Less-known clinical signs in dermatology.

This paper describes various less-known clinical signs observed either on clinical examination and investigations in the subject of dermatology.

INTRODUCTION

A previous compilation of clinical signs in dermatology have been published.[12] In continuation of the previous publications, authors have attempted to describe less well-known clinical signs in the subject of dermatology.

Berliner sign

Berliner sign refers to eyelid edema in a child giving clinical look of heavy eyelids,” or a “droopy” or “sleepy” appearance. This sign is often useful in the pre-eruptive diagnosis of roseola infantum (exanthem subitum or sixth disease). The edema is reported to disappear after appearance of rash.[3] It was first described by Benjamin C. Berliner.

Blue dot sign

A blue or black nodule is visible under the skin on the superior aspect of the testis or epididymis. This clinical finding is noted in a case of torsion of the testicular epididymis and appendices.[4]

Bucket handle sign

A fracture occurring through the degenerating metaphysis leading to exuberant callus formation resulting in a cap over the metaphysis is called Bucket handle sign. It is characteristic of syphilis.

Cornflake sign

Cornflake sign is seen in Kyrle's and Flegel's diseases. The papules have a characteristic irregular margin (corn flake sign) and underlying erythematous base. The polygonal irregular configuration of the lesions is quite characteristic. The lesions tend to occur over the lower extremities.[56]

Dot-in-circle sign

Dot-in-circle sign has recently been proposed as a highly specific magnetic resonance imaging (MRI) and ultrasonography (USG) sign of mycetoma. Dot-in-circle sign, seen as tiny hypointense foci within the hyperintense spherical lesions, was initially described by Sarris et al. in 2003 on T2-weighted, STIR, and T1-weighted fat-saturated gadolinium-enhanced images. Correlating the MRI and histological findings, they suggested that the high-signal areas seen on MRI represented inflammatory granulomata, the low-intensity tissue seen surrounding these lesions represented the fibrous matrix, and the small central hypointense foci within the granulomata represented the fungal balls or grains.[7]

The USG appearances were initially described by Fahal et al. who demonstrated on in vitro imaging of the mycetoma lesions that the hyper-reflective echoes corresponded to the grains; eumycetoma grains produce sharp hyperechoic foci, while actinomycetomas produce fine hyperechoic foci that commonly settle at the bottom of the rounded lesions. The USG “dot-in-circle” sign is similar to the MRI sign, with multiple round hypoechoic lesions containing hyperechoic foci.[8]

Doughnut sign

Scleromyxedema is a sclerotic variant of lichen or papular mucinosis characterized by lichenoid papules and scleroderma-like features. Induration of skin with central depression over proximal interphalangeal joint is referred as doughnut sign.[9]

Enamel paint sign

Described in patients with kwashiorkor, a state of nutritional deficiency. There occurs sharply demarcated hyperpigmented desquamating patches and plaques resembling enamel paint on the skin, predominantly in areas of pressure and irritation.[10]

Drip sign

Patterned burned areas corresponding to the areas of dripping of the corrosive liquid when applied by the patient. It is found in patients of dermatitis artefacta.[11]

Dubois sign

It is a late stigma of congenital syphilis in which there occurs shortening of the little finger.[12]

Hoagland's sign

Infectious mononucleosis (“kissing disease”) is an infection caused by Epstein–Barr virus (human herpes virus 4). Major clinical symptoms are sore throat, fever, fatigue, anorexia, myalgia, headache and rarely nausea, coughing, vomiting and arthralgia. Periorbital edema is also known to be a symptom of infectious mononucleosis. The association of peri-orbital edema with infectious mononucleosis was first described by Hoagland and is referred to as Hoagland's sign.[13]

Panda's sign

Refers to the persistence of the nevus of Ota in the periorbital location following laser therapy, whereas other peripheral sites clear well.[14]

Prayer/table top sign

Diabetic cheiroarthropathy is a cutaneous condition characterized by thickened skin and limited joint mobility of the hands and fingers, leading to flexion contractures, a condition associated with diabetes mellitus. Patients with diabetic cheiroarthropathy show two peculiar signs: “Prayer” and “table top” signs. The prayer sign is said to occur whenever there is incomplete approximation of one or more of the digits when the patient attempts to approximate the palmar surfaces of the proximal and distal interphalangeal joints with palms pressed together and the fingers abducted. Table top sign refers to inability to place palms flat on a horizontal surface.[15]

Sarcophagus sign

Periosteal new bone formation resulting in layers of marrow trapped between layers of subperiosteal bone. This radiological finding is noted in congenital syphilis.

School chair sign

Refers to allergic contact dermatitis to nickel, in which the rash occurs over the posterior thighs, corresponding to contact with a school chair.[16] The chairs have a plastic seat and back with metal legs affixed to the seat with exposed studs. The child's usual habit of sitting obliquely with her right leg crossed over her left leg leads to the regularly spaced, symmetric placement of the school chair hardware resulting in her unusual asymmetric distribution of dermatitis over posterior thighs.[17]

Tent sign

Described in relation to pilomatricoma in which, on stretching the overlying skin, the lesion appears to be multifaceted and angulated, giving a “tent”-like appearance. Calcification occurring in the lesion is responsible for such appearance.[18]

Thumb print sign

This sign is seen in patients with disseminated strongyloidosis in which there occurs periumbilical purpura resembling multiple thumbprints. When patients of such kind receive respiratory assistance, there occurs transient rise in portal pressure leading to shunting of portal blood through the periumbilical shunt. At this location, the larvae cause extravasation of red blood cells into the dermis, resulting in the characteristic petechiae and purpura.[19]

Walzel sign

This clinical sign refers to livedoreticularis seen in association with acute and chronic pancreatitis. Other signs seen in patients with pancreatitis are Grey Turner's sign, Cullen's sign, and Trousseau's sign.[20]

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