DERMATOLOGI VETERINER

“DIASCOPY TEST”

OLEH :
KELAS B
KELOMPOK
I GEDE ERICK ERISTIAWAN ( 1609511094)
ACH MOH ABD MUHSI (1609511097)

FAKULTAS KEDOKTERAN HEWAN

UNIVERSITAS UDAYANA
DENPASAR
2018
 A. PENDAHULUAN
Proses diagnosis merupakan perpaduan antara kegiatan intelektual dan tindakan-tindakan
menipulatif, sehingga dapat ditentukan adanya suatu penyakit kulit. Diagnosis lesi kulit
melibatkan prinsip dan pendekatan yang sama seperti pada gangguan medis lainnya.Dalam
menegakkan diagnosis suatu penyakit kulit, diperlukan riwayat dermatologi yang pertinent
dan pemeriksaan fisik yang teliti, dibantu oleh prosedur diagnostik penunjang.Tentu saja
kunci diagnostik penyakit kulit adalah riwayat klinis dan pemeriksaan fisik yang teliti (“ask,
look, manipulate”), tetapi untuk mendapatkan suatu diagnosis yang tepat,kadang-kadang
diperlukan juga teknik-teknik dan tes tertentu untuk membantu menunjangsuatu diagnosis
penyakit kulit. Indikasi, limitasi, interpretasi, dan teknik-teknik prosedur diagnosis haruslah
dipahami dengan benar untuk memperoleh informasi yang bermanfaat dan reliable agar
diagnosis suatu penyakit kulit dapat ditegakkan. Dalam referat ini, akan dibahas tentang uji
diascopy.

Diascopy adalah tes untuk blanchability yang dilakukan dengan menerapkan tekanan
dengan jari atau kaca geser dan mengamati perubahan warna. Ini digunakan untuk
menentukan apakah lesi adalah vaskular (peradangan atau kongenital), nonvaskular (nevus),
atau hemoragik (petekie atau purpura). Lesi hemoragik dan lesi nonvaskuler tidak pucat
("diascopy negatif"); lesi inflamasi lakukan ("diascopy positif"). Diascopy kadang-kadang
digunakan untuk mengidentifikasi lesi kulit sarcoid, yang ketika diuji, mengubah warna jeli
apel.

A. TUJUAN DIASKOPY TEST

Tujuannya untuk membedakan antara eritema (akibat vasodilatasi) dengan purpura

(akibat ekstravasasi eritrosit); juga warna apple jelly (kekuningan), dapat terlihat pada lupus
vulgaris.

1
B. ALAT dan BAHAN

Kaca atau diascope plastik

C. CARA KERJA

Pertama potong bulu hewan pada daerah yang mengalami lesi setelah itu tekan menggunakan
kaca atau diascope plasttik kemudian amati perubahan yang terjadi

Jika lesi hemoragik dan lesi nonvaskuler tidak pucat ("diascopy negatif"); lesi inflamasi
lakukan ("diascopy positif").

2
 DAFTAR PUSTAKA

Jayadi, Nana N. 2015. "LUPUS VULGARIS DENGAN LESI DISEMINATA." Departemen Ilmu Kesehatan Kulit
dan Kelamin.

Kang, Min-Hee. 2012. "Putative peanut allergy-induced urticaria in a dog." Case Report Rapport de cas.

Pérez-López, Daniel. 2016. "Clinical value of diascopy and other non-invasive techniques on differential
diagnosis algorithms of oral pigmentations: A systematic review." Diascopy and others on oral
pigmentation diagnosis .

3
Case Report  Rapport de cas

Putative peanut allergy-induced urticaria in a dog

Min-Hee Kang, Hee-Myung Park

Abstract — A 9-year-old, spayed male schnauzer dog was presented with vomiting, diarrhea, generalized erythema,
pruritic urticaria and conjunctival hyperemia after ingestion of peanut. The history, clinical signs, and histopathol-
ogy of the lesions were compatible with a hypersensitivity reaction. The clinical signs resolved rapidly after treat-
ment with prednisolone and antihistamine. This is the first report of urticaria caused by peanut ingestion in a dog.

Résumé — Urticaire putative induite par une allergie aux arachides chez un chien. Un chien mâle Schnauzer
stérilisé âgé de 9 ans est présenté avec des vomissements, de la diarrhée, un érythème généralisé, de l’urticaire
pruritique et une hyperémie conjonctivale après l’ingestion d’arachides. L’anamnèse, les signes cliniques et
l’histopathologie des lésions sont compatibles avec une réaction d’hypersensibilité. Les signes cliniques se sont
résorbés rapidement après le traitement avec de la prednisolone et des antihistaminiques. Il s’agit du premier rapport
d’urticaire causé par l’ingestion d’arachides chez un chien.
(Traduit par Isabelle Vallières)
Can Vet J 2012;53:1203–1206

F ood allergy, especially peanut allergy, can occur as a fatal

anaphylactic reaction in humans (1,2). Nausea, vomit-
ing, urticaria, angioedema, progressive respiratory symptoms,
hypotension, and dysrhythmias may develop within minutes
to a few hours after ingestion of the food (3). Food allergy may
cause various dermatologic and gastrointestinal signs in dogs but
the incidence is not known. Food allergy was first described in
dogs in 1967 (4), and subsequent studies have identified many
food allergens (5,6). Beef, dairy products, lamb, fish, poultry,
egg, wheat, barley, and other foods have been identified as com-
mon food allergens in dogs (5–10). In this report, we describe
a dog with clinical signs of hypersensitivity accompanied by
skin lesions, especially urticaria caused by ingestion of peanut.
Case description
A 9-year-old spayed male schnauzer dog was presented with
acute onset of vomiting, diarrhea, and severe urticaria the same
day it had ingested peanut. The amount of peanut ingested by
the dog was unknown. There were no known exposures to envi-
ronmental allergens, insect bites, or other food allergens. The
referring veterinarians treated the dog with an anti-inflammatory
dose of prednisolone and fluid for 2 d. Because there was no
BK21 Basic & Diagnostic Veterinary Specialist Program
for Animal Diseases and Department of Veterinary Internal
Medicine, College of Veterinary Medicine, Konkuk University,
Seoul, 143-701, South Korea.
Address all correspondence to Dr. Hee-Myung Park; e-mail:
parkhee@konkuk.ac.kr
Use of this article is limited to a single copy for personal study.
Anyone interested in obtaining reprints should contact the
CVMA office (hbroughton@cvma-acmv.org) for additional
copies or permission to use this material elsewhere.
response to the therapy and the urticaria worsened, the patient
was referred to our hospital.
Upon presentation, the dog was normothermic, tachypneic
(60 breaths/min), mildly dehydrated and had abdominal disten-
sion with pain. Systolic blood pressure was normal (138 mmHg,
Cardell Model 9401; Sharn Veterinary, Tampa, Florida, USA).
The abnormal skin lesions at presentation were generalized ery-
thema, pruritic urticaria, and conjunctival hyperemia (Figure 1).
Diascopy was performed by applying pressure with a glass slide
and blanched erythema revealed vasodilation (Figure 2). A
hemogram was normal and serum chemistry profiles showed
mild azotemia (urea nitrogen, 12.1 mmol/L; reference range
(RR): 2.9 to 3.3 mmol/L and creatinine, 176.8 mmol/L;
RR: 44.2 to 114.9 mmol/L), and elevated alanine transaminase
(74 U/L; RR: 19 to 70 U/L) and aspartate aminotransferase
(63 U/L; RR: 15 to 43 U/L) activity. The dog had no recent
vaccination or drug therapy. An 8-mm skin punch biopsy (KAI
Sterile Dermal Biopsy Punch; Kai Industries Co., Seki City,
Japan) was obtained on demarcated urticarial lesions at the
right axillary area including adjacent normal skin. The biopsy
sample was fixed in 10% neutral formalin, processed for paraffin
embedding, and stained with hematoxylin and eosin (H&E) for
histologic examination. Histology showed an edematous super-
ficial dermis with wide spaces between collagen fibers. Dermal
lesions consisted of diffuse superficial perivascular inflammation
in the urticarial areas. Vessels in the dermis were mildly dilated
and congested. Eosinophic and mastocytic inflammation were
diffusely present in the superficial dermis (Figure 3). Based on
the history, skin lesions, and histological findings, the dog was
diagnosed with peanut allergy induced urticaria. Prednisolone
(Solondo, Yuhan Medica, Seoul, Korea), 1 mg/kg body weight
(BW), PO, q12h, chlorpheniramine (Peniramin; Yuhan Medica,
Seoul, Korea), 0.5 mg/kg BW, PO, q8h, and pentoxyfylline
(Trental; Handog Pharm, Seoul, Korea), 10 mg/kg BW, PO,

CVJ / VOL 53 / NOVEMBER 2012 1203

R A P P O R T D E CA S
Figure 1.  Generalized raised erythematous lesions developed as an acute urticarial reaction
associated with peanut allergy. Note the conjuctival hyperemia (A), well-dermarcated
erythematous lesions at the axillary area (B and D), and the inner thigh (C).
Figure 2.  Diascopy was performed on a dog diagnosed as
having peanut allergy. Blanching erythema was achieved by
pressing with a glass slide.
q12h treatment was initiated for 1 wk then tapered. The dog
was reevaluated weekly for 1 mo after presentation during which
the lesions had completely resolved without side effects and
recurrence (Figure 4). Treatment was discontinued and the dog
was assessed monthly for 2 more months; there was no evidence
of recurrence.
Cutaneous adverse food reaction involving urticaria is uncom-
mon in dogs and is extremely rare in cats. The reaction is a
cutaneous hypersensitivity reaction that is manifested as an
edematous skin disease (8–11). In humans, life-threatening
anaphylactic reactions due to peanut and other nut allergies
are well-known (3,12); however, there have been no clinical
reports describing cutaneous adverse food reaction related to
nut allergies in dogs and cats. Extracts of peanut, walnut, and
Brazil nut have been tested for allergenic response in dogs as
a canine model of food allergy (13). The dogs were sensitized
1204
subcutaneously with the allergens in alum and intradermal skin
test, IgE immunoblotting to nut proteins, and oral challenges
with the nuts were performed. The authors demonstrated that
nut extracts elicited clinical responses in dogs that were simi-
lar to those in humans and that the peanut extract was more
allergenic than the other nut extracts (13). Peanuts (Arachis
hypogaea) belong to the legume family and 2S albumins, vicilins,
and legumins seed storage proteins are major allergens (1,13).
Specific IgE antibody produced in response to the allergen
results in degranulation of mast cells and release of histamine,
which is thought to be the major mediator of anaphlyaxis (14).
Late-phase response to IgE-mediated mast cell degranulation
and type III hypersensitivity response to immune complexes
also contribute to cutaneous adverse food reaction (15). This
may be the cause of the eosinophilic infiltration and chronic
inflammation in cutaneous adverse food reaction (1).
In this case, the dog showed immediate hypersensitivity reac-
tion after ingestion of peanut. Diascopy performed to determine
whether the lesions were hemorrhagic or inflammatory showed
that there was vasodilation. Histopathological results were not
specific for urticaria with peanut hypersensitivity, and due to
ethical considerations a challenge was not conducted. However,
other diagnoses such as folliculitis, vasculitis, erythema mul-
tiforme, and mast cell tumors were ruled out. Moreover, the
history and clinical symptoms also support the diagnosis of
peanut allergy in this dog. Management of this dog consisted
of glucocorticoids and antihistamines. Dramatic improvements
were achieved within a week and no recurrence was noted during
a 3-month follow-up period.
In conclusion, this is the first report of naturally occurring
urticaria in a dog caused by peanut ingestion. A diagnostic
CVJ / VOL 53 / NOVEMBER 2012
 CA S E R E P O R T
Figure 3.  Skin biopsy from an acute urticarial lesion in a dog with peanut allergy. A — Note the edematous
superficial dermis and interstitial dermatitis with mononuclear cells, neutrophils, eosinophils, and mast
cells [hematoxylin and eosin (H&E) stain; bar = 200 mm]. B — High power magnification of A (H&E stain;
bar = 50 mm).

