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 Table of Contents  
Year : 2022  |  Volume : 6  |  Issue : 1  |  Page : 59

Spots in dermatology

Department of Dermatology, Sapthagiri Institute of Medical Sciences and Research Center, Bengaluru, Karnataka, India

Date of Submission03-Nov-2020
Date of Decision12-Apr-2021
Date of Acceptance21-May-2021
Date of Web Publication25-Feb-2022

Correspondence Address:
A S Savitha
Department of Dermatology, Sapthagiri Institute of Medical Sciences and Research Center, Bengaluru - 560 090, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cdr.cdr_128_20

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How to cite this article:
Prasannan S, Savitha A S, Nagesh T S. Spots in dermatology. Clin Dermatol Rev 2022;6:59

How to cite this URL:
Prasannan S, Savitha A S, Nagesh T S. Spots in dermatology. Clin Dermatol Rev [serial online] 2022 [cited 2022 Sep 25];6:59. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/1/59/338585

  Introduction Top

A spot is a circumscribed area or place, usually distinguished by its color. The origin of the word “spot” can be traced to 1200 AD from the Old English term splott which means a blot or a patch (of land) and partly from or related to the Middle Dutch term spotte which means a “spot or speck.”[1] Various spots have been described in Dermatology. In this study, we have attempted to compile various “spots” in Dermatology which can help the postgraduates to correlate and recall different skin conditions. For a better understanding, we have categorized spots under the following subheadings; spots on skin, spots on mucous membrane, spot tests in Dermatology, and spot procedures in Dermatology.

  Spots on Skin Top

1. Antimony spots are caused by air-borne contamination with antimony resulting in pustular eruption on the trunk and limbs. These are seen close to the sweat and sebaceous glands and resemble miliaria rubra.[2] This dermatitis is more commonly seen in association with hot weather and in workers exposed to high temperatures.[3],[4],[5] Transferring the worker to a cooler environment often resulted in the rash clearing up within 3–14 days.[6]

2. Ash leaf spots (ALS) are also known as Fitzpatrick patch as he named it after the leaf of the European mountain ash tree. They are the earliest indicator of tuberous sclerosis (TSC).[7],[8] They appear usually at birth or during infancy and are present in more than 90% of patients with TSC.[9] These are present as hypopigmented off-white-colored macules 1–3 cm in size, predominantly over the trunk and buttocks. Their shape may vary, classical lesions are ovoid or leaf shaped hence their name [Figure 1]. Other morphological patterns include confetti-like, thumb print-shaped or segmental lesions.[10] In fair-skinned individuals, ALS can be made prominent by Wood's light examination. Up to two ALS in the absence of other manifestations of TSC are considered normal but three or more lesions form major diagnostic criteria of TSC.[9],[11]
Figure 1: Ash leaf spots

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3. Black-spot poison ivy is an uncommon clinical manifestation of contact with Toxicodendron plants. The black lacquer that results from oxidation of the oleoresin after contact with the plant develops within hours of exposure and precedes allergic contact dermatitis, in some cases by weeks.[12], [13,],[14] It is characterized by pruritic erythematous papules and vesicles in a linear distribution along with black lacquer-like macules with surrounding erythema.[15]

4. Bier spots are pale, irregularly shaped macules about 10 mm in size, found on the upper and lower extremities of young adults. The spots are a type of vascular mottling that can be elicited by placing the limbs in a dependent position. They resolve when the limbs are raised and disappear when the surrounding skin is blanched. They represent areas of localized vasoconstriction surrounded by relative vasodilation. Although primarily idiopathic, it has been reported with cryoglobulinemia and scleroderma renal crisis and with pregnancy.[16],[17]

5. Café au lait spots (CALS) or café au lait macules are birthmarks that are pigmented.[18] The word café au lait has its origin from French which literally means “coffee with milk” because of their light-brown color. They are also called as “giraffe spots.”[19] If these pigmentations have oval and smooth borders, they are called as “Coast of Maine spots,” alternatively if they exhibit jagged borders, they are referred to as “Coast of California spots.” Clinically, they are evidenced by well circumscribed, regularly pigmented macules or patches that have a diameter ranging from 1 to 2 mm to >20 cm in longest diameter. Smooth borders are typical of neurofibromatosis-1, and jagged borders may point out at McCune-Albright syndrome. Histologically, CALS shows increased melanin content of melanocytes and basal keratinocytes.[20],[21]

