Dermoscopy of Chromoblastomycosis.

A 55-year-old male, farmer by occupation, resident of Garhwal region of Uttrakhand presented to us with reddish raised lesions over left arm for 5–6 years. History of trauma while working in the fields prior to development of the lesion was present. On clinical examination, single, 5 × 6 cm, ill- to well-defined erythematous plaque with overlying scales and crust along with areas of atrophy was present over dorsal aspect of left forearm [Figure 1]. Upon closer examination of the plaque, scattered tiny, black dots were seen. Dermoscopic examination (DermLite II hybrid m; 3Gen; polarized mode, ×10 magnification) revealed multiple, scattered, reddish black dots, and yellowish orange ovoid areas over a pinkish white background. Polymorphic vessels were seen surrounding these yellowish orange ovoid areas. Also seen were thick yellowish white scales and crusts [Figure 2a and b]. Histopathological examination was done which showed hyperkeratotic, acanthotic epidermis exhibiting pseudoepitheliomatous hyperplasia. Well-defined epithelioid granulomas admixed with langhans giant cells, neutrophils, and plasma cells were seen in dermis. Higher power shows dark colored, 10–12 μm thick-walled sclerotic bodies were seen engulfed by the giant cell and lying freely in the dermis [Figure 3]. Mycological examination was non-contributory. Based on the clinical, dermoscopic, and histopathological correlation we reached to the diagnosis of chromoblastomycosis and the patient was started on itraconazole 200 mg twice a day.

Figure 1

Single, 5 × 6 cm, erythematous plaque with overlying scales and crust along with areas of atrophy over dorsal aspect of left forearm. Blackish dots also seen over the plaque

Figure 2

(a) Multiple, scattered, reddish black dots (black circles), and yellowish orange ovoid structures (black arrows) over pink and white areas, along with scales and crusts. (b) Polymorphic vessels (blue circles) were seen surrounding these yellowish orange ovoid areas (black arrow)

Figure 3

(a) Epidermis showing hyperkeratosis, acanthosis with pseudoepitheliomatous hyperplasia. Dermis shows well-defined collection of epitheloid granulomas (H and E, ×10). (b) Higher power shows dark colored, pigmented thick-walled 10–12 μm spherical bodies (medlar bodies) inside the giant cell and (c) lying freely (black arrow) in the dermis (H and E, ×100)

Chromoblastomycosis is a chronic, progressive subcutaneous mycosis caused by traumatic inoculation of dematiaceous fungi namely Fonsecaea pedrosoi, Phialophora verrucosa, Cladophialophora carrionii, and so on. The hallmark of the mycosis is presence of sclerotic bodies also known as medlar bodies which can be demonstrated by hematoxylin and eosin staining or potassium hydroxide (KOH) mount.[1] The dermoscopic findings in our case are in line with those reported earlier.[23] Pink and white areas seen on dermoscopy represent the rough uneven areas of the lesion clinically. The most characteristic dermoscopic finding is the presence of multiple reddish black dots which ascribes to the process of transepidermal elimination of inflammatory cells, foreign fungal elements, and hemorrhage seen clinically as black dots.[2] The yellowish orange structures represent mycotic granulomas but are not specific to chromoblastomycosis as they can also be seen in other granulomatous disorders. The dermoscopic findings of chromoblastomycosis and its differentials have been discussed in Table 1. Surprisingly, on detailed literature search we could come across just a handful of case reports focussing on dermoscopy in chromoblastomycosis. Thus, we wish to highlight the dermoscopic findings of chromoblastomycosis which can act as a supplementary tool in a physician's armamentarium to clinch the diagnosis of this difficult to diagnose mycosis.

Table 1

Dermoscopic findings of chromoblastomycosis and its differentials

Disorders	Dermoscopic findings
Chromoblastomycosis	Yellowish orange ovoid structures (black arrows) over pink and white areas, along with scales and crusts. Multiple, scattered reddish black dots are the most characteristic finding
Sporotrichosis[4]	Generalized erythema, yellowish structureless areas with clustered pustules at the periphery. White scar-like areas and yellowish structureless area surrounded by arborizing telangiectasias are also present
Lupus vulgaris[5]	Structure-less focal or diffuse orange areas and focused linear or branching vessels are seen. In addition, milia-like cysts can also be observed
Cutaneous leishmaniasis[5]	Erythematous papular lesion shows generalized erythema, yellow tear drop structures, and vascular structures (comma-shaped vessels and linear irregular vessels). More advanced lesions show central erosion, white starburst pattern, and peripheral vascular pattern (comma-shaped vessels, dotted vessels, and hairpin vessels)

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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.