of lupus erythematosus, as its features are usually characteristic. The
sharply circumscribed outline, the reddish or violaceous patch with
elevated border, the tendency to central depression and atrophy, the
plugged-up or patulous sebaceous ducts, the adherent grayish or
yellowish scales, together with the region attacked (generally the nose
and cheeks), are characters which, when taken together, are common to
no other disease. Lupus vulgaris may be excluded by the absence of
papules, tubercles, and ulceration. The sebaceous involvement and the
peculiar atrophy and superficial scarring are, moreover, not seen in
lupus vulgaris. Erythematous lupus begins, as a rule, during adult
life; lupus vulgaris usually in childhood. In psoriasis the course and
symptoms peculiar to that disease will distinguish it from lupus
erythematosus. It is scarcely possible to confound the disease with
eczema or syphilis. In some cases in the beginning of the affection it
may resemble seborrhoea; in fact, it often has its starting-point in
that disease. The inflammation, infiltration, sharply-defined
characters, atrophy, and scarring are absent in seborrhoea.
TREATMENT.--The prognosis of lupus erythematosus, as regards the
general health and welfare of the patient, is good, but respecting the
disappearance and cure of the disease an opinion should always be
guarded. Occasionally the patches yield readily, but, on the other
hand, cases are frequently met with that prove exceedingly rebellious,
responding only after long-continued treatment. Constitutional remedies
are in most cases of but little value. Occasionally arsenic and
cod-liver oil, used continuously for a long period, prove serviceable.
Iodized starch, in the dose of one or two teaspoonfuls three times
daily, has been recommended, and in some cases potassium iodide has a
favorable influence.
It is to the external treatment, however, we look for positive effects.
In the selection of remedial applications it is to be remembered that
the patches of disease sometimes disappear spontaneously, occasionally
with little or no scarring, and therefore treatment that would have as
an effect marked scarring or disfigurement is to be avoided. The
simplest remedy, at times useful, is soft soap, the sapo viridis of the
shops. This may be used as such or in solution in alcohol, two parts of
the soap to one of alcohol, constituting the well-known spiritus
saponatus kalinus. It is to be energetically rubbed into the diseased
parts once or twice daily. The application of the sapo viridis as a
plaster is a more energetic method. After several days the soap is to
be discontinued and a soothing ointment applied. In addition to its
therapeutic properties, sapo viridis--or, better, its alcoholic
solution--may be advantageously employed to cleanse the parts
preparatory to other remedial applications. Mercurial plaster
constantly applied to the patches will in some cases effect a cure. A
10 to 25 per cent. oleate-of-mercury ointment, rubbed on the parts once
or twice daily, is sometimes of value.
In almost every case where the inflammatory symptoms are marked the
following lotion will prove palliative, and in some cases of the mild
and superficial form of the disease it has in time effected a cure:
{692}
Rx. Zinci sulphatis,
Potassii sulphidi, aa. drachm ij;
Aquæ, fluidounce iij;
Alcoholis, fluidounce j.
The salts are to be dissolved separately in the water, and then mixed,
and after reaction the alcohol is to be added. Properly made, the
resulting lotion is without odor, contains a whitish sediment, which
when agitated gives the lotion a milky appearance. It is to be shaken,
and the parts dabbed with it for from fifteen to thirty minutes twice
daily, allowing it to dry on. Sulphur ointment and alcoholic sulphur
lotion, such as are used in the treatment of acne, are also sometimes
serviceable. Tincture of iodine, either alone or with an equal part of
glycerin, painted over the parts once or twice daily until a coating
forms, in some cases proves useful. The same may be said of the
following formula:
Rx. Iodinii,
Potassii iodidi, aa. drachm iv;
Glycerinæ, drachm j.
M.--Sig. Paint over the part until a coating is produced. Painting pure
carbolic acid over the patches is sometimes followed by good results. A
mixture that is serviceable as a stimulant is the following:
Rx. Olei cadini,
Alcoholis,
Saponis viridis, aa. drachm iij.
M.--Sig. Rub into the patches night and morning.