Figure 4.  Four weeks after therapy with prednisolone and chlorpheniramine, the dog’s gross lesions
(A — conjuntiva, B and D — axillary area, and C — inner thigh) had completely resolved.

and therapeutic approach to this dog was described. The dog Acknowledgment
responded well to the immunosuppressive and antihistamine This work was supported by the National Research Foundation
treatments; prevention by exposure avoidance is the first line of of Korea (NRF) grant funded by the Korea government (MEST)
management in peanut allergy. (No. 2010018275). CVJ

CVJ / VOL 53 / NOVEMBER 2012 1205

 References
1. du Plessis K, Steinman H. Practical aspects of adverse reactions to
peanut. Curr Allergy & Clin Immunol 2004;17:10–14.
2. Johnson RF, Peebles RS, Jr. Anaphylactic shock: Pathophysiology, recog-
nition and treatment. Semin Respir Crit Care Med 2004;25:695–703.
3. Sampson HA. Peanut allergy. N Engl J Med 2002;346:1294–1299.
R A P P O R T D E CA S
4. Walton GS. Skin responses in the dog and cat to ingested allergens.
Observations on one hundred confirmed cases. Vet Rec 1967;81:
709–713.
5. Jeffers JG, Meyer EK, Sosis EJ. Responses of dogs with food aller-
gies to single-ingredient dietary provocation. J Am Vet Med Assoc
1996;209:608–611.
6. Paterson S. Food hypersensitivity in 20 dogs with skin and gastro-
intestinal signs. J Small Anim Pract 1995;36:529–534.
7. Verlinden A, Hesta M, Millet S, Janssens GP. Food allergy in dogs and
cats: A review. Crit Rev in Food Sci Nutr 2006;46:259–273.
8. Kennis RA. Food allergies: Update of pathogenesis, diagnoses, and
management. Vet Clin Small Anim 2006;36:175–184.
Answers to Quiz Corner
Les réponses du test éclair
1. d) Epidural anesthetics should not be used when there is
trauma, bleeding, or infection at the injection site.
d) Les anesthésiques épiduraux ne devraient pas être utilisés
en présence de traumatisme, d’hémorragie ou d’infection
au site d’injection.
2. c) Immature forms include band cells.
c) Les formes immatures comprennent les neutrophiles non
segmentés.
3. a) Omentum adheres to the intestinal incision rapidly, creat-
ing a fluid-tight seal.
a) L’omentum adhère rapidement à l’incision intestinale,
créant ainsi un bouchon étanche contre les fuites.
4. a) The degree of callus formation is inversely related to the
stability of a fracture.
a) Le degré de formation du cal osseux est inversement relié
à la stabilité de la fracture.
5. a) This tumor secretes erythropoietin.
a) Cette tumeur sécrète de l’érythropoïétine.
6. b) Clostridium piliforme (formerly Bacillus piliformis) causes
Tyzzer’s disease.
b) Clostridium piliforme (anciennement Bacillus piliformis)
cause la maladie de Tyzzer.
1206
9. Gaschen FP, Merchant SR. Adverse food reactions in dogs and cats. Vet
Clin Small Anim 2011;41:361–379.
10. Martín A, Sierra MP, González JL, Arévalo MA. Identification of aller-
gens responsible for canine cutaneous adverse food reactions to lamb,
beef and cow’s milk. Vet Dermatol 2004;15:349–356.
11. Medleau L, Hnilica KA. Hypersensitivity disorders. In: Small
Animal Dermatology: A Color Atlas and Therapeutic Guide, 2nd ed.
Philadelphia, Pennsylvania: WB Saunders, 2006:160–161.
12. Leung DY, Sampson HA, Yunginger JW, et al. Effect of anti-IgE therapy
in patients with peanut allergy. N Engl J Med 2003;348:986–993.
13. Teuber SS, Del Val G, Morigasaki S, et al. The atopic dog as a model
of peanut and tree nut food allergy. J Allergy Clin Immunol 2002;110:
921–927.
14. Untersmayr E, Jensen-Jarolim E. Mechanisms of type I food allergy.
Pharmacol Ther 2006;112:787–798.
15. Day MJ. The canine model of dietary hypersensitivity. Proc Nutr Soc
2005;64:458–464.
7. a) Hypovitaminosis A causes increased cerebrospinal fluid
pressure accompanied by papillary edema and at times
central nervous system signs.
a) L’hypovitaminose A cause une augmentation de la pression
du liquide cérébrospinal accompagnée de l’œdème
papillaire et, parfois, de signes du système nerveux central.
8. a) The unilateral and developmental nature of this lesion
makes lymphosarcoma the most likely possibility.
a) La nature unilatérale et l’évolution de cette lésion
indiquent que le lymphosarcome constitue la possibilité
la plus probable.
9. a) Given the history and the signs, this is the most likely
diagnosis. Scrotal swelling is not marked in all stallions
with acquired inguinal or scrotal hernia.
a) D’après l’anamnèse et les signes, la hernie inguinale est
le diagnostic le plus probable. L’enflure scrotale n’est pas
marquée chez tous les étalons qui souffrent d’une hernie
inguinale ou d’une hernie scrotale.
10. a) Inguinal herniorrhaphy is indicated to correct the problem
and to prevent recurrence. Resection and anastomosis of
small intestine may also be necessary.
a) La herniorraphie inguinale est indiquée pour corriger
le problème et empêcher une rechute. La résection et
l’anastomose d’une partie du petit intestin peuvent aussi
être nécessaires.
CVJ / VOL 53 / NOVEMBER 2012
 LUPUS VULGARIS DENGAN LESI DISEMINATA

1
Nana N. Jayadi
1
Niken Ernaningtyas
1
Nurdjannah J. Niode
2
Marthen C. P. Wongkar

1
Departemen Ilmu Kesehatan Kulit dan Kelamin
2
Bagian Ilmu Penyakit Dalam
Fakultas Kedokteran Universitas Sam Ratulangi Manado
Email: novia_jayadi@yahoo.com

Abstract: Lupus vulgaris (LV) is a chronic progressive form of paucibacillary cutaneous

tuberculosis. Lesion is usually solitary in the form of nodes or erythematous plaques with an
apple-jelly sign on diascopy. Disseminated LV is a rare form of cutanoeus tuberculosis with
multiple lesions in several body areas. We reported a male of 40 years old with a suppurative
wound on the left neck and reddish nodules on the face, neck, trunk, and limbs along with
fever, night sweats, weight loss, and history of previous TB infections. There were multiple
erythematous nodules and painful suppurating ulcers with enlargement of several lymph
nodes. Apple-jelly sign appeared on diascopy. The FNAB showed specific granulamatous
inflammation for TB with lymphocytes, epitheloid macrophages, and multinucleated giant
cells. The histopathological finding showed tubercles surrounded by macrophages and
lymphocytes. Anti-tuberculosis drugs category I were given for 6 months, ofloxacin, and open
wound care compressed with NaCl 0.9%. In the third month of observation, there was
significant improvement. Conclusion: This case was diagnosed as lupus vulgaris based on the
history of lymphadenitis TB and scrofuloderma, lesions in several body area with positive
diascopy test, the FNAB as well as the histopathologic result supporting the diagnosis of
tuberculosis, and there was significant improvement after treatment with antiTB drugs.
Keywords: lupus vulgaris, diseminata, tuberculosis, ofloksasin

Abstrak: Lupus vulgaris (LV) merupakan tuberkulosis (TB) kutis pausibasiler kronis dan
progresif. Lesi biasanya soliter, berupa nodus atau plak eritematosa dengan gambaran apple-
jelly pada diaskopi. Lupus vulgaris diseminata merupakan bentuk TB kutis yang jarang
ditemukan dengan lesi multipel pada beberapa area tubuh secara bersamaan. Kami melaporkan
seorang laki-laki, 40 tahun, dengan luka bernanah pada leher kiri dan benjolan-benjolan
kemerahan pada wajah, leher, badan, dan tungkai disertai demam, keringat malam, penurunan
berat badan dan riwayat infeksi tuberkulosis sebelumnya. Pada pemeriksaan fisik tampak
nodus eritematosa multipel disertai ulkus bernanah dan pembesaran beberapa kelenjar getah
bening. Gambaran apple-jelly tampak pada diaskopi. Pemeriksaan FNAB menunjukkan
gambaran radang granulomatik spesifik TB dengan adanya sel-sel radang limfosit, kelompok
makrofag epiteloid, dan sel-sel datia Langhans. Pemeriksaan histopatologis memberikan
gambaran tuberkel yang dikelilingi oleh makrofag dan limfosit. Terapi diberikan berupa OAT
kategori I selama 6 bulan, ofloksasin, dan kompres terbuka dengan NaCL 0,9%. Pada bulan
ketiga tampak perbaikan signifikan. Simpulan: Pada kasus ini, diagnosis lupus vulgaris
ditegakkan berdasarkan adanya riwayat limfadenitis TB dan skrofuloderma, lesi di beberapa
area tubuh sekaligus dengan pemeriksaan diaskopi positif, gambaran FNAB dan histopatologis
menunjang diagnosis TB, dan pengobatan dengan OAT memberikan perbaikan bermakna.
Kata kunci: lupus vulgaris, diseminata, OAT, ofloksasin

