This document discusses several clinical signs seen in dermatology. It begins by describing Auspitz sign, seen as pinpoint bleeding when removing the last layer of scale in psoriasis. It then discusses other signs like Nikolsky sign seen in pemphigus vulgaris, and Asboe-Hansen sign seen in bullous pemphigoid. The document provides details on signs seen in various conditions like Darier's disease, neurofibromatosis type 1, scleromyxedema and others. It also explains the mechanisms and diseases associated with signs named after clinicians like Leser-Trelat, Gottron, and Turner.

1. By: Aisha Al-Moosa

2. Eyes see what the mind knows

7. • If the superficial silvery white scales are removed via curettage a
characteristic coherence is observed, as if one has scratched on a wax
candle (“signe de la tache de bougie” Candle sign).
• Subsequently, a surface membrane is seen, The lesion remains dry
until this last level is reached (sign of the last Häutchen) which will
also come off as a whole.
• If the latter is removed, then a wet surface is seen with characteristic
pinpoint bleeding. This finding is called Auspitz sign. Rupture of dilated
dermal capillaries.

8. Give two diseases with +ve Auspitz sign not
including Ps
1. Darier's disease
2. Actinic keratosis.

10. Slight rubbing of the skin results in exfoliation of the outermost
layer.
- Seen in :
•Autoimmune condition (pemphigus vulgaris).
•Bacterial infection ( Staph scalded skin syndrome).
- Negative in BP.

11. • Seen in Steven Johnson syndrome, toxic epidermal necrolysis and
in some cases of burns and bullous icthyosiform erythroderma.
• The underlying mechanism here is the necrosis of epidermal cells
and not acantholysis, as seen in true Nikolskiy's sign.
• It is elicited the same way as the true sign. However, unlike
Nikolskiy's sign, pseudo-Nikolskiy's sign is elicited only on clinically
involved or erythematous areas.

12. What is the name of the sign which is positive
in BP?

13. - Named for Gustav Asboe-Hansen (1917–1989), Danish physician.
• - AKA "indirect Nikolsky sign" or "Nikolsky II sign“. Blisterspread
sign
-Extension of a blister to adjacent unblistered skin when pressure is
put on the top of the bulla.
-Seen in
-1) Subepidermal blisters

15. ‫ك‬

16. Dimpling at knuckles on making a fist

17. - Knuckle dimple sign.
- Due to short 4th and 5th metacarpals.
- Enhanced by making a fist.
- Described by Fuller Albright .
-Found in
-Albright hereditary osteodysrtrophy.

19. McCune Albright Syndrome Albright Hereditary Osteodystrophy
AD XLD Inheritance
Polyostotic fibrous dysplasia osteodystrophy Bony lesions
Large café –au-lait macule
(cost of Maine) with
ipsilateral bony changes.
Precocious puberty.
Short stature.
Obesity.
Round face.
Mental retardation.
Brachydactaly
Soft tissue
calcification.
Short 4th and 5th
metacarpals.
Pseudohypoparathyroidism
Other symptoms

20. McCune Albright
Syndrome

23. -Named after an
English surgeon
William Henry
Battle.
-Indicates
- fracture base of skull
at the posterior fossa.
- Blood dissects through
fascia and collects at
mastoid process.

24. Racoon sign
Is a useful feature indicative of basilar skull
fracture.
The condition is seen as periorbital
ecchymosis from subconjunctival
hemorrhage, which occurs secondary to
blood dissecting from the disrupted skull
cortex to the soft tissue of the periorbital
region.

27. - The ability to invaginate the tumor/lesion into the dermal
defect with digital pressure.
- Found in neurofibromas in NF1.
Others?
- Anetoderma
- Old pigmented nevi
- Syphilitic chancre (a buttonhole-like consistency is noted on
the edge and base of the ulcer on palpation)

29. •

30. • AKA Fitzpatrick’s sign, seen in dermatofibromas.
• Lateral compression with the thumb and index finger leads
to depression of the lesion.
• This dimpling effect is secondary to the lesion being attached
to the subcutaneous fat

32. Crowe’s sign

33. • Named after Frank W. Crowe, an American physician.He noticed that axillary freckles are present in about
20-30% of patients with neurofibromatosis, but he did not see any in patients who did not have
neurofibromatosis.
- Axillary freckling in NF-1
-Occurs at a later stage compared to the Café au lait lesions.
- Can also be found in the perenium.

