practically unknown. It was first described by Hebra. It is more common
in males, and is seen chiefly in children and young people. Symptoms of
a scrofulous habit, such as glandular enlargements, ulcers, bone
disease, or lung complaint, are found associated in almost all cases.
According to Kaposi, the process is an inflammation and
cell-infiltration in and about the hair-follicles, the sebaceous
glands, and papillæ around the apertures of the follicles. Each papule,
as may be seen on close examination, has its seat about the opening of
a follicle, the inflammation beginning around the vessels and at the
bases of the follicles and glands, and subsequently the cellular
infiltration invading the interior of these structures to such an
extent as to give rise to distension and elevation into papules.
It is to be differentiated from papular eczema, lichen ruber, the
miliary papular syphiloderm, and keratosis pilaris. According to Hebra,
cod-liver oil, employed internally and externally, is the remedy to
which the disease readily yields.
Eczema.
SYMPTOMS.--Eczema, known popularly as tetter, is the most important and
the commonest of the diseases of the skin. It may be defined as an
inflammatory, non-contagious disease of the skin, characterized in the
beginning by erythema, papules, vesicles or pustules, or a combination
of these lesions, pursuing an acute or chronic course, accompanied by
infiltration and itching, terminating either in discharge with the
formation of crusts, in absorption, or in desquamation. The disease is
multiform in character, and is capable of manifesting itself in a great
variety of forms; and for this reason any definition that is attempted
must be broad enough to comprise all of its essential features. It may
begin as a circumscribed or diffuse small or large erythematous patch,
which may remain dry and become scaly, or may pass into a state of
moist exudation with crusting. It may also begin with vesicles or
pustules, which soon rupture, giving rise to a red, moist, oozing,
weeping, excoriated surface pouring forth a scanty or abundant fluid,
gummy discharge, which rapidly dries to crusts. Instead of a moist
discharging surface the skin may become dry, scaly, thickened, and more
or less fissured. In other cases small papules, discrete or confluent,
in patches or disseminated, form, constituting papular eczema. Finally,
several or all of these lesions may occur together or in the course of
the process. Thus, it will be observed, the disease is markedly
multiform and protean. Not {626} infrequently it is capricious in its
manifestations both as to the nature of the lesions and as to the
evolution. Several varieties of the disease may appear simultaneously
on one or on different regions.
Infiltration is one of the most marked features, and is present in
varying degree. In the discharging varieties the fluid exuded is
generally considerable and often excessive, giving rise to abundant
crusting. In the papular variety the exudation is plastic in character,
causing thickening of the skin, followed by more or less induration.
Scaling is also frequently a prominent symptom, giving to the condition
known as squamous eczema its peculiar features. Itching, usually
marked, is an almost constant symptom, varying in degree. As a rule, it
is an annoying feature of the disease, causing the patient to scratch
in spite of good resolutions. In some cases, as in the erythematous
variety, the sensation is of burning rather than itching, or it may be
a combination of the two. Occasionally the locality affected is the
seat of pain. The course of the disease is extremely variable. As a
rule, it inclines to chronicity. Relapses are common, especially in
adults and elderly persons. There are many cases on record, however,
where, recovery having taken place, the individual remains free of the
disease. The several varieties may now be considered.
Eczema Erythematosum.--This begins as an erythematous spot or macule,
or as a patch, variable as to color, size and outline. It is most
frequently met with upon the face, occupying a portion or the greater
part of this region, usually in the form of several discrete or
confluent patches. It generally begins as a coin-sized, ill-defined
lesion, rounded or irregular in outline, of a pale-red hue, accompanied
by itching and burning. The patch at first may be insignificant, but
from time to time it spreads and becomes redder, thicker, and the
surface slightly scaly. When fully developed, as is perhaps most
frequently encountered upon the forehead, it consists of a more or less
broken-up patch of considerably thickened somewhat swollen skin of a
mottled or streaked pale-reddish, yellowish-red or violaceous hue. The
surface is dry or excoriated and very slightly moist in places, and is
covered with a thin film of dried, ragged epidermis or with thin
adherent scales. The disease varies from time to time, being paler and
less marked one week than another. Scratch-marks and excoriations,
punctate or linear, are generally present, indicative of the scratching
and rubbing to which the skin has been subjected. As stated, several
patches generally exist, the disease tending to symmetry. The forehead,
sides of the nose, and cheeks are the localities most frequently
invaded, but other regions, as the back of the neck, axillæ, and
flexures, are all common seats.