185
186 Jurnal Biomedik (JBM), Volume 7, Nomor 3, November 2015, hlm.185-194
Tuberkulosis kutis, seperti halnya
tuberkulosis paru yang disebabkan oleh
Mycobacterium tuberculosis (M.
tuberculosis) atau mikobakterium atipikal
lainnya, masih merupakan masalah
kesehatan terutama di negara berkembang.1
Berdasarkan data World Health
Organization (WHO) tahun 2009,
Indonesia berada di posisi ke-5 dengan
jumlah penderita tuberkulosis (TB) sebesar
429 ribu orang. Dari total seluruh TB,
11.215 kasus merupakan kasus TB ekstra
paru.2 Di RS Cipto Mangunkusumo
(RSCM), skrofuloderma merupakan bentuk
yang paling sering ditemukan (84%),
disusul tuberkulosis kutis verukosa (13%).
Lupus vulgaris yang dahulunya tidak
ditemukan ternyata sekarang terdeteksi
meskipun sangat jarang.1 Hingga saat ini,
belum pernah dilaporkan kejadian kasus
lupus vulgaris di RSUP Prof Dr. R. D.
Kandou Manado.
Lupus vulgaris (LV) merupakan
bentuk TB kutis pausibasiler kronis dan
progresif, ditemukan pada individu dengan
imunitas sedang dan sensitivitas tinggi
terhadap tuberkulin. Cara infeksi dapat
melalui inokulasi langsung, serta penjalaran
hematogen dan limfogen.3 Lesi LV
biasanya soliter, namun dapat ditemukan
pada 2 atau 3 tempat secara bersamaan
berupa makula dan papul berwarna merah
kecoklatan dengan konsistensi lunak. Pada
pemeriksaan diaskopi tampak gambaran
apple-jelly. Lesi kemudian mengalami
perkembangan yang ditandai dengan
peninggian lesi, pelebaran ke arah perifer,
warna menjadi lebih kecoklatan, dan
pembentukan plak; dapat pula terjadi erosi,
ulserasi, serta jaringan parut.3,4
Lupus vulgaris diseminata adalah LV
dengan lesi multipel, terdapat pada
beberapa area tubuh secara bersamaan
akibat penyebaran secara hematogen dari
fokus tuberkulosis.3,4 Lesi LV diseminata,
seperti halnya lesi LV yang khas, dapat
dilihat dari gejala klinis dan adanya
gambaran karakteristik apple-jelly.
Pemeriksaan penunjang lainnya yaitu
pemeriksaan histopatologi, kultur, dan
polymerase chain reaction (PCR).1,3,4 Tes
Mantoux biasanya memberikan hasil positif
kuat.3-5 Prinsip pengobatan pada umumnya
sama dengan TB paru yaitu dengan
pengobatan kombinasi obat anti
1
tuberkulosis (OAT).
LAPORAN KASUS
Seorang laki-laki berusia 40 tahun,
suku Mongondow, datang ke Poliklinik
Kulit dan Kelamin RSUP Prof. Dr. R. D.
Kandou Manado dengan luka bernanah
pada leher kiri dan benjolan-benjolan
kemerahan pada wajah, leher, badan, dan
tungkai. Kelainan ini dialami sejak 3 bulan
yang lalu, diawali dengan timbulnya
benjolan-benjolan sebesar biji jagung di
leher kiri yang kemudian berwarna
kemerahan, bergabung menjadi satu,
sebagian berisi nanah dan pecah
membentuk luka. Leher kiri bengkak,
terasa keras bila ditekan dan nyeri. Keluhan
ini juga disertai demam, keringat malam,
dan penurunan berat badan. Dua bulan
kemudian, muncul benjolan-benjolan
sewarna kulit lain yang tersebar di pipi
kanan, leher kanan, dada, perut, punggung,
dan kedua selangkangan. Pasien memiliki
riwayat limfadenitis TB dan skrofuloderma
yang telah sembuh 3 tahun lalu. Riwayat
batuk-batuk lama dan trauma pada leher
tidak ditemukan; riwayat pemakaian obat
tidak diketahui; dan pasien sudah mendapat
vaksinasi BCG sebelumnya.
Pada pemeriksaan fisik didapatkan
keadaan umum baik, berat badan 65 kg,
kesadaran kompos mentis, tekanan darah
110/70 mmHg, frekuensi nadi 82x/menit,
frekuensi nafas 18 x/menit dan suhu
36,7°C. Ditemukan pembesaran kelenjar
getah bening (KGB) submandibular dekstra
dan sinistra, servikalis dekstra dan sinistra,
aksilaris dekstra dan sinistra, inguinal
dekstra dan sinistra, berdiameter ±1-2 cm,
konsistensi lunak, mobilitas (-), nyeri tekan
(-), dengan kulit diatasnya tampak normal.
Hasil pemeriksaan jantung dan paru dalam
batas normal serta tidak dijumpai
pembesaran hati dan limpa.
Pada pemeriksaan dermatologis regio
perioralis dekstra tampak nodus
 Jayadi, Ernaningtyas, Niode, Wongkar: Lupus vulgaris dengan lesi diseminata 187
eritematosa, soliter, disertai ulkus dangkal
di bagian tengah dengan diameter ±0,5 cm
disertai krusta kekuningan dan pus
(Gambar 1A). Pada regio mandibularis
dekstra, periaurikularis dekstra, torakalis
anterior et posterior, abdominalis, brakialis,
antebrakialis dekstra sinistra, inguinalis
dekstra dan sinistra ditemukan papul dan
nodus eritematosa dan sewarna kulit yang
multipel (Gambar 1B). Tampak skar atrofik
pada regio koli anterior bagian superior
(Gambar 1C). Pada regio aurikularis,
periaurikularis sinistra, koli sinistra,
supraklavikularis sinistra ditemukan edema
dan nodus eritematosa multipel, pustul
multipel, ulkus multipel dengan ukuran
bervariasi sekitar 0,5x0,5x0,2 cm hingga 5x
5x0,2 cm, tepi tidak teratur, dasar sebagian
jaringan granulasi dan sebagian tertutup
pus disertai krusta kekuningan, serta tidak
tampak adanya fistel (Gambar 1D).
Pemeriksaan diaskopi pada lesi menunjuk-
kan apple jelly sign.
Pemeriksaan pus dengan pewarnaan
Ziehl Nielsen menunjukkan adanya sel
PMN namun tidak ditemukan adanya basil
tahan asam (BTA). Pada pemeriksaan pus
dengan pewarnaan Gram tampak adanya
sel-sel PMN disertai kokus Gram positif
dan negatif.
Diagnosis banding pada pasien ini
ialah lupus vulgaris, skrofuloderma,
mineralisasi kutan, misetoma, dan limfoma
sehingga direncanakan beberapa pemerik-
saan penunjang lain berupa pemeriksaan
hematologi rutin, laju endap darah, sediaan
apus darah tepi, kimia darah, fungsi hati,
fungsi ginjal, laktat dehidrogenase,
kalsium, fosfat, elektrolit, urinalisis, feses
lengkap, kultur pus dan sensitivitas, foto
toraks, tes Mantoux, biopsi kulit, kultur
jamur, dan fine needle aspiration biopsy
(FNAB) untuk menegakkan diagnosis pasti.
Dari hasil pemeriksaan laboratorium
didapatkan kadar Hb yang menurun (10,6
/DL), peningkatan LED (101,4 mm/jam),
dan penurunan glukosa darah puasa (GDP
61 mg/dL). Fungsi hati, fungsi ginjal,
urinalisis, dan pemeriksaan feses dalam
batas normal. Kadar asam urat dalam batas
normal, sedangkan kadar kalsium, fosfat
dan laktat dehidrogenase menurun ringan.
Tidak tampak adanya pertumbuhan jamur
pada kultur jaringan. Pada kultur pus
didapatkan adanya pertumbuhan kuman
Staphylococcus aureus yang sensitif
terhadap amikasin dan fosfomisin serta
kuman Serratia marcescens yang sensitif
terhadap amikasin, ampisilin sulbaktam,
dan meropenem. Gambaran jantung dan
paru pada foto toraks dalam batas normal.
Hasil pemeriksaan FNAB pada leher
kiri menunjukkan adanya sel-sel radang
limfosit, kelompok makrofag epiteloid, dan
sel-sel datia Langhans. Pada pemeriksaan
histopatologik dari nodus pada punggung
tampak epidermis yang berulkus. Pada
dermis di bawahnya tampak struktur
granuloma atau tuberkel dengan nekrosis
sentral dan bagian tepi terdiri dari sel-sel
makrofag epiteloid, makrofag berbuih, dan
limfosit. Kesan dari pemeriksaan histo-
patologik ialah radang granulomatik
spesifik dengan infeksi sekunder.
Gambaran histopatologik ini sesuai dengan
lupus vulgaris.
Berdasarkan anamnesis, pemeriksaan
fisik dan pemeriksaan penunjang, diagnosis
kerja pada pasien ini ialah lupus vulgaris
(diseminata) dan limfadenitis TB. Pasien
kemudian dikonsulkan dan dirawat
bersama dengan Bagian Penyakit Dalam.
Terapi awal yang diberikan berupa
doksisiklin 2x100 mg, asam mefenamat
3x500 mg, paracetamol 3 x 500 mg bila
demam, dan kompres terbuka dengan NaCl
0,9% 3x30 menit. Setelah diagnosis lupus
vulgaris diseminata dan limfadenitis TB
ditegakkan diberikan terapi OAT berupa
fixed dose combination (FDC) 1 x 4 tablet
yang terdiri dari rifampisin (R) 10
mg/kgBB/hari, isoniazid (H) 5 mg/kgBB/
hari, pirazinamid 25 mg/kgBB/hari, dan
etambutol (E) 15 mg/kgBB setiap hari
selama 2 bulan dan kompres terbuka
dengan NaCl 0.9% 3x30 menit.
Pada kunjungan ulang (pengamatan
hari ke-50 pengobatan), bengkak pada leher
kiri pasien berkurang namun luka meluas
dan pus bertambah karena sebagian nodus
telah pecah (Gambar 2A). Nodus pada
sudut kanan bibir membesar dengan luka
188 Jurnal Biomedik (JBM), Volume 7, Nomor 3, November 2015, hlm.185-194
yang melebar (Gambar 2B). Nodus eritema
sewarna kulit pada badan dan ekstremitas
sebagian telah mendatar, pecah dan
menimbulkan luka. Pada pemeriksaan
Gram dari pus pada luka didapatkan adanya
sel-sel PMN serta kuman Gram positif dan
negatif. Pasien mengeluh adanya bengkak
dan nyeri pada sendi jari-jari tangan setelah
minum OAT.
Pasien kemudian dikonsulkan ke
Bagian Penyakit Dalam dan akan dilakukan
pemeriksaan Voluntary Counseling and
Testing (VCT), darah lengkap (DL), laju
endap darah (LED), fungsi hati, fungsi
ginjal, asam urat, dan FNAB pada nodul di
atas bibir. Dari pemeriksaan laboratorium
diperoleh hasil kadar Hb masih di bawah
normal, LED yang menurun dibanding
pemeriksaan sebelumnya (dari 101,4
mm/jam menjadi 49 mm/jam), dan
peningkatan kadar asam urat (15,0 mg/dL).
Pemeriksaan VCT pada pasien menunjuk-
kan hasil non-reaktif, dan tidak ditemukan
tanda-tanda keganasan pada pemeriksaan
FNAB. Terapi yang diberikan berupa
pemberian sisipan HRZE selama 1 bulan,
alopurinol 1x100 mg, ofloksasin 2 x 400
mg dan kompres terbuka dengan NaCl
0,9% 3x30 menit.
Pada pengobatan hari ke-80 pasien
kembali kontrol dan tampak perbaikan
bermakna, dimana ulkus pada leher kiri
mengering, pus berkurang, dan edema
minimal (Gambar 3A). Nodus eritema pada
area tubuh lain telah mendatar dengan
ulkus yang sebagian juga telah kering
(Gambar 3B). Terapi yang diberikan
berupa OAT fase lanjutan dengan RH 3 x
seminggu (rencana selama 4 bulan),
ofloksasin 2 x 400 mg, dan kompres
terbuka dengan NaCl 0.9% 3x30 menit.
BAHASAN
Istilah lupus vulgaris (LV) pertama
kali dikemukakan oleh Erasmus Wilson
pada tahun 1865.6 Lupus vulgaris adalah
salah satu bentuk TB kutis yang kronik,
progresif, ditemukan pada individu dengan
imunitas sedang, memiliki sensitivitas yang
tinggi terhadap tuberkulin dan merupakan
reinfeksi tuberkulosis kutis sebelumnya
dengan penjalaran secara hematogen,
limfogen, maupun penjalaran langsung
setelah terjadi inokulasi.4,7,8 Lupus vulgaris
diseminata merupakan bentuk LV dengan
lesi multipel atau terdapat di beberapa area
tubuh secara bersamaan sebagai
konsekuensi penjalaran hematogen dari
fokus tuberkulosis. Bentuk LV diseminata
ini biasanya ditemukan pada individu
dengan TB paru aktif atau timbul beberapa
lama setelah terjadi gangguan imunitas,
misalnya akibat terkena campak.3,4
Sebagaimana halnya dengan TB paru,
maka LV sebagai salah satu TB kutis juga
merupakan masalah kesehatan di negara
berkembang seperti Indonesia. Bentuk LV
jarang dijumpai pada negara tropis, lebih
sering dijumpai pada wanita, dan dapat
mengenai semua umur.3
Lupus vulgaris sebagai bagian dari TB
memiliki gejala lokal dan gejala sistemik.
Gejala lokal yang timbul sesuai dengan
organ yang terlibat. Gejala sistemik dapat
berupa demam, malaise, keringat malam,
anoreksia dan berat badan menurun.10
Gambaran klinis LV berupa nodus atau
plak eritematosa yang berubah warna
menjadi kuning pada diaskopi (apple-jelly
sign). Nodi tersebut dalam perkembangan-
nya dapat berkonfluensi menjadi plak yang
bersifat dekstruktif dan diikuti dengan
ulserasi.1,9 Sekitar 90% lesi LV terdapat
pada wajah dan leher. Biasanya lesi timbul
di hidung, pipi, daun telinga atau kulit
kepala dan perlahan meluas ke area yang
lain.3
Pasien seorang laki-laki berusia 40
tahun dengan benjolan-benjolan kemerahan
disertai luka bernanah pada leher kiri yang
terkadang terasa nyeri sejak 1 bulan.
Awalnya, benjolan-benjolan yang timbul
sewarna kulit dan berukuran sebesar biji
jagung, sebagian kemudian bergabung
menjadi satu, berwarna kemerahan,
bernanah dan pecah menimbulkan luka.
Beberapa minggu kemudian timbul
benjolan-benjolan lain yang tersebar di pipi
kanan, leher, dada, perut, punggung dan
kedua selangkangan.
 Jayadi, Ernaningtyas, Niode, Wongkar: Lupus vulgaris dengan lesi diseminata 189

A B C D

Gambar 1. Pengamatan saat pertama kali pasien datang berobat. A, nodus eritematosa, soliter,
disertai ulkus dangkal di bagian tengah dengan diameter ±0,5 cm disertai krusta kekuningan dan pus
pada regio perioralis dekstra. B, papul dan nodus eritematosa dan sewarna kulit yang multipel pada
regio mandibularis dekstra dan periaurikularis dekstra. C, skar atrofik pada regio koli anterior bagian
superior. D, edema dan nodus eritematosa multipel, pustul multipel, ulkus multipel pada regio
aurikularis, periaurikularis sinistra, koli sinistra, dan supraklaviularis sinistra

A B

Gambar 2. Pengamatan hari ke-50 pengobatan. A, bengkak pada leher kiri berkurang namun luka
meluas dan pus bertambah karena sebagian nodi telah pecah. B, nodus pada sudut kanan bibir
membesar dengan luka yang melebar. Nodi eritema sewarna kulit pada badan dan ekstremitas
sebagian telah mendatar, pecah dan menimbulkan luka

