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\begin{document}

\title{Case of Follicular Mucinosis Showing Brownish Yellow and Red Dots via
Dermoscopy}



\author[1]{Hiroki  Yamagishi}%
\author[1]{Mayumi Ota}%
\author[2]{Yoshimasa Nobeyama}%
\author[1]{Akihiko  Asahina}%
\affil[1]{Jikei University School of Medicine}%
\affil[2]{The Jikei University School of Medicine}%


\vspace{-1em}



  
  \date{June 13, 2024}


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\selectlanguage{english}
\begin{abstract}
We reported a case of 68-year-old man suffering from follicular
mucinosis. The dermoscopic examination showed multiple round brownish
yellow dots with a whitish rim in the follicular ostium and red dots in
the interfollicular area. This case report at first suggests that
follicular mucinosis may show such dermoscopic findings.%
\end{abstract}%



\sloppy


\textbf{Case of Follicular Mucinosis Showing Brownish Yellow and Red
Dots via Dermoscopy}

Hiroki Yamagishi, MD\textsuperscript{1}, Mayumi Ota,
MD\textsuperscript{1}, Yoshimasa Nobeyama, MD\textsuperscript{1}, and
Akihiko Asahina, MD\textsuperscript{1}

1. Department of Dermatology, The Jikei University School of Medicine,
Tokyo, Japan

Corresponding author: Yoshimasa Nobeyama, MD, PhD

Department of Dermatology, The Jikei University School of Medicine

25-8 Nishi-Shimbashi 3-chome, Minato-ku, Tokyo 105-8461, Japan

Tel.: +81-3-3433-1111 ext. 3341; Fax: +81-3-5401-0125

E-mail: nobederm@jikei.ac.jp

The authors received no financial support for this study.

The authors have no conflicts of interest to declare.

567 words, 1 figure

Key words: dermatology

\textbf{ABSTRACT}

We reported a case of 68-year-old man suffering from follicular
mucinosis. The dermoscopic examination showed multiple round brownish
yellow dots with a whitish rim in the follicular ostium and red dots in
the interfollicular area. This case report at first suggests that
follicular mucinosis may show such dermoscopic findings.

\textbf{KEY CLINICAL MESSAGE}

Follicular mucinosis may show the combination of both brownish yellow
dots and red dots dermoscopically. Dermatologists should consider the
possibility of follicular mucinosis when such dermoscopic findings are
obtained.

\textbf{INTRODUCTION}

Follicular mucinosis, also referred to as alopecia mucinosa, was
initially reported as localized alopecia histopathologically
characterized by the deposition of mucin within hair
follicles\textsuperscript{1}. The disease is classified as idiopathic
follicular mucinosis, which is not associated with other cutaneous or
extracutaneous diseases, and as lymphoma-associated follicular
mucinosis, which is associated with mycosis fungoides or S\selectlanguage{ngerman}ézary
syndrome\textsuperscript{2}. Idiopathic follicular mucinosis commonly
appears as follicular papules or indurated plaques \textsuperscript{3}.
We herein report a case of idiopathic follicular mucinosis showing
characteristic dermoscopic findings.

\textbf{CASE REPORT}

A 68-year-old Japanese man with a reddish plaque on the forehead for
several years and alopecia on the scalp for 9 months was referred to our
department. A physical examination revealed alopecic reddish plaques
measuring 3 cm in diameter on the forehead and scalp (Figure 1a). Lymph
nodes were not swollen around the head or neck. A dermoscopic
examination of the reddish plaque on the forehead showed multiple round
brownish yellow dots with a whitish rim in the follicular ostium and red
dots in the interfollicular area (Figure 1b). A peripheral blood
examination revealed no increases in the level of the soluble
interleukin 2 receptor or the number of atypical lymphocytes. A
histopathological examination with hematoxylin \& eosin staining showed
i) an eosinophilic substance in the dilated infundibulum and a pale
basophilic substance in the isthmus and outer root sheath (Figure 1c),
ii) focal follicular spongiosis and vacuolar alterations at the
interface between the outer root sheath and the dermis, iii) the
follicular and perifollicular infiltration of lymphocytes without
atypia, and iv) dilated capillary vessels in the upper dermis. The
substance deposited in the hair follicle was stained with Alcian blue at
pH 2.5 (Figure 1d). Based on the findings obtained, the patient was
diagnosed with idiopathic follicular mucinosis and the relevant
alopecia. The patient was treated 4 times each month with triamcinolone
acetonide injections, with resulted in the attenuation of lesions after
4 months (Figure 1e).

