pain, the appearance of grouped vesicles upon inflammatory bases, with
no tendency to rupture, and the limitation of the eruption to one side
of the body, are sufficiently characteristic. The vesicles are larger
than those of eczema, and lack the well-known tendency of the latter to
break and discharge a gummy fluid which rapidly forms to crusts. In
erysipelas the line of demarcation, the deep-reddish color, and the
constitutional symptoms will serve to differentiate the diseases. It is
to be distinguished from simple herpes by its location, number of
groups, unilateral distribution, and absence of relapses. The prognosis
is favorable, as the eruption usually disappears at the end of two or
three weeks; severe cases, however, may last a month or more. When
involving the eye, the possibility of its destroying the same, and even
of a fatal result, is to be kept in mind. In elderly subjects the
neuralgic symptoms are apt to prove persistent.
Treatment is mainly expectant. The disease is self-limited, and hence
severe measures are to be avoided. Internal treatment has, so far as
experience shows, very little influence upon its course. Phosphide of
zinc, in one-third grain doses every three hours, at times seems to
have a beneficial effect. Morphia, hypodermically or by the mouth, is
required if the neuralgia is severe. The galvanic current, applied once
or twice daily, will sometimes quiet the pain and favorably influence
the course of the disease. Locally, the parts are to be protected from
irritation. For this purpose dusting-powders, to which a small quantity
of morphia and camphor may be added, may be employed. The parts should
be further protected with a bandage. Oxide-of-zinc ointment, and
anodyne ointments containing powdered opium or belladonna, may also be
used. Painting the efflorescence with oil of peppermint or with
solutions of menthol, thymol, or carbolic acid will be found to relieve
the burning and pain; so also, flexible collodion, containing ten
grains of morphia to the ounce, will sometimes afford relief. The parts
subsequently may be covered with a layer of cotton batting.
Dermatitis Herpetiformis.
This disease is multiform and protean in character, consisting in the
formation of herpetic, erythematous, vesicular, pustular, and bullous
lesions, occurring separately or in various combinations, accompanied
with itching and burning sensations and pursuing usually a chronic
course with relapses.
This affection, which until recently has been confounded with other
{612} cutaneous diseases, is rare, although as its peculiar features
become belter known numerous cases will doubtless be reported. It was
first described by one of us (Duhring) in a paper read before the
American Medical Association in 1884. It is an inflammatory disease of
an herpetic character, the various lesions showing more or less
tendency to group. In some of its forms it bears likeness to erythema
multiforme and herpes iris, while in other cases it is allied to
pemphigus. It varies greatly in the degree of development. The causes
are varied, though in many cases they are neurotic in their nature;
thus, the disease may follow shock to the nervous system. It is also
met with accompanying the parturient state. In some cases it is
septicæmic in origin. It is also at times due to irregular
menstruation. As to sex, while more frequent in women, it is also
encountered in men. In severe cases there is more or less
constitutional disturbance, consisting of malaise, slight fever, and
constipation, accompanying the onset of the disease or its relapses and
exacerbations. Increased heat of skin, itching, and burning are also
prominent symptoms at such periods.
The disease manifests itself in the erythematous, vesicular, bullous,
pustular, and multiform varieties. The erythematous variety is
characterized by patches or a diffuse efflorescence of an urticarial or
erythema-multiforme-like nature, the similarity to the latter process
being sometimes marked. The disease may remain in this form, or, as is
usually the case, may pass into other varieties, especially the
vesicular. This latter is the usual form of the disease. It is
characterized by variously-sized, flat or raised, irregularly-shaped or
stellate, glistening vesicles, as a rule without marked areolæ. They
are usually firm and distended, are often difficult to detect, and have
an herpetic look, being grouped into clusters of two, three, or more.
Here and there they are aggregated into patches. When in close
proximity they tend to coalesce, forming large irregularly-shaped,
oblong, or lobulated vesicles, or even blebs. The eruption is usually
profuse. The most striking symptom is the itching, which in most cases
is severe or even intense. The vesicles make their appearance, as a
rule, slowly, several days or a week being required for their complete
development. This variety of dermatitis herpetiformis (formerly
described with the name herpes gestationis) is liable to be confounded
with vesicular eczema, but the irregularity in the size and shape of
the vesicles; their angular or stellate outline, giving them a puckered
look; their firm, tense walls, showing no disposition to spontaneous
rupture,--will all serve in the diagnosis. In some cases the
constitutional disturbance and the magnitude of the eruption, as
regards profusion, distribution, and multiformity, will also be
apparent.
In the bullous variety the lesions are more or less typical blebs,
variable as to size and shape, seated upon a slightly inflamed or
non-inflammatory base. They tend to group into small clusters, in which
case the skin between them will be red, as occurs in herpes zoster.