A B

Gambar 3. Pengamatan hari ke-80 pengobatan. A, ulkus pada leher kiri mengering, pus berkurang,
dan edema minimal. B, nodi eritema pada area tubuh lain telah mendatar dengan ulkus yang
sebagian juga telah kering
190 Jurnal Biomedik (JBM), Volume 7, Nomor 3, November 2015, hlm.185-194
Gejala sistemik yang dialami berupa
demam, keringat malam dan penurunan
berat badan sebanyak 6 kg dalam 1 bulan
terakhir. Riwayat batuk berdahak, riwayat
trauma pada leher kiri dan riwayat asam
urat disangkal. Pasien memiliki riwayat
limfadenitis TB disertai skrofuloderma
pada tahun 2011. Pengobatan dengan OAT
TB dijalankan pasien secara teratur dan
pasien telah dinyatakan sembuh.
Menurut acuan pustaka, lesi LV pada
daerah kepala dan leher biasanya berhu-
bungan dengan limfangitis dan limfade-
nitis.5 Pembesaran KGB pada kasus ini
ditemukan pada KGB submandibula
dekstra dan sinistra, servikalis dekstra dan
sinistra, dan inguinal dekstra dan sinistra
dengan diameter ± 1-2 cm, konsistensi
lunak, mobilitas (-), nyeri tekan (-), tanpa
disertai tanda-tanda radang pada kulit
diatasnya.
Lesi LV biasanya timbul sebagai lesi
soliter di atas kulit normal, namun lesi
dapat juga ditemukan pada daerah inokulasi
primer pada pembuatan tato, pada skar
skrofuloderma, atau di tempat injeksi BCG.
Lesi yang multipel atau bentuk diseminata
dapat ditemukan pada pasien dengan TB
paru aktif.3,4 Gambaran klinis LV dapat
dibagi menjadi lima bentuk tergantung
pada respon jaringan lokal terhadap infeksi,
yaitu: plak, ulserasi dan mutilasi, vegetasi,
tumor, dan papulonodular. Bentuk atipikal
juga semakin sering ditemukan.4 Mukosa
dapat pula terlibat, ditandai adanya papul,
ulkus, atau massa granuloma.3 Pada kasus
ini, ditemukan limfadenitis TB disertai lesi
kulit berupa kombinasi bentuk ulserasi
pada leher dan bentuk papulonodular yang
tampak tersebar di wajah, leher, badan, dan
ekstremitas tetapi tidak ditemukan lesi pada
mukosa. Pada sudut bibir kiri tampak nodus
eritematosa soliter disertai ulkus dangkal di
bagian tengah dengan permukaan tertutup
krusta kekuningan. Leher kiri, daerah di
sekitar telinga, dan daun telinga kiri tampak
edema dan eritema disertai nodus
eritematosa, pustul, serta ulkus dangkal
multipel yang sebagian tertutup pus dan
krusta kekuningan. Tidak tampak adanya
fistel seperti yang sering dijumpai pada
skrofuloderma. Pada pemeriksaan diaskopi,
kelompok nodus eritema tersebut berubah
warna menjadi kuning yang menandakan
apple-jelly sign positif. Skar atrofik akibat
lesi skrofuloderma sebelumnya ditemukan
pada daerah submandibularis. Nodus
eritematosa dan sewarna kulit juga tersebar
pada pipi kanan, di sekitar telinga kanan,
dada, perut, punggung, serta kedua lengan
dan paha.
Berdasarkan anamnesis dan pemeriksa-
an fisik, kasus ini pada awalnya memiliki
beberapa diagnosis banding yaitu: lupus
vulgaris, skrofuloderma, misetoma, minera-
lisasi kutan, dan limfoma. Dengan
terdapatnya beberapa gejala sistemik TB,
pembesaran KGB leher, riwayat limfade-
nitis TB, dan riwayat skrofuloderma
sebelumnya maka LV dan skrofuloderma
merupakan diagnosis banding. Pasien juga
bekerja sebagai petani jagung dan berisiko
tertusuk atau tergores tanaman sehingga
risiko infeksi seperti misetoma cukup tinggi
meski disangkal oleh pasien. Limfadeno-
pati disertai nodus eritema generalisata
dapat ditemukan pada limfoma, sedangkan
nodus sewarna kulit dapat dijumpai pada
mineralisasi kutan.
Pemeriksaan diaskopi pada lesi
memberikan gambaran apple-jelly yang
merupakan karakteristik lesi LV, meski
tidak selalu dapat ditemukan. Pada
pemeriksaan laboratorium sederhana
dengan sediaan berupa pus dari ulkus di
leher pemeriksaan Ziehl Nielsen dan
pemeriksaan Gram dengan hasil pemeriksa-
an tidak ditemukan basil tahan asam (BTA)
dengan pewarnaan Ziehl Nielsen dan
adanya sel PMN, kokus Gram positif dan
negatif dengan Pemeriksaan Gram. LV
merupakan bentuk TB kutis pausibasiler
sehingga BTA pada pewarnaan Ziehl
Nielsen dan kultur seringkali memberikan
hasil negatif.4 Diperlukan beberapa
pemeriksaan penunjang lain untuk
menyingkirkan diagnosis banding berupa
pemeriksaan pemeriksaan hematologi rutin,
LED, sediaan apus darah tepi, kimia darah,
fungsi hati, fungsi ginjal, laktat dehidro-
genase, kalsium, fosfat, elektrolit,
urinalisis, feses lengkap, kultur pus dan
 Jayadi, Ernaningtyas, Niode, Wongkar: Lupus vulgaris dengan lesi diseminata 191
sensitivitas, foto toraks, tes Mantoux,
biopsi kulit, kultur jamur, dan FNAB. Dari
hasil pemeriksaan laboratorium didapatkan
kadar Hb yang menurun (10,6 /dL),
peningkatan LED (101,4 mm/jam),
penurunan GDP (61 mg/dL), fungsi hati,
fungsi ginjal, urinalisa dan feses dalam
batas normal. Kadar asam urat dalam batas
normal, kadar kalsium, fosfat dan laktat
dehidrogenase menurun ringan serta tidak
tampak adanya pertumbuhan jamur pada
kultur jaringan sehingga diagnosis banding
mineralisasi kutan, limfoma, dan aktino-
misetoma dapat disingkirkan.
Pemeriksaan foto toraks diperlukan
pada kasus TB kutis karena paru
merupakan port d’entree lebih dari 98%
kasus infeksi TB.10 LV diseminata dengan
lesi yang multipel juga seringkali
berhubungan dengan TB paru aktif.3,4
Standar diagnosis TB kutis ialah
pemeriksaan mikroskopik, kultur, dan
pemeriksaan histopatologi dari spesimen
kulit. Tes Mantoux dan PCR juga dapat
digunakan sebagai penunjang diagnosis.1
Pada kasus ini gambaran jantung dan
paru pasien dalam batas normal. Kuman
BTA pada sediaan pus dengan pewarnaan
Ziehl Nielsen juga tidak ditemukan karena
LV merupakan TB kutis pausibasiler yang
berbeda dengan skrofuloderma yang
biasanya multibasiler.
Tes Mantoux atau uji tuberkulin adalah
tes dengan menggunakan komponen
protein kuman TB yang mempunyai sifat
antigenik kuat. Jika disuntikkan secara
intrakutan pada seseorang yang telah
terinfeksi TB maka akan terjadi reaksi
berupa indurasi di lokasi suntikan.12
Hingga saat ini, uji tuberkulin masih
mempunyai nilai diagnostik yang tinggi
terutama pada anak, namun kurang berarti
pada dewasa atau pada seseorang yang
sebelumnya pernah memiliki riwayat
TB.10,12 Pada kasus ini pasien sudah
memiliki riwayat limfadenitis TB dan
skrofuloderma sebelumnya sehingga tidak
dilakukan uji tuberkulin karena meski
hasilnya positif menjadi kurang bermakna.
Lupus vulgaris memiliki gambaran
histopatologi yang bervariasi. Gambaran
khas berupa ditemukannya tuberkel-
tuberkel yang sebagian menyatu, dengan
atau tanpa nekrosis kaseosa, dikelilingi
oleh sel epiteloid dan sel datia Langhans
pada dermis. Limfosit di sekeliling tuberkel
tampak jelas. Bakteri biasanya jarang
ditemukan. Ulserasi, atrofi atau akantosis
dapat ditemukan pada epidermis
13,14
diatasnya. Gambaran histopatologi
skrofuloderma pada dermis berupa
pembentukan abses disertai ulserasi.
Tuberkel dan nekrosis kaseosa dapat
ditemukan di perifer dengan bakteri dalam
jumlah banyak.4,13 Pemeriksaan histopato-
logi pada kasus ini berasal dari nodul pada
punggung dan memiliki gambaran
histopatologi sesuai dengan gambaran
lupus vulgaris. Dari pemeriksaan tersebut
tampak epidermis yang berulkus. Pada
dermis di bawahnya tampak struktur
granuloma atau tuberkel dengan sentral
nekrosis dan bagian tepi terdiri dari sel-sel
makrofag epiteloid, makrofag berbuih, dan
limfosit. Kesan dari pemeriksaan histo-
patologi ialah radang granulomatik spesifik
dengan infeksi sekunder (menyokong suatu
lupus vulgaris).
Pemeriksaan FNAB leher kiri juga
dilakukan pada kasus ini dengan hasil yang
juga sesuai dengan gambaran TB berupa
ditemukannya sel-sel radang limfosit,
kelompok makrofag epiteloid, dan sel-sel
datia. Pemeriksaan penunjang lain yang
dapat dilakukan untuk menegakkan
diagnosis TB kutis ialah dengan ditemu-
kannya M. tuberculosis pada kultur dan
polymerase chain reaction (PCR) namun
pada kasus ini kedua pemeriksaan tersebut
tidak dilakukan karena media kultur dan
PCR tidak tersedia.
Diagnosis lupus vulgaris diseminata
pada kasus ini ditegakkan berdasarkan
adanya riwayat infeksi TB sebelumnya,
gejala sistemik TB seperti demam, keringat
malam dan berat badan menurun disertai
gejala lokal LV berupa timbulnya nodus-
nodus eritema dan sewarna kulit multipel
pada beberapa area tubuh secara
bersamaan, nodi di leher sebagian pecah
dan mengalami ulserasi tanpa disertai
adanya fistel. Pemeriksaan diaskopi pada
192 Jurnal Biomedik (JBM), Volume 7, Nomor 3, November 2015, hlm.185-194
lesi memberikan gambaran apple-jelly yang
merupakan karakteristik LV. Pemeriksaan
FNAB pada leher dan histopatologi pada
lesi di punggung sesuai dengan gambaran
LV sehingga diagnosis lupus vulgaris
diseminata pada kasus ini dapat ditegakkan.
Namun, penyebab terjadinya penyebaran
hematogen belum diketahui pasti karena
tidak ditemukan adanya TB paru dan
riwayat adanya penyakit tertentu yang
dapat menyebabkan menurunnya imunitas
sebelum timbulnya lesi disangkal oleh
pasien.
Terapi awal yang diberikan sebelum
diagnosis pasti lupus vulgaris diseminata
ditegakkan berupa doksisiklin 2x100 mg,
asam mefenamat 3x500 mg, parasetamol 3
x 500 mg bila demam, dan kompres
terbuka dengan NaCl 0.9% 3x30 menit.
Berdasarkan International Standard for
Tuberculosis Care (ISTC), terapi antibiotik
awal pada pasien yang dicurigai TB
sebaiknya tidak menggunakan golongan
kuinolon karena golongan kuinolon
merupakan obat TB lini kedua yang
digunakan pada kasus TB resisten OAT 9
dan TB kutis (lupus vulgaris dan
skrofuloderma) merupakan salah satu
diagnosis banding pada kasus ini sehingga
penggunaan antibiotik golongan kuinolon
dihindari. Pada pemeriksaan Gram dari pus
ditemukan kokus Gram positif dan negatif
dan diberikan doksisiklin untuk mengatasi
kemungkinan adanya infeksi sekunder pada
luka. Doksisiklin merupakan golongan
tetrasiklin yang merupakan antibiotik
dengan sifat bakteriostatik. Golongan ini
memiliki spektrum antibakteri luas yang
meliputi kuman Gram positif dan negatif
serta aerobik dan anaerobik.11 Terapi
simtomatis berupa analgetik asam
mefenamat dan antipiretik parasetamol
diberikan karena pasien mengeluh nyeri
pada leher kiri dan demam. Kompres
terbuka dengan NaCl 0,9% 3x30 menit
bertujuan untuk mengangkat pus dan krusta
sehingga luka bersih dan penyembuhannya
lebih baik.
Pengobatan TB pada pasien ini dimulai
setelah diagnosis lupus vugaris diseminata
dapat ditegakkan. Prinsip pengobatan TB
kulit pada prinsipnya sama dengan TB pada
organ lain yaitu dengan OAT. Pengobatan
TB dibagi menjadi dua tahap yaitu tahap
awal (intensif) dan lanjutan. Pada
umumnya, lama pengobatan 6-8 bulan.
Pada tahap awal diberikan kombinasi 4
macam obat yaitu rifampisin (R) 10
mg/kgBB/hari, isoniazid (H) 5 mg/kgBB/
hari, pirazinamid 25 mg/kgBB/hari, dan
etambutol (E) 15 mg/kgBB setiap hari
selama dua bulan. OAT tahap lanjutan yang
diberikan ialah rifampisin dan isoniazid 3
kali perminggu selama 4 bulan.10 Dalam
kasus ini, terapi yang diberikan kepada
pasien adalah FDC 1 x 4 tablet selama dua
bulan dan vitamin B6 1x1 tablet. Pasien
dianjurkan kontrol dua bulan kemudian.
Setelah 2 bulan menjalani pengobatan
tahap intensif, bengkak pada leher kiri
pasien berkurang namun luka meluas dan
nanah bertambah karena sebagian nodus
telah pecah. Nodus pada sudut kanan bibir
membesar dengan luka yang melebar.
Nodus eritematosa sewarna kulit pada
badan dan ekstremitas sebagian telah
mendatar, pecah dan menimbulkan luka.
Pada pemeriksaan Gram dari pus pada luka
didapatkan adanya sel-sel PMN serta
kuman Gram positif dan negatif. Pasien
mengeluh adanya bengkak dan nyeri pada
sendi jari-jari tangan setelah minum OAT.
Pasien kemudian dikonsulkan ke Poliklinik
Penyakit Dalam untuk evaluasi lebih lanjut
dan dianjurkan untuk melakukan pemerik-
saan VCT, DL, LED, fungsi hati, fungsi
ginjal, asam urat, dan FNAB pada nodul
diatas bibir. Pemeriksaan FNAB pada
nodul diatas bibir perlu dilakukan untuk
melihat apakah terdapat tanda-tanda
keganasan karena lesi LV dapat berkem-
bang menjadi suatu karsinoma terutama
karsinoma sel skuamosa.3 Dari pemerik-
saan laboratorium diperoleh peningkatan
kadar asam urat (15,0 mg/dL) yang diduga
disebabkan oleh pirazinamid yang memiliki
efek samping berupa hiperurisemia dan
nyeri sendi.10 Pemeriksaan VCT pada
pasien memberikan hasil non reaktif dan
tidak tampak tanda-tanda keganasan pada
pemeriksaan FNAB.
Terapi tambahan yang diberikan
 Jayadi, Ernaningtyas, Niode, Wongkar: Lupus vulgaris dengan lesi diseminata 193
berupa alopurinol 1 x 100 mg, ofloksasin 2
x 400 mg, dan rencana pemberian sisipan
HRZE selama 1 bulan. Perbaikan klinis
yang minimal setelah menyelesaikan tahap
inisial selama dua bulan menimbulkan
dugaan adanya resistensi terhadap OAT
yang menjadi dasar pertimbangan
pemberian ofloksasin 2 x 400 mg dan
sisipan HRZE pada pasien ini meskipun
hasil kultur pus resisten terhadap
ofloksasin. Menurut acuan pustaka, diduga
terjadi resistensi obat bila setelah fase
inisial selesai tidak terlihat adanya respon
pengobatan secara klinis, pasien gagal
pengobatan atau putus obat, dan kasus
kambuh setelah pengobatan.7,15 Ofloksasin
merupakan golongan florokuinolon yang
mempunyai daya antibakteri kuat terhadap
kuman Gram negatif dan lebih lemah
terhadap kuman Gram positif. Ofloksasin
memiliki efek bakterisid ringan terhadap
mikobakterium sehingga dapat digunakan
sebagai terapi TB lini kedua.15-17
Pada pengobatan hari ke-80 tampak
perbaikan bermakna dimana luka pada
leher kiri mengering, nanah berkurang, dan
bengkak minimal. Nodus eritema pada area
tubuh lain telah mendatar dengan luka yang
juga telah mengering. Pasien kembali
dikonsulkan ke Poliklinik Penyakit Dalam
dan terapi OAT fase lanjutan, ofloksasin 2
x 400 mg dan kompres terbuka dengan
NaCl 0,9% 3x30 menit dilanjutkan.
SIMPULAN
Telah dilaporkan satu kasus lupus
vulgaris diseminata pada seorang laki-laki
berusia 40 tahun dengan gejala demam,
keringat malam, dan penurunan berat badan
disertai lesi berupa nodus eritematosa yang
sebagian mengalami ulserasi pada beberapa
area tubuh secara bersamaan seperti wajah,
leher badan serta kedua lengan dan paha
disertai gambaran apple-jelly pada
pemeriksaan diaskopi. Pada pemeriksaan
laboratorium pasien didapatkan pening-
katan LED yang biasanya ditemukan pada
TB. Diagnosis akhir lupus vulgaris
diseminata pada pasien ini ditegakkan
melalui pemeriksaan FNAB dan histo-
patologik yang memberikan gambaran khas
LV. Terapi OAT yang diberikan terbagi
atas 3 fase, yaitu fase inisial HRZE selama
2 bulan, dilanjutkan dengan sisipan HRZE
selama 1 bulan dan fase lanjutan HR yang
rencana diberikan selama 4 bulan.
Pengobatan lain berupa ofloksasin 2x400
mg, allopurinol 100 mg 1x1, vitamin B6
1x1 dan kompres luka dengan NaCl 0.9%
3x30 menit juga diberikan. Respon yang
baik terhadap terapi tampak pada bulan
ketiga pengobatan.
DAFTAR PUSTAKA
1. Djuanda A. Tuberkulosis Kutis. In: Djuanda
A, Hamzah M, Aisah S, editors. Ilmu
Penyakit Kulit dan Kelamin (5th ed.).
Jakarta: Fakultas Kedokteran Universitas
Indonesia, 2007; p. 64-72.
2. Perkumpulan Pemberantasan Tuberkulosis
Kutis di Indonesia (PPTI). TB di
Indonesia peringkat keempat. 2011.
[cited 2014 May 8]. Available from:
www.ppti.info/2012/09/tbc-di-
indonesia-peringkat-ke-5.html.
3. Sethi A. Tuberculosis and infection with
atypical mycobacteria. In: Goldsmith
LA, Katz LI, Gilchrest BA, Paleer AS,
Leffel DJ, Wolff K, editors. Fitzpatrick’s
Dermatology in General Medicine (8th
ed.). New York: McGraw Hill, 2008; p.
2225-40.
4. Yates VM. Mycobacterial infection. In:
Burns T, Breatnach SM, Cox N, Griffith
C, editors. Rook’s Textbook of
Dermatology (8th ed.). London:
Blackwell publishing Ltd, 2010; p.673-
7.
5. James WD, Berger TG, Elston DM.
Andrew’s Diseases of the skin clinical
dermatology (11th ed.). Philadephia:
Elsevier, 2015; p. 323-33.
6. Padmavathy L, Rao LL, Pari T, Ethirajan
N, Krishnaswamy B. Lupus vulgaris
and tuberculosis verrucosa cutis (TBVC)
a clinical, pathological and epidemio-
logical study of 71 cases. Indian J
Tuberc. 2008;55:203-9.
7. Pusponegoro EHD. Tatalaksana tuberkulosis
kutis. World TB Day 2012. Jakarta, 14
Mei 2012.
8. Rahman MH, Ansari NP, Hadiuzzman
MD, Nipa NI, Islam S, Mumu SA, et
194 Jurnal Biomedik (JBM), Volume 7, Nomor 3, November 2015, hlm.185-194
al. Lupus vulgaris on the buttock
mimicking tinea corporis. Journal of
Pakistan Association of Dermatologists.
2011;21(4):295-7.
9. Tim kelompok kerja tuberkulosis.
Tuberkulosis: pedoman diagnosis dan
penatalaksanaan di Indonesia. Jakarta:
Perhimpunan Dokter Paru Indonesia,
2011.
10. Shimizu H. Mycobacterial infections. 2013.
[cited 2014 May 8]. Available from:
http://www.derm-hokudai.jp/shimizu-
dermatology/pdf/26-01.pdf.
11. Setiabudy R. Golongan tetrasiklin dan
kloramfenikol. In: Gunawan SG,
Setiabudy R, Nafrialdy, Elysabeth,
editors. Farmakologi dan Terapi.
Jakarta: Departemen Farmakologi dan
Terapeutik Fakultas Kedokteran
Universitas Indonesia, 2007; p. 694-703.
12. Rahajoe N, Basir D, Makmuri MS,
Kartasasmita CB. Pedoman Nasional
Tuberkulosis pada Anak (2nd ed.).
Jakarta: UKK Respirologi PP IDAI,
2005; p. 30-8.
13. Calonje JE, Brenn T, Lazar AJ, McKee
PH. McKee’s Histopatology of the Skin
(4th ed.) Kanada: Elsevier, 2012; p. 811-
25.
14. Agrawal R, Kumar M, Kumar P.
Cutaneous tuberculosis, a clinico-
pathological study. Indian Journal of
Medical Specialties. 2012;3(2):138-42.
15. World Health Organisation. Guidelines for
the management of drug resistant
tuberculosis. WHO/TB/96.210 (Rev.1).
Geneva, 2007.
16. Setiabudy R. Golongan kuinolon dan
florokuinolon. In: Gunawan SG,
Setiabudy R, Nafrialdy, Elysabeth,
editors. Farmakologi dan Terapi.
Jakarta: Departemen Farmakologi dan
Terapeutik Fakultas Kedokteran
Universitas Indonesia, 2007; p. 718-22.
17. Yew WW. Newer fluoroquinolones for the
treatment of tuberculosis. [cited 2014
Jun 5]. Available from:
http://www.infectweb.com/only/02_Rev
1_DrWW_Yew.pdf.
J Clin Exp Dent. 2016;8(4):e448-58. Diascopy and others on oral pigmentation diagnosis

