DOI: 10.1111/jdv.

12860 JEADV

REVIEW ARTICLE

100 years of Wood’s lamp revised

J.L. Klatte,1,* N. van der Beek,2,4,5 P.M.J.H. Kemperman1,3
1
Department of Dermatology, Waterland Hospital, Purmerend, The Netherlands
2
ZBC Multicare, Independent Treatment Centre for Dermatology, Hilversum, The Netherlands
3
Department of Dermatology, Amsterdam Medical Centre, Amsterdam, The Netherlands
4
Department of Dermatology, Erasmus Medical Centre, Rotterdam, The Netherlands
5
University of Wales Trinity St. David, Swansea, Wales, United Kingdom
*Correspondence: J.L. Klatte. E-mail: [email protected]

Abstract
The Wood’s lamp is a diagnostic tool in dermatology. Unfortunately, this useful tool is often overlooked in the busy and
hectic outdoor dermatology clinic. To emphasize its value in modern dermatology, we present an updated review of the
principles and applications and shed new light on its proper place in our practice.
Received: 4 September 2014; Accepted: 20 October 2014

Conflict of interest
See conflict of interest forms. Original publication.

Funding sources
No funding.

Introduction The skin contains a plethora of fluorescent compounds, such

In dermatology, diagnosis is often based on observation, patient as collagen, elastin, coenzymes and many others, which respond
history, dermatoscopy and histopathology. From the perspective notably to UVA light. Unfortunately, their concentration is so
of the dermatologist, a diagnostic method must be easy and low that if the skin is irradiated by UV light, it is unlikely that
quick to perform while delivering an accurate and consistent the concentrations and distributions of the various fluoro-
result. An example of a diagnostic tool that meets these criteria phores can be distinguished. Under darkened conditions
is the Wood’s lamp. Using UV-light, the lamp provokes fluores- though, the picture changes. If, in a darkened room, one sub-
cence of the skin. Previous reviews of the applications of the jects the skin to radiation from a high-pressure mercury arc
Wood’s lamp in dermatology have dealt with the historical lamp, filtered by a barium silicate and 9% nickel oxide filter,
aspects in detail.1–3 We shall limit ourselves to the basic princi- better known as Wood’s lamp,7 one can observe a bluish fluo-
ples and clinical applications of this tool, referring to previous rescence due to these fluorophores. That is, if the skin is intact
work where necessary. and not influenced by diseases or external factors.8,9 Basically,
the application of the Wood’s lamp is more about detecting
Physics disturbances to the normal fluorescence pattern than it is about
Any visual inspection utilizes reflection, scattering and absorp- the fluorescence of the skin per se. In vitiligo, for example,
tion properties of the inspected skin. Whether it is an accurate diagnosis is confirmed by the lack of absorption by melanin
measurement from a sophisticated sensor registering a response residing in melanocytes or keratinocytes, resulting in bright
from the skin, or simply a dermatologist looking at the skin in a bluish-white patches. An exception is porphyria, in which there
room lit by fluorescent tubes. A photon hitting the skin can be is an excess of fluorescent compounds in the skin, or skin
reflected away from the skin, scattered deeper into the skin, or infections caused by certain fungal or bacterial microorganisms
absorbed by a molecule. Following absorption, the skin heats up, that produce fluorescent chemicals. Table 1 gives an overview
undergoes a photochemical response or transmits a new photon. of the applications of the Wood’s lamp and its associated
The latter phenomenon is known as fluorescence or phosphores- fluorescences.
cence.4,5 The probability that one of these events occurs is
dependent on the wavelength of the applied light. Blue light, for Requirements
example, is very well absorbed by melanin and haemoglobin, Although the Wood’s lamp itself is quite inexpensive and readily
whereas red light is not.6 available from a multitude of suppliers, its effective use requires

JEADV 2015, 29, 842–847 © 2014 European Academy of Dermatology and Venereology
Applications of Wood’s lamp in dermatology 843

