Warfare related eponyms in dermatology

Introduction

Warfare-related eponymous signs in dermatology highlight the unique intersection of dermatology and military events. With the growing list of newer signs being described for various dermatological conditions, an engaging way to connect what we read to what we see in daily life serves to make learning impactful.

List of clinical signs

• 1.

  Armour plate: The scales in lamellar ichthyosis are large and thick, firmly adhering to the skin with the appearance of an armour plate [Figure 1]. ¹

• 2.

  Barbed wire appearance: It refers to the dermoscopic appearance of scaling present over the ridges and furrows in lesions of pityriasis versicolor.

• 3.

  Battle sign: Bruising of the retroauricular area secondary to head trauma is known as a battle sign. It suggests a basilar skull fracture [Figure 2]. ²

• 4.

  Club hair: Another name for telogen hair owing to its club-like bulbous end.

• 5.

  Coat of armour scales: In harlequin ichthyosis, the entire body of the infant is covered in tight, rigid, yellow-brown skin, resembling a thick, hyperkeratotic armour [Figure 3]. ¹

• 6.

  Delta wing jet contrail appearance: In the dermoscopy of scabies, the delta wing jet appearance refers to the head part of the mite, while the contrail refers to the burrow traversed by it.

• 7.

  Double-edged scale: It refers to the two rows of scales at the circumference of erythematous plaques in Netherton syndrome. It is also described as a dermoscopic feature of pityriasis versicolor wherein stretching the skin breaks up the scales and the skin creases into two. ¹

• 8.

  En coup de sabre: A linear depressed sclerotic plaque on the frontoparietal scalp seen in linear morphoea as if struck with a sword [Figure 4].

• 9.

  Gauntlet sign: Refers to the symmetrical brown-red discolouration of the dorsum of both hands and lower one-third of the forearm with a well-demarcated erythematous border. This resembles a gauntlet (glove which extends above the wrist) [Figure 5].

• 10.

  Gunmetal grey necrotic centres: The palpable purpura of meningococcaemia have necrotic centres displaying a gunmetal grey hue. It is also described for the eschar of ecthyma gangrenosum. ³

• 11.

  Holster sign: The presence of a confluent, flat, purplish-red rash on the outer aspect of the hips and thighs are referred to as the “Holster sign”. It is seen in Dermatomyositis. ⁴

• 12.

  Horse riding stance: The characteristic “horse-riding” stance appearance is due to incomplete extension of both the hip and knee joints, along with the inability to extend the elbow fully. It is seen in stiff skin syndrome and progeria.

• 13.

  Knife cut sign: The characteristic linear deep fissures noted in the inter-labial and inguinal creases in case of metastatic Crohn’s disease. Similar lesions are also seen in erosive HSV-1 infection in various folds of the body [Figure 6]. ⁵

• 14.

  Mace sign: The distal splaying of hair secondary to manipulation in trichotillomania gives an appearance of a mace on trichoscopy, which is the most specific trichoscopic finding in this disease [Figure 7].

• 15.

  Portuguese man-of-war: This is a common name for Physalia physalis, an Atlantic coelenterate. Its sting is associated with shock-like symptoms and leaves behind linear cutaneous hyperaemic or purpuric lesions, with or without wheals.

• 16.

  Regimental badge area: It refers to the area of the skin over the inferior portion of the deltoid, which is supplied by the axillary nerve. Paraesthesia or anaesthesia can result from damage to the axillary nerve.

• 17.

  Sabre shin: In late congenital syphilis, cortical thickening of the tibia leads to a sharp anterior border with forward bowing. This is likened to a sabre (sword with a curved blade) . ⁶

• 18.

  Sentinel pile: A harmless growth of skin that is present perianally over the region of a chronic anal fissure.

• 19.

  Sentinel sign: Involvement of interdigital skin in hand eczema prior to the involvement of other areas. ⁷

• 20.

  Shield sign: The mid-chest presentation of carcinoma hemorrhagiectoides is likened to that of a medieval knight’s shield. ⁸

• 21.

  Shooter patch: Intradermal drug abuse (“skin popping”) leads to the development of ulcers that are non-healing, which subsequently develop highly vascular granulation tissue, and are called shooter’s patches. ⁹

• 22.

  Shotgunning: The act of blowing smoke of an illicit drug into the oral or nasal apertures of another. ⁹

• 23.

  Target lesion: A trizonal patterned lesion with central necrotic, middle oedematous and outer erythematous rings, most often associated with erythema multiforme. ¹⁰

• 24.

