapter references focused on the published expertise of

the prestigious Indian Association of Dermatologists Venereologists and Leprologists (IADVL) and the World Health Organisation (WHO) in this field.

#### **2. Consent and precaution**

The dermatologist and patient should consider the precautions of the COVID-19 pandemic. A dermatologist's ability to manage their patients care is the single most critical criterion for patient safety. Depending on the type of treatment being conducted, the risk-benefit ratio of undergoing a procedure should be considered. Procedures that need many appointments to the institution for follow-up are best postponed, so performing treatments requiring the least number of sessions is preferable [7]. Patients should be aware of the possibility of being exposed to the infection on their visit to the healthcare facility. It is better if the dermatologist explains the risk of invasiveness of the treatment and contracting the virus. The dermatologist may also list the side effects of the procedure that may need counselling pre-procedure. Patients on treatment after the pandemic may need to be monitored by video teleconsultation serial imaging, or followed up with a USB or portable patient-friendly dermatoscope, while some other patients starting treatments may still need to undergo onsite visits and procedures [7].

It was proven that even vaccinated individuals can get infected with COVID-19 [8]. If any staff member tests positive or expresses symptoms of infection, the personnel should undergo screen testing with Polymerase Chain Reaction (PCR). According to the Centers of Disease Control (CDC) in the United States of America, the individual with a positive result should remain in quarantine until testing negative after 5 to 7 days if the individual is fully vaccinated and after 14 days if not fully vaccinated to prevent the spread of the virus [9]. Rotational shifts of staff members, in which staff members are divided into two teams for 7 days on-duty and 7 days off-duty, might be a viable alternative [10].

It is essential to support medical staff mentally during the pandemic and on the other hand avoid frightening the patients in an excessive way so that they do not abstain from medically justified procedures, including skin cancer surgery. Some individuals might seek counselling sessions and therapy to stay in their best mind and energy through the tough times. This allows the staff to stay more balanced about the seriousness of the virus.

#### **2.1 Waiting, consultation, and operating rooms precaution**

Disposable masks and sanitizers should be offered to the patients at the entrance of the healthcare institute, as all patients should enter with three layered or cotton masks. Gloves can be provided as extra protection to avoid direct skin contact with surfaces that may be exposed to the virus. A thermometer should be used at the entrance to measure the fever of individuals before entering the facility, as high fever can be a sign of infection. The waiting rooms should adhere to social distancing, with 2 meters (~6 feet) distance between individuals [11]. To avoid overcrowding, patients are allowed to have one or even no companion with them to the appointment. The waiting room should be made only available for individuals who come in time for their appointments. If a person is late, the appointment should be rescheduled for another time. The patient should be transferred promptly to the consultation room without waiting long in the waiting area, and social distance is essential even if a close inspection is required during counselling [10].

The staff must disinfect all devices and tools that come in contact with the patient. The operating rooms must be sterilised after each patient [12]. To avoid contact with

*Precautions on Contact Dermatoscopy and Other Practices in the Pandemic of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.102386*

**Figure 2.**

*Steps to take off PPEs, including gown.*

numerous surfaces throughout the process, the patient should be required to wear a gown or overall. To disinfect the operating rooms, remove all machines, beds, stools, and chairs from the room and spray a sodium hypochlorite solution over all surfaces, including the floor, doors, windows, curtains, and cupboards [10]. The operating rooms should have ventilation and enhanced airflow. A powerful exhaust fan can be used in the operation area to optimise airflow, with stand-alone air conditioning devices in the rooms instead of the central air conditioning system [10].

#### **2.2 Personalised protective equipment (PPE)**

PPEs are protective equipment meant to protect employees' health by limiting their exposure to viruses. Goggles, face shields, masks, gloves, coveralls/gowns (with or without aprons), head cover, and shoe covers are all examples of PPE. It is advised for all the staff in the clinic to use PPE for extra protection from the virus. The PPE kit differs depending on the procedure and an individual's risk of exposure.

Gown, mask, goggles/face shield, then gloves are the steps in the PPEs donning sequence, whereas gloves, goggles/face shield, gown, mask, then hand hygiene or gown and gloves, goggles/face shield, mask, and lastly, hand hygiene are the steps in the PPEs doffing sequence (**Figures 1** and **2**). Hand hygiene should be conducted before going on to the next stage if hands contact any contaminated PPE surface. They should be disposed of accordingly, depending on the procedure. The interior of the biohazard bag should be treated with a 1 per cent sodium hypochlorite solution before being knotted, and the exterior should be decontaminated with 1 per cent sodium hypochlorite [10].

The N-95 masks can be used multiple times if disinfected correctly. The authors in the reference below suggest that masks can be discarded after five usages. After use, place the mask in a permeable paper mask and set it aside for 4 days to dry. On day 6, it should be used again. Similarly, vaporised hydrogen peroxide and U.V. germicidal radiation (UVC 254 nm) can also be used to decontaminate the N-95 masks [10].

