SEMINAR FOR CLINICIANS

Differentiating Pneumothorax from the Common Radiographic

Skinfold Artifact
M. Obadah Kattea*1 and Omar Lababede2
1
Cleveland Clinic and 2Thoracic Imaging Section, Imaging Institute, Cleveland Clinic, Cleveland, Ohio

Abstract
Pneumothorax can be a critical medical condition. The radiographic
curvilinear appearance of pneumothorax can be mimicked by a skinfold
artifact. Radiographic differentiation of the two entities is achieved in
most cases by careful analysis of the characteristics of the linear shadow
and its course. A thin, sharply defined opaque density representing the
visceral pleura is the hallmark of pneumothorax. The added density of
a skinfold presents as a broad opacity, which is outlined laterally by
a sharply defined lucent line as a result of the Mach band effect and
adjacent air. Unlike pneumothorax, a skinfold produces a line that does
not follow the expected course of visceral pleura. Additional features,
such as the absence of increased lucency laterally and the projection of
lung markings across the curvilinear shadow, can help in the correct
identification of skinfolds. Repeating the chest radiograph or using
other imaging modalities can be considered in difficult cases.
Keywords: pleura; intensive care unit; diagnostic imaging

(Received in original form December 14, 2014; accepted in final form April 11, 2015 )
*M.O.K., an international medical graduate, participated in the production of this article during an observership at the Cleveland Clinic.
Correspondence and requests for reprints should be addressed to Omar Lababede, M.D., Thoracic Imaging Section, Imaging Institute, Cleveland Clinic,
9500 Euclid Avenue, L10, Cleveland, OH 44195. E-mail:lababeo@ccf.org
Ann Am Thorac Soc Vol 12, No 6, pp 928–931, Jun 2015
Copyright © 2015 by the American Thoracic Society
DOI: 10.1513/AnnalsATS.201412-576AS
Internet address: www.atsjournals.org

Pneumothorax is a leak of air into the
pleural space that causes collapse of the lung.
It is important to recognize pneumothorax
early, as it can be a life-threatening
condition and may require immediate
intervention. Pneumothorax is encountered
in the intensive care unit (ICU) setting
secondary to barotrauma from mechanical
ventilation or after invasive procedures,
such as line placement or thoracentesis.
Plain chest radiography remains the
most frequently used imaging modality
for diagnosing pneumothorax. The current
Picture Archiving and Communication
System (PACS) environment enables
clinicians to have access to the actual
radiographic images, sometimes even
before they are formally interpreted.
Skinfold shadow is a frequent artifact on
the anterior–posterior (AP) portable chest
radiographs of patients in the ICU. It is caused
by compression of redundant skin of the back
against the film, especially in older patients or
those with weight loss. When the curved
shadow of the skinfold projects over the lung,
it can mimic the visceral pleural margin and
can be misinterpreted as a pneumothorax (1).
This article reviews the radiographic
features that help in differentiating
pneumothorax from the artifact of skinfold
and briefly discusses alternative approaches
in challenging cases.
Radiographic Differentiation
of Pneumothorax from
Skinfold Artifact
In most cases, meticulous analysis of the
characteristics of a linear shadow on a chest
radiograph will be sufficient to determine its
true nature, that is, pneumothorax or
skinfold artifact.
Radiographic Findings
of Pneumothorax
Pneumothorax is an air collection in the
pleural space. The visceral pleural surface
retracts along with the collapsing lung, while
the parietal pleura remains attached to the
chest wall. The lung collapses toward the
hilum and the pneumothorax tends to
collect in the least dependent aspect of
the chest. Therefore, the radiographic
appearance of pneumothorax depends
primarily on the positioning of the body.
Other factors may also influence the
manifestations of pneumothorax on chest
radiographs. Such factors include the size of
the pneumothorax and the presence of
underlying lung or pleural disease.
On the standard upright view, air
typically starts to collect in the apical region
and laterally more than medially. The
displaced visceral pleura generally becomes
visible radiographically as a thin, sharply
defined opaque (white) line, which is
outlined by the lucent (dark) air-filled lung
on its hilar side and by the somewhat more
lucent (darker) air of the pneumothorax on
the chest wall side (Figures 1A and 1C).
The visceral pleural line can be thickened

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collapse of the various pulmonary lobes.

