Illuminating diagnostic pathways: study protocol for a prospective observational study comparing inflammoscopy and ultraviolet-induced fluorescence dermoscopy with histopathology in cutaneous lichen planus.

Varun H; Adarshlata Singh; Bhushan Madke; Bhakti sarda; Anurag Mittal; Naman Kacchawa; Swati Singh

doi:10.12688/f1000research.179446.1

Home Browse Illuminating diagnostic pathways: study protocol for a prospective...

ALL Metrics

-

Views

-

Downloads

Get PDF

Get XML

Export

▬

✚

Study Protocol

Illuminating diagnostic pathways: study protocol for a prospective observational study comparing inflammoscopy and ultraviolet-induced fluorescence dermoscopy with histopathology in cutaneous lichen planus.

[version 1; peer review: 1 approved with reservations]

Varun H ¹, Adarshlata Singh¹, Bhushan Madke¹, [...] Bhakti sarda¹, Anurag Mittal¹, Naman Kacchawa¹, Swati Singh¹

Varun H ¹, Adarshlata Singh¹, [...] Bhushan Madke¹, Bhakti sarda¹, Anurag Mittal¹, Naman Kacchawa¹, Swati Singh¹

PUBLISHED 17 Apr 2026

Author details Author details

¹ Department of Dermatology,Venereology and Leprosy, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, 442001, India

Varun H
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Adarshlata Singh
Roles: Conceptualization, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Bhushan Madke
Roles: Conceptualization, Project Administration, Supervision, Writing – Review & Editing

Bhakti sarda
Roles: Investigation, Resources, Writing – Review & Editing

Anurag Mittal
Roles: Conceptualization, Software, Writing – Review & Editing

Naman Kacchawa
Roles: Data Curation, Methodology, Visualization, Writing – Review & Editing

Swati Singh
Roles: Methodology, Resources, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Introduction

Lichen planus (LP) is an inflammatory dermatosis that is often diagnosed clinically but may require histopathological confirmation in equivocal cases. Dermoscopy enhances the visualisation of subsurface morphologic features and may improve non-invasive diagnosis. Ultraviolet-induced fluorescence dermoscopy (UVFD) is an emerging modality that may reveal additional diagnostic clues through the interaction of ultraviolet light with cutaneous structures. This study aims to investigate the dermoscopic and UVFD features of cutaneous LP, correlate them with histopathological findings, and evaluate the diagnostic accuracy of dermoscopy using histopathology as the reference standard.

Methods

This is a two-year prospective observational study to be conducted in the Dermatology outpatient department of Acharya Vinoba Bhave Rural Hospital, Wardha, India. Adults with clinically suspected cutaneous LP who are willing to undergo biopsy will be enrolled after written informed consent. Dermoscopic and UVFD findings from selected lesions will be documented before punch biopsy. Histopathological examination will serve as the reference standard. Dermoscopic, UVFD, and histopathological findings will be correlated using imaging alignment methods and image analysis software, including ImageJ and QuPath. Diagnostic accuracy measures, including sensitivity, specificity, positive predictive value, negative predictive value, agreement statistics, and receiver operating characteristic analysis, will be calculated.

Ethics and dissemination

The study has received approval from the Institutional Ethics Committee of Datta Meghe Institute of Higher Education and Research, Wardha, India (study approval number: DMIHER (DU)/IEC/2024/141; IEC registration/re-registration number: ECR/440/Inst/MH/2013/RR-2019). Written informed consent will be obtained from all participants prior to enrolment. The findings will be disseminated through peer-reviewed publication and academic presentation.

Trial registration: Clinical Trials Registry–India (CTRI): CTRI/2025/05/086296; Reference No. REF/2024/03/080873.

Keywords

Lichen planus, cutaneous lichen planus, lichenoid dermatosis, dermoscopy, inflamoscopy, ultraviolet-induced fluorescence dermoscopy, UVFD, histopathology.

