The Unsung Signs of Dermatology.

"The eye sees only what the mind is prepared to comprehend." The term "sign" refers to an objective physical finding observed by the examiner. In dermatology, the diagnosis mainly depends on the examiner and certain physical signs serve as an important clue to diagnosis of the disease. The objective of this review is to bring to light certain lesser-known signs in dermatology. Copyright:

Introduction

In the medical glossary, the term “sign” refers to an objective physical finding observed by the examiner. In dermatology, the diagnosis mainly depends on the examiner, and certain physical signs serve as an important clue to the diagnosis of the disease. Unless the observer is aware of these signs, they can very easily be missed and that could sometimes even lead to misdiagnosis. The objective of this review is to bring to light certain lesser-known signs in dermatology. These signs were obtained after a thorough search of the literature, articles, and medical dictionaries with the literature search using keywords such as “signs in dermatology” and “clinical dermatology.”

Battle's sign: Named after an English surgeon, William Henry Battle (1855–1936), Battle's sign occurs after the fracture of the base of the skull in the posterior cranial fossa. Blood accumulates beneath the fascia and causes discoloration at the mastoid process. Battle's sign is highly specific and predictive for the basal skull fracture.[1]

Biederman's sign: A dusky redness of the lower portion of the anterior pillars of the fauces in certain cases of syphilis.[2]

Borsieri's sign: Pressure by a sharp object (like a fingernail) across the skin creates a white line that quickly turns red. This is seen in the early stages of scarlet fever.[2]

Brownie nose sign: Pigmentation of the nose in post chikungunya fever, which can be due to an increased intraepidermal melanin dispersion/retention triggered by the virus. It is also known as the Chik sign.[3]

Bucket-handle sign: A fracture occurring through the degenerating metaphysis leading to exuberant callus formation resulting in a cap over the metaphysis is called the Bucket handle sign. It is characteristic of congenital syphilis.[4]

Comet sign: This is seen in Pyemotes ventricosus dermatitis. It is caused by the bite ofP. ventricosus mites. Patients affected have highly pruritic lesions consisting of a singular central vesicle/urticarial lesion surrounded by a rapidly expanding erythematous macule with a characteristic linear or serpiginous erythematous track called “comet sign.”[5]

Cuff sign: Lipedema is a painful hereditary disorder where women accumulate excess adipose tissue on their lower extremities causing enlarged calves above the malleoli but sparing the feet. This sharp demarcation at the ankle is referred to as the cuff sign. Thirty percent of patients may have upper limb involvement resulting in cuff sign at the wrist as well.[6]

Dermarquay sign: Absence of elevation of the larynx during deglutition, said to indicate syphilitic induration of the trachea. It is named after Jean Nicholas Demarquay, a French surgeon.[2]

Dirty neck sign: Dirty neck sign refers to the reticulate pigmentation of the neck seen in patients with chronic atopic dermatitis. The condition was described in 1987 by two different groups, Manabe and colleagues and Clover and colleagues. The 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.[1]

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 with dermatitis artefacta.[4]

Du Bois sign: Short 5th digit in congenital syphilis.[7]

Filipovitch's sign: Yellow discoloration of palms and soles in typhoid fever.[8]

Fountain sign: This is seen in hypertropic lichen planus. While injecting intralesional steroids by a 26-G needle, it has been found that medicine comes out through the follicular openings in a jet mimicking a “fountain.”[9]

Frosted Glass Sign: Inflamed and thickened eyelids which curl in upon themselves, inverting the eyelashes, which begin to scratch the cornea causing a frosted glass appearance and blindness. An indication of infection by zoonotic Chlamydia trachomatis transmitted by the fly known as Musca sorbens. Also known as “hair in eye sign.”[2]

Goldstein's toe sign: Wide space between the first two toes is called Goldstein's sign. Seen in Down's syndrome.[10]

Hanging groin sign: It describes the loose, atrophic, inelastic skin sac that contains the large inguinal nodes seen in the later stages of onchocerciasis.[11]

Headlight sign: It is the sparing of the nose and medial cheek that is perinasal and perioral areas even extensive facial involvement seen in atopic dermatitis.[3]

Kerr's sign: It is the alteration of the texture of the skin below the somatic level of a spinal cord lesion. The skin becomes stiff, dry, and tense below the level of the spinal cord lesion.[8]