Together with the blebs, vesicles and small or even minute whitish
pustules will usually be found, the combination of these varied lesions
being sometimes remarkable. The blebs generally rupture or are broken
by injury, and become the seat of yellowish or brownish crusts. This
variety of the disease is liable to be confounded with pemphigus, but
differs in its marked herpetic and more inflammatory aspect.
{613} The pustular variety is generally less clearly defined than the
vesicular, because the lesions are usually intermingled with vesicles,
vesico-pustules, and blebs. The pustules are acuminate, rounded, or
flat, are variable as to size, and are whitish or yellowish in color.
The smallest are generally flat, sometimes being no larger than a
pinpoint or pinhead, while those that attain the size of a pea are
rounded or acuminate, and are surrounded with a marked red areola. The
largest are flat, and incline to spread out and to run together,
forming patches which later become covered with greenish crusts.
Grouping occurs here as in the other varieties, and is sometimes
peculiar in that a central pustule may be surrounded by a variable
number of smaller pustules in a circinate form, as in herpes iris. This
variety of the disease is the same condition described by Hebra with
the title impetigo herpetiformis.
The papular manifestation is an ill-defined form of disease, consisting
of small reddish, firm, more or less grouped papules, resembling in
general appearance the papular lesions sometimes met with in abortive
herpes zoster. They resemble at times also certain phases of relapsing
chronic papular eczema. Owing to itching and scratching they are
generally excoriated.
Finally, there remains to be described the multiform variety, which
consists of several of the foregoing varieties occurring in
combination, a phase of the disease which is not infrequent. It
comprises erythematous, sometimes slightly raised, urticarial patches
of variable size and shape, often marginate or confluent, and of a
reddish, yellowish, or variegated color. In addition, there may be
present more or less well-defined irregularly-shaped or rounded
maculo-papules and flat patches of infiltration, papules, and
papulo-vesicles in various stages of evolution. Vesicles, blebs, and
pustules may also exist, together with pigmentation. Thus it will be
noted there exists a mixture or combination of lesions, calling to mind
the peculiarities of eczema, although the process is both more
capricious and varied in its behavior.
It must also be stated that the disease may at any period change its
type; thus the vesicular variety may exist for weeks or months, to be
followed by a crop of blebs or of pustules. The mingling of several
varieties at one or another period in the course of the affection is
usually a marked feature. It is variable in its course, but is in most
cases chronic, and not infrequently is of many years' duration. It
inclines to persist and to show itself in distinct crops or attacks at
irregular intervals, the patient in the mean time being comparatively
free of eruption. Relapses are common. It is in most cases very
rebellious to treatment. The prognosis should be guarded. The pustular
and bullous varieties are the most grave, and at times may prove fatal,
especially in connection with the parturient state.
Concerning the treatment, with the knowledge now at hand but little
encouragement can be given. The general state of the patient should
receive attention, and the cause inquired into and modified or remedied
if possible. The therapeutics must be conducted on general principles.
Arsenic and its preparations do not seem to be of value, at least in
the cases that have fallen under our observation. Locally, the remedies
most useful are those usually employed in chronic eczema and in
pemphigus.
{614} Psoriasis.
Psoriasis may be defined as a chronic disease of the skin,
characterized by reddish, dry, inflammatory, infiltrated patches,
variable as to size, shape, and number, covered usually with abundant
whitish, mother-of-pearl-colored, imbricated scales. It varies
considerably in the degree of its development, but as a rule the
lesions are numerous and their features clearly defined. It is the most
uniform in its symptoms of all the diseases of the skin. It is
therefore easy to recognize. In the first stage it appears as a small
reddish spot, as large as a pinhead or a pea; it grows rapidly or
slowly, and from the beginning shows signs of scaling, the scales being
whitish, imbricated, and easily detached by scraping. They are
reproduced readily, so that the lesion is usually well covered. In
their early stages the lesions usually develop rapidly until their
determinate size has been attained. The usual course is for the lesion
to begin as a pinhead-sized spot, and grow to the size of a small or
large coin. Several may appear side by side in close proximity, in
which event they tend to coalesce, and to form larger, rounded,
ovoidal, or figure-of-eight-shaped patches. Thus in time large surfaces
of disease, the size of a hand or larger, may result. In other cases
the lesions remain small, but through their great number may involve a
considerable portion of the whole integument.
When typically developed, the lesions are of a bright- or dull-red
color, and are covered with whitish, grayish, or pale-yellowish scales.
