|Ahead of print publication
Newer signs in dermatology [2016-2020]
Anupam Das1, Anand Toshniwal2, Bhushan Madke3
1 Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
2 Consultant Dermatologist, Aesthetic Aura Skin and Hair Clinic, Hyderabad, Telangana, India
3 Department of Dermatology, Venereology and Leprosy, Jawahar Lal Medical College and Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra, India
|Date of Submission||08-Apr-2020|
|Date of Decision||04-Apr-2020|
|Date of Acceptance||28-Jun-2020|
|Date of Web Publication||19-Sep-2020|
Address Building “Prerana” 19 Phoolbagan, Kolkata - 700 086, West Bengal
Source of Support: None, Conflict of Interest: None
| Introduction|| |
Dermatologists have the skill to identify the conditions by the visual appeal of it. The ever increasing conditions in dermatology and their closeness to a number of other conditions make dermatology an extremely challenging field. Refreshing the brains with newly diagnosed signs can help in delineating and correctly diagnosing the conditions and even an underlying systemic disorder. There has been some criticism on the increasing description of signs in the literature, but these are some of the areas, which the residents (especially those having an interest in quizzes) must have an idea about. Literature search was performed using the keywords “sign[it]” in PubMed (with a filter of 5 years), and the results relevant to dermatology were taken into consideration.
| Clinical|| |
Axillary ecchymosis sign
In acute pancreatitis, due to the formation of methalbumin; deep blue-colored ecchymosis can be seen in the axilla, which can help in the early diagnosis of pancreatitis and this is also an indicator of the severity of the disease [Figure 1].
Hiker's feet sign
It is seen in inflammatory myositis and characterized by bilateral dryness, cracking, and hyperkeratosis on the plantar aspect of the foot.
It refers to arctic blue discoloration of the surface of the lesions of actinic keratosis. It is caused due to usage of toning shampoos for white-blonde hair. It is thought to result from the deposition of acid violet dye, which gets trapped amidst the layers of parakeratosis.
Inverse Gottron sign
It is characterized by erythematous flat and ulcerated lesions on the palmar aspects of fingers. It is seen in anti-melanoma differentiation-associated gene 5 (anti MDA5) antibody-associated dermatomyositis. It is caused due to vasculopathy associated with the antibody-induced damage.
It is seen in traction alopecia. Also known as fold sign, it is characterized by folding of an area of the scalp in the hands. In normal conditions, the scalp cannot be folded as the hair follicles tightly adhere to galea aponeurotica.
Molluscum pendulum necklace sign
It is seen in tuberous sclerosis and characterized by multiple molluscum pendulum (acrochordons) arranged linearly in a necklace pattern on the neck.
Nail flag sign
It is characterized by alternating white and red sequential transverse bands on the nail plate. It is seen in patients having diabetes, leprosy, vitiligo, heart transplant recipients, and diverticulosis; attributed to peripheral vascular changes [Figure 2].
Orange–brown chromonychia sign
It is seen in acute stages of Kawasaki disease in children and characterized by orange–red to brown transverse lines on nails. It is caused due to alteration in nail plate keratinization or a vascular inflammation leading to residual color changes [Figure 3].
Ovoid palatal sign
It manifests as arcuate erythema with whitish macules on the palate, in dermatomyositis associated with anti-TIF1-γ (p155) antibodies. It is significantly associated with internal malignancy.
Paired ear creases of the helix sign (PECH)
Similar to Frank sign, it is seen in coronary artery disease and metabolic syndrome. It is characterized by paired creases on the helix of the ear. The creases reflect the loss of elastin, and this is attributed to the loss of caliber of the coronary arteries [Figure 4].
Plantar ecchymosis sign
This refers to a centrally located mid plantar ecchymosis, due to calcaneal or Lisfranc fracture, because of accumulation of blood in the middle compartment of the foot.
The true fringe sign is seen in traction alopecia where hairs at the implantation site are spared due to traction. In the initial stages of frontal fibrosing alopecia, there is sparing of the implantation site but later, the fringe becomes rarified and is replaced by scar tissue, with loss of follicular ostia.
Tin tack sign
The appearance of horny plugs on the undersurface of the scale (removed from the affected site) resembles a carpet or a tin tack. It is seen in discoid lupus erythematosus, pemphigus foliaceous, seborrheic dermatitis, lymphoma, captopril- induced lichen planus, and cutaneous leishmaniasis (recently described).
Triangular nasal notch sign
It is seen in patients of Crohn's disease who are on treatment with TNF alpha inhibitors and it is characterized by erythematous-squamous lesions along with fissuring and triangular cicatricial lesion on the nasal soft triangle.
This refers to the presence of dilated superficial venous collateral vessels on the shoulder and the upper arm. It is seen in Paget–Schroetter syndrome.
| Histological|| |
Candle wax sign
It is seen in aggressive basal cell carcinoma. It presents as a restrained investment of the epidermal surface, similar to the drop of wax that has fallen on the ground and hardened as a delicate film.
It is seen in pityriasis rosea where a mound of parakeratotic stratum corneum next to spongiotic focus shows elevation on one side and it is attached to the other side of stratum corneum. This angulated parakeratosis is attached at one end and free at the other end, resembling a salute.
It is seen in acne keloidalis nuchae wherein, the inflammatory infiltrate involves the isthmus and mid dermis. Spade sign refers to thin dilated space which is in the shape of a balloon or spade of playing cards, seen in the sub-acute stage of acne keloidalis nuchae.
| Radiological|| |
Bull's head sign
It is seen in synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. Bone scintigraphy in these cases reveals an increased technitium uptake over the sternoclavicular joints and sternum, giving a bull's head appearance.
