An Overview of the Auspitz Sign

The Auspitz sign (a.k.a. Auspitz's sign) refers to pinpoint bleeding that can occur when the surface of a scaling rash has been removed and capillaries just beneath the skin's surface rupture. Although the Auspitz sign is commonly associated with psoriasis, it can appear with other skin diseases including actinic keratosis and Darier's disease. Its presence can often help doctors make a diagnosis.

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 accompanying symptoms, may provide clues as to the type of disease involved. Potentials include:

• Psoriasis: An autoimmune disease that affects skin and nails
• Actinic keratosis (solar keratosis): A precancerous growth that develops on areas of sun-damaged skin
• Darier's disease (keratosis follicularis): A rare genetic disorder 

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 are needed.

Psoriasis

Psoriasis is diagnosed with a physical examination and a review of your medical history, 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 (flat and fish scale-like).

Actinic Keratosis

The diagnosis of actinic keratosis is similar to that of psoriasis. For this condition, the doctor will look for evidence of sun damage. A 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, a 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.

Treatment

The Auspitz sign is not treated, per se. Rather, the aim is 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:

• Skin moisturizers
• Topical corticosteroids
• Topical retinoids
• Phototherapy
• Oral immunosuppressant drugs like methotrexate
• Injected biologic drugs like Humira (adalimumab) or Enbrel (etanercept)

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:

• Skin moisturizers with urea or lactic acid
• Sunscreen
• Vitamin C supplements
• Topical benzoyl peroxide
• Topical corticosteroids
• Topical or oral retinoids
• Topical Voltaren (diclofenac sodium)
• Oral antibiotics
• Cyclosporine