#### **3. Aesthetic procedure protection**

The aesthetic procedures are classified into three categories depending on the invasiveness of the procedure; these categories are invasive, minimally invasive, and non-invasive. According to the Indian Association of Dermatologists Venereologists


#### **Table 1.**

*Protection and precautions of the aesthetic procedures to be utilised.*

and Leprologists (IADVL) each category requires different protection and precautions [7] summarised in **Table 1**. Invasive procedures include those that have the potential for aerosolisation and ablation because they expose the patient and health workers to the infection [7]. It is advised only to perform invasive procedures if no other treatment is possible. The non-invasive procedures require basic protection and caution. The dermatologist should wear a N-95 respirator mask and Latex/ Nitrile gloves. The patient is required to wear a three-layered mask. In contrast, the precautions of minimally invasive procedures include advanced caution, moderate protection, and additional protective equipment. Reasonable protection includes goggles, a N-95 respirator mask, Latex/Nitrile gloves, and a gown. Extreme caution, advanced safety, and additional protective equipment are mandatory to perform invasive procedures. Advanced protection requires goggles, face-shield, N-95 respirator mask, surgical gloves, coverall/gowns, head cover, and shoe cover.

#### **4. General principles**

The World Health Organisation (WHO) have issued a list of precautions and recommendations guideline to help prevent the spread of COVID-19. The facility must follow these guidelines for the safety of both the patients and staff. Personalised protective equipment (PPE) should be worn with an examination in negative pressure rooms must be followed if there is a high possibility of being exposed to infection [12].


*Precautions on Contact Dermatoscopy and Other Practices in the Pandemic of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.102386*


#### **4.1 Avoided procedures**

Some treatment procedures might have a high risk of exposure to infection; hence, safer alternative treatments can be used instead of what is needed to be avoided. For example, platelet-rich plasma, platelet-rich factor, and growth factor concentrate are part of the blood and blood product treatments that can be avoided until after the pandemic, while mesotherapy using hair growth concentrates can substitute these procedures. If medical facials are not essential, they should be deferred and alternated with a prescription from the dermatologist. Carbon facials are avoided because they are plume generating procedures that need extreme caution [7]. Procedures such as laser toning and carbon peels can be postponed or performed with proper PPE/overalls and the use of disposable equipment [10]. The carbon peel, just like the carbon facials, highly generates plumes.

It is obligatory to use a complete COVID-19 PPE kit for dermabrasion procedures; otherwise, they should be postponed. All disposable and personal protection kits should be discarded accordingly. Fat grafting procedures must be deferred because the danger of transmission is serious while handling tissues [7]. Hyaluronic acid filler can be used instead. It is best to avoid hot probe electrosurgery procedures that produce plumes. These procedures are electrofulguration, electrodessication, and electrocautery. To limit plume generation, cold probe devices such as higher frequency—radiofrequency devices may be utilised for electro sectioning [7]. Avoiding various procedures such as cosmetic tattooing, tattoo removing and dermaplaning is recommended. Mucosal and oozy/fissured lesions should be deferred in dermatoscopy [12].

#### **4.2 Recommendations for specific procedures**

Some procedures may need particular recommendations for precaution against the virus.



*IPL: intense pulsed light; HiFU: high intensity focused ultrasound; RF: radio frequency; Q-switched laser: Qualityswitched laser; Nd:YAG laser: (neodymium-doped yttrium aluminium garnet laser; Nd:Y3Al5O12); Er:YAG laser: (erbium-doped yttrium aluminium garnet laser); Er:glass laser: erbium glass lasers.*

#### **Table 2.**

*The technology of laser and energy based procedures [10].*

*Precautions on Contact Dermatoscopy and Other Practices in the Pandemic of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.102386*

#### **5. Dermatoscopy procedures**

The dermatologist should follow basic protection and caution before performing procedures. There must be smoke evacuators and ventilation in all the rooms where the procedures are performed as some procedures may generate plume. The dermatoscope should be wiped with 70% isopropyl alcohol and covered with a disposable dermoscopic lens [12].

These precautions may decrease the possibility of virus transmission through the device. Between the dermatoscope lens and the lesion, a polyvinyl chloride (PVC) film is applied, and a transparent adhesive tape can be put to aid contact dermatoscopy once the immersion fluid has been deposited with a glass slide can be placed over the lesion in front of the dermatoscope [12]. The PCV, tape, and glass slide act as a barrier between the patient and the device. For microscopy, a disposable polyethylene tube can be used with a USB dermatoscope [12]. It is recommended that if the dermatologist is going to use mobile phone to see photos with a dermatoscope to clean it first. A digital dermatoscopy report is preferred because an audiovisual paperless communication is desirable specially when there is a distance between the patients and the healthcare providers. Some limitation of digital dermatoscopy may remain, such as low resolution images, ethical dilemma, patient's privacy and medico-legal responsibility.

