Lichen Scrofulosus.
Lichen scrofulosus is a chronic disease characterized by milletseed-sized, flat, reddish or yellowish, more or less grouped, desquamating papules, unaccompanied by itching and occurring in those of a scrofulous disposition. The lesions, of a pale red or yellowish color, are usually numerous, are seated about the hair-follicles, and show a decided tendency to group, giving rise to patches of variable size and of a rounded or crescentic shape, which sooner or later become covered with minute scales. They are always small; are seen usually about the abdomen and chest, and exceptionally about the limbs; are chronic in character; and as a rule, are unaccompanied by itching. Pit-like, atrophic depressions may or may not follow the disappearance of the lesions.
The affection is not uncommon in Austria, but in this country it is 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 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 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.