Mediastinal shift to the contralateral side
is seen in large pneumothorax, especially
in the presence of tension. Subcutaneous
emphysema can be seen in the presence
of rib fracture, recent intervention, or
barotrauma (1–3).
In supine chest radiographs, which are
frequently obtained in ICUs, pneumothorax
becomes more difficult to detect (4). In this
position, the air collects in the anterior
costophrenic sulcus and increases the
lucency over the upper abdomen. The
lateral costophrenic angle becomes deeper
and more lucent compared with normal
(deep sulcus sign) (2–4). The visceral
pleural line can be sometimes visible in
the apicolateral region, especially with the
increase in size of pneumothorax (5).
A detailed discussion of supine chest
radiographic (CXR) findings in
pneumothorax is beyond the scope of
this article.
The radiographic findings in
a semiupright/semirecumbent CXR, which
is sometimes obtained in the ICU, depend
on the degree of inclination. In general, the
apicolateral collection of pneumothorax is
more frequent in the semiupright CXR
Figure 1. Radiographic findings of pneumothorax and artifacts related to skinfolds. (A) Upright compared with the supine view. However,
posterior–anterior chest radiograph of a 27-year-old male with spontaneous pneumothorax.
the air collection can be more anterior if the
The subtle extrapulmonary increased lucency of the pneumothorax (PTX) is outlined by the
visceral pleura, a sharp thin radiopaque linear shadow (white arrows). The lung is partially
inclination is closer to the supine position,
collapsed with no lung markings beyond the visceral pleura. (B) Portable anterior–posterior rendering a small pneumothorax more
chest radiograph of a 54-year-old male. Multiple skinfolds (SF) appear as wide curvilinear opaque difficult to detect (5).
shadows, which are sharply demarcated laterally by fine lucent lines (black arrows). Medially,
the shadows of the skinfolds fade gradually. The lung markings are present beyond some of Radiographic Features of the
the skinfolds (white arrow). The normal radiographic texture of the lung parenchyma can be Skinfold Artifact
observed on both sides of the fold shadow without actual increase in lucency laterally. The A skinfold in the chest wall may produce
skinfolds do not follow the expected course of the pleura with abrupt termination. One of the folds a curvilinear opaque (white) shadow over
extends over the chest wall (the lowermost black arrow). (C and D) Unmarked close-up views the lung that can mimic pneumothorax.
of chest radiographs (A) and (B), respectively.
There are several characteristics of this
artifact that help to differentiate it from
pneumothorax. The added density of
a skinfold produces a wide (broad) opaque
in the presence of pleural disease. It can between a small pneumothorax and the lung density that fades gradually on the hilar side
also be difficult to visualize discretely in can be subtle. Typically, no lung markings (centrally). The lateral margin of a skinfold
the presence parenchymal abnormalities, are present in the region of pneumothorax, is somewhat sharply defined by a lucent
such as subpleural airspace opacities as the lung collapses centrally. However, this line, likely related to a Mach band effect
or complete collapse of the lung. sign should be used with caution, because and the presence of air. The Mach band
The air outside the lung in the markings are normally not visualized effect is an edge enhancement phenomenon
pneumothorax can produce an increase in the most peripheral aspect of the lungs. at the margin between objects with different
in lucency (darkness) in the pleural cavity The markings are also relatively less contrast or luminance. This results in the
because of the lower density of the air prominent in the upper lungs. perception of brighter and darker lines along
relative to the lung, which contains soft Some pulmonary conditions, such the margin. This visual illusion is caused by
tissues and blood in addition to air. The as emphysema or bullous disease, can lateral inhibition of bipolar neurons by
degree of increase in lucency correlates with be associated with a paucity of lung horizontal cells in the retina (6).
the size of the pneumothorax (i.e., the markings. Infrequently, lung markings can The area lateral to the sharp margin of
pneumothorax becomes more lucent as it project beyond the visceral pleura in the skinfold artifact can be perceived as
increases in size). The difference in lucency pneumothorax, such as in cases with uneven more lucent (darker) than the lung medial to

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Table 1. Differentiating findings of pneumothorax and skinfold: Summary

Pneumothorax Skinfold

Characteristics of linear shadow d Thin d Broad

d Sharply defined d Ill-defined medially
d Opaque (white) d Opaque (white) but outlined by a sharp linear
lucent (dark) line laterally
Conformity of linear shadow with visceral Yes No (abrupt termination and crossing over the
pleural anatomy chest wall)
Lung markings crossing linear shadow Absent Present
(Pitfall: absent markings in peripheral skinfold
or in the presence of emphysema)
Increased lucency laterally Present Absent
(Pitfall: can be subtle in small (Pitfall: perception of relative lucency lateral to
pneumothorax) the added density of the skinfold)
Lung collapse Present Absent
Mediastinal shift Contralateral in large or tension Absent
pneumothorax

it. This is due to the visual effect of the added
density of the skinfold rather than to a true
change in lucency. In addition, the lung
markings and the radiographic granular
texture of normal lung parenchyma can still
be seen beyond the linear shadow of the
skinfold (1, 2). The usefulness of this
feature is limited when the suspected
skinfold projects over the peripheral and
upper aspects of the lung, because the lung
markings are normally difficult to identify
in these regions.
The linear shadow of a skinfold does
not follow the expected course of separated
visceral pleura and can terminate abruptly
over the lung parenchyma or can extend
over the chest wall beyond the boundaries of
the pleural space (3). Sometimes more than
one skinfold can be present, producing
two or more parallel lines over the lung
(Figures 1B and 1D).
The differentiating features between
pneumothorax and the skinfold artifact are
summarized in Table 1. The radiographic
findings and differences between
pneumothorax and skinfold are illustrated
in Figure 2 as well.
Alternative Approaches in
Challenging Cases with
Radiographically Suspected
Pneumothorax versus
Skinfold Artifact
The differentiation of pneumothorax from
skinfold on chest radiograph can be difficult
in some cases. Because the exact appearance
of a skinfold is rarely reproducible, repeating
the chest radiograph can help clarify the
nature of an equivocal linear shadow.
Performing the repeated radiograph with
the patient in a more upright inclination
will help increase its accuracy in detecting
pneumothorax. However, repeating the
examination involves additional exposure
to radiation and can cause some delay in
management.
Ultrasound evaluation for
pneumothorax has been reported to be more
sensitive than portable chest radiography
(7, 8). In a meta-analysis review, the

