A Single Centre Cross-Sectional Observational Study on Dermatoscopy of Oral Mucosal Disorders and Histopathological Correlation in Tertiary Care Centre from Central India

Abstract

Background: A dermatoscope is a non-invasive diagnostic imaging tool that enables to visualise superficial, deeper structures, pigmentary and vascular patterns of skin, nails, hair and mucosa. Oral mucosal lesions are abnormal alterations in colour, surface, presence of swelling, or loss of integrity of mucosal and semimucosal surface. The use of dermoscopy in the characterisation of mucosal disorder is a grey area and needs further exploration.

Aim: To describe clinical and mucoscopic features and correlate histopathologically in oral mucosal diseases.

Method: Single-centre, cross-sectional, observational study presenting to inpatient and outpatient departments of dermatology, and otorhinolaryngology. Patients fulfilling inclusion criteria were dermoscopically evaluated using DermLite DL4, 30 mm lens system and 10× magnification and documented in a prestructured proforma. Then, a mucosal biopsy was taken from the visualized site.

Results: Fordyce spots were observed as white-yellow clods with dots. Median rhomboid glossitis as atrophic filiform papillae at the centre with normal-looking peripheral papillae. Pemphigus vulgaris visualized as a red structureless area, red dots, with violaceous streaks at the periphery. Lichen planus showed a tricolor pattern, Wickham's striae, blunted tips of lingual papillae, discoid lupus erythematosus showed superficial erosions, yellow-white scale, brown pigment spots at the periphery with telangiectasia and follicular plugs at the vermilion border. Aphthous stomatitis characterised by three zones with a central yellowish-white structureless area, a surrounding white area, and a peripheral red structureless area. Actinic cheilitis showed superficial ulceration, polymorphic vessels and white scales. Warts have hyperkeratotic pointed tips with fused bases, with central thrombosed capillaries. Molluscum contagiosum showed a central pore-like structure with crown vessels. Vitiligo showed a white structureless area, a diffuse white glow with a scalloped margin. Premalignant conditions such as oral submucosal fibrosis and leukoplakia showed atrophic lingual papillae, chrysalis white structureless area, with telangiectasia and white to pink structureless area, surface corrugation, white clods and dotted vessels. Limitations in our study were a response to therapy could not be assessed and the relation with the disease activity could not be determined. Difficult-to-reach sites such as the palate, and retromolar area were not assessed. Haziness while capturing pictures due to mist formation hindered the quality of images. Not many premalignant and malignant diseases were recruited to provide the mucoscopy features in predicting the risk of conversion.

Conclusion: Mucoscopy helps in delineating various mucosal diseases with subtle features.

Keywords: Dermoscopy; histopathology; mucosa; mucoscopy; oral mucosal lesions; semimucosa.

Figure 1

Mucoscopy of Fordyce spots shows white yellow discrete ovoid structures (clods) [circle] with central opacity (dots) [arrow] with linear and branching vessels at the periphery (10×, polarized mode) [a] and geographic tongue shows an atrophic filiform papilla at the centre (blue arrow) with normal-looking peripheral papillae (yellow arrow) (10×, polarised mode) [b]. Mucoscopy of aphthae shows three zones characteristically showing a central yellowish–white structureless area, surrounding white area, and peripheral red structureless area (10×, polarised mode) [c]. Mucoscopy of pemphigus vulgaris shows peripheral white streaks (black arrow), structureless red area (blue star), and red spots (red arrow) (10×, polarized mode) [d]. Biopsy of pemphigus vulgaris shows acantholysis with suprabasal split erosion (cross), acanthosis (downward black arrow), the blood vessels (red arrowhead) [H and E, 50×] [e]. Clinical image of pemphigus vegetans over right angle of mouth [f]. Mucoscopy of pemphigus vegetans shows papillary projections with bulbous tips and individual bases with no fusion similar to fungiform papillae (10×, polarised mode) [g]

Figure 2

Mucoscopic features of SLE show white lines radiating from the periphery of the red area (blue arrow) with an erythematous background with linear and dotted vessels (red arrow) (10×, polarised mode) [a]. mucoscopy shows classic Wickham’s striae (blue arrow), peripheral violaceous streaks (red star) [polarized 10×] [b]. Pigmented lichen planus shows central Wickham’s striae with peripheral hyperpigmentation (10×, polarised mode) [c]. Tri-colour pattern (circle marked area) constituted by–1) structureless veil-like grey–white to bluish–white areas (black arrow), 2) bright red slightly depressed areas, (yellow star) and 3) interspersed violaceous-to-brown clods (green arrow) observed on mucoscopy [polarised mode, 10×] [d]. Mucoscopy shows mucocele with overlying Wickham’s striae suggestive of mucocele over oral lichen planus (10×, polarised mode) [e]. Mucoscopy represents classic Wickham’s striae (polarised mode, 10×) [f]