Krisovski's sign: Cicatricial lines radiating from the mouth, seen in congenital syphilis.[12]

Lafora's sign: It refers to the involuntary excessive picking of the nose which can be an early sign of cerebrospinal meningitis.[3]

Lyon's sign: It is seen in nasal myiasis. There is a loss of smell, collapsed nose, and the head of the patient droops. A sign that flies have deposited their ova in the nasal passages, and maggots lodging in the cribriform plate of ethmoid bone feed on soft tissues, finally causing the collapse of the nasal bridge.[3]

Nasal crease sign: It refers to a linear, gray atrophic crease in the inferior columella, which may occur with segmental facial hemangiomas involving the nose, and may portend imminent cartilage destruction and nasal collapse.[3]

Osler's sign: Scleral pigmentation is seen in alkaptonuria. It is usually seen at the site of insertion of medial and lateral rectus muscles.[13]

Patrick-Yesudian sign: Palmar melanotic macules (palmar freckling) seen in type 1 neurofibromatosis.[9]

Premlatha sign: In patients with pemphigus vegetans, there are characteristic cerebriform changes seen on the tongue. Cerebriform tongue, characterized by a pattern of sulci and gyri on the dorsum of the tongue has been reported in up to 50% cases of Neumann type.[9]

Sarcophagus sign: Periosteal new bone formation resulting in layers of marrow trapped between layers of subperiosteal bone encasing the entire shaft resembling a sarcophagus. This sign is seen in congenital syphilis.[12]

Silex's sign: Radial furrows around the mouth seen in congenital syphilis.[12]

Siegert's sign: It is the short and medially curved 5th finger. Seen in Down's syndrome.[12]

Shar-pei sign: Seen in patients with scleromyxedema, it is the deep furrowing on the trunk, shoulders, and limbs. It is called so because of the furrowing of skin seen in the Shar-pei breed of dogs.[14]

Shoulder pad sign: The “shoulder pad” sign results from amyloid deposition in periarticular soft-tissue and is pathognomonic for light chain amyloidosis, which has an increased predilection for soft-tissue deposition.[6]

Tap sign: Deep pain upon percussion of lesions over bone-in tuberculoid and borderline tuberculoid leprosy, despite superficial sensory impairment, this has been described as the “Tap Sign.” The pain elicited by the “tap sign” is not a radiating pain, but a dull aching “bony” pain that lasts several seconds. This deep pain sensation is different from the neuralgic pain along the distribution of a sensory nerve trunk or “electric current like pain” when a nerve is accidentally knocked (e.g. ulna nerve at the elbow). It is also different from paranesthesia of peripheral neuropathies. Over the area where tap sign is elicited, superficial skin sensations are impaired (when tested with cotton wool or nylon bristles). Various theories regarding the cause of this tap sign exist, but none are proven.[15]

Thompson's sign: The presence of pink or red transverse lines in the skin creases (particularly antecubital fossa) seen in the pre-eruptive stages of scarlet fever. They persist through the eruptive stage and remain as pigmented lines after desquamation. It is also known as Pastia's lines.[16]

Vieira sign: yellowish line on the nails in patients with endemic pemphigus foliaceus. The significance of this sign remains unknown.[17]

Virchow's sign: The father of modern pathology “Rudolf Carl Virchow” (1821–1902) observed that the tongue often showed a smooth base in congenital syphilis. This is called Virchow's sign.[12]

Volcano sign: It is a descriptive term for the morphologic feature of Old World cutaneous leishmaniasis. The lesion starts as a small nontender papule, which enlarges in size and ulcerates in the center. The border of the crusted ulcer has an erythematous rim.[18]

Wake sign: Scabies burrows, the only pathognomonic lesion for scabies, often occur on the creases of the palms and are followed by a pattern of scale reminiscent of the “wake” left on the surface of the water by a moving bird or a ship. This is known as the wake sign.[19]

Conclusion

A multitude of signs exist in dermatology, and a comprehensive list is difficult to prepare. With the ever-increasing signs and disorders in dermatology, signs are objective findings that are important in eliciting diagnosis or in narrowing the differential diagnosis. It is important to keep in mind that cutaneous signs are rarely pathognomonic, and each is associated with inherent sensitivity and specificity. This article will also be helpful for the postgraduates preparing for quizzes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.