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Auspitz sign is not sensitive or specific for psoriasis
Auspitz sign is not sensitive or specific for psoriasis Jeffrey D. Bernhard, MD Worcester, Massachusetts The Auspitz signrefers to the appearance of small bleeding points after successive layers of scalehave been removed from the surface of psoriatic papules or plaques. In this study the Auspitz signwaspresent in only 41 of 234 patients with psoriasis. Furthermore, small bleeding points could be produced when scale was forcibly removed from several nonpsoriatic, scaling disorders, including Darier's disease and actinic keratoses. The frequent absence of the Auspitz signin psoriasis indicates a lackof sensitivity, whereas itsoccurrence inotherdiseases indicates a lack of specificity. (J AM ACAD DERMATOL 1990;22:1079-81.)
Among the pantheon associated with psoriasis, Heinrich Auspitz is among the most important. Willan, Hebra, and Wilson are remembered for first describing and identifying psoriasis. Koebner is remembered for his description of the isomorphic response, in which trauma to the skin leads to the appearance of a psoriatic lesion. Munro and Kogoj are remembered for their pustules, and Woronofffor his ring. And the name of Auspitz is attached to the observation that pinpoint bleeding occurs when outer scales are pulled or scratched from a psoriatic papule or plaque. 1 Few medical students fortunate enough to take a dermatology elective fail to complete their course without hearing about the Auspitz sign at least once. But to the best of my knowledge the sensitivity and specificity of the Auspitz sign have never been assessed. For about a year I therefore undertook to scratch, grattage, or scrape a lesion in nearly every case of psoriasis I encountered. I also attempted to elicit the Auspitz sign from a number of other scaling disorders such as eczematous dermatitis, Darier's disease, and actinic keratoses.
ing. I allowed myright thumbnail to grow several millimeters beyond the hyponychium and used it to remove surface scale by either scratching, plucking, flicking, or grattage(a rapid, repetitive, flicking motion). Great care was taken to restrict any contact with blood to the nail plate and toavoid skin contact with blood. I madeseveral attempts to perform grattage with a curette, a No. 15 scalpel blade, a tongue depressor, and an edge of a glass slide but found that my thumbnail was most convenient andleast likely tocause injury in and of itself. Given that a sufficiently strong effort with a sufficiently sharpimplement willcause bleeding ofeven normal skin, the thumbnail seemed to provide the most appropriate level of trauma at least expense. In general, lesions on the arms, legs, and trunk, which hadthethickest scale, werechosen. In manypatients more thanonesitewas tested. Auspitz sign was defined aspresent ifpinpoint bleeding appeared after mechanical removal of scale by my thumbnail. A negative response (or absence of the sign) was defined as the failure to elicit pinpoint bleeding after I removed as much scale as I could with my thumbnail but before achieving a scratch that I judged would have caused bleeding in any event.
MATERIAL AND METHODS
The Auspitz sign was present in 33 patients with psoriasis and absent in 193. In another eight psoriasispatients it waspresent in onelocation and absent in another. A positive response (pinpoint bleeding) was also elicitedin severalpatients with other disorders, as listed in Table 1. In the eight patients with psoriasis who had a positive response in one location but a negative response in another, positivity did not appear to correlate with location.However,the study was not designed to detect a locational effect, if there was one. Several patients had a negative response on one occasion and a positive response on another. Although the study was notdesignedto determine whether the
During a period of about 1year, 234patients withpsoriasisand 46 witha varietyofotherscaling disorders were examined for the presence of Auspitz sign. Although nearly every patientwith psoriasis was tested, only a few patients with other disorders were tested when lesions weresufficiently hyperkeratotic toresemble psoriasis orto make me suspect that scale removal mightlead to bleedFrom the Division of Dermatology, University of Massachusetts Medical Center. Reprint requests: Jeffrey D. Bernhard, MD, Division of Dermatology, University of Massachusetts Medical Center, 55 Lake Ave. North, Worcester, MA 01655.