The degree of inflammation varies with the case; at times it is slight,
causing the lesions to assume merely a pale-pinkish, slightly
inflammatory look; at other times it is more active, producing a
decidedly inflammatory, strawberry- or raspberry-red hue. The majority
of cases show a well-defined dull pinkish-red color of a cold
inflammatory hue. The scaling, while usually active and abundant, is
likewise variable; where the lesions are numerous and large it is
constant, the scales being formed and shed rapidly from day to day;
where the process is active, they are large, laminated, of a whitish,
silvery, or mother-of-pearl-colored or slightly yellowish hue, varying
somewhat with the locality involved. Sometimes they are heaped up. They
are, moreover, easily detached, and can be readily picked or scraped
off, leaving beneath a dry or very little excoriated, reddish surface.
When deeply scratched, minute drops or points of blood, sometimes
appear. They never exude serum. The lesions are, as a rule,
circumscribed and sharply defined from the surrounding healthy
integument, differing in this respect from similar patches of eczema.
The skin between the lesions is perfectly healthy. In markedly
inflammatory cases they occasionally possess a slightly raised border,
and sometimes, especially in certain localities, as the hands, fissures
form, as in eczema and syphilis.
The disease pursues an eminently chronic course, often lasting years or
even throughout life, disappearing and recurring from time to time.
Relapses at intervals of months or years are the rule, sometimes
slight, at other times severe. It is a capricious disease. Usually it
is better in summer than in winter, and in some cases it makes its
appearance only during the latter season. It is generally unaccompanied
by marked subjective symptoms, although this depends largely upon the
degree of {615} inflammatory action. In most chronic cases the itching
and burning are either absent or slight, and when present are generally
most annoying during the period that new lesions are appearing or old
ones spreading. On the other hand, where the affection is highly
inflammatory and running an acute, rapid course, both sensations,
especially burning, may exist to an annoying degree. The disease is not
contagious.
The eruption takes on different appearances according to the size and
outline of the lesions, some of which require mention. They constitute
the so-called varieties of the disease, but, strictly speaking, are
forms rather than varieties. Thus, when the lesions are pinhead in size
the form is termed punctata; when larger, the size of peas, guttata,
from their resemblance to a drop of mortar; when still larger, the size
of coins, they are designated nummularis, this being the form generally
encountered. Sometimes the last-named lesions become more or less clear
in the centre, and spread on their circumference after the manner of
ringworm of the general surface, the condition being called circinata;
at other times, more rarely, they assume a figured or ribbon-like form,
causing them to have a serpentine, gyrate, or festooned appearance,
termed gyrata. Commonly, however, when they grow to a large size they
form, by the coalition of two or more lesions, irregularly-rounded
patches, covering, it may be, a considerable area, the condition being
called diffusa. The disease shows preference for certain regions, among
which may be mentioned the extensor surfaces of the limbs, the elbows
and knees, the scalp, and the trunk. The palms and soles and nails may
also be invaded alone, or, as is usually the case, in connection with
the disease upon other regions. It is usually symmetrical.
The causes of the disease seem to be varied, and are by no means well
understood. It is met with, as a rule, in subjects whose general health
is of the best, and who have hearty and strong constitutions, with no
other ailment than the cutaneous manifestation. But cases are also
encountered where the general condition is at fault: sometimes the
system is below standard, as during lactation; in other cases the
nervous system is depressed, as from some long-continued cause like
mental worry. It occurs in both sexes, and usually makes its appearance
in early adult life. It is seldom met with before the age of eight, and
does not show itself in infants. In some cases it is inherited, but
more frequently such is not the case. It occurs in all walks of life,
being found among the rich and the poor in about like proportions.
Statistics show it to be one of the most common diseases of the skin.
It is of more frequent occurrence in some countries than in others.
According to White's report of 5000 consecutive cases of skin disease
observed in Boston, 152 cases of psoriasis were recorded, while
Anderson in Glasgow reports 725 cases among 10,000 cases of skin
disease, the difference being more than two to one in favor of
Scotland. Diet in the majority of cases possesses but little influence
over the disease.
The pathological process is one of the most defined and constant in
cutaneous medicine. It is well marked throughout its course, and is
subject to little variation. According to the most recent and reliable
observations, it is held to be an inflammation induced by a hyperplasia
of the rete mucosum. The views put forth by Auspitz and by Tilbury Fox
have been substantiated by more recent observers. A. R. Robinson, {616}
and later Jamieson and Thin, have investigated the pathological anatomy
of the disease with care, and have shown that the disease consists
essentially of a hyperplasia of the rete mucosum, the increase taking
place in the interpapillary portion of the layer. The growth extends
downward, pressing upon the papillæ and corium, and setting up a
variable degree of inflammation. In the later stages the superficial
blood-vessels become dilated, more or less emigration of corpuscular
elements occurring, the connective tissue especially in the
neighborhood of the vessels becoming the seat of a round-cell
infiltration. Effusion of serum, moreover, takes place, separating the
connective-tissue bundles and fibres into an open meshwork. As the
disease is vanishing there is a gradual return to the normal state, the
hyperplasia, dilatation, and infiltration disappearing without traces.