Corresponding author: Varun H

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2026 H V et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: H V, Singh A, Madke B et al. Illuminating diagnostic pathways: study protocol for a prospective observational study comparing inflammoscopy and ultraviolet-induced fluorescence dermoscopy with histopathology in cutaneous lichen planus. [version 1; peer review: 1 approved with reservations]. F1000Research 2026, 15:551 (https://doi.org/10.12688/f1000research.179446.1) First published: 17 Apr 2026, 15:551 (https://doi.org/10.12688/f1000research.179446.1) Latest published: 17 Apr 2026, 15:551 (https://doi.org/10.12688/f1000research.179446.1)

Introduction

The exact pathogenesis of LP remains uncertain; however, it is postulated that keratinocyte damage occurs through CD8+ cytotoxic T-cell-mediated apoptosis following antigen presentation by basal keratinocytes. A deficiency in TGF-β1-mediated immunosuppression may lead to sustained overactivity of these cytotoxic T cells, contributing to the chronicity of the disease.^1,2

Accurate epidemiologic data on LP are limited. A systematic review and meta-analysis conducted in September 2019 reported a global pooled prevalence of LP at 1.01% with significant geographical variation.³ Due to the lack of robust, large-scale epidemiologic data specifically on cutaneous LP, we have used published data on oral LP as a proxy for estimating prevalence. We acknowledge this limitation, and an interim analysis is planned to validate the prevalence assumptions within our study population.

Currently, the diagnosis of lichen planus relies primarily on clinical evaluation, including assessment of the “6P’s” (planar, purple, polygonal, pruritic, papules and plaques) and distribution that commonly affects the skin of the flexor surfaces. The presence of Wickham striae, which are prominent, lacy, reticular white lines, is considered diagnostic. However, differential diagnoses such as Prurigo, Lupus Erythematosus, erythema dyschromicum perstans, psoriasis, secondary syphilis, pityriasis rosea, lichen nitidus, graft versus host disease, and keratosis lichenoides chronica must be ruled out, often necessitating histopathological confirmation via excisional biopsy.^4,5

Dermoscopy enhances the visualisation of subtle skin changes that are not apparent to the naked eye, thereby revolutionising the diagnosis of inflammatory dermatoses. Dermoscopic patterns have been shown to correlate with histopathological features; for example, Wickham striae (WS) reflect focal thickening of the stratum granulosum, while red dots indicate vascular changes.^6–9

Histologically, LP is characterised by hyperkeratosis (typically orthokeratosis), acanthosis, and irregular thickening of the stratum granulosum (hypergranulosis) resulting in the “saw-tooth” appearance of the rete ridges. Basal cell liquefaction leads to the formation of apoptotic keratinocytes (Civatte or cytoid bodies) and the development of a cleft (Max Joseph space). A dense band-like lymphocytic infiltrate (interface dermatitis) is observed at the dermo-epidermal junction, sometimes accompanied by a few plasma cells, and in drug-induced cases, eosinophils.^4,10–12

Dermoscopy offers an attractive adjunct to reduce the need for invasive biopsies. UVFD, by providing additional optical data (through penetration, absorption, scattering, and Stokes-shift phenomena), may further enhance diagnostic accuracy.^13–16

Although some literature suggests that UVFD may be less effective than non-contact polarised dermoscopy in diagnosing LP, we hypothesise that its integration will improve diagnostic accuracy by revealing both specific and non-specific features that correlate with histopathological findings. For instance, loose keratin may appear as white lines and compact keratin plugs as yellow clods on conventional dermoscopy, whereas UVFD may reveal white fluorescence in both, confirming keratin’s natural fluorescence. In early-stage disease, when vascular structures are not distinctly visible as red dots or clods, UVFD may delineate them as dark structureless areas at the lesion periphery. Accordingly, an additional rationale for this study is to document both specific and non-specific UVFD features and correlate them with polarised dermoscopy and histopathological findings.^13,17,18

Protocol

Primary outcome

1. To determine the diagnostic accuracy (sensitivity, specificity, positive predictive value, and negative predictive value) of dermoscopy in diagnosing cutaneous lichen planus, using histopathology as the reference standard.

Secondary outcomes

1. To investigate the specific and non-specific dermoscopic features of cutaneous lichen planus.
2. To document the specific and non-specific ultraviolet-induced fluorescence dermoscopic (UVFD) findings in cutaneous lichen planus.
3. To correlate dermoscopic and UVFD findings with histopathology.
4. To assess agreement between dermoscopic impression and histopathological diagnosis.
5. Predictive performance measures, including positive predictive value, negative predictive value, and area under the receiver operating characteristic curve, where applicable.

Study design and setting

This is a two-year prospective observational analytical study to be conducted in the Department of Dermatology, Venereology and Leprosy at Acharya Vinoba Bhave Rural Hospital (AVBRH), a tertiary care teaching hospital in Wardha, Maharashtra, India. The overall study workflow is outlined in Figure 1. Dermoscopic findings will be recorded using a predefined data collection form ( Figure 2), and histopathological findings will be documented using a predefined histopathology template ( Figure 3).

Figure 1. Flowchart outlining the planned strategy for participant recruitment, data collection, and analysis.