16/1/16759
RESULTS
1079
Journal of the American Academy of Dermatology
1080 Bernhard
Normal Skin
Psoriasis
Auspttzs Sign*
Fig. 1. Left panel, Nonnal skinisdepicted. Middle panel, Psoriasis isdepicted withscaling at the surface, a thickened, acanthotic epidermis, and elongated dermal papillae withtortuouscapillaryloops. Right panel, The left papilla shows that capillary bleeding maynot occur if the suprapapillary plateisnot sufficiently thinor if sufficient force is notexerted to remove scale overlying it. The sameis true of middle papilla. In right papilla three drops of blood are depicted and the Auspitz signis present because sufficient scalehas been removed over a sufficiently thin suprapapillary plate and the capillary has ruptured.
Table I. Presence of Auspitz sign in various cutaneous diseases Presence of Auspitz sign (No. of patients)
Disease
+
Psoriasis Darier's disease Mycosis fungoides Nummular eczema Atopic eczema Pityriasis rubra pilaris Pityriasis rosea Discoid LE Subacute cutaneous LE Sneddon-Wilkinson disease Pemphigus foliaceus X-linked ichthyosis Flegel's disease] Lichen planus Tinea corporis Actinic keratosis Seborrheic keratosis Bowen's disease
33 2 0 0
0 0 0
0 0 0 0 0 0 0 0 6 4 0
+ and-*
193
o 2 1 2 2 3 1 1 1 1
1 2 1 I 10 3 2
8
o o o o o o o o o o
o o o o o o o
LE, Lupus erythematosus. *In eight patients with psoriasis the Auspitz sign was present in one location and absent in another. [Bleeding after removal of scale in Flegel's disease (hyperkeratosis lenticularis perstans) has been noted elsewhere. 8
presence of the Auspitz sign could be correlated with disease activity, it did seem that a positive response could be elicited more easily when the disease was undergoing an acute flare. The sign was positive in 6 of 14 cases where acute worsening of psoriasis was noted. In one additional case a change from negative to positive was associated with the initiation of etretinate therapy.
Of the different ways to mechanically remove scale with the thumbnail, a rapid, repetitive flicking (grattage) seemed to be most effective. In somecases successive scale removal led to the appearance of a final "membrane," which, when removed, left a wet surface with pinpoint bleeding,as described by Mier and van de Kerkhof. I In severalinstances successive scale removal led to the appearance of dots that could be interpreted as capillary loops,but these dots did not always bleed. In two such cases in which the presence of blood could not be determined visually, the application of a soft white tissue confirmed that pinpoint bleeding was present. DISCUSSION Heinrich Auspitz was born in 1835 and died in 1886. He was one of Hebra's greatest pupils and coined the terms parakeratosis and acantholysis. Holubar? points out that Auspitz "did not either discover or first describe the clinical phenomenon that bears his name," and notes that Hebra and Devergie had described it before. In 1870 Auspitz published a celebrated study on the relationship of the epidermis to the papillary portionof the dermis, and it may bethat the histopathologicinsight from this paper accounts for his eponymization.b" Despite an extensivesearch, we have beenunable to discoverwho first named the Auspitz sign (K. Holubar, personal communication; N. Fabiszewski, personal communication). Darier'' describes the sign with the name of Auspitz in his text and may have been responsible because he appears to have been fond of eponyms.f Pinpoint bleeding that occurs when scales from a psoriatic lesion are forcibly removed is thought to be due to rupture of papillary dermal capillaries be-
Volume 22 Number 6, Part I June 1990
neath a thinned suprapapillary plate, but there may be several reasons for its failure to appear. The most obvious is that ample force to a sufficient depth of tissue has not been applied. Unna7 also observed that psoriatic papules will not always bleed when scratched. He noted that the phenomenon "naturally depends on the excessive thinness of the suprapapillary layer, and further depends on the fact that the scales are still young, and pass gradually from the transitional layer without any sharp margin, and therefore the few prickle cells which separate the papilla from the scales are readily removed with them. Further, in the typical psoriasis papule, when it lasts long, distinct dilation of the papillary vessels is present, so that these often occupy the summit of the papule." He concludes that several "favouring circumstances," which are not always present, must be combined for bleeding to occur? (see Fig. 1). Of the several nonpsoriatic disorders in which a positive Auspitz sign can be elicited, none is likely to cause diagnostic confusion with psoriasis except perhaps for some cases of Darier's disease. Bleeding on removal of scale has also been reported in Flegel's diseasef and in clear cell acanthomas.? but it is difficult to imagine these looking enough like psoriasis to cause confusion. Although the results of this study suggest that the appearance of pinpoint bleeding on removal of scale from a skin lesion cannot be considered diagnostic of psoriasis, the phenomenon is certainly real. So long as its absence is not utilized to exclude the diagnosis of psoriasis nor its presence
