Dermoscopy, also known as dermatoscopy or epiluminescence microscopy, is a non-invasive, in vivo diagnostic technique that allows visualization of subsurface skin structures not visible to the naked eye [1]. Initially, dermoscopy gained worldwide recognition for its role in the diagnosis of pigmented lesions and melanoma, where it significantly enhanced diagnostic accuracy compared to clinical examination alone [2]. Over the last two decades, however, its applications have expanded beyond pigmented and neoplastic disorders, extending to hair and nail diseases, parasitic infestations and inflammatory dermatoses [3]. The use of dermoscopy in inflammatory skin conditions has been termed “inflammoscopy,” a field that continues to evolve but remains underutilized in many clinical settings, particularly in South Asia [4].

Inflammatory dermatoses such as psoriasis, eczema, lichen planus, pityriasis rosea and seborrheic dermatitis are among the most frequently encountered conditions in dermatology practice. Despite being common, these diseases may pose diagnostic challenges when they present with atypical morphology, overlap in clinical features, or occur in early or partially treated stages [5]. Traditionally, diagnosis relies on clinical evaluation supplemented by histopathology when required. However, biopsies are invasive, time-consuming and not always feasible in routine outpatient settings, especially in resource-limited countries [6]. In such contexts, a rapid, inexpensive and non-invasive diagnostic adjunct such as dermoscopy can be of immense value.

Several studies from Europe, North America and India have described characteristic dermoscopic patterns of inflammatory dermatoses. For example, psoriasis typically shows regular dotted vessels on a light red background with diffuse white scales, while eczema often demonstrates patchy vessels with yellow serocrusts [7, 8]. Lichen planus is distinguished by Wickham striae and pigmentary changes, pityriasis rosea by collarette scaling and seborrheic dermatitis by greasy yellow scales with patchy vascular patterns [9]. Recognition of these dermoscopic clues may allow dermatologists to differentiate between clinically similar conditions with greater confidence, thereby reducing the need for invasive investigations and expediting therapeutic decisions [10].

Although the diagnostic utility of dermoscopy in inflammatory conditions has been increasingly reported in recent years, evidence from Bangladesh and similar South Asian populations is scarce [11]. Differences in skin phototypes, disease prevalence and health care settings mean that findings from Western populations may not be directly applicable in our context. Furthermore, in darker skin (Fitzpatrick types IV and V, which are common in Bangladesh), the dermoscopic appearance of inflammatory dermatoses may vary, potentially influencing diagnostic accuracy [12]. Thus, generating local data is crucial for assessing the true clinical value of dermoscopy in our population.

The present retrospective study was undertaken in the Department of Dermatology & Venereology at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, with the aim of evaluating the diagnostic accuracy and clinical utility of dermoscopy in differentiating common inflammatory dermatoses. By systematically analyzing dermoscopic features and comparing them with reference diagnoses established by clinicopathologic correlation, we sought to determine the sensitivity, specificity, predictive values and overall accuracy of dermoscopy for each disease entity. Additionally, we aimed to explore its impact on clinical decision-making, particularly in terms of avoiding unnecessary biopsies and facilitating timely treatment.

This retrospective study was conducted in the Department of Dermatology & Venereology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, over a one-year period from March 2007 to February 2008, with a total sample of 200 patients who presented with clinical suspicion of common inflammatory dermatoses. All consecutive patients with psoriasis, eczema/dermatitis, lichen planus, pityriasis rosea and seborrheic dermatitis who had complete clinical records and dermoscopic images available were included in the study, while patients with infectious, neoplastic, adnexal, or connective tissue disorders, those with incomplete records, or poor-quality dermoscopic images were excluded. Dermoscopic examinations were performed using a handheld dermoscope with ×10 magnification in both polarized and non-polarized modes and predefined diagnostic features such as dotted vessels, diffuse white scales, Wickham striae, collarette scales and greasy yellow scales were recorded. The final reference diagnosis was established by clinicopathologic correlation including histopathology whenever available and any disagreement between two dermatologists was resolved by consensus. Data on demographics, clinical features, dermoscopic findings and final diagnoses were systematically extracted and entered into a database. Statistical analysis was carried out using SPSS version 12 and diagnostic performance of dermoscopy was assessed by calculating sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy for each disease entity, while interobserver agreement on key dermoscopic features was evaluated using Cohen’s kappa statistics. Clinical utility was measured by determining the proportion of cases in which dermoscopy supported immediate treatment decisions or reduced the need for biopsy.

