Dermatologic Signs. 내부장기의 외부반응(viscero-somatic reflex)

[문형철]

임상에서 somatic problem이 visceral problem을 유발하고, 악화시키는 상황을 수도 없이 본다.

반대로 visceral problem이 somatic problem을 유발하고 악화시키는 상황도 많다. 

내부장기의 외부반응(viscero-somatic reflex)

이 연결고리를 탐구한 논문을 찾고 있다. 

Dermatologic signs - jcms 06.pdf

- 주말은 이 논문과 함께 해야할듯하다 ㅎㅎㅎㅎ

아래 그림은 그 통찰적 해석을 암시하고 있다. 

Dermatologic Signs

Albright’s dimpling sign was described by Fuller Albright

(1900–1969) and refers to dimpling over the knuckles,

enhanced by clenching of the fist.2 It results from underdeveloped metacarpal heads in Albright’s hereditary

osteodystrophy, a syndrome characterized by short stature,

a round face, a thick neck, short limbs, obesity, and short

metacarpals. Albright’s sign is also used to refer to the

short fourth metacarpal digits observed in nevoid basal cell

carcinoma syndrome.

Asboe-Hansen sign was described in 1960 by Gustav

Asboe-Hansen (1917–1989), a Danish dermatologist.3 The

fascinating history of discovery of mechanical symptoms in

blistering dermatoses was recently reviewed by Grando and

colleagues.4 Asboe-Hansen sign is also known as blisterspread

sign, which refers to the ability to enlarge a blister

in the direction of the periphery by applying mechanical

pressure on the roof of the intact blister. spreading of a

blister into a clinically normal skin when lateral pressure is applied on the edge of a blister. ; 4 Angular blister formation

is thought to be associated with intraepidermal acantholytic

diseases (eg, pemphigus), whereas rounded blister

formation is associated with subepidermal acantholytic

diseases (eg, bullous pemphigoid). It is also observed in

bullous drug eruptions. Importantly, the sign is different

from Nikolsky’s sign (reviewed below).

Typical plaque psoriasis presents with dry, thin, silverywhite

or micaceous scale. Auspitz sign refers to the

appearance of a red, glossy surface with pinpoint bleeding

on removal of the scale by scraping or scratching. This

occurs as a result of removal of overlying suprapapillary

epithelium with subsequent rupture of dilated dermal

capillaries. Although Heinrich Auspitz, an Austrian

dermatologist (1835–1886), is credited for the Auspitz

sign, the term is a misnomer. Both Devergie Jeune (1860) and Hebra (1845) observed this clinical sign before

Auspitz, as did Robert Willan (1808), Joseph Plenck

(1776), and Daniel Turner (1736).5 Importantly, Auspitz

sign is neither sensitive nor specific for psoriasis6 as it

occurs in other skin conditions, including Darier’s disease

and actinic keratosis.

Named after an English surgeon, William Henry Battle

(1855–1936), Battle’s sign occurs after 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.

Blue dot sign can manifest as the torsion of the

testicular epididymis and appendices. A blue or black

nodule is visible under the skin on the superior aspect of

the testis or epididymis.7 The area is also usually quite

tender.

Butterfly sign is characterized by erythema over the

malar eminence, corresponding to the wings of a butterfly,

and the nasal bridge, representing the body of the

butterfly.8 This sign is classically described in lupus

erythematosus, but it is important to differentiate it from

other causes of facial erythema, such as rosacea, seborrheic

dermatitis, and erysipelas. Butterfly sign is also occasionally

used in reference to a butterfly-shaped area of

sparing observed over the upper central back, corresponding

to the zone that is difficult to reach by hands, in

conditions with severe generalized pruritus, such as atopic

dermatitis.9

Buttonhole sign classically refers to cutaneous neurofibromas.

It indicates the ability to invaginate the tumor

into the underlying dermal defect with digital pressure.

The resulting sensation is that of inserting the finger into a

buttonhole.10 This occurs owing to the soft myxoid stoma

and dermal defect caused by the protruding tumor.

Buttonhole sign may also be present in syphilitic chancre;

a buttonhole-like consistency is noted on the edge and

base of the ulcer on palpation. Furthermore, the sign may

also be present in old pigmented nevi.