Stronger applications are often necessary if the disease fails to yield
to the simpler remedies. Pyrogallic acid in ointment, from forty to
ninety grains to the ounce, and chrysarobin in the same strength, are
serviceable. The latter is a dangerous remedy to use about the face,
occasioning at times a violent conjunctivitis with oedema. Pyrogallic
acid is safer, and sometimes proves more satisfactory when applied in
flexible collodion or liquor gutta-perchæ than in ointment form, as in
the following formula:
Rx. Acidi pyrogallici, drachm j;
Liquor. gutta-perchæ, fluidrachm iv.
M.--S. Apply with a brush. This is to be painted over the patches
several times daily until considerable reaction takes place or a crust
forms, then discontinued, and as soon as the crust is removed or falls
off the application is to be repeated. If there is much scaling, thirty
grains of salicylic acid may be added to the above formula. In most
cases it is advisable as soon as the crust forms to remove it, and
immediately to resume the pyrogallic-acid painting. Cantharidal
blistering fluid, repeatedly applied, has been recommended. Nitrate of
silver, either in stick or strong solution, is a comparatively safe
caustic, and is at times useful. Treatment by linear scarifications,
especially in obstinate, sluggish, and infiltrated patches, is often
valuable. The scar left is, as a rule, insignificant. Erasion with the
curette is a method that sometimes proves of advantage in the severer
and deeper-seated forms of the disease. Although in almost all
instances stimulating or active treatment is demanded and well borne,
there are cases occasionally met with in which, on account of the
inflammation and pain, soothing applications must, for a time at least,
be employed. These cases, it will be found, are aggravated by
stimulating remedies.
{693} Lupus Vulgaris.
Lupus vulgaris (known also as lupus exedens, lupus vorax) is a cellular
new growth, characterized by variously-sized, soft, reddish-brown
patches, consisting of papules, tubercles, and flat infiltrations,
eventually terminating in ulceration and cicatrization. The disease
appears differently as seen in the several forms and stages of its
development. All the varieties usually begin in one and the same way.
The primary lesions are pinhead- to small pea-sized, deep-seated,
brownish-red or yellowish papules, having their seat in the deeper part
of the corium. They are softer and looser in texture than normal
tissue, and as the disease progresses form variously sized and shaped
patches. They may be so closely aggregated as to form flat
infiltrations. The patches tend to be round, serpiginous, or ill
defined. As the papules increase in size they may be distinctly
recognized both by the eye and by passing the finger over the surface;
later even reaching the size of small peas. The lesions having attained
a certain size or development and being covered with imperfectly-formed
epidermis, may so remain for a time, or retrogressive changes may
immediately occur. They may disappear by absorption, fatty degeneration
taking place, leaving a desquamating, atrophic or cicatricial
tissue--lupus exfoliativus--or disintegration and destruction of the
diseased skin may occur, resulting in ulceration--lupus exedens, or
exulcerans. This latter is the usual course of the disease. The
ulcerations are rounded, shallow excavations with soft and reddish
borders. If the ulcerations are the seat of exuberant granulations, the
condition is known as lupus hypertrophicus. Papillary outgrowths may
occur in the healing ulcers, and a rough, verrucous condition
results--lupus verrucosus.
The lesions of lupus are seldom painful. The ulcers secrete a slight or
moderate amount of pus which forms crusts. Soft or firm cicatricial
tissue finally results. In almost all cases of long standing the
several stages of the disease may be recognized, each lesion, whether
the first or the last, going through a similar course, either of
absorption and exfoliation or ulceration and cicatrization. The deeper
parts may be involved in the process, subcutaneous connective tissue,
cartilage, and mucous membrane being liable to invasion. The mucous
membrane of the mouth, gums, velum and larynx may even be primarily the
seat of the lupus infiltration, considerable destruction eventually
resulting. The face, especially the nose, is the most common site of
the disease. Occurring about the eye, the process may eventually
destroy that organ. The ears are likewise frequently attacked. Not
infrequently the extremities, and occasionally the trunk, are invaded.
The disease begins, as a rule, in childhood. It is always a destructive
process, usually resulting in disfiguring cicatrices.
