Floral Eponyms in Dermatology: A Blooming Collection of Patterns, Signs, and Appearances

Introduction Nature-inspired patterns, analogies, and terminologies have long played a pivotal role in medicine, often aiding in the recognition and understanding of clinical conditions. Dermatology, with its rich visual spectrum, has embraced such references extensively, particularly from flora. This article delves into a variety of “flower-inspired” analogies and descriptions in dermatology, encompassing infections, dermoscopic features, histopathological findings, and miscellaneous conditions, which are summarized in Table 1.Table 1: Summary of floral eponyms in dermatology: Patterns, signs, and appearancesA. Infections: Rose gardeners’ disease – Sporotrichosis:Sporotrichosis is a chronic subcutaneous fungal infection caused by Sporothrix schenckii complex, a group of dimorphic fungi found on decaying vegetable matter, tree barks, moss, shrubs, thorns, and soil. The infection is typically acquired through the traumatic implantation of fungus into the skin after a thorn prick or minor trauma, commonly affecting gardeners, forest workers, and manual laborers, and subsequently develops into a chronic granulomatous mycosis referred to as “rose gardeners’ disease.”[1] It can manifest as cutaneous (fixed, lymphocutaneous, and disseminated forms) and extracutaneous involvement, such as pulmonary, osteoarticular, and neurologic complications in immunocompromised individuals. The lesions typically present as painless papules or pustules that evolve into ulcerated nodules, often spreading along lymphatic channels in a sporotrichoid pattern [Figure 1]. The fixed cutaneous form appears as localized verrucous, ulcerative, or erythematous plaques without lymphatic spread.[1]Rose spots – Typhoid fever:Rose spots, seen in 15%–30% of enteric fever cases, are asymptomatic, 2–4mm erythematous macules that blanch on pressure. It is also reported in psittacosis, leptospirosis, brucellosis, rat-bite fever, and shigellosis. They appear in crops within the first week of illness and disappear within 35 days. These lesions are typically found on the trunk, extending to the extremities and back, due to bacterial inflammatory response.[2,3]Dew drop on rose petal appearance– Varicella:The “dew drop on a rose petal” appearance is a typical cutaneous manifestation of varicella (chickenpox) [Figure 2], characterized by clear fluid-filled vesicles surrounded by an erythematous halo, resembling a dew drop on a rose petal.[4,5]Corymbose pattern - Secondary syphilis:The term “korymbos,” derived from Greek, refers to a convex cluster resembling a “flat-topped flower bouquet.” It describes a central papule surrounded by smaller lesions, often seen in secondary syphilis, accompanied by fever and lymphadenopathy.[6,7]Rose-colored rash - Roseola infantum:Roseola infantum, or sixth disease, is caused by human herpes virus (HHV)-6 and occasionally HHV-7. It affects infants under 2 years, presenting with high fever for 1–5 days, followed by a sudden rash of blanching and rose-pink macules and papules on the trunk, spreading outward. It is self-limiting and managed supportively.[8]Roseolar syphilide - Secondary syphilis:Roseolar syphilide, also known as roseola syphilitica, is a common cutaneous manifestation of secondary syphilis, caused by Treponema pallidum. It is a macular eruption characterized by 0.5–2 cm discrete, pink, round-to-oval macules predominantly distributed on the trunk, upper extremities, palms, and soles.[9] Figure 1: Sporotrichoid pattern of rose gardeners disease on the thigh of an 8-year-old boy with erythematous, ulcerative, nodular lesions along lymphatic channelsFigure 2: Clinical image of varicella presenting with a typical dew drop on a rose petal appearance, featuring fluid-filled vesicles on an erythematous base, observed on the backB. Dermoscopy: Dahlia-like pattern – Filiform wart:The “dahlia-like pattern” is a dermoscopic feature of verruca filiformis [Figure 3a and b], characterized by tapered, finger-like projections with keratotic white tips and pigmented zones, resembling the flower petals of a dahlia.[10]Daisy pattern - Chondrodermatitis nodularis helices (CNH):Dermoscopic findings of CNH reveal a “daisy pattern,” with thick white lines radiating towards a central yellow/brown clod, representing keratin or sero-crust.[9] CNH is a benign, painful inflammatory condition, presenting as firm, skin-colored to red papules with a central keratotic or crusted area on the ear.[11]Cherry blossom vascular pattern - Seborrheic dermatitis:The trichoscopic appearance of seborrheic dermatitis shows multiple glomerular and comma vessels surrounding a conglomerate of arborizing vessels, giving a cherry-blossom vascular pattern.[12]Day lily pattern – Macular amyloidosis:Alternating white and brown streaks radiating from a central white hub, is noted on dermoscopy of the lesions in macular amyloidosis [Figure 4]. This closely resembles the alternating yellow and reddish-brown petals of a day lily flower.[13]Rosette sign:The four-dot sign, also known as rosettes, appears as four bright white globules resembling a four-leaf clover in dermoscopy. While characteristically seen in actinic keratosis and squamous cell carcinoma, it has also been reported in various conditions such as basal cell carcinoma, lichen planus, lichen sclerosus et atrophicus, discoid lupus erythematosus, apocrine hidrocystoma, dermatofibroma, melanoma, and molluscum contagiosum. This phenomenon is believed to result from an optical interaction between polarized light and follicular structures. Smaller rosettes arise from polarized horny material at adnexal openings, whereas larger rosettes are attributed to perifollicular fibrosis.