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Pseudo-Leser-Trélat sign in a Christmas tree pattern
*Corresponding author: Linza P. Zachariah, Department of Dermatology, Aswini Hospital Limited, Thrissur, Kerala, India. linzajojy@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Zachariah LP, Najma P. Pseudo-Leser-Trélat sign in a Christmas tree pattern. J Skin Sex Transm Dis. doi: 10.25259/JSSTD_169_2025
A 54-year-old male, with no known comorbidities, presented with a sudden onset of multiple asymptomatic, hyperpigmented lesions on the back of the trunk. On examination, there were numerous waxy papules and plaques, ranging in size from 0.5 × 1 cm to 2 × 3 cm, with a distinct stuck-on appearance, distributed in a Christmas tree [Figure 1a]. Dermoscopic evaluation revealed characteristic features, including gyri and sulci, comedo-like openings, milia-like cysts, and a moth-eaten border, suggestive of seborrheic keratoses [Figure 1b]. Given the abrupt eruption and patterned distribution of the lesions, the Leser–Trélat sign was considered. However, thorough systemic evaluation – including laboratory investigations and imaging – revealed no evidence of internal malignancy.
- Multiple hyperpigmented papules and plaques with a stuck-on appearance, distributed in a Christmas tree pattern; (b): Comedo-like openings (yellow arrow), milia-like cysts (white arrow), and moth-eaten border (green arrow) (DermLite DL4 Dermoscope, CA, USA, polarized mode 10x).
Based on these findings, a diagnosis of Pseudo-Leser-Trélat sign in a Christmas tree pattern was established. The sudden appearance of multiple seborrheic keratoses is classically associated with the Leser-Trelat sign, often linked to aggressive internal malignancies. However, similar presentations without an underlying malignancy are classified as the Pseudo-Leser-Trélat sign. The Christmas tree distribution, though rare in this context, has been previously described in viral exanthems and pityriasis rosea. The morphology may represent a tadpole or raindrop-like variant of seborrheic keratosis, a form that has been attributed to friction or a Koebner-like phenomenon. This case highlights the importance of distinguishing the Pseudo-Leser-Trélat sign from its malignant counterpart. Accurate diagnosis requires detailed history, clinical examination, and appropriate investigations to rule out occult malignancy and avoid unnecessary anxiety or interventions.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for their images and other clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
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