6. Café noir spot is a term proposed in 1971 by Gorlin et al., by analogy to café-au-lait spots, to describe larger and more pigmented lentigines in patients with LEOPARD syndrome.[22] The word café noir has its origin from French which means “coffee without milk.” It is also seen in familial progressive hyper-and hypopigmentation which is a rare genodermatosis.[23]

7. Campbell de Morgan spots (syn-cherry angiomas [CA], cherry hemangiomas, senile angiomas)[24] are the most common form of acquired vascular proliferation of the skin and were first described in 1872 by Campbell de Morgan.[25] CA develops due to abnormal proliferation of well-differentiated endothelial cells.[26] They appear as 1–5 mm, dome-shaped, bright, red papules located mainly on the trunk or upper extremities [Figure 2].[27] The exact pathogenesis is unknown. Hyperprolactinemia, pregnancy, human herpesvirus 8 infection, mustard gas poisoning, immunosuppression induced by cyclosporine, underlying malignancy, some chemokines, bromide, and 2-butoxyethanol exposure all have been incriminated.[28],[29],[30],[31],[32],[33]
Figure 2: Campbell de Morgan spots with Pityriasis versicolor

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8. Cayenne pepper spots occur as a result of hemosiderin deposition in the skin. They are seen in Zoon's balanitis and Schamberg's disease.

Zoon's balanitis presents as single or multiple well-circumscribed, orange-red, shiny, moist, glistening macular to slightly raised plaques. Cayenne pepper spots appear as multiple pinpoint, bright red spots speckled on the background of these orange-red plaques [Figure 3].[34]
Figure 3: Cayenne pepper spots in Schamberg's disease

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Schamberg's disease (progressive pigmented purpuric dermatoses) is a capillaritis of unknown etiology characterized by orange to fawn-colored macules and plaques usually localized to the lower limbs.[35] Here, the cayenne pepper spots are seen at the periphery of the lesions.[36],[37]

9. Ink spot lentigo (Syn: Sunburn lentigo, reticulated black solar lentigo)[38] is a benign melanotic macular lesion described by Bolognia in 1992. It is distinguished clinically by its dark color and wiry or beaded, markedly irregular outline. It has a reticulated pattern and resembles a spot of ink on the skin.[39] It is commonly described in fair-skinned individuals on sun-exposed areas of the body.[40] Ink spot lentigines may suggest melanoma because of their dark color, irregular border, and unique number.[41]

10. Janeway spots are named after Theodore Caldwell Janeway (1872–1917), an American professor of medicine. They are nontender, erythematous, or hemorrhagic macular or nodular lesions on the palms or soles seen in infective endocarditis.[42] Pathologically, the lesion is a microabscess of the dermis with thrombosis of small vessels without vasculitis.[43] They are caused by septic emboli that deposit bacteria leading to the formation of microabscesses.[44]

11. Liver spots: This term has been used as a synonym to describe various skin conditions such as solar lentigo, flat seborrheic keratosis, and pityriasis versicolor.

Solar Lentigo or Lentigo Senilis, or Age spots are persistent, benign, discrete, hyperpigmented, round or oval macules occurring on sun-damaged skin such as back of the hands, cheeks, and forehead.[45] Ultraviolet radiation can cause local proliferation of melanocytes and thus an accumulation of melanin in the skin cells (keratinocytes).[46]

Flat seborrheic keratosis is termed “liver spots” when located at the dorsal hands. Seborrheic keratoses are one of the most common benign cutaneous neoplasms encountered in older adults mainly over the trunk and head-and-neck region.[47],[48],[49] They begin as flat, tan, superficial 1-to 3-mm papules with a dull surface and later increase in size and thickness to become keratotic.[50]