The causes of the disease are obscure. Although it usually appears in
early life, it is never congenital. Heredity has little if any
influence. It is comparatively rare in this country, less so in England
and Ireland, but is more common in Austria, Germany and France. It is
most generally observed among the strumous and debilitated, but is also
frequently seen in those who enjoy all the advantages of life and who
are otherwise in average health. It is entirely distinct and
independent of syphilis. The French consider it a scrofuloderm
(scrofulide), and yet in many cases there {694} is clinically a
considerable difference. On the other hand, cases are met with in which
its close relationship, if not identity, with the scrofulodermata is
not to be questioned. The view that it is a tuberculosis of the skin
due to the same cause as at present advanced for tuberculosis of the
lungs--the bacillus--has lately been suggested. The disease attacks
both sexes, but is somewhat more common in women than in men.
Anatomically, the process is a chronic inflammation, consisting
essentially of small-cell infiltration, affecting primarily the corium,
eventually spreading to other parts. The epithelial structures are
usually involved in the first stages of the disease. Recent lesions are
rich in vessels, the vascularity when retrogressive changes take place
rapidly decreasing, beginning at the centre of the nodule. The
cutaneous tissues undergo cicatricial contraction, a part, however,
being organized into coarse connective tissue. In addition to the
formation of the nodular mass, the cell-infiltration is found to spread
along the vessels of the corium and papillæ, and also into the deeper
portions of the skin. The papules may be so close and the
cell-infiltration so extensive that a large area of disease results and
undergoes the same changes as an individual lesion. The sweat and
sebaceous glands are involved. Sometimes epithelial hyperplasia takes
place, the epithelial outgrowth from the rete dipping down and joining
similar outgrowths from the cells of the sweat-glands and hair
root-sheaths, forming an epithelial network which may become a
histological basis for the development of epithelioma. The occurrence
of this latter disease in lupus tissue, in association or as a sequela,
has been noted by several observers. According to the latest
investigations the infiltration of lupus is due chiefly to
cell-proliferation and outgrowth from the protoplasmic walls and
adventitia of the blood-vessels and lymphatics. The fibrous-tissue
network, vessels, and a portion of the cell-infiltration are thus
produced, the fixed and wandering connective-tissue cells of the
inflamed stroma of the cutis being responsible for the other portion of
the new growth.
DIAGNOSIS.--Ordinarily, the features of lupus vulgaris are so
distinctive as to render a diagnosis a matter of no difficulty. The
characteristic soft, small, reddish-brown subcutaneous papule--the
primary efflorescence of the disease--is generally to be found,
especially about the periphery of the patch, and when present is
diagnostic. At times, however, it bears resemblance to syphilis,
epithelioma, lupus erythematosus, and acne rosacea.
It is chiefly in the serpiginous forms of the late tubercular and
ulcerative syphilodermata that the resemblance to lupus vulgaris is
sometimes very close. There are several points of difference. Syphilis
is much more rapid in its course, marked ulceration following
frequently within a few weeks or months of its appearance. With lupus,
on the other hand, years may elapse before the same amount of
destruction results. In lupus there are usually several points of
ulceration; in syphilis, one or several, which incline to coalesce. The
ulcers of lupus are apt to be superficial, whereas those of syphilis
are usually deep, with a punched-out appearance. Lupus papules are
small, soft and but slightly elevated, and frequently reappear in the
scars left by the disease; the papules or tubercles of syphilis are
larger, more elevated, firm and harder, and are seldom seen in the scar
or track of the disease. The secretion of the {695} syphilitic ulcer is
abundant, purulent and offensive, and the crusts thick, often
oystershell-like, and of a greenish or blackish color; the secretion of
lupus ulceration is slight, odorless, the crusts thin and scanty and of
a reddish or reddish-brown color. The scar of lupus is generally hard,
shrunken, yellowish, and more or less distorted, while that of syphilis
is soft and, compared to the amount of ulceration, but slightly
disfiguring. The bone-structures are not involved in lupus; they may be
in syphilis. The two diseases have different histories: lupus generally
begins in childhood and runs a slow and chronic course; syphilis is
usually seen after adolescence or adult age, and progresses more
rapidly. In syphilis, moreover, other evidences of the disease may
usually be found.
Lupus vulgaris differs from epithelioma in several important points.