Its course is variable. As a rule, it inclines to assume chronicity,
varying in intensity from time to time, or even disappearing and
reappearing at irregular intervals. It is exceedingly liable to
relapse, perhaps more so than any other variety. Having established
itself, it may remain erythematous in character or may pass into other
varieties of the disease. Thus, a moist or weeping surface may take the
place of the erythema, followed by crusting, giving rise to eczema
madidans, or eczema rubrum. Not infrequently the patch becomes markedly
scaly, and continues in this form, producing eczema squamosum. When it
occurs in regions where two opposing surfaces come in contact, as under
the mammæ, between the {627} nates, and about the genitalia, an
excoriated moist condition is produced known as eczema intertrigo, or
eczema mucosum.
Eczema Vesiculosum.--This may be regarded as the typical and perfect
expression of the disease. It is characterized in the beginning by a
diffuse redness with puncta, which rapidly become small pinpoint- to
pinhead-sized, more or less perfect vesicles, accompanied with heat and
usually intense itching. As a rule, the lesions are small and are
discrete or confluent. They soon mature and burst, the fluid oozing
forth on and over the surface, forming yellowish honeycomb-like scanty
or abundant crusts. The skin of such a patch is generally slightly
swollen, and at times considerably infiltrated with serum (eczema
oedematosum). The disease may thus develop upon a small surface, or, as
is oftener the case, over an extensive area, as, for example, the
flexor surface of the forearm. There is no disposition for the lesions
to group, but they incline to appear in areas, a large patch being
usually composed of several smaller patches. The amount of serous fluid
poured forth is often great, large bulky crusts forming which in time
completely mask the skin beneath. The exudation may take place rapidly
in the course of a few days and cease, or it may continue, oozing
slowly from day to day or with intermissions from time to time
indefinitely, constituting acute, subacute or chronic vesicular eczema.
The amount will, moreover, depend somewhat upon the locality involved
and whether the disease be properly treated or irritated.
Vesicular eczema may show itself typically, the whole of the affected
skin taking on vesicular formation, or, as frequently happens, it may
be associated with other varieties of the disease, more particularly
pustules and papules. Abortive vesicles and vesico-pustules and
vesico-papules are common, occurring here and there mixed with the
vesicles and about the circumference of the patch. The amount of
surface invaded varies. The disease often manifests itself in different
regions simultaneously, as, for example, upon the neck and flexor
surfaces of the forearms or upon the trunk and the thighs. In infants
the face is the locality usually attacked, constituting the so-called
crusta lactea, or milk-crust, of former writers. While the disease
tends to manifest itself upon the thin skin of the flexor surfaces of
the extremities and upon the face, such is not always the case, for the
hands and fingers are also often invaded.
Eczema Pustulosum.--This variety of the disease (designated by some
writers eczema impetiginosum) is closely allied to the preceding
variety. The lesions may develop as pustules or may become pustular
from pre-existing vesicles; both lesions are not infrequently found
together, although one of the two will usually predominate. In pustular
eczema the swelling, heat, and itching are seldom so marked as in the
vesicular variety, and the lesions are generally larger and firmer. As
in the case of the vesicles, they rupture and dry, forming yellowish or
greenish bulky crusts. This variety is most frequently encountered
about the face and scalp, and in those--especially young people--who
are strumous, ill-nourished, or in a depraved state of health.