[14]Tulip bulb hairs – Trichotillomania:Tulip hairs are short, light-colored hairs with dark, flared, tulip-shaped ends caused by diagonal hair shaft fractures. This specific finding, first named by Rakowska et al.,[16] is characteristic of trichotillomania but may also appear in conditions such as alopecia areata and traction alopecia. The stout, hyperpigmented ends result from repeated pulling or trauma, leading to a diagonal fracture. Tulip hairs provide valuable diagnostic clues in hair disorders.[15-17]Lotus leaves on the water – Keratosis follicularis squamosa (Doha):Keratosis follicularis squamosa (KFS) is a keratinizing disorder primarily reported in Japan, characterized by asymptomatic, scaly patches with elevated margins and brown follicular papules. Commonly located on the trunk and thighs, it is diagnosed based on its unique appearance, described as “lotus leaves on the water.” Histology reveals dilated hair follicles with follicular plugs surrounded by lamellar orthohyperkeratosis.[18,19] Figure 3: Clinical image (a) shows a filiform wart on the left side of the chin, while polarized dermoscopy (DL4 10x) (b) reveals a dahlia flower-like pattern with a tapered finger structures, keratotic white tips, and pigmented zonesFigure 4: Polarized dermoscopy (DL4 10x) reveals a “day-lily” pattern (red circle) characterized by parallel lines and interspersed pigmented streaks, a distinctive feature of macular amyloidosisC. Histopathology: Daisy appearance – Telogen hair:The “daisy appearance” in transverse scalp biopsy sections is characterized by a central keratinized club hair surrounded by concentric layers of collapsed outer root sheath, resembling daisy petals [Figure 5]. This pattern helps identify telogen hair, aiding in diagnosing conditions such as telogen effluvium.[20] Figure 5: H and E section (40x) showing a telogen hair in the transverse section with a characteristic “daisy pattern”D. Miscellaneous: Tulip fingers - Allergic contact dermatitis to tulip:Allergic contact dermatitis to tulip species, common among tulip pickers, presents as erythematous scaly plaques with painful fissuring on the fingertips and periungual areas, termed “tulip fingers.” Tuliposide A is the main allergenic compound. Similar reactions occur with Alstroemeria, garlic, and daffodils. Diagnosis is confirmed through patch testing.[21,22]Rose petal appearance– Pigmented fungiform papillae:Pigmented fungiform papillae present as ovoid hyperpigmented projections with dichotomized vessels resembling “rose petals.” Seen in darker-skinned individuals, it is distinct from clinical mimics such as oral melanotic macules or Addison’s disease. Histopathology shows melanophages, positive for melanin and negative for iron.[23]Heliotrope erythema in dermatomyositis:The heliotrope rash is a characteristic skin finding of dermatomyositis, presenting as a violaceous or erythematous rash on the upper eyelids with or without periorbital edema [Figure 6]. It is more noticeable in lighter skin, resembling the heliotrope flower. It occurs bilaterally and is seen in patients aged 5–15 and 40–60 years.[24]Rose sign in deep vein thrombosis:Rose sign in deep vein thrombosis is characterized by the skin of one leg feeling warm and stiff when pinched, indicating localized inflammation.Sunflower-like configuration of intraepidermal neutrophilic type of IgA pemphigus:The “sunflower-like” pattern in IgA pemphigus refers to the clinical appearance of flaccid vesiculopustules arranged in an annular fashion with central crusting [Figure 7]. This distinctive configuration is seen in the intraepidermal neutrophilic subtype, often resembling the petals and center of a sunflower.[25]Daffodil picker’s rash in irritant contact dermatitis to daffodil:Daffodil picker’s rash is an irritant contact dermatitis characterized by erythema, fissures, and scaling on areas exposed to daffodil sap. It occurs in individuals handling daffodils, as the sap contains needle-shaped calcium oxalate crystals (raphides). When the stem is snapped, these crystals, along with alkaloids, cause skin irritation.[26] Figure 6: A 42-year-old female with heliotrope rash presenting as violaceous erythema with periorbital edema, a characteristic cutaneous manifestation of dermatomyositisFigure 7: A case of IgA pemphigus showing characteristic “sunflower-like” lesions, with annular or circinate pustules surrounding a central patch of crusted erythemaConclusion The use of flower-inspired analogies in dermatology demonstrates how nature’s forms and patterns continue to influence medical terminology and diagnostics. These vivid descriptions enrich the understanding of dermatological conditions, bridging science and art. Recognizing these analogies enhances diagnostic acumen and adds a layer of appreciation for the intricate interplay between dermatology and the natural world. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Use of artificial intelligence (AI) The preparation of this manuscript was carried out entirely by the author without the use of artificial intelligence technologies.