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Atopic Dermatitis in Adults: A Diagnostic Challenge

Silvestre Salvador JF, Romero-Pérez D, Encabo-Durán B Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, Spain

J Investig Allergol Clin Immunol 2017; Vol. 27(2): 78-88 doi: 10.18176/jiaci.0138

See it to know it

Different clinical appearances

In Dermatology

  1. ASBESTOS LIKE APPEARANCE
  • Pityriasis amiantacea

  2.  BEEFY RED TONGUE

  • Vitamin B12 deficiency
  • Folic acid deficiency

3. BEEFY RED ULCER

  • Ulcerogranulomatous type of donovanosis that bleed easily due to its high vascularity giving rise to beefy red appearance
  • Wounds healing by secondary intention

4. BEEFY RED EARS

  • Relapsing polychondritis

5.BUTTERFLY RASH

  • Lupus erythematosus
  • Acne
  • Rosacea
  • Seborrheic dermatitis
  • Photo allergic contact dermatitis
  • PMLE
  • Measles, rubella, roseola infantum
  • Dermatomyositis

6. CAULIFLOWER APPEARANCE

  • Genital wart
  • Verrucous carcinoma
  • Cauliflower ear or wrestler’s ear seen in trauma or continuous friction to outer ear

7. CAVIAR LIKE APPEARANCE 

  • Long term application of hydroquinone
  • Sublingual varices on tongue

8. CAYENNE PEPPER APPEARANCE

  • Schamerg disease (Pigmented purpuric dermatosis

9. CIGARETTE PAPER SCAR APPEARANCE OR PAPYRACEOUS SCAR

  • Tertiary syphilis
  • Ehler danlos syndrome
  • Mycosis fungoides
  • Lichen sclerosus
  • Striae distensae
  • Poikiloderma atrophicans vasculare

10.  CLIFF DROP APPEARANCE

  • Atrophoderma of Pasini and Pierini 

11. CLUSTER OF JEWELS OR STRING OF PEARLS

  • Linear IgA dermatoses
  • Chronic bullous dermatosis of childhood where vesicles and bulla arranged in annular rosette plaque around central crusted plaque
  • Herpes gestationis
  • Bullous pemphigoid

12.  COAST OF CALIFORNIA AND COAST OF MAINE APPEARANCE

  • Cafe au lait macules in neurofibromatosis are small with smooth borders called as Coast of California
  • Cafe au lait macules in McCune Albright syndrome are large with rough borders called as Coast of Maine

13. COFFEE WITH MILK APPEARANCE

  • Denotes cafe au lait macules seen in Neurofibromatosis, McCune Albright syndrome, Cowden syndrome and Silver russel syndrome

14. COBBLESTONE APPEARANCE

  • Mucosal involvement in Dariers disease
  • Hecks disease
  • Punch grafting for vitiligo

15. CONFETTI LIKE APPEARANCE

  • Amyloidosis cutis dyschromica
  • Dyschromatosis symmetrica hereditaria (Acropigmentation of Dohi)
  • Dyschromatosis universalis hereditaria
  • Dermatopathia pigmentosa reticularis
  • Pseudo ochronosis
  • Tuberous sclerosis
  • Vitiligo ponctue
  • IGH
  • Extra genital LSA
  • After photochemotherapy

16. CRUMPLED CIGARETTE PAPER APPEARANCE

  • Acrodermatitis chronica atrophicans in late stage of borreliosis

17. DEW DROPS ON ROSE PETAL APPEARANCE

  • Varicella vesicular stage

18. DIGITATE APPEARANCE

  • Small plaque parapsoriasis

19. DIRTY NECK APPEARANCE

  • Atopic eczema
  • X linked Ichthyosis
  • Terra firma forme dermatosis

20. DOG EAR APPEARANCE (2 Types – Standing full cone and lying half cone)

  • Puckering of skin after surgical wound closure)

21. DOLL HAIR APPEARANCE/SIGN

  • Folliculitis decalvans

22. EBBING TIDE APPEARANCE

  • Oral leukoplakia of floor of mouth

23. FIGURE OF 8 OR HOUR GLASS APPEARANCE

  • Lichen sclerosus et atrophicans of female anogenital region

24. FIR TREE OR CHRISTMAS TREE APPEARANCE

  • Pityriasis rosea

25. FISH MOUTH OR PURSE STRING APPEARANCE

  • Systemic sclerosis

26. FLAGELLATE APPEARANCE

Flagellate erythema

  •  after bleomycin therapy
  • Dermatomyositis
  • Paedrus dermatitis
  • Chikungunya fever
  • After intake of Shiitake mushroom