Pityriasis versicolor is a superficial mycosis, affecting the superficial layer of stratum corneum. It is known by various names such as tinea versicolor, dermatomycosis perforatia, tinea flava, liver spots, or achromia parasitica. It is characterized by hypopigmented, hyperpigmented, leucodermal, or erythematous scaly macules or patches primarily on the trunk and proximal extremities [Figure 2].[51] It is caused by Malassezia furfur which was first recognized as a fungal disease in 1846 by Eichstedt and demonstrated in the scales of tinea versicolor by Robin in 1853.[52]

12. Lucio's spotted leprosy (diffuse lepromatous leprosy of Mexico, La Lepra “Manchada” de Lucio) was described by Lucio in 1852, in Mexico. The Spanish word “manchada” signifies primarily “spotted, speckled, and stained.”[53] It is a variety of leprosy distinguished chiefly by the appearance of circumscribed erythematous macules on the extremities which progresses to vesiculation, superficial necrosis, and scarring.[54]

13. Milk spots (Syn: Milium, oil seed) are common benign keratinous cysts clinically seen as pearly white, dome-shaped lesions measuring 1–2 mm in diameter that occurs most commonly on the face, particularly over eyelids and the cheeks.[55] Primary milia arise spontaneously and may be present at birth. Secondary milia arise as a cutaneous reaction to traumatic stimuli or pathologically altered integument and are localized to the involved body site such as trauma, burns, and a variety of blistering skin conditions.[56],[57]

14. Mongolian spot is a type of dermal melanocytosis, which presents at birth as an ill-defined area of slate gray to blue-black pigmentation over the lumbosacral region and disappears during childhood. It was a German professor Edwin Baelz who, in 1885, described it in Mongolians and named it “Mongolen Flecke” or Mongolian spot.[58],[59] It occurs when melanocytes fail to complete their migration from the neural crest to the basal layer of the epidermis. The melanocytes end their migration in the middle to lower dermis, where based on the Tyndall effect, their brown pigment gives the skin's surface a blue-gray color [60],[61],[62]

15. Oil spots or Salmon spots represent psoriatic plaques in the most distal matrix and the nail bed [Figure 4]. This area looks like paper on which a drop of oil has fallen. A yellowish-brownish spot with a red margin shines through the plate because the psoriatic squames compressed under the nail are imbibed with serum. When a salmon spot reaches the hyponychium, the parakeratosis breaks out and psoriatic onycholysis develops.[63]
Figure 4: Oil spots

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16. Orange palpebral spots are asymptomatic, yellow-orange oval macules that lie symmetrically over the inner portion of the upper eyelids usually seen in middle-aged women with fair skin. Unlike xanthelasma, there is no cholesterol deposition under the skin instead there is an increase in colored pigments such as carotenoids and lipofuscin. An additional theory is that the pigment is a result of local trauma or rubbing and excessive blinking.64]

17. Rose spots are defined as asymptomatic, rose-red, 2–4 mm, discrete, macules, or papules seen in salmonellosis (typhoid fever). Their characteristic distribution is over the anterior trunk between the level of the nipples and umbilicus, at times extending to the proximal aspects of the extremities and the back. They are usually first seen between the 7th and 10th day of illness, recurring in crops for the next 1–2 weeks. Lesions are not more than 6–12 in number and fade completely in 3–4 days. Occasionally, rose spots may first make their appearance at the time of relapse.[65]

18. Roseolar spots (roseolar rash, macular syphilide, syphilitic roseola) are the most common presentation and first clinical sign of secondary syphilis. They appear as symmetrical, coppery red, round or oval spots that do not scale or itch, predominantly on the trunk and flexures of upper limbs and lasts for about 2 weeks.[66],[67]

19. Shin spots (Binkley's spots, pigmented pretibial patches, spotted leg syndrome, diabetic dermangiopathy) are the most common dermatologic manifestation of diabetes. The phrase diabetic dermopathy was coined by Binkley in 1965. They are dull, red papules that progress to small, well-circumscribed, round, atrophic, hyperpigmented lesions commonly over the pretibial area, although other bony prominences such as the forearms, lateral malleoli, or thighs may be involved [Figure 5]. Mild trauma to affected areas, hemosiderin and melanin deposition, microangiopathic changes, and destruction of subcutaneous nerves have all been suggested as the etiologies.[68]
Figure 5: Shin spots (Binkley's spots)

