Triads in dermatology

Bhushan Madke, Chitra Nayak

 Department of Skin & VD, Topiwala National Medical College and B.Y.L. Nair Hospital, Mumbai, India

Correspondence Address:
Chitra Nayak
Department of Skin & VD, OPD 14, Second floor, OPD building, Topiwala National Medical College and B.Y.L. Nair Hospital, Mumbai Central, Mumbai
India

Most of the medical and surgical diseases/conditions/disorders are characterized by some clinical symptoms/signs/findings/observations, which form a triad and is considered pathognomonic for that condition. Signs and symptoms of various disorders are not always easy to remember. If there are three main signs and symptoms in a condition, grouping them as a triad facilitates their recall. We list here many such triads---however no explanation of the pathophysiology of these clinical signs and symptoms is undertaken as that is beyond the scope of this paper.

Adiposis dolorosa (Dercum′s disease)

This rare idiopathic condition is characterized by painful plaques, ecchymosis, and obesity, in the menopausal women. ^[1]

Birt-Hogg-Dube syndrome

It is an autosomal dominant condition having benign skin appendageal tumors/hamartomas that show difference toward hair follicles, i.e., (a) fibrofolliculomas (toward the mantle of the hair follicle); (b) trichodiscomas (toward the mesodermal components of the hair discs); and (c) acrochordons (skin tags). ^[2]

Churg-Strauss syndrome (Allergic granulomatosis)

This disease is characterized by asthma, peripheral blood eosinophilia, and necrotizing vasculitis with extravascular granulomas. ^[3]

Cryoglobulinemia (Meltzer′s triad)

Purpura, asthenia, and arthralgia have been together termed Meltzer′s triad seen in cryoglobulnemia. ^[4]

Congenital syphilis (Hutchinson′s triad)

The triad of interstitial keratitis, Hutchinson′s teeth, and eighth-nerve deafness forms "Hutchinson′s triad" of syphilitic stigmata. ^[5]

Dyskeratosis congenita

Reticulate hyperpigmentation of the skin, nail dystrophy, and leukokeratosis of mucous membrane. ^[6] [Figure - 1] and [Figure - 2]

Figure 1: Onychodystrophy of fingernails characterized by longitudinal ridging

Figure 2: Reticulate pattern of hyperpigmentation on anterior aspect of neck

Follicular Occlusion Triad/Tetrad

Acne congoblata, dissecting cellulitis of scalp, pilonidal sinus, and hidradenitis suppuritiva. ^[7]

Gorlin Goltz syndrome (Basal cell nevus syndrome)

The autosomal dominant Patched mutation condition is characterized by (i) more than two basal cell carcinomas or one appearing in patient < 20 years old; (ii) odontogenic cyst of the jaw confirmed by histopathology; (iii) three or more palmar or plantar pits. ^[8]

Graham Little-Piccardi-Lassueur syndrome

Triad of cicatricial alopecia of the scalp, nonscarring alopecia of the axillae and/or groin, and keratotic follicular papules. ^[9]

Grave′s disease

Pretibial myxedema, thyroid acropachy, and exophthalmos-Diamond′s triad. ^[10]

HAIR-AN syndrome

The triad of hyperandrogenism, insulin resistance, and acanthosis nigricans in women is known as the HAIR-AN syndrome. ^[11]

Hermansky-Pudlak syndrome

Triad of albinism, platelets lacking dense bodies and storage of ceroid-like material in tissues. ^[12]

Klippel-Trenaunay syndrome

The condition is characterized by the triad of (i) capillary malformations (port-wine stain/nevus flammeus), (ii) venous malformations (abnormal varicosities, persistent embryonic veins, and (iii) disproportionate limb growth of soft tissue and/or bone ^[13] [Figure - 3].