Cluster of jewels sign, also termed string of pearls or

rosettes sign, refers to an early stage of chronic bullous

disease of childhood, when new lesions appear at the

margin of older ones, resembling a cluster of jewels.11

Corn-flake sign is seen in Kyrle’s and Flegel’s diseases.

The polygonal irregular configuration of the lesions is

quite characteristic. The lesions tend to occur over the

lower extremities.

Crowe’s sign, also known as axillary freckling, is one of

the defining features of type 2 neurofibromatosis.

Freckling occurs in the axillae but may also be observed in other areas, such as the perineum. Crowe’s sign typically

develops at a later age than cafe´ au lait macules.

Cullen’s sign, also known as Turner-Cullen sign, is

accredited to Thomas Stephen Cullen (1868–1953). The

sign consists of periumbical bruising, seen several days

after subcutaneous intraperitoneal hemorrhage, which can

result from etiologies such as ruptured ectopic pregnancy

and acute pancreatitis.12 In patients with acute pancreatitis,

Grey Turner’s sign (see below) may also be seen,

although both of these signs occur in only approximately

5% of cases. <

Darier’s sign was named after Ferdinand-Jean Darier

(1856–1938), a French dermatologist.13 The sign consists

of whealing, circumferential erythema, and localized

pruritus elicited by scratching or rubbing of a lesion. It

occurs in conditions with an increase in the number of

mast cells in the dermis, including urticaria pigmentosa,

systemic mastocytosis, insect bite reactions, neurofibroma,

juvenile xanthogranuloma, and acute neonatal lymphoblastic

leukemia. Pseudo-Darier’s sign is elicited when

stroking causes transient induration with piloerection and

is present in several conditions, including smooth muscle

hamartoma and Becker’s nevus.

Deck chair sign, or papuloerythroderma of Ofuji,

presents as a widespread eruption of erythematous papules

that coalesce into rectangular plaques. The term refers to

the distinctive pattern of sparing of the natural skin folds,

resembling the slats of a deck chair.14 The sign is not

specific and has also been reported in cutaneous

Waldenstro¨m’s macroglobulinemia and other conditions.

15

Dimple sign, also known as Fitzpatrick’s sign, is a clinical

feature used in diagnosing 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. The

sign may be useful in differentiating dermatofibromas

from other lesions, including malignant melanoma.

However, the sign is not completely sensitive or specific

to dermatofibromas, and other diagnostic investigations,

such as dermatoscopy, may help confirm‎ the clinical

suspicion of dermatofibroma.16

Dirty neck sign refers to 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 Colver and colleagues.17,18 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.19 Doughnut sign is seen in patients with scleromyxedema.

20 Central depression surrounded by an elevated rim

of skin is noted on the extended proximal interphalangeal

joint.

Drip sign is 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.

Dubois’ sign is shortening of the little finger associated

with congenital syphilis.21 This feature is seen occasionally

as a late stigma of the disease. It may be associated with

other stigmata of congenital syphilis, such as Hutchinson’s

triad (deafness, keratitis, and pointed teeth), perioral

rhagades, optic atrophy, and broad-based saddleback nose.

Ear lobe sign is observed in patients who develop

contact dermatitis to a substance applied with the hand to

the face and neck. Sparing of the diagonal crease of the ear

lobe on the ipsilateral side occurs, whereas the contralateral

side is affected. This pattern is secondary to the

hand-sweeping movement made during application of the

substance.22

Enamel paint sign is seen in patients with kwashiorkor,

a nutritional deficiency endemic in tropical and subtropical

regions. Sharply demarcated hyperpigmented desquamating

patches and plaques resembling enamel paint occur

on the skin, predominantly in areas of pressure and

irritation.23 The underlying skin is inflamed and raw.

Exclamation mark hair sign refers to the proximal

tapering of hair occasionally seen in alopecia areata, where

the dot represents the remains of the bulb. The sign is not

pathognomonic for alopecia areata, and its presence may

lead to misdiagnosis.24

Flag sign refers to horizontal alternating bands of

discoloration in the hair shafts corresponding to periods of

normal and abnormal hair growth. The discoloration may

be reddish, blonde, gray, or white depending on the

original hair color. The flag sign may be seen in patients

with nutritional deficiencies, such as kwashiorkor, and

with certain medications, such as intermittent high dosage

of methotrexate or following chemotherapy.25 Patients

with ulcerative colitis may manifest the flag sign.