Journal section: Oral Medicine and Pathology doi:10.4317/jced.53005

Publication Types: Review http://dx.doi.org/10.4317/jced.53005

Clinical value of diascopy and other non-invasive techniques on differential

diagnosis algorithms of oral pigmentations: A systematic review

Daniel Pérez-López 1, Maite Pena-Cristóbal 2, Eva-María Otero-Rey 3, Inmaculada Tomás 4, Andrés Blanco-
Carrión 5

1
PhD Student, Facultade de Medicina e Odontoloxía, Departamento de Estomatoloxía, Universidade de Santiago de Compostela,
Spain
2
Postgraduate Student, Facultade de Medicina e Odontoloxía, Departamento de Estomatoloxía, Universidade de Santiago de
Compostela, Spain
3
PhD, Facultade de Medicina e Odontoloxía, Departamento de Estomatoloxía, Universidade de Santiago de Compostela, Spain
4
Senior Lecturer, Oral Sciences Research Group, Facultade de Medicina e Odontoloxía, Departamento de Estomatoloxía, Univer-
sidade de Santiago de Compostela, Spain
5
Senior Lecturer, GI-1319, Facultade de Medicina e Odontoloxía, Departamento de Estomatoloxía, Universidade de Santiago de
Compostela, Spain

Correspondence:
Facultade de Odontoloxía, rúa Entrerríos s/n,
15782, Santiago de Compostela, Galicia, Spain
daniel.perez.lopez@rai.usc.es Pérez-López D, Pena-Cristóbal M, Otero-Rey EM, Tomás I, Blanco-
Carrión A. Clinical value of diascopy and other non-invasive techniques
on differential diagnosis algorithms of oral pigmentations: A systematic
review. J Clin Exp Dent. 2016;8(4):e448-58.
Received: 28/01/2016
Accepted: 10/02/2016
http://www.medicinaoral.com/odo/volumenes/v8i4/jcedv8i4p448.pdf

Article Number: 53005 http://www.medicinaoral.com/odo/indice.htm

© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: jced@jced.es
Indexed in:
Pubmed
Pubmed Central® (PMC)
Scopus
DOI® System

Abstract
Objectives: To determine the diagnostic value of diascopy and other non-invasive clinical aids on recent differential
diagnosis algorithms of oral mucosal pigmentations affecting subjects of any age.
Material and Methods: Data Sources: this systematic review was conducted by searching PubMed, Scopus, Dentis-
try & Oral Sciences Source and the Cochrane Library (2000-2015); Study Selection: two reviewers independently
selected all types of English articles describing differential diagnosis algorithms of oral pigmentations and checked
the references of finally included papers; Data Extraction: one reviewer performed the data extraction and quality
assessment based on previously defined fields while the other reviewer checked their validity.
Results: Data Synthesis: eight narrative reviews and one single case report met the inclusion criteria. Diascopy
was used on six algorithms (66.67%) and X-ray was included once (11.11%; 44.44% with text mentions); these
were considered helpful tools in the diagnosis of intravascular and exogenous pigmentations, respectively. Surface
rubbing was described once in the text (11.11%).
Conclusions: Diascopy was the most applied method followed by X-ray and surface rubbing. The limited scope of
these procedures only makes them useful when a positive result is obtained, turning biopsy into the most recom-
mended technique when diagnosis cannot be established on clinical grounds alone.

Key words: Algorithm, differential diagnosis, flow chart, oral mucosa, oral pigmentation, systematic review.