Table 1: Baseline Characteristics of Study Patients (n = 200)

Table 1 presents the baseline characteristics of the study population (n = 200). The mean age of the patients was 32.8 ± 11.4 years, with an age range from 12 to 65 years, indicating inclusion of both adolescents and adults. Males slightly outnumbered females, comprising 54.0% (n = 108) of the sample, while females accounted for 46.0% (n = 92). The majority of patients (71.0%) had Fitzpatrick skin phototypes IV–V, reflecting the predominant skin type distribution in the study population. The median duration of disease was 9 weeks, with an interquartile range of 6 to 14 weeks, suggesting that most patients presented within the early to intermediate phase of their disease course.

Table 2: Distribution of Diagnoses (n = 200)

Table 2 shows the distribution of clinical diagnoses among the study population (n = 200). Psoriasis was the most common inflammatory skin disease, accounting for 30.0% (n = 60) of cases, followed by eczema/dermatitis in 25.0% (n = 50). Lichen planus represented 20.0% (n = 40) of cases, while pityriasis rosea and seborrheic dermatitis each constituted 12.5% (n = 25).

Table 3. Key Dermoscopic Features in Different Diseases

Table 3 summarizes the key dermoscopic features observed across the five common inflammatory skin diseases in the study population (n = 200). Regular dotted vessels were predominantly seen in psoriasis (86.7%), while they were less frequent in eczema (24.0%), lichen planus (12.5%), pityriasis rosea (16.0%) and seborrheic dermatitis (24.0%). White diffuse scales were most characteristic of psoriasis (81.7%) but were also observed to a lesser extent in eczema (40.0%) and pityriasis rosea (40.0%). Wickham striae were highly specific for lichen planus, appearing in 90.0% of cases and were virtually absent in other dermatoses. Collarette scaling was a hallmark of pityriasis rosea (84.0%), whereas yellow greasy scales were predominantly noted in seborrheic dermatitis (88.0%).

Table 4. Diagnostic Accuracy of Dermoscopy

Table 4 presents the diagnostic accuracy of dermoscopy for differentiating each inflammatory skin disease from the others (one-vs-rest analysis). Dermoscopy demonstrated the highest sensitivity for lichen planus (90.0%) and seborrheic dermatitis (88.0%), while specificity was greatest for seborrheic dermatitis (97.0%) and pityriasis rosea (96.0%). Positive predictive values ranged from 72.0% in eczema/dermatitis to 88.2% in lichen planus and negative predictive values were consistently high, ranging from 89.0% to 97.0%, indicating reliable exclusion of other diseases when the feature was absent. Overall accuracy was highest for seborrheic dermatitis (95.0%) and pityriasis rosea (93.5%), followed by lichen planus (93.0%), psoriasis (90.0%) and eczema/dermatitis (82.5%).

Table 5. Clinical Utility of Dermoscopy

Table 5 illustrates the clinical utility of dermoscopy in the study population (n = 200). Dermoscopy facilitated the avoidance of unnecessary biopsies in 62 cases (31.0%), indicating its value as a non-invasive diagnostic tool. It supported immediate treatment decisions in 74 cases (37.0%), allowing timely initiation of therapy without waiting for histopathology. Additionally, dermoscopy led to a change in the initial clinical diagnosis in 28 cases (14.0%), demonstrating its potential to improve diagnostic accuracy and guide management in challenging or atypical presentations

The present study provides a comprehensive assessment of the prevalence and risk factors of superficial fungal infections (SFIs) among patients attending a tertiary care hospital in Bangladesh. The findings reveal important demographic, clinical, and epidemiological patterns that correspond with, and in some cases diverge from, previous research conducted in South Asia and globally.

