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CORRESPONDENCE
Year : 2022  |  Volume : 67  |  Issue : 2  |  Page : 186-188
Dermoscopy as a tool to differentiate reactive arthritis from psoriatic arthritis


1 From the Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab; Department of Dermatology, IQRAA Aesthetics, IQRAA International Hospital and Research Centre, Calicut, Kerala, India
2 Department of Dermatology, IQRAA Aesthetics, IQRAA International Hospital and Research Centre, Calicut, Kerala, India
3 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India

Date of Web Publication13-Jul-2022

Correspondence Address:
Keshavamurthy Vinay
Department of Dermatology, IQRAA Aesthetics, IQRAA International Hospital and Research Centre, Calicut, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_749_21

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How to cite this article:
Razmi MT, Ashraf R, Vinay K, Aggarwal D, Chatterjee D, Narang T, Dogra S. Dermoscopy as a tool to differentiate reactive arthritis from psoriatic arthritis. Indian J Dermatol 2022;67:186-8

How to cite this URL:
Razmi MT, Ashraf R, Vinay K, Aggarwal D, Chatterjee D, Narang T, Dogra S. Dermoscopy as a tool to differentiate reactive arthritis from psoriatic arthritis. Indian J Dermatol [serial online] 2022 [cited 2022 Aug 17];67:186-8. Available from: https://www.e-ijd.org/text.asp?2022/67/2/186/350812




Sir,

Reactive arthritis (ReA) is a seronegative inflammatory arthritis that may show mucocutaneous lesions in up to 50% of patients. The typical cutaneous findings include psoriasiform plaques, pustulations, and crusting, which may appear before or after the onset of the oligoarthritis.[1] In the presence of cutaneous lesions, differentiation of ReA from psoriasis with psoriatic arthritis (PsA) is important because of differences in the treatment strategies and overall prognosis.

This was a cross-sectional study that compared the dermoscopic features of age-matched ReA (n = 6, males = 6, mean age = 25 years, diagnosed as per American College of Rheumatology criteria) and PsA (n = 15, males = 12, females = 3, mean age = 31 years, diagnosed as per Classification Criteria for Psoriatic Arthritis criteria; 5 had cutaneous lesions of pustular psoriasis) patients. All patients were seronegative for HIV infection.

Dermoscopy of ReA patients on Dermlite DL4; 3Gen, CA; polarized mode, at 10× magnification [Figure 1]a and [Figure 1]b showed closely placed islands of brownish plates separated at their edges from the surrounding flaccid pustules, simulating a “double-edged scale.” Active pustulations were noted at the periphery of these brownish crusts, removal of which revealed regularly arranged glomerular and dotted vessels on a background of erythema, akin to psoriasis. Silvery white scales were noted in the older lesions. PsA patients showed regularly arranged red dots and silvery-white scales. Both micro- and macro-pustules were seen in cases of pustular psoriasis. However, islands of brownish plates with “double edged scales” were typically lacking [Figure 1]c and [Figure 1]d. Dotted vessels and glomerular vessels were seen variably in both ReA and PsA. Statistical analysis (Fisher exact test) revealed islands of brownish plates with double-edged scales as specific dermoscopic findings in ReA [Table 1]. Histopathology of the cutaneous lesions in both conditions showed psoriasiform dermatitis, and we were unable to delineate these entities based on histology alone [Figure 1]e and [Figure 1]f.
Figure 1: (a) Dermoscopic features of cutaneous lesions of reactive arthritis. Dermoscopy of early lesion shows white-yellow blotches of pus (blue star) that has dried at the center to leave brownish plate/crust (white star). Mature lesions with islands of brownish plates (black star) with double-edged scales (black arrows) are also evident. (b) Another case of reactive arthritis showing brownish plates (star) detached at periphery (arrows) with surrounding pustulation (circle) forming a double-edged scale. (c) Dermoscopic features of psoriasis/pustular psoriasis in psoriatic arthritis patients. Dermoscopy shows yellowish white randomly placed scales (asterisk) with minute pustules (arrow) distributed diffusely in the lesion. Dotted vessels are highlighted with a circle. (d) Dermoscopy of pustular psoriasis shows silvery white to yellowish scales (white arrow) on an erythematous background with macropustules (black arrow) and dotted vessels (circle); (Dermlite DL4; 3Gen, CA; polarized mode, 10 × magnification). (e and f) Histopathological image of lesion from reactive arthritis showing marked parakeratosis, regular acanthosis with club shaped rete ridges, neutrophilic exocytosis and focal neutrophilic micro-abscesses (Hematoxylin and Eosin; 100× (e) and 200× (f)).

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Table 1: Comparison of dermoscopic features observed in cutaneous plaques of reactive arthritis and PsA

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Although the clinical history and evolution of the skin lesions or arthritis may help in clinical differentiation, the diagnosis may become difficult in ReA patients who present later in their disease course or who have been partially treated. To the best of our knowledge, there has been no report on dermoscopic features of ReA. We documented the dermatoscopic features of ReA, which correlates with the evolution of the lesions and histopathology. The early pustular phase showed homogenous yellow lakes of pus (giant yellow-globules) corresponding to the larger spongiform epidermal neutrophilic collections [Figure 1]a. Older lesions showed islands of brownish plates, which are the result of dried-up macropustules leaving brownish plates in the center which separate at the weaker flaccid walls of pustules giving an appearance of “double-edged scales” [Figure 1]b. This corresponded to parakeratotic debris. Hemorrhagic spots and dotted/glomerular vessels corresponded to dilated dermal capillaries on histology.

Circinate morphology of cutaneous lesions in ReA has been reported.[2] Such a global appearance cannot be appreciated on a 3–4-mm skin biopsy specimen, which may be the reason for the inability to differentiate these entities on histology. Dermoscopic differentials of “double-edged” or “trailing” scales are ichthyosis linearis circumflexa lesions of Netherton's syndrome, erythema annulare centrifugum, and pityriasis rosea.[3]

In summary, we put forward “islands of brownish plates with double-edged scales” as a dermoscopic clue to the diagnosis of ReA. However, a larger comparative study is warranted to validate our findings.

Acknowledgements

We thank the patients for granting permission for clinical photography. We would like to thank our dermatology colleagues in Calicut, Kerala for helping in the patient recruitment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Stavropoulos PG, Soura E, Kanelleas A, Katsambas A, Antoniou C. Reactive arthritis. J Eur Acad Dermatol Venereol 2015;29:415-24.  Back to cited text no. 1
    
2.
Razmi T, De D, Handa S, Saikia U. Image gallery: Generalized circinate cutaneous lesions simulating circinate balanitis. Br J Dermatol 2017;177:e224.  Back to cited text no. 2
    
3.
Sonthalia S, Gupta A, Jha AK, Sarkar R, Ankad BS. Disorders of pigmentation. In: Lallas A, Errichetti E, Ioannides D, editors. Dermoscopy in General Dermatology. 1st ed. United States: CRC Press, 2018. p. 257-69.  Back to cited text no. 3
    


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