The edges of the epitheliomatous ulcer are hard, elevated, and waxy;
the base is uneven, and the secretion is thin, scanty, and apt to be
streaked with blood; the ulceration usually starts from a single point;
it is often painful; the tissue-destruction may be considerable; and,
finally, epithelioma is, as a rule, a disease of advanced age. Lupus
vulgaris differs essentially in all these particulars.
As a rule, there is no difficulty in differentiating lupus vulgaris
from lupus erythematosus. The absence of papules, tubercles and
ulceration is sufficiently distinctive. Lupus erythematosus is,
moreover, a superficial disease, pinkish or violaceous in color,
showing itself in circumscribed patches covered with thin adherent
scales, and with usually evident involvement of the sebaceous glands.
It rarely begins before adult age, whereas lupus vulgaris, as a rule,
first appears in childhood. Attention to the ordinary characters of
acne rosacea--the hyperæmia, the dilated vessels, comedones, acne
papules and pustules, its advent at or after maturity, and the
history--will prevent an error in diagnosis.
TREATMENT.--Lupus vulgaris is always a chronic disease, and one that
calls for a guarded opinion as to treatment. Although it be removed,
relapses are prone to occur, and new papules may show themselves even
about the scar resulting from treatment. If it is localized the chances
of permanent cure are more favorable. The deformity attending and
following the disease is often great,--contraction of joints,
destruction of cartilages, and sometimes partial closure of the
orifices resulting. The general health is usually good. Death by
tuberculosis of the lungs has been noticed in some cases.
Treatment has in the main two objects,--to limit the development or
spread of the disease and to remove the morbid tissue that is already
present. In accomplishing the former constitutional treatment is
occasionally useful; although much cannot usually be attained in this
way, yet from our own observations we are convinced that in some cases
the disease may be favorably influenced and its spread limited.
Cod-liver oil, administered in full doses and for a long period, is
sometimes of decided value. Potassium iodide is another remedy which at
times proves serviceable. Iodoform in half-grain doses three times
daily has been recommended, as have also muriate of lime, in the dose
of twenty grains three times a day, and calx sulphurata, in small
doses. Hygienic measures are to be enforced, and a generous, nutritious
diet advised.
External remedies are essential in every case, and constitute the only
plan of treatment to be relied upon. Removal of the diseased tissues by
{696} caustics or operation is the method practised. In the earlier
stages of the disease or before adopting radical measures it is
advisable to make an attempt to bring about absorption by the
employment of stimulating applications. Equal parts of tincture of
iodine and glycerin, or one part each of iodine and potassium iodide
and two parts of glycerin, may be painted over the parts daily or every
other day. Mercurial plaster, renewed once or twice a day and kept
constantly applied, is valuable in some cases. Corrosive sublimate in
the form of a lotion or ointment, one-half to two grains to the ounce,
has lately been advised. Cashew-nut oil applied with friction has been
recommended for the non-ulcerative form. Tar and sulphur ointments may
also be employed. Chrysarobin, either in the form of an ointment or as
a solution in liquor gutta-perchæ, has also been advised.
For the radical treatment of the disease there are numerous caustics in
use, but there are some which are more positive in their effect and
whose action may be controlled. Nitrate of silver, pyrogallic acid,
arsenic, caustic potash, the curette, scarifier, and the actual and
galvano-cautery are all valuable. Nitrate of silver is best used in
stick form. The lesions are forcibly pierced and bored with the stick,
and thoroughly cauterized. The operation is to be repeated every three
or four days. It is a safe remedy, and is especially useful about the
face, as the scars left are soft and smooth. Pyrogallic acid in the
form of an ointment or plaster, from 15 to 25 per cent. strength, is
often of great value. It is a mild and safe caustic; it is usually
painless and leaves a smooth, soft scar. The ointment should be stiff
and adhesive, and kept applied constantly for several days or more,
renewing twice daily. The following formula serves well:
Rx. Acidi pyrogallici, drachm ij;
Emplastri plumbi, drachm j;
Cerati resinæ comp., drachm v.
M.--Sig. Apply as a plaster. In winter the lead plaster may be omitted.
The remedy may also be applied in liquor gutta-perchæ, but is not so
satisfactory. The tissues become soft and blackish, and then the parts
are to be poulticed and the slough removed; and if the diseased tissue
is not sufficiently destroyed the dressing is to be renewed.