  Vietnamese time bomb: The American soldiers exposed to Burkholderia pseudomallei from contaminated water in Vietnam manifested the disease after a long incubation period thus the disease melioidosis came to be known as the ‘Vietnamese time bomb’. ¹¹

• 25.

  Whiplash rash: Dermatoses characterised by parallel streaks with tapering ends like the mark of whipping. It is commonly seen with bleomycin chemotherapy [Figure 8]. ¹²

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Figure 1:

Armour plate-like scales in lamellar ichthyosis.

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Figure 2:

Battle sign in basilar skull fracture.

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Figure 3:

Coat of armour scales in harlequin ichthyosis.

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Figure 4:

En coup de sabre presenting as a depressed, atrophic, indurated band on forehead.

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Figure 5:

Gauntlet sign in pellagra.

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Figure 6:

Knife cut sign in cutaneous Crohn disease.

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Figure 7:

Trichoscopy in trichotillomania (black circle) showing mace hair.

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Figure 8:

Whiplash rash secondary to bleomycin chemotherapy in a patient with mixed germ cell tumour of the testes.

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List of histopathological signs

• 1.

  Arrow sign: When the distal part of the outer root sheath undergoes degeneration and the proximal part undergoes splitting, it gives rise to an appearance of an arrow. It is seen in patients who are on epidermal growth factor receptor (EGFR) inhibitors for lung/head and neck cancer. ¹³

• 2.

  Barbed wire appearance: The thickened elastic fibres with lateral projections seen in penicillamine-induced elastosis perforans serpiginosa have a typical barbed wire appearance. ¹⁴

• 3.

  Brass knuckle sign:The chains of yeastlike cells with thick walls in lobomycosis appear like brass knuckles. ¹⁵

• 4.

  Bronze age battle axe sign: The interconnecting elongated rete ridges in focal epithelial hyperplasia give rise to a pattern resembling a battle-axe. ¹⁶

• 5.

  Buckshot scatter: The enlarged, neoplastic melanocytes in melanoma in situ appear scattered amidst the keratinocytes, like those formed by a buckshot. It can also be seen in extramammary Paget disease and Bowen disease [Figure 9]. ¹⁷

• 6.

  Cannon ball appearance: The lobular pattern of capillary tufts in tufted angioma appears like cannon balls. This pattern can also be seen in pseudo-kaposi sarcoma [Figure 10]. ¹⁸

• 7.

  Flame-thrower-like appearance: In telogen, club hairs display a bulb without pigment and an uneven, shaggy border. When these hairs are outlined by vibrant red trichilemmal keratin in vertical haematoxylin and eosin sections, they have a flame-thrower-like appearance. ¹⁸

• 8.

  Hand grenade in chains appearance:Alternaria is the most common agent implicated in phaeohyphomycosis. Its macroconidia are seen to have vertical and horizontal striations that give it the characteristic ‘hand-grenade in chains’ appearance. ¹⁹

• 9.

  Salute sign: A mound of parakeratotic stratum corneum that forms an angle to the epidermis, resembling the common salute gesture to honour senior sergeants [Figure 11].

• 10.

  Saw-tooth appearance: The histological appearance of regularly pointed rete pegs owing to atrophic epithelium in lichen planus [Figure 12].

• 11.

  Toy soldier sign: Basilar epidermotropism in mycosis fungoides is characterised by atypical lymphocytes assembling along the dermo-epidermal junction, akin to toy soldiers [Figure 13]. ²⁰

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Figure 9:

Histology of Bowen’s disease showing buckshot scatter sign - (black circle) (Haematoxylin and eosin, 40x).

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Figure 10:

Histology of tufted angioma showing cannon ball appearance (Haematoxylin and eosin, 40x).

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Figure 11:

Histology of pityriasis rosea showing salute sign (red arrow) (Haematoxylin and eosin, 40x).

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Figure 12:

Histology of lichen planus showing saw tooth-shaped rete ridges (red arrow) (Haematoxylin and eosin, 40x).

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Figure 13:

Histology of mycosis fungoides showing toy soldier sign (black arrow), (Haematoxylin and eosin, 100x).

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Conclusion

Eponyms were originally meant to make learning easier, but the growing number of new eponyms has ironically made it is more difficult and overwhelming. Grouping eponyms by themes using familiar everyday objects for inspiration could help make learning less stressful. This organised collection can assist residents in learning more effectively and efficiently.