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Dermoscopic features of Orf disease

Orf disease, also known as ecthyma contagiosum, is an infection caused by a Parapoxvirus genus of the family Poxviridae which usually occurs after contact with contaminated or recently vaccinated sheep and goats. The human orf disease was first documented in 1934 by Newson et al. The incubation period lasts 3 to 5 days. After the incubation period, the disease advances in six clinical stages, each lasting about 1 week as follows: maculopapular, target, acute nodular, regenerative, papillomatous, and regressive. The lesions heal spontaneously in 6 to 12 weeks. Erythema multiforme, bullous pemphigoid, and secondary infections are seen as complications of orf disease. The differential diagnosis consists of angiokeratoma, herpes infection, pyogenic granuloma, Milkers’ nodules, keratoacanthoma, and tularemia. The histopathology of the nodules is usually helpful to diagnose. The main histopathological features are hyperkeratosis, papillomatosis, vacuolar degeneration, eosinophilic intracytoplasmic, and/or intranuclear inclusions in some of these cells, intraepidermal vesicles, and mixed inflammation cell infiltration along vascular parts of the dermis. Topical imiquimod, antiviral cidofovir cream, or surgical excision is the option for resistant cases. Cryotherapy is a viable option, especially for immunocompromised patients. A 62-year-old male patient presented with a few weeks’ history of three nodules on the dorsal part and two nodules on the palmar part of his right hand (Fig. 1a). They were violaceous, well-defined, hard, and had a crust in the center. He had no pain or itching. He denied contact with sheep or goats but did have exposure to mice feces. The histopathology of the nodules shows epithelial hyperplasia, stromal fibrosis, vascular proliferation, and mixed inflammation cell infiltration, which showed the late stage of orf nodule (Fig. 1b). Dermoscopic appearance of the nodules is sharply-defined nodules with a yellow central crust. There are structureless areas that present with white and yellow color in the center and pinkish white on the periphery of the nodules. There are milky red globules in a linear arrangement on the white background in the eroded central part of the lesion. The periphery of the lesion has lacunas and milky red globules in nonlinear arrangement. (Fig. 1c and d). We used an epiluminescence microscopy (Ri-derma XL 2.5 V, Riester, Jungingen, Germany) without immersion. Our findings differ from the only case report published on the dermoscopy of ecthyma contagiosum by milky red globules and lacunas. The dermoscopic findings of the previous case were a well-defined nodule with a central crust, white structureless areas, and white shiny streaks, surrounded by dotted vessels, hairpin vessels, and a fine peripheral scale. The diagnosis of orf nodule is usually based on clinical features and sometimes histopathology. Patients generally have a history of direct contact with animals. When there is no typical