doi: 10.1111/1346-8138.

13701 Journal of Dermatology 2017; 44: 533–537

CONCISE COMMUNICATION
Diagnostic usefulness of dermoscopy in differentiating lichen
aureus from nummular eczema
Kee Suck SUH, Jong Bin PARK, Myeong Hyeon YANG, Soo Young CHOI,
Hyun HWANGBO, Min Soo JANG
Department of Dermatology, Kosin University College of Medicine, Busan, Korea

ABSTRACT
Lichen aureus (LA) is a variant of pigmented purpuric dermatosis that is characterized clinically by rust macules,
papules or plaques, mainly on the legs. In some cases, LA can be difficult to be distinguished from nummular
eczema (NE) with the naked eye. Dermoscopy can be applied to skin lesions, revealing additional features that
can be highly valuable for correct diagnosis. This study was conducted to investigate characteristic dermoscopic
findings of LA and to identify distinctive features that can differentiate it from NE. Fourteen LA patients and 14 NE
patients diagnosed by skin biopsy were enrolled. Skin lesions were evaluated via polarized dermoscopy. On
dermoscopy, “coppery orange diffuse coloration of background”, “round to oval red globules”, “gray dots”, and
“networks of brownish to gray interconnected lines” were more commonly seen in LA (100%, 92.9%, 42.9% and
64.3%, respectively) compared with NE. “Scales”, “shiny yellow clods” and “irregularly distributed brownish-red
globules” were more commonly seen in NE (100%, 85.7% and 57.1%, respectively) compared with LA.
Dermoscopy provides valuable information for diagnosis of LA and aids in differentiating it from NE.
Key words: dermoscopy, diagnosis, lichen aureus, nummular eczema, pigmented purpuric dermatosis.

INTRODUCTION METHODS
Subjects
Lichen aureus (LA) is a variant of pigmented purpuric dermato-
Among the patients who visited the outpatient dermatology
sis (PPD) that is characterized clinically by discrete or confluent
clinic of our hospital for 5 years and 11 months, from June
rust macules, papules or plaques, mainly on the legs.1,2 As the
2010 to May 2016, 14 patients with LA and 14 patients with
skin lesions of LA and nummular eczema (NE) have similar pat-
NE confirmed by skin biopsy were enrolled in this study. Only
terns (round patches or plaques with similar sizes and mainly
lesions with localized distribution and discrete boundaries were
occurring on the lower extremities) and are predominant in
enrolled in LA group. In addition, lesions that showed “cayenne
males, it can be difficult to differentiate LA from NE by the
pepper” appearance, purpura with annular pattern and liche-
naked eye.
noid dermatitis were excluded from LA group.
Dermoscopy can be applied to pigmented and non-pigmen-
ted skin lesions, revealing additional features that can be highly
valuable for correct diagnosis. In a previous study, Zaballos Methods
et al.1 analyzed the dermoscopic findings of three LA patients
Clinical assessment
and reported: (i) a brownish to coppery-red diffuse coloration
Age, sex, location, clinical features, symptoms and disease
of the background; (ii) round to oval red dots, globules and
duration of patients were examined.
patches; (iii) some gray dots; and (iv) a network of brown or
gray interconnected lines. Dermoscopic findings of NE were
Dermoscopic observation
reported in only a few cases, and presence of shiny yellow
In the lesions of LA or NE patients, two dermatologists
clods was also reported.3 However, there have been no previ-
checked for the presence of a “coppery-orange diffuse col-
ous studies focusing on dermoscopic differences between LA
oration of the background”, “round to oval red globules”, “gray
and NE. The present study was conducted to investigate the
dots”, “a network of brownish to gray interconnected lines”,
usefulness of dermoscopy in differentiating the two diseases
“scales”, “shiny yellow clods” and “irregularly distributed
through evaluating dermoscopic findings of 14 patients with LA
brownish-red globules” via polarized dermoscopy (DermLite
and 14 patients with NE confirmed by skin biopsy.

Correspondence: Min Soo Jang, M.D., Department of Dermatology, Kosin University College of Medicine, 262 Gamcheon-ro, Seo-gu, Busan
49267, South Korea. Email: derma94@hanmail.net
Received 4 September 2016; accepted 14 October 2016.

© 2016 Japanese Dermatological Association 533

K.S. Suh et al.

DL3, 910 magnification; 3Gen, Dana Point, CA, USA). Only
consistent findings were utilized for the outcome analysis.
Histopathological evaluation
After dermoscopy was conducted, the dermoscopic and
histopathological findings were compared.
Statistical analysis
For statistical analysis, SPSS version 17.0 for Windows (SPSS,
Chicago, IL, USA) was used. To compare the differences in
dermoscopic findings of the patients with LA to those with NE,
the v2-test and Fisher’s exact test were performed. The statis-
tical results were considered significant at P < 0.05.