38. Area was scratched

39. Wheeling, circumscribed erythema and
localzed pruritis caused by scratching or
rubbing the lesions.
• Seen in
• Urticaria pigmentosa,
• Systemic mastocytosis, insect bite reactions,
neurofibroma,
• juvenile xanthogranuloma, and acute neonatal
lymphoblastic leukemia.

40. Hoagland’s sign
• is early and transient bilateral
upper lid edema occurring in
patients with infectious
mononucleosis.
• The sign is usually present only
for the first few days of the
clinical presentation of the
illness.

43. - Transient piloerection and elevation or increased induration of
a lesion induced by rubbing.
- Observed in
1. Congenital smooth muscle hamartoma
2. Becker’s nevus.

47. Darier-Roussy subcutaneous
sarcoidosis

48. Continue ?

51. - Central depression surrounded by an elevated skin
rim.
-Seen in
-scleromyxedema.
- On the extended proximal intelphalenges.

52. What stains would you use for a skin biopsy of
a scleromyxedema case?

55. • Symmetric confluent violacous erythema
over the knuckles, wrists, knees is called
Gottron’s sign
•Violaceous papules over MP joints (Gottron’s
papules)

56. What are the other features of
dermatomyositis?

57. Photodistributed
poikiloderma
involving the “V” of the
chest and the upper back
is often referred to
as the “shawl sign”
(Samitz sign)
cuticular dystrophy and nail fold
telangiectasias.
The cuticles are “ragged” and within the
proximal nail fold,
dilated capillary loops alternate with vessel
dropout
Heliotrope sign
(most characteristic)

58. Holster sign
Pruritic, macular, violaceous erythema
affects the lateral aspects of hips and
thighs.

59. CALCINOSIS CUTIS

60. • BLEOMYCIN treatment
•Adult -onset Still's disease
• Shiitake mushroom
dermatitis.

61. .Juvenille DM vs adult DM – list 5 clinical differences
Juvenile Adult
Calcinosis cutis No calcinosis
No malignancy Malignancy (ovarian)
No sex predominance F:M = 2-7:1
10% overlap with other CTD 20% overlap with other CTD
More vasculitis Less vasculitis

62. • Erythema over the malar eminence
•This sign is classically described in
lupus erythematosus
Important to differentiate it from
other causes of facial erythema, such as rosacea,
seborrheic dermatitis, and erysipelas
Butterfly sign

64. Prurigo nodularis.
B Numerous lesions on the trunk, with
sparing of the mid upper back
(“butterfly sign”)

67. - After the English surgeon George Grey Turner ( 1877 – 1951 ).
- Induration and brusing of skin over the costovertebral angel
secondary to the spread of blood from the anterior pararenal
space.
- Commonly with acute hemorrhagic pancereatitis.
- Can be with any other causes of retroperitoneal hemorrhage.

68. What other signs are seen in acute
hemorrhagic pancereatitis ?

69. - Cullen's sign :
hemorrhagic discoloration
of the umbilicus.

72. - Around 20% of lymphogranuloma venereum.
- Caused by a mass of femoral and inguinal nodes
separated by the femoral ligament.

73. LYMPHOGRANULOMA VENEREUM
Incubation
Period ??
3-21 days
Chlamydia
trachomatis L1, L2, or L3 Ccc
histology??
Gamma-Favre bodies - Basophilic
inclusion bodies located in the
cytoplasm of endothelial cells
Doxycycline 100 mg PO bid for 21
d
Erythromycin base 500 mg PO qid
for 21 d

76. - A cutaneous sign of neural tube defect on the scalp.
- Coarse dark hair surrounding the underlying defect.
- Can be seen in : aplasia cutus congenita, encephalocele,
meningocele, ectopic brain tissue.