Eczema Papulosum.--Eczema papulosum is characterized by small, rounded
or acuminated papules about the size of a pinhead. Sometimes they are
well defined and circumscribed, but more frequently they possess no
sharply-marked outline or form. They are reddish in color, the tint
varying with the individual and with other circumstances, and are
usually {628} discrete, although not infrequently they are so numerous
and so crowded together as to coalesce and form patches or aggregations
of disease, which often show considerable infiltration. They begin as
papules, and usually preserve this character throughout their course.
Vesicles or vesico-papules not infrequently coexist. Sooner or later
the lesions disappear, but are usually replaced by others, the process
in this manner continuing its course for weeks or months. The itching
is in almost all cases severe and persistent, the patient generally
scratching himself to the extent of producing excoriations and
blood-crusts. Papular eczema shows a preference for certain regions,
notably the extremities, especially the flexor surfaces. The face is
seldom attacked. It is one of the most obstinate varieties of the
disease.
* * * * *
In addition to the principal varieties of eczema, just described, there
are other forms of the disease which on account of their peculiar
features require mention. Of these eczema rubrum, or eczema madidans,
may first be spoken of. It is to be viewed as a secondary condition
resulting from one or another of the primary varieties. Thus it usually
follows eczema vesiculosum or pustulosum. It is characterized by a
reddish, moist or discharging surface, the serum, sometimes bloody,
usually exuding freely and forming thick yellowish or brownish crusts,
together with more or less thickening of the skin and other secondary
changes. In other cases discharge is wanting. The condition varies with
the stage of the process and with other circumstances: at one time the
red, inflammatory dry or oozing skin is the most striking feature,
while in other cases this is completely obscured by large, diffuse
masses of crust. It may occur upon any region, but it is most
frequently met with on the legs, especially in adults, and more
particularly in elderly people. It is usually chronic in its course,
and may continue for years, better and worse from time to time, but
usually evincing no disposition to spontaneous recovery.
Another clinical form of the disease is known as eczema squamosum,
which frequently has been preceded by the erythematous variety, and in
many cases is to be viewed as a stage of that variety. It may also
follow other varieties. It appears in the form of reddish, dry, more or
less infiltrated, scaly patches, the amount of scaling being variable.
The scales are usually small or fine, and as a rule are scanty. The
condition is generally chronic, and is often met with on the scalp.
Fissures, superficial or deep, are not infrequently met with in eczema,
usually in the chronic or recurrent forms of the disease, and may be so
pronounced as to give rise to the so-called eczema fissum. This is
often seen about the fingers and hands, especially the palms. In
localized infiltrated patches of chronic eczema a peculiar warty
condition is occasionally met with, which is known as eczema
verrucosum; or if simply hard, rather than wart-like, eczema sclerosum.
Eczema is divided into acute and chronic, the several forms of the
disease being so different in their clinical pictures as to demand such
a division, which relates rather to the pathological changes than to
time. Thus the disease may show acute symptoms throughout its course,
or, on the other hand, may in the beginning take on a chronic action.
As a rule, it tends to chronicity, secondary changes in the skin
usually manifesting themselves early in the course of the process.
{629} ETIOLOGY.--Eczema is the commonest of the cutaneous diseases, and
seems to be of more frequent occurrence in this country than in Europe.
It is met with among all classes of society and at all ages.
Individuals with light hair and florid complexions are more often
subjects of the disease than those of the opposite temperament. Not
infrequently the disease is hereditary, although examples are very
common in which no such history obtains. So-called eczematous subjects,
in which at longer or shorter intervals throughout life and under
variable conditions the disease manifests itself, are of frequent
occurrence in practice. The state, though well known clinically, is
difficult to define, consisting of a peculiar inherent condition of the
system at large and of the skin itself which under favorable
circumstances permits the disease to assert itself from time to time.
The association in some cases of chronic bronchitis and allied
affections of the respiratory tract with eczema, and the clinical
observation that as one disease improves the other becomes worse, has
led some dermatologists to regard eczema as being catarrhal in its
nature.