Table 1 Wood’s lamp applications and its fluorescences

Condition Chromophore Colour of fluorescence
Pigmentary disorders Vitiligo Absence of melanin Bright bluish-white
Anaemic naevus Auto-fluorescence
Pityriasis alba Auto-fluorescence
Progressive macular hypomelanosis Absence of melanin and Bluish-white and follicle-bound
coproporphyrine III coral-red
Lentigo maligna Melanin Dark-brown to black
Ephelides (Epi)dermal melanin Dark-brown
Melasma (Epi)dermal melanin Dark-brown
Tuberous sclerosis Decrease of melanin White
Fungal infections Dermatomycosis
Microspora species Pteridine Bright-green
Trichophyton schoenleinii Blue
Pityriasis versicolor Mallasezia furfur Chamois leather-like
Pityrosporum folliculitis Mallasezia furfur Follicle-bound bluish-white
Bacterial infections Erythrasma Coproporphyrine III Coral-red
Propionbacterium acnes -Coproporphyrine III/Protoporphyrin IX Coral-red
Pseudomonas infections Pyoverdin Yellow-green
Porphyria Porphyria cutanea tarda Porphyrins in urine and faeces Pink-red
Erythropoietic porphyria Porphyrins in teeth and blood Pink-red
Non-melanoma skin Basal cell carcinoma/squamous cell 5-aminolevulinic-induced Coral-red
cancer carcinoma including actinic keratosis protoporphyrin IX

the fulfilment of a few requirements. The first and most obvious Practical applications
requirement is a completely darkened room for the investiga-
tion. Second, the user should be aware that the human eye needs Pigment disorders
some time to adjust to the lowlight environment in which the Melanin absorbs light emitted by the Wood’s lamp very well;
investigation takes place. Thirdly, as with any method, practice thereby, it diminishes the intensity of the fluorescence signal.
makes perfect.3 This makes the Wood’s lamp quite useful in the evaluation of

Figure 1 Vitiligo: bright bluish-white

fluorescence in Wood’s light.

JEADV 2015, 29, 842–847 © 2014 European Academy of Dermatology and Venereology
844 Klatte et al.

Figure 2 Progressive macular

hypomelanosis: bright bluish-white lesions
and follicle-bound coral-red fluorescence.

pigment disorders such as melasma, vitiligo and progressive in PMH is due to a substance made by Propionbacterium
macular hypomelanosis. acnes.10

Melasma Melasma is a common hyperpigmentary disorder of Tuberous sclerosis An ‘ash-leaf’ macule is a leaf-shaped, hypo-
the skin. It is caused by an overproduction of pigment on sun- pigmented macule, a characteristic of tuberous sclerosis. The
exposed areas, mainly the face, which results in hyperpigmented ‘ash-leaf’ lesion can appear anywhere on the human body. On a
patches. In melasma, the hyperpigmentation can be epidermal, light skin type, this lesion can be hard to see but easily detected
dermal or mixed. Melasma is treated with depigmenting creams with the Wood’s lamp.2
or with other methods such as laser and IPL therapy. In this
treatment, mainly the epidermal pigment responds. The Wood’s Infections of the skin
lamp is not only beneficial to confirm diagnosis; in addition, it Microorganisms such as bacteria and fungi can be detected with
can distinguish whether the hyperpigmentation is epidermal, the Wood’s lamp because of the fluorescent compounds they
dermal or mixed and thereby determine whether therapy is contain.
effective or not.3
Fungi and yeasts Fungi and yeasts cause dermatomycoses of
Vitiligo Vitiligo is a disease in which skin and hair lose their skin, hair and nails. Fungi are divided into three different strains,
melanocytes resulting in depigmented patches on the skin, Microspora, Trichophyton and Epidermophyte species. The
varying in size and shape. The Wood’s lamp can be used to
confirm diagnosis when vitiligo is suspected. Furthermore, it
allows to distinguish vitiligo from an anaemic naevus, pityria-
sis versicolor and pityriasis alba. In vitiligo, because of loss of
epidermal melanin, depigmented patches appear bright
bluish-white with sharp demarcations in the Wood’s light
(Fig. 1). In contrast, an anaemic naevus, caused by local
dermal vasoconstriction with normal overlying epidermal pig-
ment, does not show up in the Wood’s light. In pityriasis
versicolor, the yeast causing the skin disorder gives a yellow-
gold fluorescence. Finally, pityriasis alba, with irregular para-
keratosis and little melanocyte activity, is not noticed in the
Wood’s light.3

Progressive macular hypomelanosis PMH is a pigment dis-

order with non-itching, non-scaly, hypopigmented macules,
mainly localized on the trunk. Westerhof10 found a relation
between PMH and Propionbacterium acnes. Examination of
PMH with the Wood’s lamp showed bright bluish-white fluo-
rescence of the skin lesions due to the lack of melanin, as
well as follicle-bound coral-red fluorescence due to copro-
porfyrine III. Coproporfyrine III is a chromophore produced
Figure 3 Tinea manuum: bright-green fluorescence in Wood’s
by Propionbacterium acnes (Fig. 2). Upon this finding, Wester- light.
hof10 formulated the hypothesis that the hypopigmentation

JEADV 2015, 29, 842–847 © 2014 European Academy of Dermatology and Venereology
Applications of Wood’s lamp in dermatology 845

Figure 4 Tinea capitis caused by

Microsporum: bright-green fluorescence.