79. - Loss of lateral third of eye brow.
-Seen in a list of diseses:
-AA, trichotillomania, leprosy, ectodermal dysplasia, syphilis, KP,
alopecia mucinosa, systemic sclerosis and hypothyroidism.

80. • Symmetric, prominent horizontal fold(s) (single or double) just beneath the
margin of the lower lid, originating at or near the inner canthus and
extending one-half to two-thirds the width of the lid

81. • Peri oral pallor due to
cheilitis ( inflammation of
the skin around the lips)
Periorbital darkening (“allergic
shiners”)
• Skin around the eyes appears
gray to violet–brown, while the
rest of the facial skin is rather
pale
• Periorbital edema and
lichenification may also be seen

82. Dirty neck sign

83. Dirty neck sign
Reticulate pigmentation of the neck seen in patients with chronic
atopic dermatitis.
• label ‘‘dirty neck’’ was given because of the resemblance to
• The appearance of unwashed skin, with the anterolateral
aspects of the neck typically affected. The pigmentary changes
are secondary to melanin incontinence.

85. ● It is seen in
keratosis pilaris in
which individual
follicles show a
long strand of
keratin glinting
when examined in
tangentially
incident light

89. -Almost a certain sign of subungual malignant
melanoma.
The possibility of melanoma should be considered for all
pigmented nail bands in fair-skinned individuals, especially
if they are
• darkly pigmented,
• have irregular pigmentation and/or
• have a width ≥3 mm.

90. What other “ hutchinsons” do you know ?

91. - In congenital syphilis:
Hutchinsons teeth
Eighth nerve palsy
Keratistis

92. • (V1; ~10–15% of zoster patients)
• presence of vesicles occurring on the tip of
the nose in patients with herpes zoster.
• This presentation indicates that the
nasociliary branch is affected and that eye
involvement may be present or forthcoming;
• Therefore, an ophthalmologic assessment is
necessary for these patients.
• May lead to ocular scarring and visual loss
Herpes zoster Ophthalmic
division of the trigeminal nerve

97. ● Classically described in Papulo-erythroderma of Ofuji, wherein
there is flat-topped red papules that become generalized
erythrodermic plaques without the involvement of abdominal skin
folds
Cutaneous Waldenstro¨m’s macroglobulinemia

99. SUDDEN
ERUPTION?

100. - After the European surgeon Edmund Leser
( 1853 – 1916 ).
• Rapid appearance or growth of multiple seborrheic keratoses;
• Often these patients have acanthosis nigricans and generalized pruritus.
• Adenocarcinomas are typically reported, particularly of the stomach and
colon but also of the breast, uterus, esophagus, and pancreas
• Eruptive seborrheic keratoses can also develop in erythrodermic patients
who do not have an underlying malignancy

101. • Pseudo sign of Leser Trelat (Patton et
al J. Drugs dermatology 3:565,
2OO4):
• Increase in size of seborrheic
keratosis which can be seen after the
use of cytarabene for the the
treatment of acute myelogenous
leukemia.
• Cytarabene causes inflammation of
existing seborrheic keratosises

104. Tripe palms
• acanthosis palmaris and pachydermatoglyphy,
• refers to the rugose thickening of the palmar surface of the
hands, with accentuation of the normal dermatoglyphic ridges,
• strongly associated with internal malignancy, most commonly
• carcinoma of the stomach and LUNG .

105. Association with adenocarcinoma of the stomach or
other sites within the GI or GU tracts
How do you know its MALIGNANT
acanthosis nigricans ?
•If it is :
• Sudden onset
• With constitutional symptoms and
weight loss
• Extensive and involves sites such as
the palms and soles and mucous
membaranes .
• With other paraneoplastic features

106. Bazex syndrome (acrokeratosis
paraneoplastica)
•Acral psoriasiform plaques, typically with
involvement of the nose and helices; often
the lesions are violaceous .
•Occurring in the upper aerodigestive tract
(pharynx, larynx or esophagus)