The constitutional causes which may produce the disease are numerous,
and are worthy of careful study as bearing directly upon the treatment.
Disorders of the digestive tract, including dyspepsia in its many forms
and constipation, are not infrequently found to be the exciting cause
of an attack, while faulty excretion through the several emunctories,
and the existence of a gouty or rheumatic disposition, may all prove
potent factors. Deterioration in the tone of the system, arising from
varied causes, with impaired nutrition--as seen, for example, during
pregnancy and lactation--is sometimes accompanied with an outbreak of
the disease, while nervous exhaustion and other neurotic states, as is
now well established, are not infrequently active causes.
In some cases excitants, external or internal--as, for example,
cutaneous irritants and intestinal worms--may determine an outbreak. In
like manner, dentition and vaccination may call forth the disease.
Among the local causes producing the so-called artificial eczemas the
preparations of mercury, sulphur, croton oil and tincture of arnica are
most notable. Contact with the several varieties of the rhus plant,
though usually producing a peculiar dermatitis, may in eczematous
subjects provoke a genuine eczema. Heat and cold, especially the rays
of the sun, are also factors to be considered, while it is well known
that the disease in many instances is influenced by the seasons, being,
as a rule, worse in winter than in summer. There are many subjects who
suffer only in winter. In sensitive skins water, soap, alkalies and
acids, all prove more or less injurious, giving rise to harshness or
chapping of the skin, and sometimes to eczema. In the same manner the
presence of parasites and the consequent scratching are productive of
more or less simple dermatitis, and in eczematous subjects the disease
under discussion. Eczema is not contagious, a question which is
frequently asked by the patient.
PATHOLOGY.--The changes which occur in the skin in the various
eczematous conditions are somewhat different as the process is of short
or long duration and mild or intense in character. In all cases
hyperæmia and exudation, constant symptoms of all inflammations, are
present, varying according to the activity and duration of the process.
The rete mucosum is also involved in all cases, being oedematous and
infiltrated. In {630} the erythematous form the blood-vessels of the
papillary layer are dilated, exudation and congestion as well as
increasing activity of the rete taking place. In the papular variety
the process is mainly limited, primarily at least, to the follicles.
The exudation is confined to small circumscribed areas and gives rise
to papular elevations. In the vesicular variety fluid exudation occurs
in the upper strata of the corium and in the rete, and the formation of
vesicles results. The contents of the vesicles consist of a clear
liquid containing a few rete-cells and later some pus-corpuscles. In
the pustular form the process is more intense in character, and the
cell-emigration and multiplication increased. In the chronic forms of
the disease the infiltration involves the deeper parts of the corium
and even the subcutaneous tissues, which, in addition to the new
connective-tissue formation sometimes taking place, gives rise to
considerable thickening. The papillæ are enlarged, and at times are
considerably hypertrophied, as exemplified by the so-called verrucous
eczema. The exudation and cell-infiltration are especially marked along
the blood-vessels. In squamous eczema the blood-vessels of the corium
and papillæ are dilated, and these parts infiltrated with round cells
and changed connective-tissue corpuscles. Pigmentation may take place
in the deeper layers of the rete and in the corium, especially about
the vessels. The pathological process in eczema seems to have its
starting-point in disturbance of the capillary circulation, the origin
and nature of which it is difficult to determine.
DIAGNOSIS.--It must be remembered that the disease is capable of
appearing in a multitude of forms, some of which are so dissimilar in
their clinical features as sometimes to occasion embarrassment in the
diagnosis. No other disease except syphilis manifests itself in such a
variety of forms. In all cases where the lesions are varied or where
they are ill defined the eruption should be viewed as a whole, when the
characters of the process will usually be apparent. Thus a variable
amount of infiltration, with swelling or thickening, is almost always
present, the skin being more or less red and inflammatory. Moisture or
positive discharge, with slight or extensive crusting, is a frequent
though by no means a constant symptom, and when present is
characteristic. Itching is experienced in almost all cases, and is
generally a marked symptom. In some cases heat and burning are
complained of.
