European Journal of Cardiovascular Medicine

High-frequency ultrasonography (HFUS) has become an important non-invasive imaging tool in dermatology because it allows real-time assessment of skin structure with good resolution and without the need for tissue sampling. Its main advantage lies in the ability to visualize epidermal and dermal architecture, quantify skin thickness, assess echogenicity, and identify inflammatory changes in vivo. Over the past two decades, HFUS has gained wider application in the evaluation of both normal skin and a range of cutaneous disorders, including inflammatory, neoplastic, and autoimmune dermatoses.[1–3]

The basic principle of HFUS in dermatology is the use of higher-frequency probes to obtain better axial and lateral resolution for superficial tissues. This makes the technique especially suitable for skin imaging, where subtle variations in epidermal thickness, dermal density, and subepidermal changes may reflect disease activity. Earlier reviews have emphasized that HFUS offers objective and

reproducible information that can complement clinical examination, particularly in disorders in which visual assessment may not fully reflect the extent of underlying inflammation.[1,2]

Among inflammatory dermatoses, psoriasis has been one of the most studied conditions with HFUS. Psoriatic plaques typically show increased epidermal and dermal thickness and may demonstrate characteristic inflammatory changes that can be quantified sonographically. Gupta et al. showed that high-frequency ultrasound could be used to assess plaque severity in psoriasis, supporting its role as an objective adjunct to clinical evaluation.[4] More recent reviews have also reinforced the usefulness of HFUS in inflammatory and autoimmune skin disorders by highlighting its value in documenting structural changes and monitoring disease activity.[1,3]

HFUS is also increasingly used in dermatitis, particularly atopic dermatitis, where the subepidermal low-echogenic band (SLEB) has emerged as a useful imaging marker. SLEB is thought to reflect inflammatory oedema and other superficial dermal changes and has been described as a relevant sonographic feature in inflammatory skin disease. A systematic review by Nicolescu et al. highlighted the clinical utility of SLEB in diagnosis and follow-up, especially in conditions associated with cutaneous inflammation.[6] More recent work has also suggested that HFUS may help identify subclinical inflammation in atopic dermatitis, adding to conventional clinical assessment.[5]

The broader role of HFUS should also be viewed in the context of non-invasive dermatologic imaging. Along with dermoscopy and other imaging techniques, ultrasound offers a practical bedside method for assessing disease morphology and extent while avoiding invasive procedures.[7] This is particularly relevant in chronic inflammatory skin diseases such as psoriasis and dermatitis, in which repeated clinical assessment is often needed and where objective imaging markers may improve evaluation of severity and follow-up.

Despite the growing use of HFUS in dermatology, comparative data on psoriasis and dermatitis remain limited, particularly in relation to standard clinical severity measures. The present study was therefore undertaken to evaluate high-frequency ultrasonographic findings in psoriasis and dermatitis and to correlate these findings with clinical severity, with the aim of assessing the usefulness of HFUS as an objective adjunct in the evaluation of inflammatory skin diseases.

OBJECTIVES

1. To assess the high-frequency ultrasonographic features of skin lesions in psoriasis and dermatitis.
2. To determine the clinical severity of psoriasis and dermatitis using standard clinical scoring systems.
3. To correlate ultrasonographic parameters with clinical severity in psoriasis and dermatitis.

This prospective observational study was conducted in the Department of Dermatology, Government Medical College, Aurangabad, Maharashtra, from January 2017 to July 2017. A total of 120 patients with inflammatory skin disease were included, comprising 60 patients with psoriasis and 60 patients with dermatitis, who attended the dermatology outpatient or inpatient services during the study period.

Patients were enrolled consecutively after obtaining written informed consent. Inclusion criteria were: patients aged 18 years or older; a clinical diagnosis of psoriasis or dermatitis; and the presence of active cutaneous lesions suitable for both clinical and high-frequency ultrasonographic evaluation. Exclusion criteria were: presence of secondary infection over the lesion; overlapping or uncertain dermatoses; prior systemic or topical treatment likely to significantly alter lesion morphology; and unwillingness to participate in the study.