Forchheimer’s sign refers to an enanthem of red macules

or petechiae confined to the soft palate in patients with

= rubella. The sign presents in up to 20% of patients during

the prodromal period or on the first day of the exanthem.

> Frank’s sign, originally described in 1973, refers to a

diagonal groove across the ear lobe in adults. The sign has

been observed to be a marker of the coronary disease,

independent of risk factors but frequently associated with

them.26 However, more recently, Frank’s sign was reported to have no association with coronary artery disease or

retinopathy in a group of patients with type 2 diabetes.27

Gorlin’s sign is seen in patients with Ehlers-Danlos

syndrome and is accredited to Robert James Gorlin, an

American oral pathologist and geneticist. It is used to

described the ability to touch the tip of the nose with the

extended tongue.

Gottron’s sign is a feature of dermatomyositis and is

named after Heinrich Adolf Gottron (1890–1974), a

German dermatologist. The sign refers to symmetric

confluent macular violaceous erythema that occurs over

the knuckles, hips, knees, and medial ankles. This feature is

seen in 70% of patients with dermatomyositis but may be ?

also observed in systemic lupus erythematosus. Gottron’s

sign is different from Gottron’s papules, which are small

lichenoid hyperkeratotoic violaceous papules located

primarily over the interphalangeal joints of the hands.

Grey Turner’s sign is accredited to the English surgeon

George Grey Turner (1877–1951). The sign refers to

induration and bruising seen on the skin over the

costovertebral angle secondary to the spread of blood

from the anterior pararenal space. The condition is

commonly associated with acute hemorrhagic pancreatitis

and other causes of retroperitoneal hemorrhage.28

Groove sign is classically noted in heterosexual males

with lymphogranuloma venereum.29 The term refers to the

inflammatory mass of femoral and inguinal nodes

separated by a depression or groove made by Poupart’s

(inguinal) ligament, which occurs in 20% of affected men. @

Hair collar sign is an important cutaneous marker for

neural tube closure defects of the scalp.30 The sign consists

of a ring of dark coarse hair surrounding a malformation,

such as aplasia cutis, encephalocele, meningocele, or

heterotropic brain tissue. The defect is often in the

midline, and the occipital or parietal scalp is typically

affected.

Hanging curtain sign is seen in patients with pityriasis

rosea.31 When the skin is stretched across the long axis of

the herald patch, the scale is noted to be finer, lighter, and

attached at one end, which tends to fold across the line of

stretch.

Heliotrope sign is seen in patients with dermatomyositis

as a violaceous erythema involving the periorbital skin.32

The term refers to the purplish color of the flowers of the

heliotrope plant, so named because its flowers rotate to

face the sun. Similar to Gottron’s sign, the heliotrope sign

is strongly suggestive of dermatomyositis.

Hertoghe’s sign, also known as madarosis, is characterized

by the lack of the outer third of the eyebrows. During

the 1980s, Hanifin and Rajka included Hertoghe’s sign as part of the minor criteria for diagnosing atopic dermatitis.

However, the validity of these criteria has been subsequently

debated. The differential diagnosis of Hertoghe’s

sign includes atopic dermatitis, trichotillomania, ectodermal

dysplasia, alopecia areata, alopecia mucinosa, leprosy,

syphilis, ulerythema ophryogenes, systemic sclerosis, and

hypothyroidism. It can also sometimes be seen in normal

elderly patients.

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. Hoagland also

described other criteria important for diagnosing infectious

mononucleosis.33

Holster sign is found in dermatomyositis. Pruritic,

macular, violaceous erythema affects the lateral aspects of

hips and thighs.

Sir Jonathon Hutchinson (1828–1913) was a renowned

English surgeon, whose name is accredited to many signs

and eponyms. Hutchinson’s nail sign was first described in

1886 and refers to periungual extension of brown-black

pigmentation onto the proximal and/or lateral nail folds.