The demographic analysis of our study population demonstrated that young adults were the most affected, particularly those aged 21–30 years (30.0%) and 31–40 years (25.0%). This finding is in close agreement with earlier studies, which consistently highlight that dermatophytoses and other superficial fungal infections are particularly common in young and middle-aged adults, largely due to higher levels of outdoor activity, occupational exposures, and perspiration.^1,7 This age-related predilection has been consistently reported in global studies.^1,8 Similarly, a Saudi Arabian study demonstrated high prevalence of onychomycosis in adults (40.3%) and tinea capitis in children (21.9%), further reinforcing the age-related distribution patterns observed in our study.⁹ With respect to gender distribution, males (55.0%) were slightly more affected than females (45.0%). This male predominance aligns with existing studies. In the study of Tan et al.¹⁰, where 72.3% of patients (n=9335) were males. Interestingly, Abanmi et al.⁹ also reported a female predominance in their Saudi cohort, underscoring possible regional and cultural influences on gender distribution.

In our study, tinea cruris and tinea pedis were predominantly male infections, affecting 75.0% and 66.7% of males, respectively, findings that correspond closely with the study of Tan et al.¹⁰, where the most common infection was tinea pedis (27.3%), followed by pityriasis versicolor (25.2%) and tinea cruris (13.5%). Candidal infections were also common (n=1430), the majority of which were cases of candidal intertrigo. Conversely, candidiasis was more common among females (60.0%), consistent with the established association between candidal infections and female hormonal, anatomical, and hygiene-related factors.³ Pityriasis versicolor demonstrated no significant gender bias in our cohort, a pattern also documented in earlier studies.¹ Importantly, although tinea corporis was more common among males, this difference did not reach statistical significance, which may suggest that while gender differences exist, they are not uniformly consistent across all clinical types.

The risk factor profile of our patients further reinforces the role of socioeconomic and environmental determinants in shaping the epidemiology of SFIs. Overcrowding (42.5%) and poor personal hygiene (35.0%) emerged as the most common contributors, followed by low socioeconomic status (30.0%). These findings parallel those of Ingordo et al.⁵, who reported high prevalence of tinea pedis, cruris, and onychomycosis among Italian navy cadets, strongly linked to communal living, footwear, and occupational settings. Diabetes mellitus was identified in 15.0% of cases, and immunosuppression in 7.5%, corroborating earlier observations that host-related factors substantially increase susceptibility to recurrent and chronic fungal infections.³ Additionally, the contributions of fomite sharing (20.0%) and occupational exposure (10.0%) observed in this study highlight behavioral and environmental routes of transmission that have also been well documented in prior epidemiological work.¹ Many risk factors for contracting tinea pedis have been suggested, including a close community living, occlusive shoes, a hot and humid climate, sports practice as a profession.^11-14 In terms of clinical distribution, tinea corporis (25.0%), tinea cruris (20.0%), and tinea pedis (15.0%) were the most common infections in our cohort, echoing trends documented worldwide.^1,15 Onychomycosis (12.5%) was also common, especially in older adults, in agreement with global data suggesting a rising burden of nail infections in aging populations.⁸ Tinea capitis (10.0%) was concentrated in children, while candidiasis (10.0%) and pityriasis versicolor (7.5%) were more evenly distributed across age groups, with a slight concentration in young adults, consistent with earlier epidemiological findings.³

Taken together, the findings of this study demonstrate that the epidemiology of superficial fungal infections in Bangladesh is broadly consistent with patterns observed in other tropical, resource-limited settings. The predominance of young adults, the significant contribution of overcrowding and low socioeconomic conditions, the gender-linked differences in clinical patterns, and the age-specific distribution of entities such as tinea capitis and onychomycosis are all well supported by prior literature. However, the relative scarcity of hospital-based epidemiological studies from Bangladesh underscores the importance of this work in providing local evidence. This retrospective study evaluated the diagnostic accuracy and clinical utility of dermoscopy in differentiating common inflammatory skin diseases, including psoriasis, eczema/dermatitis, lichen planus, pityriasis rosea and seborrheic dermatitis. Our findings demonstrate that dermoscopy offers distinctive visual clues that substantially enhance diagnostic precision and, importantly, have tangible implications for patient management.

The overall diagnostic accuracy of dermoscopy in this study ranged from 82.5% to 95.0%, with the highest performance noted in seborrheic dermatitis and pityriasis rosea. These results are consistent with the emerging recognition of dermoscopy as an invaluable extension of clinical examination in non-tumoral dermatoses. Argenziano et al., highlighted that dermoscopy had initially been established in the context of melanoma diagnosis but was rapidly expanding into the evaluation of inflammatory skin diseases, an observation that our findings strongly support [13].