All dermoscopic examination materials should be disposed of according to biomedical waste rules. To decrease the nosocomial infection when practicing dermatoscopy, there are many precautions to be taken into consideration, especially when dealing with suspected COVID-19 cases such as:


#### **6. Conclusion**

It is vital to have a set of precautions and recommendations for the dermatologists to help them carry on their clinical practice safely in COVID-19 era; it is rightly said that "prevention is better than cure". The pandemic of COVID-19 has significantly affected many sectors all over the world. We did not expect such a catastrophic outbreak, and it might not be the last. The presence of clear and informative safety consensus guidelines for the dermatologists when dealing with suspected or confirmed cases of COVID-19 is essential to stop the viral transmission from the patients to health care providers and then to their family members.

#### **Acknowledgements**

The authors thank Mr. Josip Knapic, the author service manager at Intechopen Limited (U.K.), for following up during this chapter's writing phase.

*Dermatoscopy*

### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Walid Al-Zyoud\* and Dana Erekat German Jordanian University, Amman, Jordan

\*Address all correspondence to: walid.alzyoud@gju.edu.jo

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Precautions on Contact Dermatoscopy and Other Practices in the Pandemic of COVID-19 DOI: http://dx.doi.org/10.5772/intechopen.102386*

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[2] Bai Y, Yao L, Wei T, Tian F, Jin DY, Chen L, et al. Presumed asymptomatic carrier transmission of COVID-19. Journal of the American Medical Association. 2020;**323**:1406-1407. DOI: 10.1001/JAMA.2020.2565

[3] Piccolo V, Argenziano G. The impact of novel coronavirus on dermatology. Dermatology Practical & Conceptual. 2020;**10**(2):e2020049. DOI: 10.5826/ DPC.1002A49

[4] Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. The Journal of Hospital Infection. 2020;**104**:246-251. DOI: 10.1016/J.JHIN.2020.01.022

[5] Belluco S, Mancin M, Marzoli F, Bortolami A, Mazzetto E, Pezzuto A, et al. Prevalence of SARS-CoV-2 RNA on inanimate surfaces: A systematic review and meta-analysis. European Journal of Epidemiology. 2021;**36**:685-707. DOI: 10.1007/S10654-021-00784-Y

[6] Piana A, Colucci ME, Valeriani F, Marcolongo A, Sotgiu G, Pasquarella C, et al. Monitoring COVID-19 transmission risks by quantitative real-time PCR tracing of droplets in hospital and living environments. MSphere. 2021;**6**(1):e01070-20. DOI: 10.1128/MSPHERE.01070-20

[7] Arora G, Arora S, Talathi A, Kandhari R, Joshi V, Langar S, et al. Safer practice of aesthetic dermatology during the COVID-19 pandemic: Recommendations by SIG aesthetics (IADVL Academy). Indian Dermatology Online Journal. 2020;**11**:534. DOI: 10.4103/IDOJ.IDOJ\_328\_20

[8] Antonelli M, Penfold RS, Merino J, Sudre CH, Molteni E, Berry S, et al. Risk factors and disease profile of postvaccination SARS-CoV-2 infection in UK users of the COVID symptom study app: A prospective, community-based, nested, case-control study. The Lancet Infectious Diseases. 2021:1. DOI: 10.1016/ S1473-3099(21)00460-6

[9] COVID-19 Quarantine and Isolation. CDC. 2021. Available from: https:// www.cdc.gov/coronavirus/2019-ncov/ your-health/quarantine-isolation.html [Accessed: December 10, 2021]

[10] Dhawan S, Kumari P, De A, Pall A, Pudukadan D, Romi E, et al. Lasers use in dermatology practice in the evolving COVID-19 scenario: Recommendations by SIG Lasers (IADVL Academy). Indian Dermatology Online Journal. 2020;**11**:337. DOI: 10.4103/IDOJ. IDOJ\_239\_20

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[13] Bali RK, Chaudhry K. Maxillofacial surgery and COVID-19, The Pandemic!! Journal of Oral and Maxillofacial Surgery. 2020;**19**:159. DOI: 10.1007/ S12663-020-01361-8

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#### *Dermatoscopy*

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## *Edited by Paweł Pietkiewicz*

This book is a collection of chapters on dermatoscopy, which is a fast, easy-to-learn, low-cost, and non-invasive diagnostic method utilizing the Rayleigh scattering phenomenon to visualize epidermal and subepidermal structures. Dermatoscopy has become increasingly popular for allowing visualization of structures that are impossible to see with the naked eye. Its use provides insight into the biological potential of skin lesions, enabling efficient management and follow-up. The book focuses on the features of some of the most common skin neoplasms, such as combined nevi, as well as those that are more challenging to assess, such as pigmented lesions of the eyelid margins. It also provides novel insights into the role of dermatoscopy in palmoplantar dermatoses and discusses precautions in dermatoscopy during the SARS-CoV2 pandemic.

Published in London, UK © 2022 IntechOpen © Somkhana Chadpakdee / iStock

Dermatoscopy

Dermatoscopy

*Edited by Paweł Pietkiewicz*