Auspitz sign 1081 utilized to make the diagnosis in the absence of other confirmatory features, the eponym is useful because it describes a phenomenon and memorializes an important contributor to dermatology. Because we should take every possible precaution to prevent the transmission of hepatitis and the acquired immunodeficiencysyndrome, testing for Auspitz sign should not be performed with the ungloved hand. Other implements, such as a curette, forceps, or edge of a glass slide, should be used. Given its lack of sensitivity and specificity, other diagnostic methods should be used to establish a diagnosis. REFERENCES I. Mier PD, van de Kerkhof PCM. Textbook of psoriasis. Edinburgh: Churchill Livingstone, 1986. 2. Holubar K. Remembering Heinrich Auspitz. Am J Dermatopathol 1986;8:83-S. 3. Crissey JT, Parish LC. The dermatology and syphilology of the nineteeth century. New York: Praeger, 1981. 4. Auspitz H. Ueber das verhaltniss der oberhaut zur papillarschicht. Arch Dermatol Syph [Prague] 1870;2:24-S7. 5. Darier J. Textbook of dermatology. 2nd cd. (Pollitzer S, trans.) Philadelphia: Lea & Febiger, 1920. 6. Bernhard JD, Elliot AD. A letter from Darier to Bowen on the naming of Bowen's disease. Arch Dermatol 1983; 119:261-2. 7. Unna PO. The histopathology of the diseases of the skin. (Walker N, trans.) Edinburgh: WF Clay, 1896:203. 8. Pearson LH, Smith 10, Chalker DK. Hyperkeratosis lenticularis perstans (Flegel's disease). J AM ACAD DERMATOL 1987;16:190-S. 9. MacKie RM. Tumours of the skin. In: Rook A, Wilkinson OS, Ebling FJG, et al, eds. Textbook of dermatology; vol 3. 4th ed. Oxford: BlackwellScientific Pu blications, 1986:239S.
Among the pantheon associated with psoriasis, Heinrich Auspitz is among the most important. Willan, Hebra, and Wilson are remembered for first describing and identifying psoriasis. Koebner is remembered for his description of the isomorphic response, in which trauma to the skin leads to the appearance of a psoriatic lesion. Munro and Kogoj are remembered for their pustules, and Woronofffor his ring. And the name of Auspitz is attached to the observation that pinpoint bleeding occurs when outer scales are pulled or scratched from a psoriatic papule or plaque. 1 Few medical students fortunate enough to take a dermatology elective fail to complete their course without hearing about the Auspitz sign at least once. But to the best of my knowledge the sensitivity and specificity of the Auspitz sign have never been assessed. For about a year I therefore undertook to scratch, grattage, or scrape a lesion in nearly every case of psoriasis I encountered. I also attempted to elicit the Auspitz sign from a number of other scaling disorders such as eczematous dermatitis, Darier's disease, and actinic keratoses.
ing. I allowed myright thumbnail to grow several millimeters beyond the hyponychium and used it to remove surface scale by either scratching, plucking, flicking, or grattage(a rapid, repetitive, flicking motion). Great care was taken to restrict any contact with blood to the nail plate and toavoid skin contact with blood. I madeseveral attempts to perform grattage with a curette, a No. 15 scalpel blade, a tongue depressor, and an edge of a glass slide but found that my thumbnail was most convenient andleast likely tocause injury in and of itself. Given that a sufficiently strong effort with a sufficiently sharpimplement willcause bleeding ofeven normal skin, the thumbnail seemed to provide the most appropriate level of trauma at least expense. In general, lesions on the arms, legs, and trunk, which hadthethickest scale, werechosen. In manypatients more thanonesitewas tested. Auspitz sign was defined aspresent ifpinpoint bleeding appeared after mechanical removal of scale by my thumbnail. A negative response (or absence of the sign) was defined as the failure to elicit pinpoint bleeding after I removed as much scale as I could with my thumbnail but before achieving a scratch that I judged would have caused bleeding in any event.