Panda and lambda sign
It is seen on a Gallium scan, in patients of sarcoidosis. The panda sign is characterized by increased uptake in parotid and lacrimal glands, whereas lambda sign is increased uptake in the hilar, paratracheal, and mediastinal lymph nodes.
It is seen in esophageal candidiasis on a barium swallow. The yellowish-white plaques seen endoscopically appear as irregular filling defects on barium swallow and in advanced cases, these plaques become confluent giving rise to a snakeskin or cobblestone appearance.
| Miscellaneous|| |
A 20-minute occlusive testing may be helpful in identifying urticarial reaction, which could be missed in conventional patch testing which is read at 72 hours. In cases of chronic urticaria, the adhesive patches are peeled off, and the area is identified after 20 minutes, which reveals a pink rim around the allergen strips.
Tasleem's water jet sign
While injecting local anesthesia into warts before ablation, local anesthetic ejects out through the warts like a jet. The reason for the jet is due to the dense papillomatosis which is separated by potential weak spaces. The presence of dense hyperkeratosis, the tough connective tissue of palms and alignment of bent rete ridges towards the center of the wart, does not allow the solution to go deeper, as a result of which the water ejects out like a jet.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Madke B, Nayak C. Eponymous signs in dermatology. Indian Dermatol Online J 2012;3:159-65.
] [Full text]
Pandiaraja J. Another cutaneous sign of acute pancreatitis. Indian J Crit Care Med 2016;20:313-4.
] [Full text]
Cox JT, Gullotti DM, Mecoli CA, Lahouti AH, Albayda J, Paik J, et al
. “Hiker's feet”: a novel cutaneous finding in the inflammatory myopathies. Clin Rheumatol 2017;36:1683-6.
Mir-Bonafe JF, Mir-Bonafe M, Mozos A, Lopez-Sanchez C, Piquero-Casals J, de Dios-Velazquez A, et al
. Iceberg sign in actinic keratosis neglecta caused by toning shampoo for blonde and white hair. Int J Dermatol 2020;59:e64-5.
Jain S, Sharma A. Inverse Gottron's sign in anti-MDA5 antibody-associated dermatomyositis. Rheumatology (Oxford) 2020. pii: keaa108. doi: 10.1093/rheumatology/keaa108.
Ancer-Arellano J, Tosti A, Villarreal-Villarreal CD, Chavez-Alvarez S, Ocampo-Candiani J. Positive Jacquet's sign in traction alopecia. J Eur Acad Dermatol Venereol 2018;32:e446-7.
Sachs C, Lipsker D. The molluscum pendulum necklace sign in tuberous sclerosis complex: A case series A pathognomonic finding? J Eur Acad Dermatol Venereol 2017;31:e507-8.
Cohen PR. The nail flag sign in heart transplant recipients: Case reports and review of the patients with the flag sign of the nail. Dermatol Online J 2019;25. pii: 13030/qt6883w7ss.
Yamazaki-Nakashimada MA, Deguchi K, Gámez-González B, Ulloa-Gutierrez R, Hamada H. Orange-brown chromonychia: A valid sign in Kawasaki disease in children of different ethnicities. Int J Rheum Dis 2019;22:1160-1.
Bernet LL, Lewis MA, Rieger KE, Casciola-Rosen L, Fiorentino DF. Ovoid palatal patch in dermatomyositis: A novel finding associated with anti-TIF1γ (p155) antibodies. JAMA Dermatol 2016;152:1049-51.
Pathmarajah P, Rowland PC. Paired ear creases of the helix (PECH): A possible physical sign. Cureus 2017;9:e1884.
Sherman SC, Lee J. Plantar ecchymosis sign. J Emerg Med 2019;57:e57-8.
Pirmez R, Vano GS. Acknowledging the pseudo “fringe sign” in frontal fibrosing alopecia has diagnostic and prognostic implications. J Am Acad Dermatol 2018;78:e19.
Rather S, Yaseen A. “Tin Tack” Sign in localized cutaneous leishmaniasis: A finding from a nonendemic disease focus. Indian J Dermatol 2017;62:535-7.
] [Full text]
Mesnard C, Aubert H, Bourreille A, Trang C, Gagey CV, Le CY, et al
. The triangular nasal notch sign in patients with Crohn disease treated with tumour necrosis factor inhibitors. Br J Dermatol 2019;181:1103-4.
Lawless SM, Samson R. Urschel's sign in Paget Schroetter syndrome. Am J Med 2017;130:e537.
ODonnell B. The candle wax sign and aggressive basal cell carcinoma. Dermatol Surg 2019;45:1697.
Thomas M, Khopkar U. Salute sign: A nonambiguous histopathological sign in pityriasis rosea. Indian Dermatol Online J 2016;7:543-4
Cheng AY, Lee CN, Hsieh FN, Lo TK, Huang HY, Hsu CK, et al
. “Spade sign” and inflammation/fibrosis limited to the upper and mid-dermis as the pathognomonic features of acne keloidalis. J Dermatol 2020;47:41-6.
İlgen U, Turan S, Emmungil H. Bull's head sign in a patient with SAPHO syndrome. Balkan Med J 2019;36:139-40.
Harada K, Yasuda M, Otsuka F. 'Panda and lambda sign' in sarcoidosis. QJM: An Int J Med 2020;113:61-2.
Xiang H, Han J, Ridley WE, Ridley LJ. Snakeskin sign: Oesophageal candidiasis. J Med Imaging Radiat Oncol 2018;62(Suppl 1):108-9.
Isaac J, Goldminz AM, Scheinman PL. Pink sign: The importance of short-term occlusive testing in suspected cases of contact urticaria. Dermatitis 2019;30:168-9.
Arif T, Amin SS. Tasleem's water jet sign-A new sign in dermatology. Our Dermatol Online 2015;6:382-3.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]