All enrolled patients underwent detailed clinical evaluation at baseline. Demographic and clinical data recorded included age, sex, duration of disease, body surface area involved, lesion-site distribution, and itch severity assessed using a visual analogue scale (VAS). Disease severity was assessed using the Psoriasis Area and Severity Index (PASI) in patients with psoriasis and the Eczema Area and Severity Index (EASI) in patients with dermatitis. Based on the respective clinical scores, patients were further categorized into mild, moderate, and severe disease.

High-frequency ultrasonographic examination was performed on a representative active lesion in each patient. The same lesion selected for clinical examination was used for sonographic assessment to ensure clinicoradiological correlation. The ultrasonographic parameters recorded were epidermal thickness, dermal thickness, subepidermal low-echogenic band (SLEB) thickness, dermal echogenicity index, Doppler vascularity grade, and lesion depth. Doppler vascularity was assessed on a semiquantitative scale from 0 to 3.

Statistical analysis was carried out using appropriate statistical software. Continuous variables were expressed as mean ± standard deviation, and categorical variables as frequency and percentage. Between-group comparisons were performed using the independent t test for continuous variables and the chi-square test for categorical variables. Doppler vascularity grade was compared using the Mann-Whitney U test. Correlation between clinical severity scores and ultrasonographic parameters was assessed using Pearson’s correlation coefficient. A p value of less than 0.05 was considered statistically significant.

Study population and baseline profile

A total of 120 patients were included, comprising 60 patients with psoriasis and 60 with dermatitis. The two disease groups were comparable with respect to age, sex distribution, duration of disease, body surface area involved, and lesion-site distribution. Patients with dermatitis reported higher itch severity than those with psoriasis.

Table 1. Baseline characteristics of the study population

 Clinical severity profile

Clinical severity was graded using PASI in psoriasis and EASI in dermatitis. In the psoriasis group, mild and moderate disease were equally common, while nearly one quarter of patients had severe disease. In dermatitis, most patients were in the moderate severity category, with smaller proportions of mild and severe disease.

Table 2. Clinical severity scores and category distribution

 High-frequency ultrasonographic findings

HFUS demonstrated clear differences between the two inflammatory skin diseases. Psoriasis showed greater epidermal and dermal thickness, higher dermal echogenicity, greater Doppler vascularity, and deeper lesions than dermatitis. In contrast, dermatitis showed a thicker subepidermal low-echogenic band.

Table 3. Comparison of HFUS parameters between psoriasis and dermatitis

Correlation of HFUS parameters with psoriasis severity

Among patients with psoriasis, PASI score showed strong positive correlations with epidermal thickness and lesion depth, and moderate positive correlations with dermal thickness, SLEB thickness, and vascularity grade. Dermal echogenicity showed a moderate inverse correlation with PASI score.

Table 4. Correlation between PASI score and HFUS parameters in psoriasis

Correlation of HFUS parameters with dermatitis severity

In the dermatitis group, EASI score correlated positively with epidermal thickness, lesion depth, and SLEB thickness, while inverse correlation was observed with dermal echogenicity. The strength of correlation was generally moderate, supporting the clinical relevance of HFUS-derived structural parameters in dermatitis.

Table 5. Correlation between EASI score and HFUS parameters in dermatitis

The present study showed that high-frequency ultrasonography can detect meaningful structural differences between psoriasis and dermatitis and that these changes parallel clinical severity in both disorders. Psoriatic lesions had significantly greater epidermal thickness, dermal thickness, dermal echogenicity, Doppler vascularity, and lesion depth, whereas dermatitis showed a thicker subepidermal low-echogenic band. Several ultrasound parameters also correlated significantly with PASI in psoriasis and EASI in dermatitis. This supports the use of HFUS as an objective adjunct to clinical assessment in inflammatory skin disease.