Figure 2. Data collection form for recording dermoscopic features in suspected cutaneous lichen planus.

Figure 3. Data collection form for documenting histopathological features in suspected cutaneous lichen planus.

Operational diagnostic criteria

For the purposes of this study, the presence of Wickham striae on dermoscopy will be considered highly suggestive of lichen planus. In lesions without obvious Wickham striae, the presence of at least three of the following five dermoscopic domains will be recorded as supportive of a provisional dermoscopic diagnosis: background colour, vascular pattern, pigmentation, surface changes, and other associated features. UVFD findings will be documented descriptively and explored as adjunctive diagnostic features.

Histopathologically, wedge-shaped hypergranulosis, band-like lymphocytic infiltrate, Max Joseph spaces, and Civatte bodies will be considered major features, while other compatible findings will be treated as minor features. A histopathological diagnosis of lichen planus will require either two major features or one major feature with at least two minor features.

Eligibility criteria

Adults aged 18 years or older attending the AVBRH outpatient department with clinically suspected cutaneous lichen planus and willing to provide written informed consent will be considered eligible. Patients with isolated mucosal, genital, or scalp lichen planus will be excluded. Patients who have received topical or systemic treatment likely to alter lesional morphology within one month prior to enrolment will also be excluded.

Participant recruitment and lesion selection

Potentially eligible participants will be recruited consecutively from the dermatology outpatient department during the study period. After clinical evaluation and written informed consent, one representative cutaneous lesion planned for punch biopsy will be selected for dermoscopic examination, UVFD assessment, and histopathological correlation. Dermoscopic and UVFD assessments will be performed before biopsy.

Study procedure

For each enrolled participant, demographic and clinical details will be recorded in a structured proforma. The selected lesion will undergo dermoscopic examination and ultraviolet-induced fluorescence dermoscopic assessment. Images will be captured and archived for analysis. A provisional dermoscopic impression will be recorded before biopsy. Punch biopsy will then be performed from the same representative lesion, and the specimen will be processed for histopathological examination. Dermoscopic, UVFD, and histopathological findings will subsequently be correlated.

Blinding

Dermoscopic and UVFD findings will be documented before histopathological examination. Wherever feasible, the histopathologist will be blinded to the dermoscopic and UVFD impressions at the time of histopathological assessment to minimise observer bias.

Sample size and statistical analysis

Sample size

Published data specifically addressing the diagnostic accuracy of dermoscopy in cutaneous lichen planus are limited. Therefore, a pragmatic minimum sample size of 96 participants has been planned for this prospective observational study. This estimate was derived using a prevalence-based approach as an initial planning method, while acknowledging that prevalence-based calculations are not the ideal method for diagnostic accuracy studies. Because robust epidemiologic data for cutaneous lichen planus are scarce, published prevalence estimates for oral lichen planus were used as a proxy during protocol development, based on the systematic review by González-Moles et al.³ This limitation is acknowledged, and the assumptions underlying the sample size will be revisited during the conduct of the study. The sample size estimation approach is illustrated in Figure 4.

Figure 4. Diagram illustrating the formula used for sample size estimation.

Statistical analysis

All analyses will be conducted using R version 4.3.2. Continuous variables will be summarised using mean, standard deviation, median, minimum, and maximum values, as appropriate. Categorical variables will be summarised using counts and percentages.

Histopathology will serve as the reference standard for the diagnosis of cutaneous lichen planus. The diagnostic performance of dermoscopy will be assessed by calculating sensitivity, specificity, positive predictive value, and negative predictive value, together with 95% confidence intervals where appropriate. Agreement between dermoscopic and histopathological findings will be evaluated using percentage agreement and the kappa statistic.¹⁹ Receiver operating characteristic analysis and area under the curve will be used where applicable.²⁰

Categorical variables will be compared using the chi-square test or Fisher’s exact test, as appropriate.²² Continuous variables will be compared using the independent t-test or Wilcoxon Mann–Whitney U test, depending on data distribution.²¹ A p-value of less than 0.05 will be considered statistically significant.

Limitations

1. Correlation between dermoscopic and histopathological findings may be challenging because dermoscopy provides an axial surface view, whereas histopathology provides a cross-sectional tissue view.^23,24
2. As this is a single-centre study conducted in central India, the study population may be relatively homogeneous, which may limit generalisability to other settings and skin phototypes. Future multicentre studies will be required for broader validation.

