The blueberry sign Nadir Goksugur1, MD, Sevil Bilir Goksugur2, MD, Betul Sereflican1, MD, and Hatice Kaya1, MD

Departments of 1Dermatology, and 2 Pediatrics, Faculty of Medicine, Abant Izzet Baysal University, Bolu, Turkey Correspondence Nadir Goksugur, MD Department of Dermatology Faculty of Medicine Abant Izzet Baysal University 14280 Golkoy Bolu Turkey E-mail: [email protected] Conflicts of interest: None.

Case report Cryotherapy is an effective treatment modality for various skin diseases. It is most commonly used to destroy viral warts, actinic keratosis, and seborrheic keratosis. Although cryotherapy is a relatively safe procedure, it can have a wide variety of side effects.1 A 14-year-old boy presented with a wart over the dorsum of his right hand. The lesion was treated with two freeze–thaw cycles of cryotherapy using an open-spray technique with freeze time of 15 s. A painful, blue–black, hemorrhagic blister developed over the posterior of the


Figure 1 A 14-year-old boy displays the blueberry sign, a blueberry-like, tense, hemorrhagic bulla on the dorsum of the hand following cryotherapy International Journal of Dermatology 2015, 54, 1064–1065

right hand on day 3 of treatment (Fig. 1). Because it so closely resembled a blueberry fruit (Fig. 2), we named this phenomenon the blueberry sign. Neither the patient’s history nor laboratory investigations revealed any systemic disorder, and the lesion healed completely.

Figure 2 The blueberry fruit ª 2015 The International Society of Dermatology

Goksugur et al.

Discussion In most cases, the first-line choice for the destructive treatment of warts is cryotherapy. As its main mechanism of action is based on freezing, erythema, edema, pain, the formation of tense blisters filled with clear fluid (rarely hemorrhagic), and the oozing of fluid are all common results of cryotherapy. Other occasional side effects of cryotherapy include infection, scar development, dyspigmentation, and damage to underlying tissue (nerves, tendons).1 Many clinicians accept blister formation as indicative of the efficacy of treatment. However, in rare situations extensive hemorrhagic blisters may reflect an underlying hematologic disorder.2 In such circumstances, the appropriate laboratory investigations must be performed. In dermatology, the Auspitz sign is well known in the context of psoriatic lesions. It refers to the development of bleeding at punctate spots when psoriasis scales are scraped off. This is a characteristic feature of psoriasis and reflects tortuous, dilated, and elongated blood vessels within the dermal papillae, which bleed easily. As in the Auspitz sign, the development of hemorrhagic bullae following cryotherapy indicates that the depth of freeze has extended to the dermal papillae. It also means that treatment will be successful.

ª 2015 The International Society of Dermatology

Blueberry sign


Medical knowledge is increasing exponentially, and thus its assimilation is becoming more demanding. The use of acronyms and other terms for well-defined signs saves time in medical education and in communication with patients.3 Using signs is also an easy way to explain the properties of disease or the possible outcomes of treatments to patients.3,4 It is easier to understand, learn, define, teach, and remember the content of a subject area if the signs of its medical manifestations can be named appropriately according to the resemblances they show. References € ktasß M, Yardˇmcˇ G, et al. Evaluation 1 Kutlubay Z, K€ ußcu of effectiveness of cryotherapy on the treatment of cutaneous Kaposi’s sarcoma. Dermatol Surg 2013; 39: 1502–1506. 2 Hancox JG, Graham GF, Yosipovitch G. Hemorrhagic bullae after cryosurgery in a patient with hemophilia A. Dermatol Surg 2003; 29: 1084–1086. 3 Madke B, Nayak C. Eponymous signs in dermatology. Indian Dermatol Online J 2012; 3: 159–165. 4 Kangle S, Amladi S, Sawant S. Scaly signs in dermatology. Indian J Dermatol Venereol Leprol 2006; 72: 161–164.

International Journal of Dermatology 2015, 54, 1064–1065


The blueberry sign.

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