Figure 3: Ateriovenous malformation of right lower limb with limb lengthening and cutaneous ulceration

Kasabach Merritt syndrome

Triad comprising vascular tumors, thrombocytopenia, and bleeding diathesis. ^[14]

Livedoid vasculopathy

Triad of livedo reticularis, atrophie blanche, and very painful, small punched-out ulcers that have a very poor tendency for healing ^[15] [Figure - 4].

Figure 4: Multiple punched ulcers on lateral malleolar area with porcelain white scars

McCune Albright syndrome

The condition is characterized by triad of poly/monostotic fibrous dysplasia, café-au-lait macules (CALMs), and hyperfunctioning endocrinopathies including precocious puberty, hyperthyroidism, and hypercortisolism, hypersomatotropism, and hypophosphatemic rickets. ^[16]

Melkersson-Rosenthal syndrome

Triad of recurrent labial and/or recurrent facial edema, relapsing facial paralysis, and fissured tongue ^[17] [Figure - 5].

Figure 5: Gross diffuse swelling of lower lip with fissuring at places

Naxos syndrome

This autosomal condition is due to desmoplakin mutation known for its triad of woolly hair, striate palmar-plantar keratoderma, and arrythmogenic right ventricular cardiomyopathy. ^[18]

Netherton-Comel syndrome

Netherton Comel syndrome has two triads. This autosomal recessive ichthyosiform disorder is typified by triad of generalized infantile erythroderma, diarrhea, and failure to thrive from the perspective of a general physician. Dermatologic examination reveals a classical clinical triad of ichthyosis linearis circumflexa, trichorrhexis invaginata (bamboo hair), and atopic diathesis. ^[19]

Pellagra

This niacin deficiency disorder is characterized by clinical triad of 3 Ds i.e., dermatitis, diarrhea, and dementia and rarely by the fourth ′D′-- death. ^[20]

Primary systemic amyloidosis

Triad of carpal tunnel syndrome, macroglossia, and mucocutaneous skin lesions. ^[21]

Ramsay--Hunt syndrome (Herpes zoster oticus)

As the name suggests VZV infection of the facial nerve with ipsilateral facial palsy along with ear pain and vesicles on external ear or tympanic membrane constitutes the triad of Ramsay--Hunt syndrome. ^[22]

Reiter′s syndrome

The triad of urethritis, arthritis, and conjunctivitis forms the triad of reactive arthritis or Reiter′s syndrome. ^[23]

Sèzary syndrome

Sèzary syndrome is characterized by triad of (i) erythroderma, (ii) peripheral lymphadenopathy, and (iii) atypical mononuclear cells (Sézary cells) comprising 5% or more of peripheral blood lymphocytes on a buffy coat smear, or more than 20% of total lymphocyte count or a total Sézary count of more than 1000/mm ³ . ^[24]

Sclero-Atrophic syndrome of Huriez

Autosomal dominant congenital syndrome comprises the triad of diffuse sclero-atrophy of the dorsal aspect of the hands; palmoplantar keratoderma and hypoplastic nail changes. The characteristic electron microscopic picture shows the absence of epidermal Langerhans cells contributing to increased incidence of malignancy. ^[25]

Tuberous sclerosis: Vogt′s Triad (epiloia)

This is described for a neurocutaneous disorder, tuberous sclerosis characterized by diagnostic clinical triad of epilepsy, low intelligence, and facial angiofibromas (adenoma sebaceum). ^[26]

Wegener′s granulomatosis

It is classically described as a triad consisting of systemic small vessel vasculitis, necrotizing granulomatous inflammation of both the upper and lower respiratory tracts, and glomerulonephritis. ^[27]

Wiskott-Aldrich syndrome

Triad of early onset thrombocytopenia, recurrent infection, and eczema characterizes this X-linked recessive condition. ^[28]

Yellow nail syndrome

Yellow nail syndrome is the triad of yellow nails, primary lymphedema, and pleural effusion. ^[29]

The above list of triads may increase in future as many more are to be added to it. For now, students of dermatology will find this list helpful especially while revising for their examinations.

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