Discussion

This study is expected to clarify the diagnostic utility of dermoscopy and ultraviolet-induced fluorescence dermoscopy in cutaneous lichen planus and to identify imaging features that correlate with histopathological findings. By exploring both conventional dermoscopic patterns and UVFD-derived observations, this protocol may contribute to the development of more refined non-invasive diagnostic approaches for lichen planus. The study’s prospective design and planned clinicodermoscopic-histopathological correlation are strengths, although its single-centre setting may limit generalisability. The findings may also provide preliminary data to inform future multicentre validation studies.

Ethics and consent

This study has been approved by the Institutional Ethics Committee of Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India (study approval number: DMIHER (DU)/IEC/2024/141; IEC Re-reg. No. ECR/440/Inst/MH/2013/RR-2019) in December 2023. Written informed consent will be obtained from all participants before enrolment into the study. Separate written consent will be obtained for the use of clinical images where applicable. The study will be conducted in accordance with the ethical principles of the Declaration of Helsinki.

Trial registration

Clinical Trials Registry–India (CTRI): CTRI/2025/05/086296; Reference No. REF/2024/03/080873. Registered on 05/05/2025 URL: https://ctri.nic.in/Clinicaltrials/regtrial.php?modid=1&compid=19&EncHid=71931.98915

Dissemination

The study findings will be disseminated through publication in peer-reviewed journals and presentation at academic conferences.

Software availability

Image analysis will be performed using ImageJ and QuPath. Statistical analysis will be conducted using R version 4.3.2. These are publicly available software tools. No custom source code was generated or used for this study protocol.

Use of generative AI and language tools

During manuscript preparation, the authors used OpenAI ChatGPT (GPT-5.4 Thinking), Google Gemini 3.1 Pro, and Grammarly (Superhuman Go, running on OpenAI’s GPT-4.1 family) solely to improve the English language, enhance readability, and cross-check journal author guidelines. These tools were not used for data generation, statistical analysis, interpretation of findings, or scientific decision-making. All generated suggestions were critically reviewed and edited by the authors, who take full responsibility for the final manuscript content.

Data availability

Primary data availability

No primary data are associated with this article.

Extended data

SPIRIT 2013 checklist for “Illuminating diagnostic pathways: study protocol for a prospective observational study comparing inflammoscopy and ultraviolet-induced fluorescence dermoscopy with histopathology in cutaneous lichen planus”. Zenodo. https://doi.org/10.5281/zenodo.19221491. This project is available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Universal).²⁵

Reporting guidelines

This study protocol has been prepared in accordance with relevant guidance for observational study protocols. A completed SPIRIT 2013 checklist for this study protocol has been deposited in Zenodo and is available at: https://doi.org/10.5281/zenodo.19221491.

Acknowledgements

The authors thank the study participants, the Department of Biostatistics of DMIHER for statistical guidance, and the outpatient and ward nursing staff for their assistance during patient care and study procedures.

