Causes of the Auspitz Sign

What pinpoint blood spots tell dermatologists

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Auspitz Sign

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The Auspitz sign (also sometimes called Auspitz's sign) refers to the bleeding that can occur when the surface of a scaling rash has been removed. Removing a scale ruptures the capillaries just beneath the skin's surface. The pinpoint spots of bleeding can often help doctors identify the type of skin disease involved.

Although the Auspitz's sign is commonly associated with psoriasis, it can appear with other skin diseases including actinic keratosis and Darier's disease.

The Auspitz sign was named after Heinrich Auspitz (1835-1886), the Austrian dermatologist who first identified the clinical symptom.

Symptoms

The Auspitz sign may be visible to the naked eye or require a close-up examination of the skin with a magnifying lens called a dermascope. It typically occurs where the skin has been scratched or abraded by clothing.

The clustered blood spots may be large or small depending on the area of skin involved. If scratched intensely, there may even be crusted clots on the surface of the skin. In other cases, the skin maybe peppered with tiny red spots, almost pore-like in their distribution, with little to no bleeding.

The location of the Auspitz sign, along with the accompanying symptoms, may provide clues as to the type of disease involved.

Psoriasis

With psoriasis, the skin lesions (called plaques) mainly affect the extensor surfaces. This the skin on the opening side of a joint, such as the area in front of the knee or the elbow-side of the forearm. Other commonly affected sites include the scalp, neck, lower back, feet, and hands.

Psoriasis plaques are comprised of well-defined areas of dry, red, thickened skin covered with silvery-white scales.

Actinic Keratosis

Actinic keratosis, also known as solar keratosis, is a precancerous growth that develops on areas of sun-damaged skin. Common sites include the face, lips, ears, back of the hands, forearms, scalp, and neck.

Actinic keratosis lesions are blotchy, uneven, and as much as an inch in diameter with scaly, dry patches of skin. The affected skin color can range in color from pink to dark brown.

Darier's Disease

Darier's disease, also known as keratosis follicularis, is a rare genetic disorder characterized by wart-like blemishes. The lesions are usually situated around follicles and are yellowish in color, slightly greasy, and thick. They can also emit a strong odor. Common skin sites include the scalp, forehead, upper arms, chest, back, knees, elbows, and behind the ear.

Unlike psoriasis or actinic keratosis, Darier's disease can also affect mucosal tissues of the mouth, esophagus, and vagina.

Causes

The Auspitz sign is caused by abnormal growth of skin cells known as keratinocytes. The scaling develops when the cells push to the surface of the skin faster than they can be shed, causing them to dry out and harden.

Because the underlying cells have not yet matured into the enclosed outer layer of skin, called the stratum corneum, the capillaries just below remain largely unprotected. If scales are removed prematurely, they can rupture the still-developing tissues along with the walls of the capillaries.

Diagnosis

The Auspitz sign is diagnosed by visual inspection. While the appearance of the Auspitz sign is strongly suggestive of psoriasis, actinic keratosis, and Darier's disease, it cannot diagnose any of these diseases on its own. Other procedures will be needed.

Psoriasis

Psoriasis is diagnosed with a physical examination and a review of your medical history to provide supporting evidence (such as a family history of psoriasis or a recent incident that may have triggered the event).

If needed, tissue samples can be examined under the microscope to look for the characteristic flattening and compression of cells, called acanthosis. The skin scales will also appear lamellar (meaning flat and fish scale-like).

Actinic Keratosis

The diagnosis of actinic keratosis similar to that of psoriasis. For this condition, the doctor will look for evidence of sun damage. If needed, the microscopic examination of a skin biopsy would reveal a "flag sign" in which alternating layers of skin cells—some with nuclei and others without—are visible. The skin scales will also be more horn-like rather than lamellar.

Darier's Disease

Most people with Darier's disease will have a family member with a history of the condition. If no family history is found, a skin biopsy may be performed.

Under the microscope, the pathologist would see three things: the thickening of tissue, a plugging of hair follicles, and the granulation of keratinocytes near the surface of the skin. The scales would also have a characteristic "carpet tack" appearance similar to other follicular diseases.

To confirm the diagnosis of Darier's disease, a genetic test can be performed to identify the ATP2A2 gene mutation. Another tell-tale sign is the appearance of mucosal lesions.

Treatment

The Auspitz sign is not treated per se other than to prevent infection with warm soap and water and a topical antibiotic. To resolve the symptom, you would need to resolve the underlying disorder.

With psoriasis, this may involve:

With actinic keratosis, this may involve:

  • Sunscreen
  • Protective clothing
  • Phototherapy
  • Topical retinoids
  • Cryotherapy
  • Laser surgery
  • Chemical peels
  • Surgical excision of lesions
  • Topical anti-wart medication like trichloroacetic acid
  • Oral chemotherapy drugs like Adrucil (fluorouracil)

With Darier disease, the may involve:

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