In psoriasis, the greater epidermal and dermal thickness seen on HFUS is consistent with the underlying epidermal hyperproliferation and dermal inflammatory infiltration that characterize psoriatic plaques. In our study, epidermal thickness showed the strongest correlation with PASI, suggesting that it may be one of the most useful sonographic markers of disease activity in psoriasis. A similar pattern was reported by Șomlea et al., who showed that psoriatic plaques are clearly distinguishable from uninvolved skin on HFUS and that lesional skin is substantially thicker, with a characteristic hypoechoic band in the upper dermis that reflects inflammation.[8] Their findings support the view that HFUS can provide a quantitative measure of plaque activity in routine clinical evaluation.

The psoriasis group in our study also showed positive correlations of PASI with dermal thickness, SLEB thickness, Doppler vascularity, and lesion depth, together with an inverse correlation with dermal echogenicity. These relationships fit well with active plaque inflammation. Increased thickness and lesion depth likely reflect greater inflammatory burden, while increased vascularity corresponds to the well-recognized vascular proliferation of psoriatic plaques. The inverse association with dermal echogenicity is also plausible, as oedema and inflammatory cell infiltration reduce acoustic reflectivity. Dini et al. reported that ultra-high-frequency ultrasound could detect rapid decreases in plaque vascularization and SLEB thickness during ixekizumab treatment, showing that these sonographic parameters are responsive to changes in inflammatory activity.[10] Although their study addressed treatment monitoring, it strengthens the interpretation that vascularity and low-echogenic inflammatory bands are meaningful markers of active psoriasis.

An interesting finding in the present study was that psoriasis had a higher dermal echogenicity index than dermatitis on between-group comparison, even though dermal echogenicity decreased with increasing PASI within the psoriasis group. This does not necessarily represent a contradiction. It more likely reflects differences in the pattern of inflammation between the two diseases. Dermatitis, particularly eczematous dermatitis, is more strongly associated with superficial dermal edema and spongiosis, which may lower echogenicity more diffusely. Within psoriasis, however, increasing plaque severity may still reduce echogenicity because of increasing inflammation. Comparative work by Yazdanparast et al. also showed that psoriasis and dermatitis differ in ultrasonographic properties such as epidermal thickness and dermal density, supporting the value of ultrasound in distinguishing inflammatory dermatoses as well as assessing activity.[13]

The thicker SLEB in dermatitis was one of the clearest discriminatory findings in our study. This observation is clinically relevant because dermatitis is closely linked to barrier dysfunction, spongiosis, and superficial dermal oedema, all of which contribute to the appearance of a low-echogenic subepidermal band. In our dermatitis group, SLEB thickness correlated significantly with EASI, suggesting that it is a useful structural marker of disease severity. This is in agreement with recent studies in atopic dermatitis. Liu et al. found that SLEB thickness decreased significantly during dupilumab therapy and correlated with clinical scores, indicating that HFUS can detect inflammatory improvement that may extend beyond what is visible on clinical examination.[12] Similar findings were reported by Dini et al., who showed that SLEB thickness, epidermal thickness, and vascular signals all decreased significantly in lesional skin during dupilumab treatment.[15] Taken together, these studies support the clinical value of SLEB as an objective marker in dermatitis.

The inverse correlation between dermal echogenicity and EASI in our study further supports the inflammatory basis of the sonographic changes in dermatitis. Lower echogenicity usually reflects increased water content and inflammatory infiltration within the dermis. In practice, dermal echogenicity may be most useful when interpreted alongside SLEB thickness and epidermal thickness rather than in isolation. The broader importance of SLEB has been emphasized in the systematic review by Nicolescu et al., who described it as a reproducible and increasingly useful marker of inflammatory activity in several dermatologic conditions, including atopic dermatitis.[14] Our results are in keeping with that review and show that SLEB also has practical value in correlating with clinical severity in dermatitis.