107. Erythema gyratum repens
Variable sites and types of malignancy

108. Glucagonoma syndrome
(Necrolytic migratory erythema),
•With angular cheilitis, glossitis
•Due to a glucagon-secreting tumor of the pancreas.
•Patients are often treated for intertrigo before the syndrome is
diagnosed.
•Weight loss and diabetes mellitus accompany the dermatosis

109. Don’t mix between
Necrolytic MIGRATORY erythema ( paraneoplastic )
with
Necrolytic ACRAL erythema ( associated with HCV and zinc def
)

110. Acquired hypertrichosis
lanuginosa
(malignant down)
•Growth of fine lanugo
hairs in a generalized
distribution or
•localized to the face. With
time, these hairs may
become
coarser
•carcinoma of the lung,
colon or breast

111. Sister Mary Joseph sign, refers to a palpable nodule bulging
into the umbilicus as a result of metastasis of a malignant
cancer in the pelvis or abdomen.
Gastrointestinal malignancies account for about half of
underlying sources (most commonly gastric cancer, colonic
cancer or pancreatic cancer,

112. Pitryasis rotunda
associated with HCC
(in type 1)

113. Trousseau syndrome
Migratory superficial thrombophlebitis’
with Pancreatic cancer

117. - Hyperpigmentation of the neck occurring in pellagra
patients.
What is deficient in pellagra ????????????
Niacin

120. - Blue sclera.
-Seen in multiple cases:
– Osteogenesis imperfecta,
– Ehler danlos syndrome,
– nevus of Ota,
– argyria and
– Alkaptinuria.

123. - The new blisters arises around the
old leasions forming linear
sequential lesions.
- Seen in CBDC.
•Target antigen:
•9 7 kDa Ag ( LAD-1 or LABD97 ):
cleaved ectodomain of
BPAG2
termed string of pearls or rosettes sign

124. IgG staining IgA staining
linear deposition of IgA along the BMZ

127. • Sometimes used for scale crust of pemphigus foliaceous.
• Cornflake sign seen in Flegel's disease is characterized by 2-3
mm keratotic scaly papules with discrete irregular margins.
• The scale separates from many lesions, leaving a non-
exudative red base.

130. • This sign is diagnostic of Discoid Lupus
Erythematosus [DLE].
• Removal of an adherent scale from a
lesion of DLE reveals the undersurface
to be covered with horny plugs
[resembling carpet tacks] overlying
dilated hair follicular openings

133. • This is pathognomic of Congenital Syphilis.
• congenital thickening of the medial aspect of the clavicle

134. V

137. • This is seen in Kwashiorkor and other diseases leading to severe
protein malnutrition like extensive bowel resection, severe
ulcerative colitis etc.
• Presence of alternating white and dark bands along individual
hair shafts SEEN BY NAKED EYES
• The bands are formed due to intermittent severe protein
malnutrition.

138. Enamel paint sign
• Seen in patients with kwashiorkor
• Sharply demarcated hyperpigmented
desquamating patches and plaques
resembling enamel paint occur on the
skin, predominantly in areas of pressure
and irritation.

139. What else can cause this sign
FLAG Sign?

140. ?
Tiger tail appearance : alternating light
and dark bands under polarizing light
Seen in Trichothiodystrophy
(autosomal recessive disorder
characterized
by sulfur-deficient hair)

143. • It is the ability of patients to touch the tip of the nose
with the tip of their tongue.
Seen:
Ehlers-Danlos syndrome

146. • This sign is seen in Rubella and was originally described by
Forschheimer.
• The name is given to an enanthem [mucosal rash] red macules that is
confined to the soft palate during the prodromal period in Rubella

147. Pastia’s sign or Pastia’s lines
refer to pink or red transverse
lines found in the antecubital
fossae and axillary folds.

149. Slapped cheek sign
• is seen in children with fifth disease
• as confluent, erythematous, edematous plaques on the
cheeks.

151. Friar-Tuck signFriar-Tuck sign

152. • This is seen in Trichotillomania.
• In severe forms of the disease, when the whole scalp is
involved the hair at the margins is characteristically
spared.