Figure 3

Mucoscopic and histological features of oral lichen planus. Dermoscopy showing tricolor pattern, biopsy from the marked site (blue star) corresponds to wedge-shaped hypergranulosis (black arrowhead) and lichenoid infiltrate (blue arrow) histologically [HPE 4×] [a and b]. Mucoscopic and histological features of oral discoid lupus erythematosus. Keratin plugs (white star), lichenoid infiltrate (yellow star), pigment incontinence (black star), dilated vessel observed on histopathology (HPE, 4×) corresponds to follicular plugs (white arrow), violaceous hue, white structureless area (yellow arrow), blue–grey peppering (black arrow), telangiectasia and dotted vessels (polarised 10×) [c and d]

Figure 4

Mucoscopy features of actinic cheilitis showing superficial ulceration, polymorphic vessels (red, yellow, blue star), white scales (black arrow), whitish red background (purple arrowhead) with occasional blood spots (polarised 10×) [a]. Mucoscopy of granulomatous cheilitis shows the yellow-red structureless area (blue star) with a honeycomb network (black arrow) with red background [polarised, 10×] [b]. Mucoscopy of pigmented fungiform papillae of the tongue shows pigmentation at the tips of individual fungiform papillae giving a rose petal appearance (polarised 10×) [c]. Mucoscopy of the black hairy tongue shows variegated pigmentation even in between the filiform papillae (polarised 10×)[d]. Mucoscopic features of oral lentigines showing structureless pattern (blue circle), delicate pigment network (green circle), prominent pigment network (blue arrow), fingerprint pattern (red circle), parallel lines (black arrow) [polarised 10×][e-g]

Figure 5

Mucoscopic features of molluscum contagiosum shows crown vessels (blue arrow) and central white structureless area and rosette (circle) [polarised 10×] [a]. mucoscopy of mucosal verruca shows a verrucous surface with white pointed tips and fused base over the dorsa of the tongue and mosaic pattern observed over the lips of verruca [b and c]. Mucoscopy shows an orange-yellow hue [d] and periadnexal well-defined multiple granulomas (HPE, 4×)[e]. Mucoscopy of the venous lake shows a purple hue (blue arrow), red blue globule (red circle), and dark blue hue (yellow star) [f]. Mucoscopy shows blue hue (red circle), elongated red-brown lines (blue arrow), erythematous background (black star), red globules (black circle) [g-i]

Figure 6

Mucoscopy of lingual varicosities shows red to dark blue lacunae (blue circle), shiny structureless area (blue star), linear vessels (black arrow), and discretely arranged (red circle) [a]. Mucoscopy of oral submucosal fibrosis shows telangiectasia (black arrow), fibrotic bands (red star), homogeneous structureless white area (blue arrow) [right image, polarised 10×][b]. Mucoscopy of porokeratosis shows peripheral keratin rim with fine telangiectasia (red arrowhead) with central hyperpigmented reticular area (blue arrow) [c]. Clinical [d] and mucoscopy features of leukoplakia white to pink structureless area (red down arrow) [e]. Clinical image of erythroplakia [f] and mucoscopy features shows white clods (red star), dotted vessels (black circle), surface corrugations (blue arrow), white pink veil at the periphery (black arrow)[g]. Mucoscopic features of white clods (red arrow) correspond to squamatisation (red star), dotted vessels (black circle) correlate with the vasculature (red circle), white structureless area (blue star) correlate with acanthosis and hyperkeratosis (blue arrow) [h and i]

Figure 7

Clinical image of Steven–Johnson syndrome shows superficial erosion with yellow crust and mucoscopy (polarised 10×) shows blood spots (red arrow), comma vessels (blue star) with red structureless area [a and b]. Mucoscopy (polarised 10×) of mucocele which shows blue hue (blue arrow) and reticular branching vessels (red arrow) which correlates with mucin (blue star) and dilated vessels (red star) histologically (right image) (HPE, 10×) [c and d]. Mucoscopy of mucosal fibroma shows a white non-translucent area and dotted vessels (Dermlite DL4, polarized 10×) correlates with acanthosis and fibrovascular core histopathologically (HPE 10×, right image) [e and f]