Doppler vascularity was significantly higher in psoriasis than in dermatitis in the present study, and it correlated with severity in both groups, although more strongly in psoriasis. This suggests that vascular changes are a more prominent component of psoriatic plaque biology, while still contributing to disease activity in dermatitis. Earlier treatment-monitoring studies support this interpretation. In psoriasis, Dini et al. observed a rapid fall in vascularization soon after initiation of biologic therapy.[10] In atopic dermatitis, Dini et al. also found that vascular signal decreased in lesional skin during dupilumab treatment.[15] These findings indicate that Doppler assessment adds functional information to structural HFUS measurements.

Lesion depth was another parameter that differed significantly between the two groups and correlated with severity in both diseases. This measure is less frequently emphasized in the literature than epidermal thickness or SLEB, but in the present study it appeared to capture clinically relevant lesional involvement, especially in psoriasis. The stronger correlation with PASI may reflect the more sharply demarcated and hyperplastic morphology of psoriatic plaques. From a practical perspective, lesion depth may be useful as a composite marker when serial measurements are performed during follow-up.

A broader implication of our findings is that HFUS may complement conventional clinical scoring systems by adding objective and reproducible structural information. PASI and EASI remain standard tools, but both are observer-dependent and may not fully reflect subclinical inflammatory activity. Ultrasound can narrow that gap. This wider role of ultrasound is also evident in other manifestations of psoriatic disease. Michelucci et al. demonstrated that ultra-high-frequency ultrasound can detect structural changes in psoriatic nails and monitor improvement during therapy.[9] Graceffa et al. similarly showed that ultrasound measurement of enthesis thickness can distinguish skin-only psoriasis from psoriatic arthritis, highlighting the value of ultrasound beyond cutaneous plaque assessment alone.[11] Although these studies address different tissue compartments, they reinforce the concept that ultrasound can provide objective information across the psoriatic disease spectrum.

One strength of the present study is that psoriasis and dermatitis were evaluated within the same prospective framework using comparable sonographic parameters. This allowed direct comparison of disease-specific patterns. The sample was also larger than in several pilot imaging studies, which improves the consistency of the observed correlations. Another useful finding was that some HFUS features were shared by both diseases, such as increasing thickness with greater clinical severity, while others were more distinctive. Psoriasis was characterized by greater epidermal thickening, higher vascularity, and deeper lesions, whereas dermatitis was marked by a more prominent SLEB. This pattern suggests that HFUS is not merely detecting nonspecific inflammation. It also captures differences in tissue architecture between inflammatory dermatoses.

The study has some limitations. First, dermatitis is a broad diagnostic category, and inclusion of different eczematous subtypes may have introduced variability in the sonographic pattern. Second, the main analysis was cross-sectional, so the results establish correlation with severity rather than dynamic responsiveness over time. Third, histopathological correlation was not available. Such correlation would have helped explain the observed changes in echogenicity and SLEB more directly. Even so, the overall agreement between our findings and previous HFUS studies in psoriasis and atopic dermatitis supports the validity of the present observations.[8,10,12,14,15]

HFUS appears to be a useful adjunct in the evaluation of inflammatory skin disease. It differentiates psoriasis from dermatitis on the basis of measurable sonographic features and shows significant correlation with accepted clinical severity scores. In psoriasis, epidermal thickness and lesion depth were especially informative. In dermatitis, SLEB emerged as a particularly relevant parameter. These findings support the incorporation of HFUS into clinical assessment when a more objective estimate of disease burden is needed, particularly during follow-up and treatment monitoring.

The study has limitations. Dermatitis is a heterogeneous category, and histopathological correlation was not available. In addition, the analysis was mainly cross-sectional, so treatment responsiveness was not assessed directly. Even so, the consistency of our results with previous studies supports the utility of HFUS in inflammatory skin disease. [8,10,12,14,15]

High-frequency ultrasonography is a useful non-invasive adjunct in the evaluation of inflammatory skin diseases. In the present study, HFUS identified distinct sonographic patterns in psoriasis and dermatitis and showed significant correlation with clinical severity in both conditions. Psoriasis was characterized mainly by greater epidermal thickness, dermal thickness, vascularity, and lesion depth, whereas dermatitis showed a more prominent subepidermal low-echogenic band. These findings suggest that HFUS can provide objective structural information beyond routine clinical examination and may be valuable in disease assessment and follow-up.