MATERIAL AND METHODS
The Auspitz sign was present in 33 patients with psoriasis and absent in 193. In another eight psoriasispatients it waspresent in onelocation and absent in another. A positive response (pinpoint bleeding) was also elicitedin severalpatients with other disorders, as listed in Table 1. In the eight patients with psoriasis who had a positive response in one location but a negative response in another, positivity did not appear to correlate with location.However,the study was not designed to detect a locational effect, if there was one. Several patients had a negative response on one occasion and a positive response on another. Although the study was notdesignedto determine whether the
During a period of about 1year, 234patients withpsoriasisand 46 witha varietyofotherscaling disorders were examined for the presence of Auspitz sign. Although nearly every patientwith psoriasis was tested, only a few patients with other disorders were tested when lesions weresufficiently hyperkeratotic toresemble psoriasis orto make me suspect that scale removal mightlead to bleedFrom the Division of Dermatology, University of Massachusetts Medical Center. Reprint requests: Jeffrey D. Bernhard, MD, Division of Dermatology, University of Massachusetts Medical Center, 55 Lake Ave. North, Worcester, MA 01655.
16/1/16759
RESULTS
1079
Journal of the American Academy of Dermatology
1080 Bernhard
Normal Skin
Psoriasis
Auspttzs Sign*
Fig. 1. Left panel, Nonnal skinisdepicted. Middle panel, Psoriasis isdepicted withscaling at the surface, a thickened, acanthotic epidermis, and elongated dermal papillae withtortuouscapillaryloops. Right panel, The left papilla shows that capillary bleeding maynot occur if the suprapapillary plateisnot sufficiently thinor if sufficient force is notexerted to remove scale overlying it. The sameis true of middle papilla. In right papilla three drops of blood are depicted and the Auspitz signis present because sufficient scalehas been removed over a sufficiently thin suprapapillary plate and the capillary has ruptured.
Table I. Presence of Auspitz sign in various cutaneous diseases Presence of Auspitz sign (No. of patients)
Disease
+
Psoriasis Darier's disease Mycosis fungoides Nummular eczema Atopic eczema Pityriasis rubra pilaris Pityriasis rosea Discoid LE Subacute cutaneous LE Sneddon-Wilkinson disease Pemphigus foliaceus X-linked ichthyosis Flegel's disease] Lichen planus Tinea corporis Actinic keratosis Seborrheic keratosis Bowen's disease
33 2 0 0
0 0 0
0 0 0 0 0 0 0 0 6 4 0
+ and-*
193
o 2 1 2 2 3 1 1 1 1
1 2 1 I 10 3 2
8
o o o o o o o o o o
o o o o o o o
LE, Lupus erythematosus. *In eight patients with psoriasis the Auspitz sign was present in one location and absent in another. [Bleeding after removal of scale in Flegel's disease (hyperkeratosis lenticularis perstans) has been noted elsewhere. 8
presence of the Auspitz sign could be correlated with disease activity, it did seem that a positive response could be elicited more easily when the disease was undergoing an acute flare. The sign was positive in 6 of 14 cases where acute worsening of psoriasis was noted. In one additional case a change from negative to positive was associated with the initiation of etretinate therapy.