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20. Sporty spots occur as a result of both epidermal cell injury and dermal vascular damage in terms of abrasions, ecchymosis, and purpura commonly noticed in athletes and celebrities. The origin of these markings is an ancient practice called “cupping,” which uses suction to attach a cup to the skin for a desired therapeutic benefit.[69]

21. Spotted fevers comprise Rocky mountain spotted fever caused by Rickettsia rickettsii; Mediterranean spotted fever caused by Rickettsia conorii and Japanese spotted fever caused by Rickettsia japonica. They are caused by ticks and mites and are characterized by an acute febrile illness accompanied by an exanthem. Other cutaneous lesions include eschars, skin eruptions, and rash with patchy necrosis (fern leaf pattern of skin necrosis).[70],[71]

22. Spotted lunula: The lunula develops small, discrete lacunae, or plaques in which the white color is absent, giving a mottled or moth-eaten appearance occurring as a result of defects in the tongue of matrical epithelium which lies under the nail plate and accounts for lunula. An analogy is drawn with Wickham's striae. It is associated with alopecia areata, systemic lupus erythematosus, and rheumatoid arthritis.[72]

23. Spotty parakeratosis/staccato parakeratosis: It is the spotty retention of nuclei in the stratum corneum. It is seen in pityriasis rosea, pityriasis rubra pilaris, large plaque parapsoriasis.[73]

24. Stasis spots are a feature of corona phlebectatica paraplantaris which is a cutaneous sign of chronic venous insufficiency. It is a direct consequence of increased capillary pressure, which causes the vessels to expand.[74]

25. Twin spots (Syn: Didymosis)/twin spotting phenomenon refers to the occurrence of two different nevi or paired patches of structurally or functionally different mutant tissue that differs from the surrounding normal skin. It is due to postzygotic crossing over resulting in two homozygous daughter cells, representing the stem cells of the two distinct types of nevi and of the additional extracutaneous defects, e.g. Nevus depigmentosus has presented as twin spotting with segmental lentiginosis as well as with Becker's nevus.[75]

26. White spot disease (Syn: Lichen sclerosus [LS], LS et atrophicus, lichen albus, Csillag's disease)[76] is a chronic inflammatory dermatosis most commonly seen in females first described by Hallopeau in 1887 [Figure 6].[77] These lesions occur predominantly in the anogenital region. In females, anogenital LS is characterized by porcelain-white atrophic papules coalescing into plaques that may become confluent extending around the vulval and perianal skin in a figure of eight configurations.[78]
Figure 6: White spot disease (Lichen sclerosus et atrophicus)

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  Spots on Mucous Membrane Top

27. Bitot's spots were first described by the French physician Pierre Bitot in 1863 in debilitated children.[79] Bitot's spots are a specific manifestation of Vitamin A deficiency. These are triangular well-defined foamy, white spots with apex toward the canthus.[80] They are mainly composed of keratin admixture with gas-forming bacteria, Corynebacterium xerosis which leads to foamy appearance. It is a fully reversible condition with oral Vitamin A replacement. If left untreated, it heralds the complete loss of vision.

28. Brushfield spots are small, white, or grayish/brown spots on the periphery of the iris in the eyes due to aggregation of connective tissue. The spots are named after the physician Thomas Brushfield, who first described them in 1924. They are a characteristic feature of the chromosomal disorder Down's syndrome or trisomy 21.[81],[82]

29. Cotton wool spots (CWS) (Syn: Inner retinal ischemic spots) are common retinal manifestations of many diseases including diabetes mellitus, systemic hypertension, and acquired immunodeficiency syndrome due to obstruction of axoplasmic transport. Retinal vasculopathy in the form of cotton wool spots is suggestive of active systemic lupus erythematosus and lupus cerebritis. On fundoscopic examination, cotton wool spots may appear as small, yellow-white (or grayish-white), slightly elevated lesions with a fimbriate border in the superficial retina. The principal constituent of the CWS is cytoid bodies.[83],[84]