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J Clin Exp Dent. 2016;8(4):e448-58. Diascopy and others on oral pigmentation diagnosis

Introduction lesions in several related review articles were taken into

Oral mucosal pigmentations are relatively common in account (2,3,14,15), to which haemangiolymphangio-
daily dental practice and usually mean a diagnostic cha- ma, peripheral giant cell granuloma and thrombus were
llenge for clinicians (1-3). added based on the authors´ experience (Table 1). Fur-
In this sense, diascopy has been proposed as a possible thermore, non-English papers were excluded (16) and a
diagnostic tool for this type of conditions, being defined 15-year period was established to conduct the review.
as a procedure of removing the camouflaging effect of
congested blood to reveal the true colour of underlying Table 1. Oral pigmentations considered on study screening.
lesions (4). This is done by means of a glass or plastic
Endogenous
diascope, usually a microscopic slide, pressed against a pigmentations
cutaneous or mucous lesion (4-6). Its characteristic blan- Non-melanin-related lesions
ching effect is due to the phenomenon of blood dissipa- Melanin-related lesions Vascular
ting intravascularly under compression, giving the tissue Melanotic Extravascular conditions
a pale appearance (4,7,8). Even though dermatologists Physiologic pigmentation Petechia
Post-inflammatory Ecchymosis
regularly use epiluminescence microscopy in the early
Smoker´s melanosis Hematoma
diagnosis of malignant melanoma and pigmented skin Oral melanotic macule Peripheral giant cell
lesions, magnified or unmagnified diascopy is someti- Endocrine disorders granuloma
mes applied on large cutaneous pigmentations (5,6,9- Addison´s disease Kaposi´s sarcoma
12). In dentistry, its most common application consists Addisonian pigmentation Intravascular conditions
of obtaining a positive result for blanchability to poten- Melasma Haemangioma
Hyperthyroidism Vascular malformation1
tially identify the intravascular nature of oral pigmented Syndromes Telangiectasia2
lesions; however, not all intravascular conditions seem Peutz-Jeghers syndrome Varix/thrombus
to comply with this rule (4). This is of utmost importan- Multiple
Lymphatic or
ce for an accurate diagnosis and the appropriate mana- neurofibromatosis
Albright syndrome lymphatic/vascular
gement of oral pigmentations. In view of the lack of any Lymphangioma
study that has methodologically assessed the current cli- Laugier-Hunziker
syndrome Haemangiolymphangioma
nical value of diascopy and other non-invasive clinical HIV melanosis Salivary
aids on this kind of lesions, this new systematic review Mucocele
Melanocytic
has been conducted to provide scientific evidence on this Melanoacanthoma Ranula
field. Nevi Systemic-related
-The following objectives were addressed: Lentigo pigmentations
•Primary: to determine the current diagnostic value of Melanoma (vascular/melanotic)
diascopy on the differential diagnosis of oral mucosal Hemochromatosis
pigmentations, all types of recently published articles Exogenous pigmentations
that described a differential diagnosis algorithm about Amalgam tattoo Heavy metal pigmentation
such lesions in which this diagnostic technique was Other foreign bodies Drug-induced pigmentation
present were reviewed, against those that did not use it, tattoos
1
Considering Sturge-Weber syndrome; 2 Considering Rendu-Osler-
aimed at subjects of any age affected by these oral con-
Weber and CREST syndromes.
ditions.
•Secondary: to determine the diagnostic value of other
non-invasive clinical aids on the previously mentioned Types of participants: subjects of any age affected by
differential diagnosis flow charts, as well as the most re- oral mucosal pigmentations.
commended method to reach a definitive diagnosis. Types of intervention: application of diascopy or other
non-invasive clinical aids on oral mucosal pigmenta-
tions.
Material and Methods
Types of comparator: no application of diascopy or other
- Protocol
non-invasive clinical aids on such lesions.
This systematic review was conducted according to a
Types of outcome measures: 1. Primary: the diagnostic
previously established protocol. Likewise, the PRISMA
value of diascopy on current differential diagnosis pro-
Statement recommended items were addressed whene-
tocols of oral mucosal pigmentations; 2. Secondary: the
ver possible (13).
diagnostic value of other non-invasive clinical techni-
- Eligibility criteria
ques on these protocols and the most recommended me-
Types of studies: all kind of recently published articles
thod to achieve a definitive diagnosis.
describing differential diagnosis flow charts of oral mu-
- Information sources
cosal pigmentations, including diascopy or not as a diag-
Four electronic databases were searched: PubMed (Na-
nostic step were considered. Only the most mentioned
tional Center for Biotechnology Information, U.S. Natio-
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J Clin Exp Dent. 2016;8(4):e448-58.
nal Library of Medicine, National Institutes of Health),
Dentistry & Oral Sciences Source, DOSS (EBSCO
Host), and the Cochrane Library (Wiley Online Library)
and Scopus (Elsevier). A time filter was imposed from 1
January 2000 to 25 May 2015 and all the databases were
researched up to 1 June 2015 (a total period of 15 years
and five months). No language filter was imposed in this
phase. Reference checking of finally included articles was
also performed. Additionally, authors of these finally se-
lected papers were contacted to clarify doubtful informa-
tion, absent data and confirm the extracted evidence. The
search protocol was developed and conducted by one of
the reviewers (DPL), once it was validated by the group.
- Search
The following search terms were used to search the four
databases: oral cavity, oral mucosa, pigmented, pigmen-
tation, pigmentations, vascular, discoloration, discolo-
rations, discolouration, discolourations, hyperpigmen-
tation, hyperpigmentations, lesion, lesions, diagnosis,
flow chart, protocol, differential diagnosis, algorithm,
and guide. The search strategy for each database was
previously specified in the systematic review protocol.
- Study selection
Once the articles were retrieved from each of the four
databases and the duplicates were dismissed by one of
the reviewers (DPL), the eligibility assessment of all
the references was independently carried out by two re-
viewers (DPL and MPC). As a first step, the titles and
abstracts were screened by language and inclusion cri-
teria. Then, the full texts of potentially relevant studies
were examined for inclusion criteria compliance. Re-
ference checking of finally included studies was first
performed by title; if the corresponding abstracts were
considered suitable, the full texts were examined. When
titles and abstracts did not provide enough information
to make a decision or the abstracts were not available
but the titles were considered suspicious of being related
to the purposes of the review, the respective full arti-
cles were assessed. Reasons for exclusion were stated
at each stage, except for title selection during reference
checking. Disagreements between reviewers were sol-
ved by consensus at each step. If the two reviewers did
not agree, a third investigator (IT) was contacted.
- Data collection process
A data extraction sheet based on a priori established data
items was developed and accordingly modified after pi-
lot-testing it on three of the finally included studies. On
this occasion, only one of the reviewers (DPL) extracted
the data from the corresponding studies while the other
reviewer (MPC) checked its validity. Again, disagree-
ments were solved by consensus. If no agreement could
be reached, a third investigator (IT) was consulted.
As stated, authors of the finally included articles were
contacted to obtain ambiguous or absent data, as well as
to confirm the performed data extraction.
e450
Diascopy and others on oral pigmentation diagnosis
- Data items
Information was extracted from each included study on:
1) Study design: justification, aims, type of study accor-
ding to previously reported classification (17), type and
language of cited documents, and funding.
2) Participants: features of the population for which the
differential diagnosis protocol was developed, type of
included lesions, and features of case reports, if present.
3) Intervention/comparator: main aspect that determines
the first step on the differential diagnosis protocol; pre-
sence of diascopy, at which level and type of lesions;
and presence of other clinical diagnostic techniques, at
which level and type of lesions.
4) Outcomes: diagnostic value of diascopy and other
non-invasive clinical techniques applied on the included
protocols, as well as the most recommended method for
reaching a definitive diagnosis, and other conclusions.
As already reported, the data extraction sheet was de-
veloped a priori, but three additional items were added
after reading the finally included articles. It was decided
to include the type and language of the documents cited
on finally included papers to provide information about
what kind of data they were based on. Likewise, the as-
sessment of the main aspect or procedure that determi-
ned the first step on each of the differential diagnosis
protocols was introduced since it was considered to be a
very useful contribution to daily dental practice.
- Quality assessment
Since the finally included studies were expected to
mainly consist of narrative reviews, risk of bias as-
sessment was not considered. For this reason, their
“quality” was assessed through a self-designed checklist
based on six parameters that were considered important
for their clinical application. Based on the authors’ cli-
nical experience, three features related to the algorithm
per se and another one focused on the article text were
initially proposed for the quality appraisal: one classi-
ficatory aspect per step (to allow establishing a hierar-
chical diagnostic process), self-explanation of each step
(clearly described clinical aspects or techniques to ease
its implementation), presence of distinctly specified le-
sions (to clarify which types of lesions clinicians should
mainly consider with each protocol) and description of
outstanding malignancies in text (to alert clinicians to
base the differential diagnosis on their exclusion). This
checklist was modified after completely reading the arti-
cles selected by screening titles and abstracts, with two
more text parameters added: thorough explanation of the
algorithm (to reinforce its understanding and solve any
doubt from its isolated assessment) and clearly stated al-
gorithm limitations (to become aware of its scope).
As in the data collection process, the quality assessment
was performed by one of the reviewers (DPL), while the
other reviewer (MPC) checked its validity. In the case of
several flow charts, only algorithms based on oral pig-
J Clin Exp Dent. 2016;8(4):e448-58. Diascopy and others on oral pigmentation diagnosis

mentations were considered. Disagreements were solved
by consensus. If no agreement could be reached, a third
investigator (IT) took part.
- Summary measures and synthesis of results
A descriptive data analysis was performed. The fo-
llowing aspects were considered: the percentage of stu-
dies applying diascopy or other non-invasive clinical
techniques (either in protocols or in protocol/text com-
bination), the most recommended method for a defini-
tive diagnosis and its percentage of use (regardless of
its place of mention), and the different main aspects or
procedures that determined the first step in the several
algorithms and their prevalence (either individually or
coupled with others) (Table 2).
Results
- Study selection
A total of nine studies were finally included in the review.
The searches of PubMed, Scopus, DOSS and the Co-
chrane Library databases provided a total of 172 studies.
After adjusting for duplicates, 155 remained. Of these,
137 studies were discarded after reviewing their titles
and abstracts since it was considered that they did not
meet the inclusion criteria. The exclusion criteria in this
phase were classified into four groups: group 1 (n= 41),
involving studies that mentioned the previously reported
included lesions without evidence of a differential diag-
nosis flow chart; group 2 (n= 26), in relation to studies
that described other oral lesions (distinct from caries);
group 3 (n= 60), comprising studies of other medical
disciplines, congress abstracts, articles related to caries
or not focused on differential diagnosis (regardless of
the type of lesions assessed), lesions beyond the limits of
the oral cavity, and miscellaneous; and group 4 (n= 10),
concerning non-English studies. Thus, 18 studies were
selected for the full texts to be read. It appeared that ten
studies did not meet the inclusion criteria and another
one could not be retrieved, so seven articles were inclu-
ded in the systematic review from the database electro-
nic search. Additionally, seven studies were also consi-
dered for full text reading by checking the references of
the seven studies mentioned above; five of them were

Table 2. Results of individual studies and synthesis, in chronological order.

Included studies Diascopy Other clinical aids Definitive 1st aspect/procedure
diagnosis
Flaitz, 2000 (18) Yes No Biopsy Colouration

Carpenter and Rudd, 2000 Yes X-ray1 Biopsy Colouration

(19)

Rudd et al., 2001 (4) Yes No Biopsy Colouration2

Coleman et al., 2002 (20) Yes No Biopsy Colouration/distribution

Kauzman et al., 2004 (21) Yes X-ray Biopsy Distribution

Meleti et al., 2008 (22) No X-ray Biopsy Medical history/colouration3

Müller, 2010 (1) No X-ray Biopsy Distribution

Vachiramon and Yes4 No Biopsy Colouration/diascopy4

McMichael, 2012 (23)

Pai et al., 2012 (24) No Surface rubbing Biopsy Medical history

Colouration alone: 3/9 (33.33%),
X-ray1: 1/9 and combined: 6/9 (66.67%)
TOTAL Yes: 6/9 (11.11%), and Distribution alone: 2/9 (22.22%),
Biopsy: 9/9
(66.67%) combined: 4/9 and combined: 3/9 (33.33%)
(100%)
(44.44%) Medical history alone: 1/9
Surface rubbing: 1/9 (11.11%), and combined: 2/9
(11.11%) (22.22%)
Combined diascopy: 1/9
(11.11%)
Combined: sum of times a specific procedure or clinical aspect is considered, either alone or together with others.
1
The unique “X-ray” mentioned in an algorithm. The remaining “X-ray” and surface rubbing were included in the respective
texts.
2
Information assumed from the text, but not confirmed.
3
Information provided by the authors, who were contacted by email.
4
Information provided by Dr Vasanop Vachiramon, who was contacted by email.