The presence of Hutchinson’s sign should raise the

suspicion of subungual melanoma; however, the sign is

neither highly specific nor sensitive. Pseudo-Hutchinson’s

sign represents the presence or illusion of pigment in the

perionychium and can be associated with a variety of

disorders.34 Kawabata and colleagues examined 6 subungual

melanomas in situ and 18 subungual melanocytic

nevi and compared pigmentation of the nail plates and

hyponychium with the use of a dermatoscope.35

Hutchinson’s sign on the hyponychium was not always

evidence of subungual melanoma; however, a wide

difference was observed in dermatoscopic features, suggesting

that dermatoscopy can help with the diagnosis of

subungual melanoma.35

Hutchinson’s nose sign refers to the 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. However, some believe that

this association is not as strong as once believed.36

Jellinek’s sign refers to eyelid pigmentation occasionally

seen in hyperthyroidism. The hyperpigmentation is

secondary to increased corticotrophin levels and may also

occur on other areas of the face but usually spares the

buccal mucosa.

Leser-Tre´lat sign, also known as eruptive seborrheic

keratosis, is accredited to two European surgeons, Edmund

Leser (1853–1916) and Ulysse Tre´lat (1828–1890). The

sign is defined as the sudden eruption of multiple

seborrheic keratoses, which are often pruritic, and is

classically associated with internal malignancy.37

Adenocarcinomas are typically reported, particularly of

the stomach38 and colon but also of the breast, uterus,

esophagus, and pancreas. Other reported associations

include lung cancer,39 melanoma,40 and mycosis fungoides.

41 Because both seborrheic keratoses and cancer are

preval‎ent in the elderly, the validity of Leser-Tre´lat sign has

been questioned.42 An association with malignant

acanthosis nigricans has been proposed as one of the

features that support the legitimacy of the sign as a

paraneoplastic marker.43 Besides acanthosis nigricans,

other signs of malignancy may occur with Leser-Tre´lat

sign, including acquired hypertrichosis, tylosis, florid

cutaneous papillomatosis, and acrokeratosis of Bazex.

Muehrcke’s sign refers to paired, transverse, narrowed

white bands that run parallel to the lunula of the nails and

are seen in patients with hypoalbuminemia or those

receiving chemotherapy agents. They occur usually on the

second, third, and fourth fingernails but not on the

thumbnail. The distal band tends to be wider than the

proximal band. Conditions resulting in Muehrcke’s sign

that are associated with hypoalbuminemia include nephrotic

syndrome, glomerulonephritis, liver disease, and

malnutrition.

In patients with scleroderma, ridging and tightening of

the neck skin can form a visible and palpable tight band

that lies over the platysma in the hyperextended neck.44 It

is referred to as neck sign but should not be confused with

Brudzinski’s sign, which is seen in patients with meningitis

and is also referred to as neck sign.

Necklace of Casal sign refers to hyperpigmentation

occurring on the neck owing to pellagra. The ‘‘necklace’’

can extend as a broad collar-like band around the entire

circumference of the neck.45 Sometimes the necklace

extends anteriorly over the sternum to the level of the

nipples and ends in a point or square. Cutaneous changes

in pellagra appear primarily on sun-exposed areas on the

neck, face, and dorsal parts of the hands, arms, and feet,

but patients usually also have dermatitis elsewhere.

Nikolsky’s sign was originally initially described in 1896

by Peter Vasiliyevich Nikolsky, a Russian dermatologist

(1858–1940), in patients with pemphigus foliaceus. The

original statement highlighted two methods in manifesting

the sign: ‘‘by pulling the ruptured wall of the blister it is

possible to take off the horny layer for a long distance on a

seemingly healthy skin’’ and ‘‘the rubbing off of the

epidermis between the bullae by slight friction without breaking the surface of the skin and leaving moist surface

of the granular layer.’’46 As recently reviewed by Grando

and colleagues, two variants of Nikolsky’s sign exist.4

Marginal sign refers to the ability to split the epidermis of

the skin beyond the preexisting erosion by pulling the

remnant of a ruptured blister or rubbing at the periphery

of existing lesions. On the other hand, direct sign refers to

the ability to split the epidermis on skin areas distant from

the lesions by lateral pressure with a finger. Both variants

are observed in pemphigus vulgaris, pemphigus foliaceus,

and staphylococcal scalded skin syndrome. In contrast to

Asboe-Hansen sign, these are negative in autoimmune

subepidermal blistering diseases (eg, bullous pemphigoid)

and the bullous drug eruptions erythema multiforme,

Stevens-Johnson syndrome, and toxic epidermal necrolysis.