The hair is affected from the beginning in the form of hyperplasia of
the external root-sheath, but the sebaceous and sweat glands are not
found to be involved.
DIAGNOSIS.--The diagnosis, as a rule, offers no difficulties. The
characteristic features are so constant and are usually so well marked
that in ordinary cases errors are not likely to occur. When localized,
as upon the scalp or upon the hands, it may be, however, readily
confounded with other diseases. The general aspect of the eruption, the
form of the lesions, the peculiar character of the scaling, the
localities invaded, and the course of the process must be kept in view.
It may be confounded with squamous eczema, especially where only one or
two lesions are present, but the scales are usually more abundant,
larger, and whiter than in eczema. The patches of psoriasis, moreover,
are circumscribed, often sharply defined, and are always dry. In eczema
there is not infrequently a history of moisture; itching is also
generally an annoying symptom, much more marked than in psoriasis.
The papulo-squamous syphiloderm at times closely resembles psoriasis,
especially as it occurs upon the palms and soles. Symmetry usually
exists in psoriasis, but in syphilis it is often lacking, even in
connection with disease of the palms and soles. Apart from the question
of a history of syphilis, it will be found that psoriasis generally
involves more surface, and in a more disseminate form, than the
syphilitic eruption; also, that the scales are whiter, larger, and more
copious than in syphilis. The color of the lesions in both diseases is
similar, but in psoriasis it is pinker or redder, and free from the
yellowish, brownish, ham-colored tint that generally characterizes the
later syphilitic eruptions. The infiltration and thickening of the skin
in a psoriatic patch are less than in syphilis, this observation being
a valuable point in the diagnosis. The character of the inflammatory
product in the diseases is different, that of psoriasis being simpler
and less dense and firm. Finally, the course of psoriasis is peculiar,
the lesions always manifesting the same general characters, often
disappearing spontaneously and again reappearing.
Seborrhoea, especially of the scalp, sometimes simulates psoriasis, but
the patches in the former disease are ill defined, are not so
marginate, and are covered with finer, looser, and fatty scales. The
lesions of psoriasis are redder and more infiltrated, and will usually
be found to exist also in other localities. The disease may also be
mistaken for lupus erythematosus in its early stage. The involvement of
the sebaceous glands in {617} almost all cases in the latter affection,
the character of the scaling, and the fact that the face is the usual
locality attacked, will aid in the diagnosis. Ringworm of the general
surface may also bear resemblance to psoriasis, especially to the
circular form, but the parasitic disease is more superficial and more
marginate, is less scaly, and runs a more acute course. In doubtful
cases the microscope should always be employed to determine the
question.
TREATMENT.--The disease is rebellious to treatment, sometimes even
where the lesions are few and small. It must be regarded as one of the
most stubborn and persistent of the inflammatory diseases of the skin,
for, while many cases yield readily to either internal or external
remedies, the majority will often resist the best-directed therapeutics
looking toward a permanent cure. It may often be happily dissipated for
the time being, but immunity from relapses is a difficult task. To
relieve the patient of the lesions, and, secondly, to prevent, if
possible, relapses, should be the aim. To accomplish this demands
usually both external and internal treatment. Before entering upon
therapeutic measures the case should be viewed from a general
standpoint. The condition of the general health should be inquired
into, and the cause, if possible, determined. The history of the
disease in chronic cases should be learned, and, if a relapse, the
behavior of the lesions on former occasions. The influence of the
several well-known remedies, such as arsenic internally, and tar,
chrysarobin, and the mercurials locally, should also be ascertained.
Finally, the acuteness or chronicity of the attack, the activity of the
process, the amount of disease present, the locality invaded, and the
general circumstances of the patient and the time that can be devoted
to the treatment, should all receive consideration.
Among internal remedies, arsenic and its preparations occupy the most
prominent position. For the majority of cases this remedy will be found
valuable, and, if administered when indicated and in suitable doses for
sufficient length of time, good results may be expected. It is not
indicated in every case, as is shown by the fact that sometimes,
instead of relieving, it aggravates the disease. It should be used
tentatively at first, with the view of determining its tolerance and
effect, not only upon the skin, but on the general system and
alimentary canal. It is a powerful remedy, and should always be
employed with due caution. At the same time, there need be no
hesitation in prescribing it, or even in employing it for a long
period, if attention be directed to its effects. Toxic symptoms should
never be permitted to occur. In acute stages, whether in first attacks
or in relapses, where the process is active, characterized by marked
redness, inflammation, and heat, it should be withheld. At these
periods it usually aggravates the disease. The more chronic the
process, the more useful will the remedy probably prove.