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 bleed-
ing 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 inotherdis-
eases 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 re-
membered for his description of the isomorphic re-
sponse, in which trauma to the skin leads to the ap-
pearance 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 ob-
servation that pinpoint bleeding occurs when outer
scales are pulled or scratched from a psoriatic pap-
ule or plaque. 1 Few medical students fortunate
enough to take a dermatology elective fail to com-
plete 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 there-
fore undertook to scratch, grattage, or scrape a le-
sion 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 eczema-
tous dermatitis, Darier's disease, and actinic kera-
toses.
ing. I allowed myright thumbnail to grow several milli-
meters 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 sharpimple-
ment willcause bleeding ofeven normal skin, the thumb-
nail 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.
RESULTS

MATERIAL AND METHODS
During a period of about 1year, 234patients withpso-
riasisand 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 bleed-
From the Division of Dermatology, University of Massachusetts Med-
ical 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
The Auspitz sign was present in 33 patients with
psoriasis and absent in 193. In another eight psori-
asispatients it waspresent in onelocation and absent
in another. A positive response (pinpoint bleeding)
was also elicitedin severalpatients with other disor-
ders, 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 cor-
relate with location.However,the study was not de-
signed to detect a locational effect, if there was one.
Several patients had a negative response on one oc-
casion and a positive response on another. Although
the study was notdesignedto determine whether the
1079
 Journal of the
American Academy of
1080 Bernhard Dermatology

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 withtortu-
ouscapillaryloops. 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 Of the different ways to mechanically remove
cutaneous diseases scale with the thumbnail, a rapid, repetitive flicking
Presence of Auspitz sign
(grattage) seemed to be most effective. In somecases
(No. of patients) successive scale removal led to the appearance of a
final "membrane," which, when removed, left a wet
Disease + + and-*
surface with pinpoint bleeding,as described by Mier
Psoriasis 33 193 8 and van de Kerkhof. I In severalinstances successive
Darier's disease 2 o o scale removal led to the appearance of dots that
Mycosis fungoides 0 2 o could be interpreted as capillary loops,but these dots
Nummular eczema 0 1 o did not always bleed. In two such cases in which the
Atopic eczema 0 2 o presence of blood could not be determined visually,
Pityriasis rubra pilaris 0 2 o
Pityriasis rosea 0 3 o the application of a soft white tissue confirmed that
Discoid LE 0 1 o pinpoint bleeding was present.
Subacute cutaneous LE 0 1 o
Sneddon-Wilkinson disease 0 1 o DISCUSSION
Pemphigus foliaceus 0 1 o Heinrich Auspitz was born in 1835 and died in
X-linked ichthyosis 0 1 o
Flegel's disease] 0 2 o 1886. He was one of Hebra's greatest pupils and
Lichen planus 0 1 o coined the terms parakeratosis and acantholysis.
Tinea corporis 0 I o Holubar? points out that Auspitz "did not either dis-
Actinic keratosis 6 10 o cover or first describe the clinical phenomenon that
Seborrheic keratosis 4 3 o bears his name," and notes that Hebra and Devergie
Bowen's disease 0 2 o
had described it before. In 1870 Auspitz published
LE, Lupus erythematosus. a celebrated study on the relationship of the epider-
*In eight patients with psoriasis the Auspitz sign was present in one lo-
cation and absent in another. mis to the papillary portionof the dermis, and it may
[Bleeding after removal of scale in Flegel's disease (hyperkeratosis len- bethat the histopathologicinsight from this paper ac-
ticularis perstans) has been noted elsewhere. 8 counts for his eponymization.b" Despite an exten-
sivesearch, we have beenunable to discoverwho first
presence of the Auspitz sign could be correlated with named the Auspitz sign (K. Holubar, personal com-
disease activity, it did seem that a positive response munication; N. Fabiszewski, personal communica-
could be elicited more easily when the disease was tion). Darier'' describes the sign with the name of
undergoing an acute flare. The sign was positive in Auspitz in his text and may have been responsible
6 of 14 cases where acute worsening of psoriasis was because he appears to have been fond of eponyms.f
noted. In one additional case a change from negative Pinpoint bleeding that occurs when scales from a
to positive was associated with the initiation of psoriatic lesion are forcibly removed is thought to be
etretinate therapy. 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 "natural-
ly depends on the excessive thinness of the supra-
papillary 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 dif-
ficult 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 im-
portant contributor to dermatology.
Because we should take every possible precaution
to prevent the transmission of hepatitis and the ac-
quired immunodeficiencysyndrome, testing for Aus-
pitz 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 meth-
ods should be used to establish a diagnosis.
REFERENCES
I. Mier PD, van de Kerkhof PCM. Textbook of psoriasis. Ed-
inburgh: Churchill Livingstone, 1986.
2. Holubar K. Remembering Heinrich Auspitz. Am J Der-
matopathol 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 papil-
larschicht. 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 lenti-
cularis 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.