Of the different ways to mechanically remove scale with the thumbnail, a rapid, repetitive flicking (grattage) seemed to be most effective. In somecases successive scale removal led to the appearance of a final "membrane," which, when removed, left a wet surface with pinpoint bleeding,as described by Mier and van de Kerkhof. I In severalinstances successive scale removal led to the appearance of dots that could be interpreted as capillary loops,but these dots did not always bleed. In two such cases in which the presence of blood could not be determined visually, the application of a soft white tissue confirmed that pinpoint bleeding was present. DISCUSSION Heinrich Auspitz was born in 1835 and died in 1886. He was one of Hebra's greatest pupils and coined the terms parakeratosis and acantholysis. Holubar? points out that Auspitz "did not either discover or first describe the clinical phenomenon that bears his name," and notes that Hebra and Devergie had described it before. In 1870 Auspitz published a celebrated study on the relationship of the epidermis to the papillary portionof the dermis, and it may bethat the histopathologicinsight from this paper accounts for his eponymization.b" Despite an extensivesearch, we have beenunable to discoverwho first named the Auspitz sign (K. Holubar, personal communication; N. Fabiszewski, personal communication). Darier'' describes the sign with the name of Auspitz in his text and may have been responsible because he appears to have been fond of eponyms.f Pinpoint bleeding that occurs when scales from a psoriatic lesion are forcibly removed is thought to be due to rupture of papillary dermal capillaries be-
Volume 22 Number 6, Part I June 1990
neath a thinned suprapapillary plate, but there may be several reasons for its failure to appear. The most obvious is that ample force to a sufficient depth of tissue has not been applied. Unna7 also observed that psoriatic papules will not always bleed when scratched. He noted that the phenomenon "naturally depends on the excessive thinness of the suprapapillary layer, and further depends on the fact that the scales are still young, and pass gradually from the transitional layer without any sharp margin, and therefore the few prickle cells which separate the papilla from the scales are readily removed with them. Further, in the typical psoriasis papule, when it lasts long, distinct dilation of the papillary vessels is present, so that these often occupy the summit of the papule." He concludes that several "favouring circumstances," which are not always present, must be combined for bleeding to occur? (see Fig. 1). Of the several nonpsoriatic disorders in which a positive Auspitz sign can be elicited, none is likely to cause diagnostic confusion with psoriasis except perhaps for some cases of Darier's disease. Bleeding on removal of scale has also been reported in Flegel's diseasef and in clear cell acanthomas.? but it is difficult to imagine these looking enough like psoriasis to cause confusion. Although the results of this study suggest that the appearance of pinpoint bleeding on removal of scale from a skin lesion cannot be considered diagnostic of psoriasis, the phenomenon is certainly real. So long as its absence is not utilized to exclude the diagnosis of psoriasis nor its presence
Auspitz sign 1081 utilized to make the diagnosis in the absence of other confirmatory features, the eponym is useful because it describes a phenomenon and memorializes an important contributor to dermatology. Because we should take every possible precaution to prevent the transmission of hepatitis and the acquired immunodeficiencysyndrome, testing for Auspitz sign should not be performed with the ungloved hand. Other implements, such as a curette, forceps, or edge of a glass slide, should be used. Given its lack of sensitivity and specificity, other diagnostic methods should be used to establish a diagnosis. REFERENCES I. Mier PD, van de Kerkhof PCM. Textbook of psoriasis. Edinburgh: Churchill Livingstone, 1986. 2. Holubar K. Remembering Heinrich Auspitz. Am J Dermatopathol 1986;8:83-S. 3. Crissey JT, Parish LC. The dermatology and syphilology of the nineteeth century. New York: Praeger, 1981. 4. Auspitz H. Ueber das verhaltniss der oberhaut zur papillarschicht. Arch Dermatol Syph [Prague] 1870;2:24-S7. 5. Darier J. Textbook of dermatology. 2nd cd. (Pollitzer S, trans.) Philadelphia: Lea & Febiger, 1920. 6. Bernhard JD, Elliot AD. A letter from Darier to Bowen on the naming of Bowen's disease. Arch Dermatol 1983; 119:261-2. 7. Unna PO. The histopathology of the diseases of the skin. (Walker N, trans.) Edinburgh: WF Clay, 1896:203. 8. Pearson LH, Smith 10, Chalker DK. Hyperkeratosis lenticularis perstans (Flegel's disease). J AM ACAD DERMATOL 1987;16:190-S. 9. MacKie RM. Tumours of the skin. In: Rook A, Wilkinson OS, Ebling FJG, et al, eds. Textbook of dermatology; vol 3. 4th ed. Oxford: BlackwellScientific Pu blications, 1986:239S.