30. Drusen-like spots are tiny yellow or white extracellular deposits consisting of proteins and lipids that build up between Bruch's membrane and the retinal pigment epithelium of the eye. They occur in pseudoxanthoma elasticum and age-related macular degeneration.[85]

31. Forchheimer spots appear in about 20% of patients with rubella with as distinctive pinhead-sized petechiae, 5–20 in number at the junction of the soft and hard palate occasionally preceding a rash. They are not specific to rubella and can also be seen in scarlet fever.[86]

32. Fordyce spots are ectopically located sebaceous glands characterized by minute, orange, yellowish, pinhead-sized macules or 1–3 mm papules in the mucosa of the lips, cheeks, and gums, first described by Fordyce in 1896. Prominent lip involvement may result in a lipstick-like mark left on a rim of a glass mug after consuming a hot beverage (Meffert's sign).[87],[88]

33. Herman spots are blue-gray stippling that appears on the tonsils in measles. It develops 1 to 2 days before the exanthem. The exanthem lasts for 5–6 days, whereas the enanthem lasts for 2–3 days.

34. Koplik spots are considered to be a diagnostic/pathognomic feature of measles/rubeola in the pre-eruptive stage. The term Koplik spot derives its name from Dr. Henry Koplik of New York, who described them in 1896. They appear as bluish-white spots, slightly raised with a diameter of approximately 2–3 mm on an erythematous base on the buccal mucosa, opposite the first molar usually 1 day before the onset of rash and persists for 2 or 3 days. This characteristic appearance of Koplik spots is sometimes referred to as “grains of salt on a red background”.[89],[90]

35. “Leopard skin spotting” or “peau d'orange” or “string of pearls” changes consisting of speckled, yellowish mottling of the posterior pole which is most noticeable temporal to the macula. This finding is virtually pathognomonic of pseudoxanthoma elasticum and it usually precedes the appearance of angioid streaks.[91] Other causes include syphilis, leukemia, systemic form of large-cell non-Hodgkin lymphoma, systemic carcinoma with bilateral diffuse uveal melanocytic proliferation, and idiopathic uveal effusion syndrome.[92]

36. Nagayama spots or uvulopalatoglossal spots are erythematous papules found on the soft palate and uvula in roseola infantum.[93]

37. Roth spots are white-centered retinal hemorrhages first described by Moritz Roth, a Swiss physician in 1872, initially considered to be a pathognomonic finding for bacterial endocarditis secondary to septic emboli within the retina. Recent data suggest that Roth spots are the result of retinal capillary rupture and intraretinal hemorrhage as a result of endothelial cell dysfunction. It can also occur in leukemia, anemia, hypertensive retinopathy, preeclampsia, diabetic retinopathy, and anoxia.[94]

  Spot Tests in Dermatology Top

38. Black spot test: The oxidation of urushiol oleoresin from Toxicodendron plants (black poison ivy, poison oak, poison sumac) forms the basis of the black spot test, which involves blotting an injured leaf or other plant material on a piece of white paper and waiting for black lacquer formation, a way to confirm the identity of the Toxicodendron plants.[14],[95]

39. Monospot test or mononuclear spot test is a latex agglutination test which utilizes equine erythrocytes as the primary substrate and tests for specific heterophile antibodies produced by the human immune system in response to infectious mononucleosis caused by EpsteinBarr virus. When these specific antibodies are present in the patient's blood specimen, exposure to equine erythrocytes will lead to clumping of the sample, thus signaling a positive agglutination reaction.[96],[97]

40. Spot tests in allergic contact dermatitis:

For certain allergens, such as nickel, cobalt, chromium, and formaldehyde, spot tests exist, which are quick and easy ways to assess exposures.