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J Clin Exp Dent. 2016;8(4):e448-58.
excluded for not providing a differential diagnosis flow
chart. Therefore, a total of nine studies were finally in-
cluded in our review (Fig. 1).
Fig. 1. Flow of information through the different phases of the sys-
tematic review. *Comprising studies of other medical disciplines,
congress abstracts, articles related to caries or not focused on differ-
ential diagnosis (regardless of the type of lesions assessed), lesions
beyond the limits of the oral cavity, and miscellaneous.
Eight authors of the included articles were contacted
by email for further information, mainly related to the
funding source, population features and the main aspect
or procedure that determined the first step in the diffe-
rential diagnosis algorithms. Likewise, the same authors
were contacted to verify the accuracy of the extracted
data by sending them a copy of the respective draft chart
by email. All authors responded, with one exception
that provided the first-stage information without subse-
quently confirming the data extraction. The whole pro-
cess was performed by one of the reviewers (DPL).
- Study characteristics (Table 3, Table 3 continue, Table
3 continue-1)
•Study design
The nine studies finally selected for the qualitative as-
sessment consisted of eight narrative reviews (1,4,18-
23) and one single case report (24). One narrative review
was followed by a case series of three melanin-related
oral pigmentations (21) and the oral melanoma case re-
port was followed by a narrative review mainly based
on this entity (24). Almost all of the included studies
arose from the large variety of mucosal pigmentations
e452
Diascopy and others on oral pigmentation diagnosis
that may appear in the oral cavity and their challenging
differential diagnosis, with the main purpose of helping
clinicians identify and manage them. Within these stu-
dies, the greatest part of the cited documents was in En-
glish and mainly comprised of published articles on the
global calculation; nonetheless, some papers individua-
lly showed the same or greater number of book citations
than published articles (4,18-20). Only one study had a
funding source (20).
•Participants
With the exception of two articles (18,22) that were res-
pectively focused on children and adolescents and on
subjects from an outpatient clinic of Oral and Maxillo-
facial Surgery, the remaining papers (1,4,19-21,23,24)
did not specify the features of the population beneficiary
of the differential diagnosis protocols beyond subjects
affected by the corresponding included oral lesions.
Lesions included in the algorithms varied from just oral
pigmentations, either focal or multifocal/diffuse, mela-
nin or non-melanin related (1,4,19,21-24), to oral pig-
mentations coupled with white lesions, ulcerative condi-
tions and tissue enlargements (18,20).
As already mentioned, one article reported three cases of
oral pigmentations histopathologically diagnosed as com-
pound nevus, melanoacanthoma and melanoma, in a 28-
year-old East Indian man, a 13-year-old East Indian male
and a 77-year-old Asian man, respectively (21). Additio-
nally, another article reported a case of malignant mela-
noma in a 58-year-old man diagnosed through its clinical
appearance, fine needle aspiration cytology of the left
submandibular lymph node, orthopantomograph, compu-
ted tomography and a complete haemogram (24).
•Intervention/comparator
Diascopy was used in six protocols (4,18-21,23), while
only one algorithm reported the use of X-ray as a non-
invasive clinical aid (19); nonetheless, the use of X-ray
was mentioned more in text (1,21,22). Likewise, surface
rubbing was mentioned once in the text in the diagnosis
of oral malignant melanoma (24). Colour determination
was the most frequently described first step amongst al-
gorithms, either alone or combined (4,18-20,22,23).
•Outcomes
•Primary
Three articles stated briefly the diagnostic value of
diascopy (4,19,21), while the other three studies that in-
cluded this technique in their algorithms did not state its
value anywhere (18,20,23).
•Secondary
Two articles briefly described the clinical value of X-
ray (19,21), while the other two that mentioned its use
did not state its value (1,22). Biopsy was recommended
everywhere to reach a definitive diagnosis (1,4,18-24).
- Quality assessment (Table 4)
Only one study met all of the parameters assessed (21).
One study met five of them (19) and the other two fulfi-
 Table 3 . Characteristics of the included studies, in chronological order.
Source Study design
Justification: extensive DD of OML, best
summarised with the use of flow charts.
Aims: to draw attention to both common
and unusual diseases with a paediatric
Flaitz, 2000 (18) onset.
Type of study: narrative review.
Cited documents: 7 (6 B, 1 PA).
Cited documents language: English.
Funding: none1.
Justification: risk of malignancy, and
importance of identification and proper
management of focal, flat POM.
Aims: to assist the clinician in establishing
Carpenter and Rudd, a clinical approach to the diagnosis of
e453
2000 (19) focal, flat POM.
Type of study: narrative review.
Cited documents: 15 (7 B, 7 PA,
1 submitted).
Cited documents language: English.
Funding: none3.
Justification: dentists can quickly
determine the vascular nature of many
OML by applying diascopy.
Aims: to describe the circumstances in
Rudd et al., 2001 (4) which diascopy can be used in dental
practice and what useful information it
provides.
Type of study: narrative review.
Cited documents: 5 (3 B, 2 PA).
Cited documents language: English.
Funding: none3.
Participants
Population features: children and adolescents with
included lesions.
Included lesions: white, dark and ulcerative OML.
Dark OML: flat or elevated, focal (vascular, epithelial
thinning, malignancies, reactive, cystic, melanin-related
and exogenous) and multifocal/diffuse (vascular,
infectious, immunologic, reactive, malignancies,
syndromes, melanin-related and exogenous) (different
algorithms).
Case reports: none. Illustrative images shown.
Population features: not directly specified. All people
with the included lesions.
Included lesions: flat POM, mainly focal (vascular,
epithelial thinning or dysplasia, endogenous4 and
exogenous) (in the algorithm).
Case reports: none. Illustrative images shown.
Population features: not directly specified. All people
with the included lesions.
Included lesions: focal POM of a vascular nature (in the
algorithm).
Case reports: none. Illustrative images shown.
Intervention/Comparator
Main aspect or procedure in dark
lesions: the exact colouration (red or
blue vs. pigmented2 brown, grey or
black).
Diascopy: 1st step on focal and
multifocal or diffuse, red or blue lesions
(intra vs. extravascular and other type of
lesions).
Other clinical aids: not reported.
Main clinical aspect: the exact
colouration (red, blue or purple vs.
brown or black).
Diascopy: 1st step on red, blue or purple
focal, flat POM (intra vs. extravascular,
epithelial thinning or dysplasia).
Other clinical aids: X-ray: 1st step on
brown or black focal, flat POM
(endogenous vs. exogenous
pigmentations).
Main clinical aspect: the exact
colouration (red, bluish or purple vs.
non-vascular)5.
Diascopy: 1st step on POM of a vascular
nature (intravascular vs. extravascular
blood).
Other clinical aids: not reported.
Outcomes
Diascopy: although any explicit
J Clin Exp Dent. 2016;8(4):e448-58.
assessment is reported, in this study this
technique is used as a diagnostic
procedure for distinguishing between
intravascular and other non-blanchable
conditions, on focal and multifocal or
diffuse, red or blue lesions.
Biopsy for a definitive diagnosis.
Other: erythroplakia does not blanch.
Diascopy may often be helpful to
distinguish intra from extravascular
lesions, but the former may not blanch
-large number of feeder vessels or small
vascular lumens- (haemangioma or
Kaposi´s sarcoma).
X-ray may be useful for differentiating
endogenous from exogenous
pigmentations, but the latter may not be
detected -small particles-.
Biopsy for a definitive diagnosis.
Other: erythroplakia does not blanch.
Diascopy can be a valuable adjunct to
distinguish between erythema and
purpura, although the former may not
blanch -large number of small channels-
(haemangioma) and to screen lesions for
malignancy (Kaposi´s sarcoma,
melanoma and erythroplakia do not
blanch). Limited scope.
Biopsy for a definitive diagnosis.
Diascopy and others on oral pigmentation diagnosis
 Table 3 continue. Characteristics of the included studies, in chronological order.
Justification: the diagnosis of OSTL is a
daily challenge for dentists and DD is the
most effective approach.
Aims: to provide a conceptual framework
for understanding the DD strategy of
OSTL, that is the basis of a designed DD
Coleman et al., 2002 (20)
computer program.
Type of study: narrative review.
Cited documents: 6 (5 B, 1 PA).
Cited documents language: English.
Funding: the Texas Cancer Council, the
Dental Oncology Education Program and
the Texas Dental Foundation.
Justification: POM are common, and the
understanding of their causes and the
appropriate evaluation of the patient are
essential.
Aims: to present an algorithm to guide the
assessment of POM.
Kauzman et al., 2004 Type of study: narrative review/case series.
(21) Cited documents: 33 (2 B, 31 PA).
e454
Cited documents language: English,
1 French.
Funding: none6.
Justification: wide range of lesions
featuring a change of colour of oral
tissues.
Aims: to discuss two groups of POM
(melanin-related and caused by other
pigments), and present a diagnostic flow
Meleti et al., 2008 (22) chart to help the clinician.
Type of study: narrative review.
Cited documents: 89 (4 B, 1 letter, 84 PA).
Cited documents language: mainly
English, 1 German, 1 Dutch, 1 French,
1 Spanish.
Funding: none7.
Population features: not directly specified. All people
with the included lesions.
Included lesions: white and dark OML, loss of mucosal
integrity, and soft tissue enlargements.
Dark OML: focal (vascular, epithelial thinning or
dysplasia, melanin-related and exogenous) and multiple
or diffuse (vascular, epithelial thinning, infectious,
immunologic, nutritional, melanin-related and
exogenous) (different algorithms).
Case reports: none.
Population features: not directly specified. All people
with the included lesions.
Included lesions: focal POM (vascular, melanin-related
and exogenous) and diffuse or bilateral (melanin-
related, vascular and exogenous) (in the algorithm).
Case reports (3). Subjects referred to an Oral Pathology
practice for consultation of a pigmented lesion5. A: 28-
year-old East Indian man, focal dark brown lesion on
right buccal mucosa, HD as compound nevus. B: 13-
year-old East Indian male, multiple brown-black
macules on both labial and buccal mucosae, and on the
anterior tonsillar pillars, HD as melanoacanthoma. C:
77-year-old Asian man, irregular greyish-black patch on
the buccal and distal maxillary gingiva, HD as
melanoma. Illustrative images shown.
Population features: population from an outpatient
clinic of Oral and Maxillofacial Surgery in the
Netherlands7.
Included lesions: melanocytic and non-melanocytic
POM (non-specified in the algorithm). Focal and
diffuse or multifocal POM (melanin-related, vascular
and exogenous) (in the text).
Case reports: none. Illustrative images shown.
Main clinical aspect in dark lesions: the
combination of colour and distribution
(isolated and multiple or diffuse red vs.
isolated and multiple or diffuse
pigmented2 brown, bluish or black).
Diascopy: 1st step on isolated and
multiple red OML (intra vs.
extravascular, epithelial thinning or
dysplasia, and malignancy).
Other clinical aids: not reported.
Main clinical aspect: distribution (focal
vs. diffuse or bilateral).
Diascopy: 1st step on focal red, blue or
purple OML (intra vs. extravascular).
Other clinical aids: X-ray on focal blue
or grey lesions (amalgam tattoo) (in the
text).
Main aspect or procedure: medical
history and colouration6 (melanocytic
blue, brown or black vs. non-
melanocytic).
Diascopy: not reported.
Other clinical aids: X-ray on focal blue,
grey or black (amalgam tattoo) (in the
text).
Diascopy: although any explicit
assessment is reported, in this study
diascopy is used as a diagnostic
technique for distinguishing between
intravascular and other type of non-
blanchable OML.
J Clin Exp Dent. 2016;8(4):e448-58.
Biopsy for a definitive diagnosis.
Other: Kaposi´s sarcoma and
erythroplakia do not blanch.
Diascopy and X-ray are clinical tests
that can be used to confirm a clinical
impression and occasionally reach a
definitive diagnosis, but neither all
intravascular lesions blanch (thrombus,
haemangioma) nor amalgam tattoos are
radiopaque in X-ray -small particles-.
Biopsy for a definitive diagnosis.
Biopsy or referring to a specialist is
indicated when:
-History does not allow distinguishing
between melanocytic and non-
melanocytic lesions.
- A malignant melanocytic lesion is
suspected.
- A melanocytic lesion with no or low
suspicion of malignancy or a non-
melanocytic lesion cannot be diagnose
on clinical grounds alone.
Diascopy and others on oral pigmentation diagnosis
 Table 3 continue-1. Characteristics of the included studies, in chronological order.
Justification: POM are common and the
DD is broad, so developing a DD is
imperative for a clinician faced with
these lesions.
Aims: to develop a DD for the most
Müller, 2010 (1) common melanin-pigmented lesions of
the OM and present an algorithm to help
clinicians manage the various POM.
Population features: not directly specified. All people
with the included lesions.
Included lesions: focal POM (melanin-related, vascular
and exogenous) and diffuse (melanin-related,
exogenous and vascular) (in the algorithm).
Case reports: none. Illustrative images shown.
Main aspect or procedure: the Biopsy or referring to specialist if
distribution (focal vs. diffuse). diagnosis cannot be made on clinical
Diascopy: not reported. findings alone.
Other clinical aids: X-ray on focal blue
or grey lesions (amalgam tattoo) (in the
text).
J Clin Exp Dent. 2016;8(4):e448-58.