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2.      Jasaitiene D, Valiukeviciene S, Linkeviciute G, Raisutis R, Jasiuniene E, Kazys R. Principles of high-frequency ultrasonography for investigation of skin pathology. J Eur Acad Dermatol Venereol. 2011;25(4):375-82.

3.      Ke C, Zhu R, Luo F, Shi Y, Liu M, Xiao Y, Xiao R. Updated role of high-frequency ultrasound in assessing dermatological manifestations in autoimmune skin diseases. Acta Derm Venereol. 2022;102:adv001969.

4.      Gupta AK, Turnbull DH, Harasiewicz KA, Shum DT, Watteel GN, Foster FS, et al. The use of high-frequency ultrasound as a method of assessing the severity of a plaque of psoriasis. Arch Dermatol. 1996;132(6):658-62.

5.      Saha B, Gupta N, Prajapati J. Utility of high-frequency ultrasound in detecting subclinical inflammation in atopic dermatitis: A prospective observational study. Int J Med Pharm Res. 2025;6:2176-82.

6.      Gniadecka, M., Gniadecki, R., Serup, J., & Søndergaard, J. (1994). Ultrasound structure and digital image analysis of the subepidermal low echogenic band in aged human skin: diurnal changes and interindividual variability. Journal of investigative dermatology, 102(3), 362-365.

7.      Koehler MJ, Lange-Asschenfeldt S, Kaatz M. Non-invasive imaging techniques in the diagnosis of skin diseases. Expert Opin Med Diagn. 2011;5(5):425-40.

8.      Șomlea MC, Boca AN, Pop AD, Ilieș RF, Vesa SC, Buzoianu AD, Tătaru A. High-frequency ultrasonography of psoriatic skin: A non-invasive technique in the evaluation of the entire skin of patients with psoriasis: A pilot study. Exp Ther Med. 2019;18(6):4981-6.

9.      Michelucci A, Dini V, Salvia G, Granieri G, Manzo Margiotta F, Panduri S, et al. Assessment and monitoring of nail psoriasis with ultra-high frequency ultrasound: Preliminary results. Diagnostics (Basel). 2023;13(16):2716.

10.   Dini V, Janowska A, Faita F, et al. Ultra-high-frequency ultrasound monitoring of plaque psoriasis during ixekizumab treatment. Skin Res Technol. 2021;27:277-82.

11.   Graceffa D, Bonifati C, Lora V, Saraceni PL, De Felice C, Chimenti MS, et al. Ultrasound assessment of enthesis thickness in psoriasis and psoriatic arthritis: A cross-sectional study. Indian J Dermatol Venereol Leprol. 2019;85:175.

12.   Liu Z, Niu Z, Zhang D, Liu J, Zhu Q. Improve the dupilumab therapy evaluation with dermoscopy and high-frequency ultrasound in moderate-to-severe atopic dermatitis. Skin Res Technol. 2023;29(1):e13260.

13.   Yazdanparast T, Yazdani K, Humbert P, Khatami A, Nasrollahi SA, Hassanzadeh H, et al. Comparison of biophysical, biomechanical and ultrasonographic properties of skin in chronic dermatitis, psoriasis and lichen planus. Med J Islam Repub Iran. 2018;32:108.

14.   Nicolescu AC, Ionescu S, Ancuta I, Popa VT, Lupu M, Soare C, et al. Subepidermal low-echogenic band—its utility in clinical practice: A systematic review. Diagnostics (Basel). 2023;13(5):970.

15.  Dini V, Iannone M, Michelucci A, Manzo Margiotta F, Granieri G, Salvia G, et al. Ultra-high frequency ultrasound (UHFUS) assessment of barrier function in moderate-to-severe atopic dermatitis during dupilumab treatment. Diagnostics (Basel). 2023;13(17):2721.