 27. FOOTPRINT IN SNOW APPEARANCE

  • Pseudopelade of Brocq with multiple patches of cicatricial alopecia

 28. FRIED EGG APPEARANCE

  • Dysplastic nevus with central papule and pigmented rim with fruzzy borders

29. FROG SPAWN APPEARANCE

  • Vesicle in Lymphangioma circumscriptum

30.  FROSTED GLASS APPEARANCE

  • Reddish brown papules with fine scales in Pityriasis lichenoides

31. GLAZED APPEARANCE

  • Juvenile plantar dermatosis with red glazed appearance with fissuring and fine scaling

32. INK SPLASHES OR SPLASH OF PAINT

  • Nevus depigmentosus or isolated hypomelanotic nevi with irregular patch and smaller macules at periphery

33. INVERTED SAUCER APPEARANCE

  • BB hansen (Midborderline hansen) with a plaque having sloping outer edge and punched out center 

34. INVERTED FIR TREE APPEARANCE

  • Median canaliform dystrophy of Heller with longitudinal split in midline or paramedian of nail plate

35. INVERTED CHAMPAGNE BOTTLE APPEARANCE

Seen in the legs in 

  • Chronic lipodermatosclerosis 
  • Charcot marie tooth type 1

36. LAKES OF PUS APPEARANCE

  • Pustular psoriasis
  • Acute Generalized Exanthemic Pustulosis

 37. LEOPARD SKIN APPEARANCE

  •   Asymptomatic spotty depigmentation seen in
  • Onchocerciasis 
  • Sclerodermatous GVHD

38.  LEATHERY APPEARANCE

  • Lichen simplex chronicus with thick, brown, leathery skin

39.  LEATHER GRAIN APPEARANCE

  • Diffuse cutaneous mastocytosis with infiltration of mast cells and edema due to their degranulation products

40. LEMON ON MATCH STICK APPEARANCE

  • Cushings disease or syndrome with central obesity and thin extremities

41. LOBSTER CLAW APPEARANCE

Congenital absence of all or part of one or more fingers seen in 

  • EEC syndrome (ectrodactyly, ectodermal dysplasia and cleft lip with or without cleft palate)
  • Goltz syndrome (focal dermal hypoplasia)

42.  MAP LIKE APPEARANCE

  • Geographic tongue with erythematous areas surrounded by whitish yellow borders that frequently changes position seen in Oral psoriasis, Down syndrome, Aarskog syndrome, Fetal hydantoin syndrome and Robinow syndrome

43.  MOTH EATEN APPEARANCE

  • Moth eaten alopecia in syphilis

44.  NUTMEG GRATER APPEARANCE

  • Pityriasis rubra pilaris with reddish brown pin point papules and central horny plug

 45. OSTRACEOUS/RUPOID APPEARANCE

  • Psoriasis (Rupoid – limpet shells, Ostraceous – Oyster shells)
  • Relapsing secondary syphilis with limpet like discoloured lesions called rupia
  • Pustular syphilis with limpet like crusts

46.  PADDY HAIR OR PLUGGED HAIR APPEARANCE

  • Larger hair grafts with 4-5 mm punch grafts used in early days for hair transplantation

 47. PAPER MONEY APPEARANCE OF SKIN (DOLLAR PAPER MARKINGS)

  • Chronic alcoholic hepatic disease where superficial vascular disorder leads to thread like capillaries resembling fine chopped silk threads in american dollar

 49. PEAU D’ORANGE APPREARANCE

  •  Any bosselated, rugose surface of skin with deep, pinpoint dimpling   seen in 
  • Mastocytoma
  • Eosinophoilic fasciitis 

50.  PEBBLY APPEARANCE 

  •  Multiple firm papules and nodules (pebbles) symmetrically between angle of scapula and posterior axillary fold seen in 
  • Hunter syndrome with iduronate 2 suphatase deficiency

51. PLUCKED CHICKEN APPEARANCE

  • Pseudoxanthoma elasticum with tiny yellow papules coalescing in to plaques also called as moroccan leather or cobblestone appearance