Cases are occasionally met with in which the eruption bears some
resemblance to erysipelas and scarlatina, but the absence of systemic
symptoms in eczema would prevent an error in diagnosis. Papular eczema
may at times simulate the papular manifestations of urticaria,
especially in children, but in ordinary cases there is no likelihood of
confounding the diseases. Herpes zoster in its early stage may bear a
resemblance to a patch of vesicular or papular eczema, but the grouping
of the lesions and the burning or pain in the former disease will
generally prove sufficient to distinguish them. Seborrhoea, especially
as it occurs upon the scalp, may be mistaken for squamous eczema, but
in seborrhoea the scales are greasy, containing more or less sebaceous
matter, and the distribution of the disease is usually more uniform
than in eczema; and, finally, in the latter affection the skin is
reddish, inflamed, often thickened, and usually itchy.
Psoriasis and squamous eczema frequently simulate each other, and in
{631} some instances the resemblance is so close that error in
diagnosis may readily occur. Both diseases are common, and are liable
to invade all regions. In eczema the patches usually fade away into the
healthy skin, whereas in psoriasis their margins are generally sharply
defined. In eczema the scales are usually scanty, thin and small; in
psoriasis they are abundant, whitish or silvery, large and imbricated.
These points, taken in connection with the history of the case, will
serve to aid in the diagnosis.
The rare disease pityriasis rubra may be confounded with squamous
eczema, but the peculiar abundant, thin, papery scaling of this
affection is not met with in eczema. Sometimes papular eczema resembles
lichen ruber, but with attention to the characteristics of the lesions
in the latter disease the diagnosis in most cases offers no difficulty.
The resemblance of tinea circinata to eczema in some cases is to be
borne in mind, but in the latter disease there is wanting the tendency
to circular and marginate forms so characteristic of the parasitic
disease. The microscope should always be employed in doubtful cases.
Both tinea sycosis and sycosis may be confounded with eczema of the
hairy portion of the face, but the follicular involvement in the former
affections is the diagnostic point to be remembered. Scabies in its
early stages often looks much like papular, vesicular, or pustular
eczema, and care should in all cases be taken to make a correct
diagnosis. The history of scabies, the regions involved, the
distribution and multiformity of the lesions, and the presence of the
parasite, as shown by the extraction of the mite or by the burrow, are
all points to be duly inquired into. Eczema seldom simulates syphilis.
They are most likely to be confounded one with the other when occurring
in chronic forms about the scalp and the hands and feet.
PROGNOSIS.--Under favorable circumstances eczema is always a curable
disease. In the prognosis of the affection as regards the probable
length of time required to remove it an opinion should be guardedly
expressed. It depends upon the extent of the disease, the duration, the
attention the patient can give to the treatment, and the ease with
which the exciting causes can be removed. Where the disease is the
result of nervous prostration, as seen in those who have been mentally
overworked from whatever cause, the cure will take place slowly, and
many relapses will probably occur before positive recovery sets in.
Where the exciting causes cannot be entirely removed recovery is slow,
and a complete or permanent cure is sometimes impossible. Thus in
eczema about the hands in those who are obliged to wet or wash the
parts frequently, to handle chemicals, dyestuffs, or otherwise expose
the parts to the action of deleterious substances, a cure of the
affection is exceedingly difficult. The same may be said in regard to
eczema of the scrotum and neighboring regions, where the natural heat
and moisture are constant and exciting, and to a certain extent
irremovable, causes. In eczema of the lower limbs depending upon a
condition of varicose veins the disease is obstinate. On the other
hand, there are many cases of acute eczema met with which run a rapid
course and end favorably. Eczema of the face, lips, and other exposed
parts is, for evident reasons, apt to prove rebellious. In each case,
then, all these points are to be taken into consideration in rendering
an opinion upon the probable duration and termination of the disease.