Figure 2. Schematic illustration of the
radiographic findings and differences between
pneumothorax and artifacts related to skinfolds.
Axial cross-sections of the chest in the cases of
(1) pneumothorax and (2) skinfold show the
direction of the X-ray beam (black dashed lines)
in anterior–posterior (AP) projection. The gray lines under the chest represent the radiographic films.
Note the skinfold (*) posteriorly in (2). The relative radiographic densities and the characteristics of
pneumothorax (PTX) and skinfold (SF) are shown in (3) and (4), respectively. The shading of the
drawings mimics the radiographic densities of the various structures (air, black; lung tissue, dark gray;
soft tissues, gray). A = air outside the body; CW = chest wall; L = lung; M = mediastinal structures;
VP = visceral pleura. Pneumothorax is more lucent than the lung. No lung markings extend
beyond the visceral pleura (VP; blue arrow). The band of skinfold (SF; red arrow) is wide and is
outlined laterally by a lucent thin line (black arrow). The ill-defined medial margin of the band is
gradually fading. The lung markings extend beyond the shadow of the skinfold. (5) and (6) represent
AP chest radiographic projections in the cases of pneumothorax and skinfold, respectively. The subtle
increased lucency of PTX is separated from the lung by a sharp thin opaque line, which conforms to
the anatomy of the visceral pleura (white arrows). The lung markings are absent lateral to this line.
The wide shadow of skinfolds (SF) is demarcated laterally by a lucent sharp margin (black arrows),
whereas the medial margin is gradually fading. The normal density of the lung is present on both sides
of the shadow without any actual increase in lucency laterally. The lung markings project beyond the
skinfold, which extends outside the boundaries of the pleura.

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Table 2. Comparison of imaging modalities used in diagnosing pneumothorax
CXR US CT
Accuracy 1 11 111
Exposure to ionizing radiation 1 None 111
Cost 1 1 111
Availability and ease of performance 11 111 1 Summary
Time (delay) to achieve diagnosis 11 1 111
Definition of abbreviations: CT = computed tomography; CXR = chest radiograph; US = ultrasound.
Note: The number of plus symbols (1, lowest; 111, highest) used in this table is intended for
comparative (not quantitative) purposes, and does not indicate positive effect or advantage.
sensitivity of ultrasound for detecting disease and the operator-dependent nature
pneumothorax was 90.9% (95% of this imaging modality. Selecting which
confidence interval [CI], 86.5–93.9) approach to use depends on availability and
and the specificity was 98.2% (95% CI, the patient condition.
97.0–99.0). The reported sensitivity of chest In rare instances, repeating the chest
radiography was 50.2% (95% CI, 43.5–57.0) radiograph and ultrasound may not resolve
and the specificity was 99.4% (95% CI, the questionable radiographic findings. In
98.3–99.8) (9). such cases, computed tomography (CT)
Ultrasound has been increasingly used of the chest can be performed. CT is
to evaluate for pneumothorax, and it may considered the “gold standard” imaging
replace chest radiography as the procedure modality in detecting pneumothorax.
of choice in certain clinical settings. In cases Compared with chest radiography, CT
with questionable radiographic findings, imaging requires more time and resources
ultrasound provides a real-time bedside to perform, and it exposes the patient to
verification of the presence or absence of a much higher radiation dose. Other
pneumothorax. The immediate availability disadvantages include the high cost and
and high sensitivity of ultrasonography are difficulty to perform in some ICU patients.
of great advantage in managing critically ill Although CT has been used as the standard
patients. The main limitations of ultrasound criterion for evaluating the accuracy of
include the presence of preexisting lung ultrasound and CXR in detecting
pneumothorax, its accuracy can be affected
by breathing motion artifacts. Table 2
compares the various imaging modalities in
the evaluation of pneumothorax.
A skinfold can produce a linear shadow on
a chest radiograph that can be mistakenly
interpreted as pneumothorax. Recognizing
the distinctive features of each of these
conditions is essential in avoiding such
a pitfall. Pneumothorax is diagnosed by
detecting a fine, sharply defined opaque
line representing the displaced visceral
pleura. The area on the chest wall side
of the line is typically more lucent than
the lung on the hilar side. The lung
markings in most cases do not traverse
across the line. Conversely, a skinfold
artifact appears as broad opacity with
gradually fading medial margin and
sharply defined lucent linear lateral margin.
The lung markings cross this margin with
no true increase in lucency on the chest wall
side of the linear artifact. In addition, the
skinfold shadow does not conform to the
expected course of separated visceral
pleura. n
Author disclosures are available with the text
of this article at www.atsjournals.org.

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