The disease-specific dermoscopic features identified in this cohort also align with previous literature. Regular dotted vessels and diffuse white scales, which were highly prevalent in psoriasis, are well-documented vascular and scaling patterns associated with psoriatic lesions. Similarly, the detection of Wickham striae in 90% of lichen planus cases corresponds to the classical description of fine white reticular lines, a hallmark sign also emphasized in early dermoscopy consensus reports [13]. The identification of collarette scaling in pityriasis rosea and greasy yellow scales in seborrheic dermatitis further demonstrates the ability of dermoscopy to distinguish between clinically overlapping presentations.

Eczema/dermatitis, in contrast, exhibited less specific dermoscopic features, which is reflected in its comparatively lower diagnostic accuracy in our analysis (accuracy 82.5%). This mirrors the clinical reality that dermatitis often presents with variable and nonspecific vascular and scaling patterns, complicating its differentiation from psoriasis and seborrheic dermatitis. Similar diagnostic challenges have been discussed by Rao et al., who questioned whether noninvasive imaging tools could ever fully replace histopathology, particularly in ambiguous cases [14]. Our findings suggest that while dermoscopy significantly improves diagnostic confidence, histology remains essential in selected cases of atypical or refractory dermatitis.

The clinical utility outcomes of this study highlight the practical advantages of dermoscopy beyond mere pattern recognition. In 31.0% of cases, biopsies were avoided due to clear dermoscopic findings, reducing the need for invasive procedures. This observation supports earlier debates by Sellheyer and Bergfeld, who questioned the appropriateness of biopsies performed by non-specialists and emphasized the importance of accurate, less invasive diagnostic strategies [15]. Furthermore, dermoscopy directly supported immediate treatment decisions in 37.0% of cases and altered the initial clinical diagnosis in 14.0%, underscoring its role in real-time patient management. Similar conclusions were drawn by Bryant, who advocated for telepathology and noninvasive adjunctive techniques to complement or even substitute traditional histopathology in certain contexts [16].

From a technological perspective, advances in dermoscopic image capture and algorithm development were already underway by the mid-2000s. Celebi described early efforts in computer-assisted dermoscopy image analysis, particularly for melanocytic lesions [17]. While our study focused on inflammatory dermatoses, the high diagnostic accuracy we observed suggests that inflammatory “inflammoscopy” could similarly benefit from future integration with automated systems, a trend already predicted in early literature. Such innovations may further reduce diagnostic ambiguity in diseases like eczema, where dermoscopy alone shows moderate specificity.

Our findings also emphasize the importance of dermoscopy in resource-limited settings, where access to immediate histopathology may be constrained. Hengge et al., emphasized that neglected skin diseases like scabies often go underdiagnosed due to lack of adequate tools [18]. By extrapolation, our study supports dermoscopy as an accessible, noninvasive modality that can strengthen dermatologic practice in similar contexts by reducing unnecessary referrals and expediting treatment.

Importantly, the reliability of dermoscopy as demonstrated in this study resonates with broader discussions on diagnostic accuracy in dermatopathology. Dadras et al. and Bansal et al., underscored the prognostic and diagnostic significance of histological markers in melanoma and fibrous papules, respectively [19, 20]. While such histological analyses remain the gold standard, our data highlight that dermoscopy can, in many cases, provide sufficient diagnostic certainty to guide immediate clinical decisions without histopathology.

Limitations of this study should be acknowledged. As a retrospective analysis, the diagnostic accuracy may be influenced by case selection and the experience of the dermatologists performing dermoscopy. Furthermore, the study was conducted in a single tertiary care center with predominantly Fitzpatrick skin types IV–V, which may influence the visibility of vascular and pigmentary structures. These factors may limit generalizability to other populations.

In conclusion, our study demonstrates that dermoscopy significantly improves the diagnostic accuracy and clinical management of common inflammatory skin diseases. Disease-specific patterns such as Wickham striae, collarette scaling and yellow greasy scales provide reliable diagnostic clues, while high sensitivity and specificity values reinforce its validity as a diagnostic adjunct. Importantly, dermoscopy reduces the need for unnecessary biopsies and supports timely treatment decisions, thereby enhancing patient care. These findings are consistent with prior international reports and highlight the evolving role of dermoscopy beyond melanoma into the realm of inflammatory dermatoses.

Financial support and sponsorship

No funding sources.

Conflicts of interest

There are no conflicts of interest.

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