Microspora species produce a metabolite, pteridine, which fluo- rescence. On the facial skin, the Wood’s lamp highlights an
resces bright-green if illuminated by the Wood’s lamp (Fig. 3). orange-red fluorescence from comedones (Fig. 5).2

Tinea capitis Tinea capitis is a trichomycosis often caused by Pseudomonas infection The Wood’s lamp can also be used to
Microspora species. When tinea capitis is suspected, the diagnosis detect Pseudomonas infections of the skin, for example, in burns
can be directly confirmed using the Wood’s lamp (Fig. 4). How- or toe web infections. Pseudomonas bacteria excrete a pigment,
ever, tinea capitis can also be caused by a Trichophyton species, pyoverdin, which fluoresces yellowish-green in the Wood’s light
which does not fluoresce. That is why a lack of fluorescence can (Fig. 6). The Wood’s lamp can be used as an early diagnostic
never exclude tinea capitis. One exception in the Trichophyton tool to detect Pseudomonas infection of burns or other wounds,
species, Trichophyton schoenleinii the cause of favus (latin for long before Pseudomonas shows up in a bacterial culture, allow-
honeycomb), causes yellowish, cup-shaped crusts, grouped in ing to start the right treatment at an early stage.2,11–13
patches like a piece of honeycomb. In the Wood’s light, it causes
a blue fluorescence.2 Erythrasma Erythrasma is a skin infection caused by over-
growth of Corynebacterium minutissimum. It occurs in body
Pityriasis versicolor Pityriasis versicolor is a superficial fungal folds and causes a scaly, red-brown discoloration of the skin and
infection of the skin caused by Malassezia furfur, a spore-forming
yeast. Infected lesions fluoresce yellow-gold, also described as
chamois leather.11

Pityrosporum folliculitis Pityrosporum folliculitis is caused by

the same yeast as pityriasis versicolor and is therefore also seen
as its local or follicular form. Overgrowth of Malassezia furfur
causes follicular ranked, erythematous papules and pustules,
sometimes itching and mainly localized on chest and upper
back.
When illuminated by the Wood’s light, a follicular pattern of
bluish-white fluorescence is seen, which allows for a clear dis-
tinction between pityrosporum folliculitis and a bacterial follicu-
litis.11

Bacterial infections The best-known bacterium causing fluo-

rescence in the Wood’s light is the Propionbacterium acnes,
which is part of the bacterial flora of the skin. Propionbacterium
Figure 5 Propionbacterium acnes in comedones: follicle-bound
acnes produces coproporphyrin III and protoporphyrin IX, in coral-red fluorescence.
the Wood’s light these chromophores show an orange-red fluo-

JEADV 2015, 29, 842–847 © 2014 European Academy of Dermatology and Venereology
846 Klatte et al.

haem, porphyrins accumulate. Due to an excess of porphyrin

metabolites, sensitivity to light occurs, which can manifest
clinically in various forms. Porphyrin fluoresces pink-red in the
Wood’s light. Depending on the type of porphyria, accumula-
tion can be noted in urine, faeces, erythrocytes or teeth.2

Tumours
The first publication about fluorescence of tumours was written
by Policard in 1924.8 He observed a red fluorescence of an ani-
mal sarcoma in UV-light because of the accumulation of endog-
enous porphyrins in the tumour. In 1943 Auler16 showed an
accumulation of haematoporphyrine in a tumour after injecting
it in the tumour. In the Wood’s light it caused heightened
visibility of the tumour-borders. Auler16 also showed that the
accumulated haematoporphyrine in the tumour cells, in combi-
nation with UV-light radiation, induces necrosis of the tumour
cells, which is the principle of photodynamic therapy. However,
nowadays the Wood’s lamp is not yet able to detect skin malig-
nancies or differentiate in tumour type.8,16

Figure 6 Pseudomonas infection: yellow-green fluorescence in Education

Wood’s light. An application which does not come to mind directly, when
thinking about the uses of the Wood’s lamp in dermatology, is
an itching or burning sensation. Corynebacterium minutissimum the education of patients regarding the proper use of topical
produces coproprophyrine III, which causes a coral-red fluores- creams. By asking the patient to apply a fluorophore containing
cence when illuminated by Wood’s light.14 Because of the coral- cream, one can easily establish whether the patient is applying
red fluorescence, the Wood’s lamp is a direct diagnostic tool to the topical drugs in a proper and effective way.1
distinguish erythrasma from intertrigo, tinea inguinalis or psori-
asis inversa (Fig. 7).15 Pitfalls
Because of its fluorescence, tinea capitis can be distinguished
Porphyria from another type of alopecia. However, most of the fungi
Porphyria is a metabolic disorder caused by an enzymatic do not fluoresce in the Wood’s light; therefore, a negative
disturbance in the biosynthesis of haem. Because of a lack of fluorescence finding cannot exclude the diagnosis of this

Figure 7 Erythrasma: coral-red

fluorescence in Wood’s light.