\textbf{DISCUSSION}

Only one English study has described multiple papular lesions on an
erythematous background as the dermoscopic finding of follicular
mucinosis \textsuperscript{3}. In the present case, the
histopathological finding of mucin deposits in the follicular
infundibulum and isthmus appear to correspond to the dermoscopic
findings of brownish yellow dots in the follicular ostium. Also, the
histopathological findings of dilated capillary vessels appear to
correspond to the dermoscopic findings of red dots in the
interfollicular area.

Yellow dots are a trichoscopic finding that corresponds to a dilated
follicular infundibulum filled with keratotic material and/or sebum.
They are observed as rounded or polycyclic structures with colors
ranging from pinkish yellow to brownish yellow \textsuperscript{4}. This
finding has been subsequently detected in various diseases, such as
alopecia areata, chronic cutaneous lupus erythematosus, androgenetic
alopecia, dissecting cellulitis, and, less frequently,
trichotillomania\textsuperscript{5}. Therefore, brownish yellow dots in
the present case are not specific to follicular mucinosis.

Red dots are a dermoscopic finding that corresponds to dilated vessels
aligned perpendicular to the skin surface \textsuperscript{6}. This
finding has been subsequently detected in melanocytic lesions such as
melanoma and melanocytic nevus as well as inflammatory diseases such as
psoriasis \textsuperscript{6}. Therefore, red dots in the present case
are not specific to follicular mucinosis. In that context, the
combination of both brownish yellow dots and red dots appears to be
non-specific. However, this case report suggests that dermatologists
should consider the possibility of follicular mucinosis when such
dermoscopic findings are obtained.

\textbf{ACKNOWLEDGMENTS}

None.

\textbf{CONFLICT OF INTEREST}

None declared.

\textbf{AUTHOR CONTRIBUTIONS}

HY: contributed to validation and writing. MO: provided resources and
contributed to data curation. YN: performed project administration. AA:
provided supervision.

\textbf{ETHICAL APPROVAL}

The case report was approved by the ethics committee of The Jikei
University School of Medicine and written informed consent was obtained
from the patient.

\textbf{REFERENCES}

1 Pinkus H. Alopecia mucinosa; inflammatory plaques with alopecia
characterized by root-sheath mucinosis. AMA Arch Derm 1957. 76: 419-424;
discussion 424-416.

2 Cerroni L, Fink-Puches R, Back B, Kerl H. Follicular mucinosis: a
critical reappraisal of clinicopathologic features and association with
mycosis fungoides and Sezary syndrome. Arch Dermatol 2002. 138: 182-189.

3 Akinsanya AO, Tschen JA. Follicular Mucinosis: A Case Report. Cureus
2019. 11: e4746.

4 Lima CDS, Lemes LR, Melo DF. Yellow dots in trichoscopy: relevance,
clinical significance and peculiarities. An Bras Dermatol 2017. 92:
724-726.

5 Inui S, Nakajima T, Nakagawa K, Itami S. Clinical significance of
dermoscopy in alopecia areata: analysis of 300 cases. Int J Dermatol
2008. 47: 688-693.

6 Martin JM, Bella-Navarro R, Jorda E. {[}Vascular patterns in
dermoscopy{]}. Actas Dermosifiliogr 2012. 103: 357-375.

\textbf{FIGURE LEGENDS}

\textbf{Figure 1}

a) Clinical findings in the first visit. Reddish plaques are evident on
the forehead and scalp. The plaque on the scalp forms a hairless area.
b) Dermoscopic findings of the reddish plaque on the forehead. Brownish
yellow dots with a whitish rim are observed in the follicular ostium.
Red dots are detected in the interfollicular area. c) Histopathological
findings (hematoxylin \& eosin stain, ×200). An eosinophilic substance
in the dilated infundibulum and a pale basophilic substance in the
isthmus and root sheath are evident. Focal follicular spongiosis and
vacuolar alterations of the interface between the outer root sheath and
dermis are accompanied by follicular and perifollicular lymphocytic
infiltration. Dilated capillary vessels are observed in the upper
dermis. d) Histopathological findings (Alcian blue stain, pH 2.5, ×200).
The substance deposited in the hair follicle is stained with Alcian
blue. e) Clinical findings at 4 months after the first visit. Alopecic
lesion on the scalp becomes less prominent.\selectlanguage{english}
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