References

1. Gru AA, Salavaggione AL: Lichenoid and interface dermatoses. Semin. Diagn. Pathol. 2017 May; 34(3): 237–249. Publisher Full Text
2. Sugerman PB, Savage NW, Walsh LJ, et al.: The Pathogenesis of Oral Lichen Planus. Crit. Rev. Oral Biol. Med. 2002 Jul 1; 13(4): 350–365. Publisher Full Text
3. González-Moles MÁ, Warnakulasuriya S, González-Ruiz I, et al.: Worldwide prevalence of oral lichen planus: A systematic review and meta-analysis. Oral Dis. 2021 May; 27(4): 813–828. PubMed Abstract | Publisher Full Text
4. Arnold DL, Krishnamurthy K: Lichen Planus. StatPearls. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 May 12]. Reference Source
5. Gorouhi F, Davari P, Fazel N: Cutaneous and Mucosal Lichen Planus: A Comprehensive Review of Clinical Subtypes, Risk Factors, Diagnosis, and Prognosis. Sci. World J. 2014 Jan 30; 2014: 1–22. Publisher Full Text
6. Szykut-Badaczewska A, Sikora M, Rudnicka L, et al.: Dermatoscopy of Cutaneous Lichen Planus - Attempt to Translate Metaphoric Terminology Into Descriptive Terminology. Dermatol. Pract. Concept. 2023 Jul 1; 13(3): e2023174. PubMed Abstract | Publisher Full Text | Free Full Text
7. Ankad BS, Adya KA: A Kaleidoscopic Navigation Through Different Shades of Colors in Dermoscopy. Nepal J. Dermatol. Venereol. Leprol. 2024 Apr 2; 22(1): 3–10. Publisher Full Text
8. Litaiem N, Mansour Y, Jones M, et al.: Dermoscopic signs of lichen planus. BMJ Case Rep. 2016 Jan 11; 2016: bcr2015213923. PubMed Abstract | Publisher Full Text | Free Full Text
9. Makhecha M, Singh T, Malladi N, et al.: Dermoscopic features of various stages of lichen planus. IJDVL. 2020 Mar 1; 86: 191. Publisher Full Text
10. Lichen planus: [cited 2024 May 12]. Reference Source
11. Anitua E, Piñas L, Alkhraisat MH: Histopathological features of oral lichen planus and its response to corticosteroid therapy. Medicine (Baltimore). 2019 Dec 20; 98(51): e18321. PubMed Abstract | Publisher Full Text | Free Full Text
12. Mukhopadhyay AK: Two eponyms in the histopathology of lichen planus: Creation and confusion. IJDVL. 2022 Feb 25; 88(2): 270–273.
13. Pietkiewicz P, Navarrete-Dechent C, Togawa Y, et al.: Applications of Ultraviolet and Sub-ultraviolet Dermatoscopy in Neoplastic and Non-neoplastic Dermatoses: A Systematic Review. Dermatol. Ther. (Heidelb.). 2024 Feb 15; 14(2): 361–390. PubMed Abstract | Publisher Full Text | Free Full Text
14. Parihar A, Sharma S, Bhattacharya SN, et al.: A clinicopathological study of cutaneous lichen planus. J. Dermatol. Dermatol. Surg. 2015 Jan 1; 19(1): 21–26. Publisher Full Text
15. Tekin B, Xie F, Lehman JS: Lichen Planus: What is New in Diagnosis and Treatment?. Am. J. Clin. Dermatol. 2024 Sep; 25(5): 735–764. Epub 2024 Jul 9. PubMed Abstract | Publisher Full Text
16. Güngör S, Topal IO, Göncü EK: Dermoscopic patterns in active and regressive lichen planus and lichen planus variants: a morphological study. Dermatol. Pract. Concept. 2015 Apr 30; 45–53. Publisher Full Text
17. Errichetti E, Pietkiewicz P, Bhat YJ, et al.: Diagnostic accuracy of ultraviolet-induced fluorescence dermoscopy in non-neoplastic dermatoses (general dermatology): A multicentric retrospective comparative study. J. Eur. Acad. Dermatol. Venereol. 2025 Jan; 39(1): 97–108. Epub 2024 Jan 30. PubMed Abstract | Publisher Full Text
18. Pietkiewicz P, Navarrete-Dechent C, Goldust M, et al.: Differentiating Fordyce Spots from Their Common Simulators Using Ultraviolet-Induced Fluorescence Dermatoscopy—Retrospective Study. Diagnostics. 2023 Jan; 13(5): 985. PubMed Abstract | Publisher Full Text | Free Full Text
19. McHugh ML: Interrater reliability: the kappa statistic. Biochem. Med (Zagreb). 2012; 22(3): 276–282. Publisher Full Text
20. Hoo ZH, Candlish J, Teare D: What is an ROC curve?. Emerg. Med. J. 2017 Jun 1; 34(6): 357–359. PubMed Abstract | Publisher Full Text
21. McElduff F, Cortina-Borja M, Chan SK, et al.: When t-tests or Wilcoxon-Mann-Whitney tests won’t do. Adv. Physiol. Educ. 2010 Sep; 34(3): 128–133. PubMed Abstract | Publisher Full Text
22. Kim HY: Statistical notes for clinical researchers: Chi-squared test and Fisher’s exact test. Restor. Dent. Endod. 2017 May; 42(2): 152–155. PubMed Abstract | Publisher Full Text | Free Full Text
23. Celebi ME, Kingravi HA, Uddin B, et al.: A methodological approach to the classification of dermoscopy images. Comput. Med. Imaging Graph. 2007 Sep; 31(6): 362–373. PubMed Abstract | Publisher Full Text | Free Full Text
24. Yélamos O, Braun RP, Liopyris K, et al.: Dermoscopy and dermatopathology correlates of cutaneous neoplasms. J. Am. Acad. Dermatol. 2019 Feb; 80(2): 341–363. Epub 2018 Oct 13. PubMed Abstract | Publisher Full Text
25. Varun H, Adarshlata S, Bhushan M, et al.: SPIRIT 2013 checklist for: Illuminating diagnostic pathways: study protocol for a prospective observational study comparing Inflamoscopy and ultraviolet-induced fluorescence dermoscopy with histopathology in cutaneous lichen planus. Zenodo. 2026.

Comments on this article Comments (0)

Version 1

VERSION 1 PUBLISHED 17 Apr 2026