(a) (c)

(b)

(d) (f)

(e)

Figure 1. (a–c) Lichen aureus. (a) Brownish confluent macules and patches on the right lower leg. (b) Histopathological findings
show dermal infiltrate of lymphocytes and histiocytes, hemosiderin-laden macrophages, extravasation of red blood cells and an
increased number of blood vessels (hematoxylin–eosin [HE], original magnification 9100). (c) Dermoscopic findings show coppery-
orange background, round red globules (red arrow) and a network of gray interconnected lines (black arrows). (d–f) Nummular
eczema. (d) A solitary erythematous scaly patch with discharge on the left thigh. (e) Histopathological findings show spongiosis,
irregular acanthosis, exocytosis of inflammatory cells, scales, serum crust and hemorrhagic crust (HE, 9100). (f) Dermoscopic find-
ings show shiny yellow clods (black arrowhead), scales (white arrowhead) and irregularly distributed brownish-red globules (red
arrowhead).

534 © 2016 Japanese Dermatological Association

 Dermoscopy in differentiating LA from NA

RESULTS were observed in all patients with LA (Fig. 1, Table 2). An

Clinical findings
The mean age of the 14 patients with LA was 51 years (Fig. 1,
Table 1). Thirteen (92.9%) of these patients had lesions on the
lower extremities and one (7.1%) had lesions on the back. Nine
patients experienced pruritus (64.3%), while four patients (28.6%)
had no symptoms and one patient (7.1%) experienced tender-
ness. The mean age of the 14 patients with NE was 38.4 years.
Seven (50%) had lesions only on the extremities, while six
(42.9%) had lesions on the extremities and trunk, and one (7.1%)
had lesions on the face. All 14 patients experienced pruritus.
Dermoscopic findings
Coppery orange diffuse coloration of background, round to
oval red globules, gray dots and networks of brownish to gray
interconnected lines were more commonly seen in LA (100%,
92.9%, 42.9% and 64.3%, respectively) compared with NE
(Fig. 1, Table 1). Scales, shiny yellow clods and irregularly dis-
tributed brownish-red globules were more commonly seen in
NE (100%, 85.7% and 57.1%, respectively) compared with LA.
All observed dermoscopic findings showed significant differ-
ences between the two groups (P < 0.05).
Histopathological findings
Dermal infiltrates of lymphocytes and histiocytes, extravasation
of the red blood cells (RBC) and hemosiderin in histiocytes
increased number of blood vessels were observed in 13
patients in whom round to oval red globules showed. Hemosi-
derin-laden macrophages were observed in six patients in
whom gray dots showed. Hyperpigmentation of the basal cell
layer and incontinentia pigmenti in the upper dermis were
observed in nine patients in whom network of brownish to gray
interconnected lines showed. In patients with NE, scales were
also confirmed histologically, and a serum crust was observed
in 12 patients in whom a shiny yellow clods showed. Addition-
ally, a hemorrhagic crust was observed in eight patients in
whom irregularly distributed brownish-red globules showed.
DISCUSSION
Lichen aureus is a rare type of PPD. Clinically, gold, purple or
brownish papules are coalesced, forming one or many patches
or plaques.1,2 It has usually occurred on the lower extremities
but other body regions can be affected also.4 As the possibility
that LA is biologically related to mycosis fungoides was
raised,5 there is a need for differential diagnosis and close fol-
low-up observation.6 NE is an eczematous disease clinically
characterized by a round or oval plaque with clear boundaries.
NE most commonly occur on the lower extremities,7 and
develops more frequently in males than in females.8,9 As
lesions of the two diseases have similar patterns (round

Table 1. Clinical findings of 14 patients with lichen aureus and 14 with nummular eczema