Subsequently the ulcer is dressed with mercurial ointment or a simple
salve. Healing should take place in the course of a few weeks. Iodoform
is well spoken of. In deep-seated infiltration the upper epidermic
layers should first be removed by a solution of caustic potassa. The
iodoform is then put on and a layer of cotton is applied over it, and
the dressing remains undisturbed for a week. The lupus nodules are soon
destroyed. Several repetitions of the remedy may be necessary.
Excepting the preliminary application of the potassa the method is
painless.
A solution of caustic potash is sometimes employed for the destruction
of the lupus deposit. It is thorough in its action, but is painful and
must be used with great caution. The cicatrices left after the use of
this caustic are apt to be large and hard. In the application, as soon
as the diseased tissue has been thoroughly destroyed by the caustic,
the further action may be stopped by neutralizing the alkali with
diluted acetic acid. Arsenic in the form of paste is another valuable
caustic. It has the advantage of sparing the healthy, and even the
cicatricial, tissues. Hebra's modification of Cosme's paste is an
eligible formula: {697}
Rx. Acidi arseniosi, scruple j;
Hydrargyri sulphuret. rub., drachm j;
Ugt. simplicis, ounce j.
M. Ft. ugt.--Sig. Spread upon a piece of kid or cloth and apply as a
plaster. The paste is to be applied for two or three days
consecutively, at the end of which time the parts are somewhat swollen
and painful. The lupus nodules are seen as black, necrosed spots.
Poultices are then applied until the slough comes away, usually in a
day or two; subsequently a mild, stimulating ointment is employed.
Rapid cicatrization usually takes place, and the cicatrices are, as a
rule, satisfactory. The chief objection to arsenical applications is
the intense pain that usually develops soon after the remedy is
applied. In other respects the method has its advantages.
Acetate of zinc in crystal form, repeatedly applied to the lesions, has
been advised. It is painful at the time of application, but the pain
may be somewhat relieved by washing the parts with water. Red iodide of
mercury in the form of a strong ointment (equal parts of the salt and a
fatty base), applied upon a piece of kid or cloth, will have a speedy
caustic effect. There are other caustic remedies which may be
mentioned. Chloride of zinc, with an equal part of chloride of antimony
and sufficient hydrochloric acid to dissolve the zinc chloride, and
enough powdered licorice added to make a paste, and applied as a
plaster, is an efficient caustic. It produces an eschar in twelve to
twenty-four hours. The parts are then dressed with a simple ointment,
and healing allowed to take place. It is a strong caustic, and is
destructive to healthy as well as diseased tissue. The same may be said
of Vienna paste, consisting of equal parts of lime and potassa. The
latter mixture is made into a paste at the time of application by
adding alcohol. It is not to be applied more than five to ten minutes,
and its further effects are to be counteracted by the application of
acetic acid. In the application of such powerful and destructive
caustics it is advisable to protect the adjacent skin with strips of
adhesive plaster. Salicylic acid has lately been recommended in the
form of an ointment of the strength of one to two drachms to the ounce.
It is thickly spread on linen and applied continuously. The remedy is a
mild one and acts slowly. Mention may also be made of lactic acid,
applications of which, it is stated, have been productive of beneficial
results.
Of late years the mechanical removal of the lupus deposits has been
largely practised. In small patches excision of the entire diseased
area has been recommended, but as considerable healthy tissue is
necessarily removed with it, and the resulting scar is deep and
disfiguring, it is not to be advised. Excision followed by
transplantation of healthy skin has also been advocated. An excellent
method of removal is by means of the dermal curette, or scraping-spoon.
It is one that answers well in many cases. The diseased tissue should
be thoroughly scraped out. It is painful, and it is often necessary to
operate under ether. The healthy tissues are unyielding and cannot be
readily scraped away, so that only the morbid deposit is removed. As it
is difficult to remove the new growth from the interstitial spaces, we
are in the habit of supplementing the operation with a caustic, either
cauterizing lightly with caustic potash, or, what is advisable in the
greater number of cases, {698} applying the pyrogallic-acid ointment
for several days following the curetting. This method--the curetting
and subsequent cauterization--has, on the whole, proved satisfactory.