Type of study: narrative review.

Cited documents: 26 (1 B, 25 PA).
Cited documents language: English.
Funding: none8.
Justification: lip hyperpigmentation is Population features: not directly specified. All people Main clinical aspect: the exact Biopsy for a definitive diagnosis.
common and it is associated with a wide with the included lesions. colouration and diascopy (red, blue or Other:
variety of situations. Included lesions: focal (melanin-related and vascular) purple blanchable vs. non-vascular)9. - Focal lesions: colour and morphology.
Vachiramon and Aims: to provide a clinical approach to and multiple or diffuse (vascular, melanin-related and Diascopy: 1st step together with colour - Multiple or diffuse lesions: age of
McMichael, 2012 (23) lip hyperpigmentations. exogenous) lip hyperpigmentations. on focal POM (vascular vs. non- onset and associated findings.
Type of study: narrative review. Case reports: not reported. Illustrative images shown. vascular)9.
Cited documents: 48 PA. Other clinical aids: not reported.
Cited documents language: mainly
English, 1 French, 1 Italian, 2 Japanese.
Funding: none.

e455
Justification: not specified. Population features: not directly specified. All people Main aspect or procedure: medical Biopsy if diagnosis is not justified on
Aims: to present a case of oral MM and with the included lesions. history (focal melanin-related vs. history.
flow charts for diagnosis and treatment Included lesions: focal and multiple or diffuse POM multifocal or diffuse melanin-related,
of POM. (vascular, melanin-related and exogenous) (in the vascular or exogenous).
Pai et al., 2012 (24) Type of study: single case report/ algorithm). Oral MM (in the text). Diascopy: not reported.
narrative review. Case reports: 1. A 58-year-old man, greyish black Other clinical aids: rubbing the surface
Cited documents: 23 PA. exophytic growth in the anterior maxilla, enlarged left of the lesion to help diagnose MM (in
Cited documents language: English. submandibular lymph node (FNAC: suggested the text).
Funding: none10. metastatic MM), HIV (-). Final diagnosis of primary
oral MM.
POM: pigmentations of the oral mucosa (including lips); B: books; PA: published articles; DD: differential diagnosis; OML: oral mucosal lesions; OSTL: oral soft tissue lesions; HD: histopathologically
diagnosed; MM: malignant melanoma; FNAC: fine needle aspiration cytology.
1
Information provided by Dr Catherine Flaitz, who was contacted by email.
2
Pigmented mucosal lesions = melanin-related or exogenous.
3
Information provided by Dr William Carpenter, who was contacted by email.
4
Endogenous pigmentations = melanin-related.
5
Information assumed from the text, but not confirmed.
6
Information provided by Dr Kauzman, who was contacted by email.
7
Information provided by the authors, who were contacted by email.
8
Information provided by Dr Susan Müller, who was contacted by email.
9
Information provided by Dr Vasanop Vachiramon, who was contacted by email.
10
Information provided by the authors, who were contacted by email.
Diascopy and others on oral pigmentation diagnosis
J Clin Exp Dent. 2016;8(4):e448-58. Diascopy and others on oral pigmentation diagnosis

Table 4. Quality assessment of included studies, in chronological order.

INCLUDED
STUDIES Flaitz, Carpenter Rudd et al., Coleman et Kauzman et Meleti et Müller, Vachiramon Pai et al., TOTAL
2000 (18) and Rudd, 2001 (4) al., 2002 al., 2004 (21) al., 2008 2010 (1) and 2012 (24) advantages/
2000 (19) (20) (22) McMichael, limitations
CHARACTERISTICS 2012 (23)

One classificatory
aspect per step in the 9 9 9 8 9 8 8 8 8 4/9
algorithm

Self-explanatory steps
in the algorithm 9 9 8 9 9 8 8 8 8 4/9

Distinctly specified
lesions in the 9 9 9 9 9 8 9 9 9 8/9
algorithm

Algorithm thoroughly
explained in the text 8 9 8 8 9 9 8 9 8 4/9

Clearly stated
algorithm limitations 8 8 8 8 9 8 8 9 8 2/9

Described outstanding
malignancies
9 9 9 9 9 9 9 9 9 9/9

TOTAL
advantages/limitations 4/6 5/6 3/6 3/6 6/6 2/6 2/6 4/6 1/6

lled four (18,23). The remaining articles complied with
three (4,20), two (1,22) or one aspect (24).
All of the studies reported outstanding malignancies
(1,4,18-24) and almost all of them included distinctly
specified lesions in their algorithms (1,4,18-21,23,24).
The less incorporated parameter was the statement of
algorithm limitations (21,23).
- Results of individual studies and synthesis (Table 2)
As has already been commented upon, the main aspect
or procedure that determined the first step in the diffe-
rential diagnosis protocols was added to the results rela-
ted to the already known review outcomes.
Diascopy was used on six of the nine included protocols
(66.67%), being mainly applied to red, blue or purple,
focal and multifocal/diffuse oral pigmentations, to dis-
tinguish between intravascular conditions and other type
of lesions (4,18-21,23). Of these, only three studies brie-
fly stated the clinical value of diascopy, considering it a
helpful and valuable tool for the previously reported ob-
jective and to screen lesions for malignancy, confirming
a clinical impression and sometimes reaching a definiti-
ve diagnosis. However, it was stated that not all intravas-
cular conditions blanch under pressure (4,19,21).
Only one of the nine algorithms (11.11%) reported the
use of X-ray on brown or black focal lesions (19). No-
netheless, in the text of the other three articles (44.44%
with the previous one), the use of this technique was
described in the diagnosis of isolated blue or grey le-
sions with the same purpose (1,21,22). Similar to before,
only two articles punctually assessed the clinical value
of X-ray, considering it a helpful tool for differentiating
melanin-related conditions from exogenous pigmenta-
tions, confirming a clinical impression and sometimes
reaching a definitive diagnosis. Nevertheless, it was re-
e456
ported that exogenous pigmentations may not be detec-
ted by X-ray (19,21).
Likewise, one article (11.11%) described in its text the
procedure of surface rubbing in the diagnosis of oral
malignant melanoma, without evaluating its diagnostic
value (24).
Biopsy was recommended without exception to reach a
definitive diagnosis when this cannot be made on clini-
cal grounds alone (100%) (1,4,18-24).
Colour determination was the main clinical aspect that
determined the first step in three of the nine (33.33%)
included differential diagnosis protocols (4,18,19). The
distribution of lesions was the main clinical aspect in
two of them (22.22%) (1,21), the combination of colour
and distribution in one (11.11%) (20), colour and me-
dical history in another (11.11%) (22) and colour and
diascopy in the other (11.11%) (23). The remaining
protocol seemed to be based on medical history alone,
without mentioning any specific clinical aspect (24).
Results from combined data (sum of times in which a
clinical aspect or procedure was applied as a first step,
either alone or together with other aspects or techni-
ques) were: colouration (6/9, 66.67%), distribution (3/9,
33.33%), medical history (2/9, 22.22%) and diascopy
(1/9, 11.11%).
Discussion
Many narrative reviews have been published describing
large sets of oral pigmented lesions without providing a
differential diagnosis flow chart (2,3,14,15,25-31). Only
some of them have considered vascular lesions to be
true oral pigmentations (3,14,25,27,30,31) and the use
of diascopy has been proposed in these cases with the
same aforementioned purposes (3,14,25,27). Likewise,
J Clin Exp Dent. 2016;8(4):e448-58.
this technique has been coupled with the so-called “head
lowering manoeuvre with abdominal compression” in
the diagnosis of eight oral capillary haemangiomas,
considering clinical appearance combined with a posi-
tive result in at least one of the previous procedures a
sufficiently reliable method for their identification and
treatment (32). Despite the lack of evidence in this re-
gard, the reported positive result for blanchability in
Kaposi´s sarcoma in one of our included studies (19)
seems not to be supported by histological data since red
blood cells extravasation is an almost constant feature
in all stages of the lesion and in almost all of its mi-
croscopic variants, although it may not be as evident in
early patches (33-37); nonetheless, a negative blanching
result even in these initial lesions has been stated (38).
Colour interpretation is a subjective procedure; small
differences may be difficult to notice and the final co-
louration is conditioned by the amount and location of
the pigment within the mucosa (1,21). In spite of the fre-
quent use of this visual sign, there is some heterogeneity
amongst algorithms and texts in this regard; for instance,
blue may be considered to represent either a vascular
lesion, a foreign-body tattoo or a melanin-related con-
dition (19-21,23). Although clinicians should know that
some colours are more related to vascular or melanin
conditions, based on the frequent colour superimposi-
tion, we recommend using diascopy on all dark oral pig-
mentations, mainly focal and regardless of colour, when
the possibility of a vascular lesion is being considered
and the technique can be applied due to location. Only a
complete or significant positive result for blanchability
will be useful in clinical practice, since a semi- or non-
blanchable result will make the clinician feel unsure of
the diagnosis and a biopsy should be considered.
In relation to X-ray, amalgam tattoo is more present on
oral pigmentation-related reviews and the application of
this technique has been well-mentioned on its differential
diagnosis (3,14,15,26,30,31); nonetheless, it has been re-
ported that fewer than 25% of these entities will be seen
as radiopaque on radiographs (26). For the same reported
reasons, we recommend using X-ray on all focal flat or
slightly raised blue, brown, grey or black oral mucosal
lesions, trying to rule out an exogenous pigmentation. If a
negative result is obtained, a biopsy should be performed
if the possibility of an oral malignant melanoma cannot be
dismissed on clinical findings alone.
Despite the frequent presence of oral melanoma in many
narrative reviews, surface rubbing is not described as a
clinical tool on its diagnosis (2,3,14,15,25-31). This pro-
cedure was first applied on 13 subjects with a clinical
suspicion of oral primary melanoma and a positive result
was achieved on 11 of the finally 13 histopathologically
diagnosed melanomas (39). Since then, some authors
have reported its use (40-44); nevertheless, it seems that
this technique has not been broadly implemented in the
e457
Diascopy and others on oral pigmentation diagnosis
literature and its value has been questioned (45).
As expected, histopathology assessment has elsewhe-
re been considered the gold standard method for rea-
ching a definitive diagnosis in oral pigmented lesions
(2,3,14,15,25-28,30,31).
Our study has several limitations. Regarding the study
and review level, the search retrieved results were scree-
ned for just including English-language publications and
only studies published in the last 15 years were conside-
red. Additionally, the set of included lesions may have
obviated some conditions that could have led us to other
diagnostic flow diagrams. Likewise, the performed title/
abstract search restriction was applied to best focus on
potentially eligible papers since it was assumed that ar-
ticles without including any of those words would not
be selected. In relation to the quality assessment, the
evaluated parameters were based more on the applica-
bility of the diagnostic flows than on their quality, so the
punctuations are not directly associated with the latter.
Finally, the Oxford Centre for Evidence-Based Medicine
does not currently consider narrative reviews or single case
reports on its Levels of Evidence Table (46). In this sense,
the articles included in this review would probably be clas-
sified into Level 5 regarding the rather well-recognised evi-
dence weakness of these study types. Moreover, the high
presence of case reports, case series and narrative reviews
cited in them and not directly related to the previously as-
sessed diagnostic techniques makes establishing a defini-
tive evidence level demanding. Nonetheless, in this parti-
cular case, better evidence about the previously addressed
topics is not expected to appear. Taking this into account, as
well as the corresponding benefits and harms of the repor-
ted procedures, the recommendations stated in this review
are considered to be evidence-supported enough for their
implementation in daily dental practice.
Based on this evidence, it was finally concluded that
diascopy was the most applied diagnostic technique on
the recent differential diagnosis algorithms of oral pig-
mented lesions, followed by X-ray and surface rubbing.
The limited scope of these techniques only makes them
useful when a positive result is obtained and turns biop-
sy into the most recommended procedure when a diag-
nosis cannot be made on clinical grounds alone.
Interested authors are encouraged to clearly state all of
the clinical techniques applied on their case report and
case series studies, as well as the respective obtained re-
sults, also providing a histopathological diagnosis. Such
information will allow investigators and clinicians to ac-
curately assess the diagnostic value and limits of those
applied procedures and their relation to different types
of lesions and their variants.
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Conflict of Interest
The authors declare no conflicts of interests.