Lichen aureus Nummular eczema

Total number of patients 14 14
Sex 10 males, four females 8 males, six females
Mean age 51 years (range, 26–66) 38.4 years (range, 2–73)
Mean duration 26.1 months (range, 1–180 months) 40.0 months (range, 0.5–180 months)
Location of lesion
Head and neck 0 (0%) 1 (7.1%)
Trunk 1 (7.1%) 6 (42.9%)
Arm 0 (0%) 8 (57.1%)
Leg 13 (92.9%) 13 (92.9%)
Distribution of lesion
Unilateral 9 (64.7%) 1 (7.1%)
Bilateral 5 (35.7%) 13 (92.9%)
Color of lesion
Erythematous 3 (21.3%) 13 (92.9%)
Erythematous to brownish 7 (50%) 1 (7.1%)
Brownish 4 (28.6%) 0 (0%)
Morphology of lesion
Patch 4 (28.6%) 6 (42.9%)
Plaque 5 (35.7%) 4 (28.6%)
Patch and macule 3 (21.3%) 0 (0%)
Patch and papule 1 (7.1%) 1 (7.1%)
Patch and plaque 0 (0%) 2 (14.3%)
Patch and petechiae 1 (7.1%) 0 (0%)
Plaque and vesicle 0 (0%) 1 (7.1%)
Symptoms
Pruritic 9 (64.3%) 14 (100%)
Asymptomatic 4 (28.6%) 0 (0%)
Tender 1 (7.1%) 0 (0%)

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K.S. Suh et al.

Table 2. Dermoscopic findings of 14 patients with lichen aureus and 14 with nummular eczema

Lichen Nummular
Dermoscopic findings Histological correlation aureus (%) eczema (%) P
Lichen aureus Coppery-orange diffuse Dermal infiltrate of lymphocytes and 14 (100%) 0 (0%) 0.0007
coloration of the background histiocytes, extravasation of RBC
hemosiderin in the histiocytes
Round to oval red globules Extravasation of RBC increased 13 (92.9%) 0 (0%) 0.0008
number of blood vessels
Gray dots Hemosiderin-laden macrophages in the 6 (42.9%) 0 (0%) 0.016
dermis
Network of brownish to gray Hyperpigmentation of the basal cell 9 (64.3%) 0 (0%) 0.001
interconnected lines layer incontinentia pigmenti in the
upper dermis lichenoid infiltrates
Nummular Scales Scales 3 (21.4%) 14 (100%) 0.0009
eczema Shiny yellow clods Serum crust 0 (0%) 12 (85.7%) 0.0008
Irregularly distributed brownish- Hemorrhagic crust 0 (0%) 8 (57.1%) 0.002
red globules

RBC, red blood cell.

patches or plaques with similar sizes and mainly occurring on
the lower extremities) and are predominant in males, it can be
difficult to differentiate LA from NE by the naked eye.
In a previous study, Fujimoto et al.10 also analyzed the der-
moscopic findings of three patients of LA and reported that not
all four of the findings reported by Zaballos et al.1 were
observed in each patient. In this study, all four dermoscopic
features of LA are not necessarily observed in all cases, and
their presence varies, probably depending on the disease
course.10 The scales observed in all patients with NE were also
observed in three patients (21.4%) with LA, and the difference
was statistically significant (P < 0.05). Thus, it is not right to
completely rule out LA with scales alone, and it is important to
closely observe the shiny yellow clods, which was reported by
Navarini et al.,3 or the irregularly distributed brownish-red glob-
ules for diagnosis of NE. Except scales, all dermoscopic find-
ings of LA and NE were observed exclusively on one side of
two diseases. Therefore, dermoscopy is thought to be helpful
for differentiating the two diseases.
In this study, dermoscopic–pathological correlation in
lesions of LA and NE were evaluated. In patients with LA, cop-
pery-orange diffuse coloration of the background would corre-
late with dermal infiltrate of lymphocytes and histiocytes, RBC
extravasation and hemosiderin in the histiocytes. Round to oval
red globules correspond to increased number of blood vessels.
Aggregation of melanophage, clumps of melanin or hemosi-
derin-laden macrophages can be detected as gray dots on
dermoscopy.1,11 Marked hemosiderin deposition in macro-
phages is a typical finding of PPD.12 We found that gray dots
correspond to hemosiderin-laden macrophages in the dermis.
In addition, network of brownish to gray interconnected lines
would correlate with hyperpigmentation of the basal cell layer
and incontinentia pigmenti in the upper dermis. In patients with
NE, scales were also confirmed histologically. Irregularly dis-
tributed brownish-red globules could be explained by a hemor-
rhagic crust. Serum exudates can be seen dermoscopically as
shiny yellow clods with a diameter of 1–2 mm.3 The
histological counterpart of shiny yellow clods was confirmed as
serum crust.
This study is significant in its description of dermoscopic
findings of LA and NE, which are rare to date, through compar-
ison in one institution. The limitation of this study includes
small number of patients, which restricts the generalizability of
our findings. Future studies should be conducted with a larger
patient group. Herein, the authors report that dermoscopy can
be employed as an assisting diagnostic tool in differentiating
LA from NE. Especially, dermoscopy can be useful for the
patients who reject invasive examination, because it can
increase compliance as it is not accompanied by pain or dis-
comfort.
CONFLICT OF INTEREST: None declared.
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