  1. Dimethylglyoxime spot test: For patients who are allergic to nickel, this test helps to detect the presence of releasable nickel from the surface of an object. A pink color indicates the presence of >0.5 μg nickel/cm2/week. In cases of suspected occupational exposure, the nickel spot test can be used directly on the hands.[98]
  2. Cobalt spot test: The dermal exposure to cobalt can be confirmed by using disodium-1-nitroso-2-naphthol-3,6-disulfonate.[99]
  3. Formaldehyde spot test: It can detect small levels of formaldehyde, in those sensitized but requires laboratory facilities.[100]
  4. Diphenylcarbazide test can detect chromium (VI).[101]

41. The nickel spot test is the best validated and has high specificity (97.5%) and moderate sensitivity (59.3%) in detecting the level of nickel ion release that may cause dermatitis.[102] The cobalt test is based on similar principles but is more difficult to read, and there is less experience with the test.[99] Using these tests to detect the presence of these metals in products can aid in avoidance.

41. Spot urine tests to assess heavy metals: It is a random urine test to assess the presence of excess heavy metals such as arsenic, lead, and mercury. It is the sampling of a single, untimed urine specimen voided spontaneously by the patient. A spot urine sample is the most commonly used sample type because its collection is relatively simple and non-invasive.[103] It is considered positive if arsenic levels exceed 50 ug/L, 100 ug/g creatinine, or 100 ug of total arsenic.[104] When the urine mercury concentration exceeds 100 μg/L, neurological symptoms can develop, and the level of 800 μg/L or above can be fatal[105]

42. Spot urine test in leprosy is a simple urine spot test for monitoring patient compliance to dapsone self-administration in leprosy therapy. This was first developed by H. Huikeshoven in Brazil. The test involves placing a drop of fresh urine on a strip of filter paper impregnated with Ehrlich's reagent. A yellow ring appears at the periphery, caused by urea, and an inner spot of orange color quickly develops when dapsone is present. The test is positive if the intensity of the central spot is equal to or greater than that given by control urine[106],[107]

  Spot Procedures in Dermatology Top

43. Spot dermabrasion (DA): DA consists of sequential planning of the raised skin/lesions with electrical and/or manual abraders and allowing the wound to heal by secondary intention, so as to achieve a leveling effect to make the lesions less conspicuous. Here, DA is done only over the lesion. Superficial spot DA till pinpoint bleeding (epidermabrasion) can be done for stable vitiligo in hairy area for faster repigmentation. For hypertrophic lichen planus, two sittings of deep spot DA are required. Other conditions were spot DA can be done includes papular lichen amyloidosis, tatto, striae, scars, lichen simplex chronicus, linear verrucous epidermal nevus, prurigo nodularis. Kindly mention the superscript 108 at the end of the sentence.[108]

44. Spot lasers: A presurgical test spot may be defined as the use of the contemplated modality in a small space (usually 1 cm2 or less), in an inconspicuous area or at the edge of the planned operative field. The advantages include evaluation of the efficacy of the procedure, better planning of a contemplated procedure, evaluation of the side effects and complications, and evaluation of the healing time.[109] Greenlight lasers often have a variable response, and thus, test spots may be prudent before treating the whole area.[110]

45. “Spot peeling” of discrete areas of hyperpigmentation may be useful since it would reduce the contrast between the normal skin and melanotic macules. It may also act as a test area when higher strength peels such as 25% trichloroacetic acid, Jessner's solution, or salicylic acid is used.[111] Common areas for test-spot testing include the lateral temple, anterior hairline, and preauricular region. The advantages of test-spot testing include the more accurate predication of peel efficacy, healing time, pigmentary response, and post-peel complications. It also facilitates the proper selection of candidates, alleviates their anxiety, and discourages impulsivity. The disadvantages of this technique include a delay of treatment, misrepresentative results, and the persistence of the test-spot until the definitive procedure takes place.[99],[112]

46. Timed spot freeze technique in cryotherapy allows greater standardization of liquid nitrogen delivery. It is performed with a small spray gun that typically holds 300–500 mL of liquid nitrogen. For the standard spot freeze technique, the nozzle of the spray gun is positioned 1–1.5 cm from the skin surface and aimed at the center of the target lesion. The spray gun trigger is depressed, and liquid nitrogen is sprayed until an ice field (or ice ball) encompasses the lesion and the desired margin. The timed spot freeze technique achieves temperatures that are adequate for tissue destruction in an ice field up to 2 cm in diameter.[113]

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