4 Furthermore, pseudo-Nikolsky’s sign refers to the

ability to peel off the entire epidermis by lateral pressure

(rubbing) only on the erythematous skin areas; it is present

in the above-mentioned bullous drug eruptions but is

negative in pemphigus and autoimmune subepidermal

blistering diseases. Recently, Uzun and Durdu reported

that Nikolsky’s sign is moderately sensitive but is highly

specific in the diagnosis of pemphigus.47

Nose sign is seen in several skin diseases, including

airborne contact dermatitis, severe atopic dermatitis, and

exfoliative dermatitis, and refers to sparing of the nose in

the eruption distribution.48

Oil drop sign is characterized by translucent, yellow-red

discoloration and circular areas of onycholysis in the nail

bed that fail to reach the free border and look like oil drops

underneath the nail. Some authors make a distinction

between oil drop sign and oil spot sign, which refers to

yellowish or brown macules beneath the nail plate that

extend distally to the hyponychium. Both findings can be

seen in psoriasis.49

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.

Pastia’s sign or Pastia’s lines refer to pink or red

transverse lines found in the antecubital fossae and axillary

folds. The lines are produced from confluent petechiae and

are seen in patients with the preeruptive stage of scarlet

fever. The lines persist through the eruptive stage,

remaining as pigmented lines after desquamation.

Pastia’s sign is named after the Roman physician

Constantin Chessec Pastia (1893–1926); it is also known

as Thomson’s sign, after the British physician Frederick

Holland Thomson (1867–1938).50

Pathergy sign refers to the elicitation of new lesions or

worsening of existing lesions by superficial trauma such as

skin testing, injections, pricks, insect bites, biopsies, and

operations. This condition is seen in some patients with

pyoderma gangrenosum or Behc¸et’s syndrome.51 A

positive pathergy test, known as a neutrophilic vascular

reaction, is performed by pricking the skin with oblique

insertion of a 20-gauge or smaller needle and is read by a

physician at 24 to 48 hours.

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 B

the soft tissue of the periorbital region.52

Roman˜a’s sign is named after Cecilio Roman˜a (1899–

1983), an Argentinian researcher.53 However, the credit for

the recognition of this sign for its specificity in diagnosing

Chagas’ disease belongs to Emanuel Dias (1908–1962) and

Evandro Chagas (1905–1940). Roman˜a’s sign refers to the

first clinical sign of sensitization response to the bite of the

Trypansoma cruzi insect and is seen in 80% of acute cases.

Clinically, severe unilateral conjunctivitis and palpable,

painless lid edema are seen. Inflammation of the tear gland

and preauricular lymphadenopathy are associated with

Roman˜a’s sign.

Rope sign refers to linear inflammatory indurations

appearing like cords that extend from the lateral trunk to

the axillae. This sign occurs in interstitial granulomatous

dermatitis with arthritis.54

Round fingerpad sign is an important early clinical

feature seen in patients with scleroderma.55 Disappearance

of the peaked contour on the fingerpads and progression

to a hemisphere-like finger contour is noted. This change

is best detected by examining the ring fingers as the first

two digits are often rounded in normal persons owing to

manual activities.

Russell’s sign refers to the lacerations, abrasions, and

callosities that are found on the dorsum of the hand

overlying the metacarpophalangeal and interphalangeal

joints. It is seen in patients with bulimia nervosa owing to

repeated contact of the incisor teeth with the skin and

during self-induced vomiting.56 These patients also

typically have associated dental enamel erosions and

gingivitis from contact with corrosive gastric contents.

School chair sign has been used to denote the

presentation of allergic contact dermatitis to nickel, when

the rash occurs over the posterior thighs, corresponding to

contact with a school chair.57

Shawl sign is seen in patients with dermatomyositis and

is characterized by confluent, symmetric, macular violaceous

erythema on the posterior shoulders and neck, giving

a distinctive shawl-like appearance. Slapped cheek sign is seen in children with fifth disease

as confluent, erythematous, edematous plaques on the

cheeks.58 This manifestation is often the first skin change

seen in patients with fifth disease. As the facial rash begins

to fade over 1 to 4 days, erythematous macules and papules

begin to appear on the trunk, neck, and extensor surfaces

of the extremities.