52.  RAIN DROPS IN DUST APPEARANCE

              Guttate hypopigmentation on a background of diffuse hypermelanosis 

  • Chronic arsenic poisoning

53.  RASPBERRY LIKE APPEARANCE

  • Yaws (Framboesia) having raspberry like excrescences

54. RELIEF MAP APPEARANCE

  • Reactive arthritis with multiple scattered, dark red scaly raised lesions with heaped up keratinised material

55. RETIFORM APPEARANCE

  • Large plaque parapsoriasis with deep red scaly plaques. Atrophy and poikiloderma can also be seen 

56. RIPPLED APPEARANCE

  • Macular amyloidosis with rippled macules over interscapular area, legs, arms

57.  ROPE LIKE APPEARANCE

  • Mondor’s disease due to localised thrombophlebitis over lateral thoracic, thoracoepigastric and superior epigastric veins

58. SALT AND PEPPER APPEARANCE

  • Systemic sclerosis
  • Quadrichrome vitiligo
  • Repigmenting vitiligo

59.  SANDS OF WINDBLOWN DESERT

  • Pachydermoperiostosis with hyperkeratotic rippled linear lesions on the palms and soles

60. SAGO GRAIN APPEARANCE

  • Dishydrotic eczema with clear vesicles that rupture and later turn golden brown

61.  SAUSAGE LIKE APPEARANCE OF DIGITS

  • Dactylitis in psoriasis, type 2 lepra reaction with leprous dactylitis (banana fingers)

62. SLAPPED CHEEK APPEARANCE

  • Erythema infectiosum

63. SPANGLED HAIR APPEARANCE

  • Pili annulati with non fragile banding leading to spangled hair

64. SPECKLED APPEARANCE

  • Speckled lentiginous nevus with numerous dark pigmented speckles on a background of tan brown hyperpigmentation

65. STUCK ON APPEARANCE

  • Seborrheic keratosis with pasted on or stuck on appearance like brown candle wax dropped on to skin

 66. STRAWBERRY APPEARANCE

  • Strawberry gums in sarcoidosis, wegeners granulomatosis (hypertrophic gingivitis)
  • Strawberry tongue in Kawasaki disease, Scarlet fever, Recurrent toxin mediated perianal erythema
  • Strawberry cervix(colpitis macularis) in Trichomoniasis

67. SUNBURN APPEARANCE OF SKIN

  • Pellagra
  • Drug induced pellagroid dermatitis

68. TAPIR NOSE APPEARANCE

  • Also called as camel nose or parrot beak nose seen in Mucocutaneous leishmaniasis (Espundia) due to mutilation of nasal apparatus

69.  TARGET AND TARGETOID APPEARANCE

  • Target lesions seen in Erythema multiforme, Stevens Johnson’s syndrome, Toxic epidermal necrolysis, Rowell syndrome in SLE
  • FDE, Erythema multiforme like drug reaction, VASCULITIS, ECM, GA, PUPPP, Targetoid hemangioma, Targetoid nevus, Acute hemorrhagic edema of infancy

70.  THIMBLE APPEARANCE OF NAILS

  • Irregular nail pitting seen in psoriasis

71.  VELVETY APPEARANCE

  • Acanthosis nigricans
  • Triple palms
  • Nevus sebaceous

72. WASH LEATHER APPEARANCE OF SLOUGH

  • Syphilitic gumma 

73.  WATCH GLASS LIKE OR DRUM STICK LIKE APPEARANCE

  • Nail clubbing (Hippocratic fingers)  seen in diseases of heart and lungs  

74. WEATHER BEATEN APPEARANCE

  • Erythropoietic proto porphyria with shallow linear or elliptical scars, waxy thickening and pebbling of skin on nose, cheeks, MPJ and perioral furrow like scars

75.  WHORLED APPEARANCE

  • Incontinenta pigments
  • Hypomelanosis of Ito
  • Conradi Hunermann happle syndrome 
  • Epidermal nevus 
  • Linear and whorled nevoid hypermelanosis

76. WOOD GRAIN APPEARANCE

  • Erythema gyratum repens 

77.  WOOD WISP APPEARANCE

  • Trichofolliculoma where vellus hair in center looks like wisp of wool

78. WORM EATEN OR VERMICULATE APPEARANCE

  • Atrophoderma vermiculata 

79. ZEBRA LIKE APPEARANCE

  • Linear and whorled nevoid hypermelanosis

Reference: Appearances in clinical dermatology

https://www.ijdvl.com/article.asp?issn=0378-6323;year=2014;volume=80;issue=5;spage=432;epage=447;aulast=Madke

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