155. • The bites of bed bugs (Cimex
lectularius) usually follow a linear
pathway in a group of three to
five blood meals and are often
referred to as “Breakfast, lunch,
and dinner” or “Breakfast, lunch,
and supper” sign

156. 29+ 30

157. sign

158. Chagas–Mazza–Romaña's sign
• Chagas’ disease
(American
trypanosomiasis),
• Unilateral swelling of
eyelids and orbit after
conjunctival
inoculation is called as
eye-sign or Chagas–
Mazza–Romaña's sign
or Romaña's sign
● It is seen in early
stages of African
trypanosomiasis
● Winterbottom's sign
is enlargement of
lymph nodes in the
posterior cervical
chain
Winterbottom's sign

162. Ugly duckling sign
• Refers to the observation that a nevus that does not resemble
a patient’s other nevi is more likely to represent a melanoma

164. A few other signs …..

165. Drip sign
• Found in dermatitis
artefacta produced by
corrosive liquids.
• Patterned burned areas
correspond to the areas
of dripping of the liquid
when applied by the
patient.

167. Foot prints in
snow'
appearance in
Pseudopelade
of Brocq

168. Asbestos-like
appearance Pityriasis
amiantacea

169. Cauliflower
appearance
Relapsing
polychondritis
Cauliflower appearance
condylomata acuminata

170. Cayenne pepper appearance
Schamberg disease

171. Cigarette paper like scars
The skin in patients with Ehler-Danlos syndrome is hyperextensible which gives
rise to gaping "fish-mouth wounds" over bony prominences like the shins, knees,
and elbows following minor trauma. Such wide, thin, papyraceous scars over the
knees and elbows are also called "cigarette paper scars."

172. Cliff drop appearance
Atrophoderma of Pasini and Pierini

173. Cobblestone appearance
In Darier's
disease

174. In crohn's disease

175. Cowden’s disease (AD)

176. In Heck's disease
What is Hecks disease
?
Focal epithelial hyperplasia:
papules on buccal, gingival, labial
mucosa resembling flat warts
What is the causative
agent ?
HPV 13, 32

177. Confetti-like appearance
Amyloidosis cutis dyschromica
(Primary cutaneous amyliodosis),
‫الورق‬ ‫قصاصات‬
‫الملونة‬

178. Purse string appearance of oral aperture in a case of systemic sclerosis

179. Figure of 8/hour glass appearance of vulva in lichen sclerosus

180. Glazed appearance
Juvenile plantar dermatosis
‫مصقول‬

181. Inverted wine bottle
appearance in
lipodermatosclerosis

182. A child with diffuse
cutaneous mastocytosis
giving a leather grain
appearance to the skin

183. Nutmeg grater appearance
Pityriasis rubra pilaris (PRP)

184. Pebbly appearance
Hunter syndrome
mucopolysaccharidosis II (MPS
II), is a lysosomal storage
disease caused by a deficient (or
absent) enzyme, iduronate-2-
sulfatase (I2S). The accumulated
substrates in Hunter
syndrome are heparan sulfate
and dermatan sulfate.
The syndrome has X-linked
recessive inheritance.

185. Pseudoxanthom a
elasticum showing
the characteristic
'plucked chicken'
appearance

186. Rippled appearance
Macular amyloidosis

187. Sandpaper appearanc
trachyonychia

189. Muehrcke’s sign
• Refers to paired, transverse, narrowed white bands that run
parallel to the lunula of the nails
Are seen in
• Patients with hypoalbuminemia or those receiving
chemotherapy agents.
• Hypoalbuminemia include nephrotic syndrome,
glomerulonephritis, liver disease, and malnutrition.

190. Speckled appearance
Speckled lentiginous nevus

191. Tapir nose appearance
Mucocutaneous leishmaniasis caused by Leishmania braziliensis and L. mexicana is
termed as "espundia," which is characterized by mutilation of the nasal apparatus. It
spares the nasal bones. When the septum is destroyed, the nasal bridge and tip of the
nose collapse, giving the appearance of a parrot beak, camel nose, or tapir nose
appearance

192. Vermiculate
atrophoderma in a
young patient with
'worm-eaten' picture

193. Zebra-like appearance
Linear and whorled nevoid hypermelanosis

194. Thank you
Dermatology