Sternberg’s thumb sign, or thumb sign, is a marker for

arachnodactyly and is seen in patients with Marfan

syndrome. A completely opposed thumb in the clenched

hand projects beyond the ulnar border.59 Another sign that

can be used to test for arachnodactyly is the Walker wrist

sign.

Tent sign is seen in patients with the benign

appendageal tumor pilomatricoma. It usually presents as

a solitary, asymptomatic, firm nodule. When the overlying

skin is stretched, the lesion appears to be multifaceted and

angulated, giving a ‘‘tent’’ appearance. The tent sign is due

to the calcification occurring in the lesion.60

Thumbprint sign refers to periumbical purpura resembling

multiple thumbprints. The condition is mainly seen

in patients with disseminated strongyloidosis.61 It occurs

when such patients receive respiratory assistance, which

results in a transient rise in portal pressure, shunting 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.

Tin-tack sign, also known as carpet tack sign, is a useful

clinical feature in diagnosing discoid lupus erythematosus.

62 Hyperkeratotic scale extending into the follicular

infundibulum creates keratotic spikes when viewed from

the scale’s undersurface, resembling a carpet tack. Other

conditions in which tin-tack sign has been reported

include cutaneous B-cell lymphoma,63 seborrheic dermatitis,

64 lichen planus,65 and pemphigus foliaceus.66

Tripe palms sign, also referred to as acanthosis palmaris

and pachydermatoglyphy, refers to the rugose thickening

of the palmar surface of the hands, with accentuation of

the normal dermatoglyphic ridges, thus resembling the

ridging of the interior surface of a bovine foregut. It is

strongly associated with internal malignancy, most commonly

carcinoma of the stomach and lung.67 Acanthosis

nigricans may be associated with tripe palms.

Two different types of Trousseau’s sign exist, referring

to distinct clinical conditions. Trousseau’s sign of visceral

malignancy, also known as migratory thrombophlebitis,

refers to the development of successive crops of tender

nodules in affected blood vessels secondary to intravascular

low-grade hypercoagulation.68 Usually, the upper

extremities or the trunk is affected. The condition occurs

predominantly with pancreatic cancer, as well as with

stomach and lung cancer. Trousseau’s sign of tetany is

elicited by compressing the brachial artery in the upper

arm with a tourniquet or blood pressure cuff for 3

minutes, resulting in carpal spasm, and is characterized by

contraction of the fingers and hands into the ‘‘obstetrical

position.’’69

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. This relates to the ‘‘ugly

ducking’’ in Hans Christian Andersen’s tale, which did

not look like its siblings because it was not a duck but a

swan. The sign was recently reviewed by Mascaro and

colleagues.70

V sign is seen in patients with dermatomyositis and

refers to the erythema secondary to photosensitivity seen

in the V area of the upper chest.

Walzel sign refers to livedo reticularis seen in association

with acute and chronic pancreatitis.71 Several other

signs may be seen in patients with pancreatitis, including

Grey Turner’s sign, Cullen’s sign, and Trousseau’s sign.

Winterbottom’s sign was described by Thomas

Winterbottom, an English physician (1765–1859). The

sign refers to the occasionally visible enlargement of lymph

nodes in the posterior cervical group, which is seen in the

Gambian form of African trypanosomiasis. There are three

stages of the infection, with Winterbottom’s sign seen in

the second stage that occurs 6 to 8 weeks into the disease.

During this stage, patients present with systemic symptoms

and also develop irregular, transient, erythematous

macules or urticarial lesions, most commonly on the

trunk.72

Conclusion

A multitude of signs exist in dermatology, and an exhaustive

list is difficult to prepare. Many signs are based on the

morphology or physical characteristics of the lesions. The

eponymous nature of some signs highlights the rich history

of dermatology. Signs are objective findings that are

important in eliciting diagnosis or in narrowing differential

diagnosis. It is important to keep in mind that cutaneous

signs are rarely pathognomonic and each is associated with

inherent sensitivity and specificity. For instance, Battle’s

sign has a low sensitivity in patients with basilar skull

fracture, but it is highly specific in that its presence is highly

suggestive of the condition. Better appreciation and

knowledge of cutaneous signs will enhance the care of

patients with dermatologic manifestations.