JEADV 2015, 29, 842–847 © 2014 European Academy of Dermatology and Venereology
Applications of Wood’s lamp in dermatology 847

condition. Furthermore, every scaling dermatosis can cause 6 Prahl SA, Jacques SL. Biomedical Optics in Portland [Internet]. Oregon
reflection in the Wood’s light, which can complicate the Health & Science University, Portland State University, the Oregon
Institute of Technology, 2001. URL http://omlc.org/spectra/(last accessed:
interpretation, for example, in pityriasis versicolor. Moreover, 17 July 2014).
erythrasma fluoresces coral-red because of coproporphyrins, 7 Wood RW. Secret communications concerning light rays. J Physiol 1919;
however, if the affected skin was washed just before inspection 5th series: t IX.
8 Policard A. Etudes Sur Les Aspects Offerts Par Des Tumeurs Experimen-
with the Wood’s lamp, it is possible that the fluorescence will
tales Examinees a La Lumiere de Wood. C. R. Soc. Biol. 1924; 91: 1423–
not be observed.14 1428.
9 Margarot J, Deveze P. Aspect de Quelques Dermatoses Lumiere
Concluding remarks Ultraparaviolette. Note Preliminaire. Bulletin de La Soci
et
e Des Sciences
M
edicales et Biologiques de Montpellier. 1925; 6: 375–378.
In its 100 years of existence, the Wood’s lamp has proven its
10 Westerhof W, Relyveld GN, Kingswijk MM, de Man P, Menke HE.
diagnostic value. The small, mobile and easy-to-use lamp has Propionibacterium acnes and the pathogenesis of progressive macular
shown to be a valuable contribution to diagnostic routines in a hypomelanosis. Arch Dermatol 2004; 140: 210–214.
dynamic dermatology outpatient department. 11 Ruocco E, Baroni A, Donnarumma G, Ruocco V. Diagnostic procedures
in dermatology. Clin Dermatol. 2011; 29: 548–556.
12 Ward CG, Clarkson JG, Taplin D, Polk HC Jr. Wood’s light fluorescence
References and pseudomonas burn wound infection. JAMA 1967; 202: 1039–1040.
1 Wigger-Alberti W, Elsner P. Fluorescence with Wood’s light. Current 13 Polk HC, Ward CG Jr., Clarkson JG, Taplin D. Early detection of pseudo-
applications in dermatologic diagnosis, therapy follow-up and preven- monas burn infection. Clinical experience with Wood’s light fluorescence.
tion. Hautarzt 1997; 48: 523–527. Arch Surg 1969; 98: 292–295.
2 Gupta LK, Singhi MK. Wood’s Lamp. Indian J Dermatol Venereol Leprol 14 Burns T, Breathnach S, Cox N, Griffiths C. Rook’s Textbook of Dermatol-
2004; 70: 131–135. ogy, 8th edn. Wiley-Blackwell, Chichester, West Sussex, 2010.
3 Asawanonda P, Taylor CR. Wood’s Light in Dermatology. Int J Dermatol 15 Yasuma A, Ochiai T, Azuma M, Nishiyama H, Kikuchi K, Kondo M,
1999; 38: 801–807. et al. Exogenous coproporphyrin III production by corynebacterium
4 Welch AJ, van Gemert MJC. Optical-Thermal Response of Laser-Irradi- aurimucosum and microbacterium oxydans in erythrasma lesions. J Med
ated Tissue, 2nd edn. Springer, Dordrecht, The Netherlands, 2011. Microbiol 2011; 60: 1038–1042.
5 Stokes GG. On the change of refrangibility of light. In Stokes GG, ed. 16 Auler H, Banzer G. Untersuchungen u €ber die Rolle der Porphyrine bei
Philosophical Transactions. The Royal Society, London, 1853: geschwulstkranken Menschen und Tieren. Zeitschrift f€ ur Krebsforshung.
385–396. 1942; 53: 65–68.

JEADV 2015, 29, 842–847 © 2014 European Academy of Dermatology and Venereology