Essentials of Diseases of the Skin Part 19

What is known in regard to the nature of the disease?

An inflamed and irritable state of the spinal ganglia, nerve tract, or peripheral branches is directly responsible for the eruption, and this state may be due to atmospheric changes, cold, nerve-injuries and similar influences. The view has also been advanced that the disease is of specific and infectious character.

Give the chief diagnostic features of herpes zoster.

The prodromic neuralgic pain, the appearance of grouped vesicles upon inflammatory bases following the course of a nerve tract, and the limitation of the eruption to one side of the body.

What is the prognosis?

Favorable; the symptoms usually disappearing in two to four weeks. In some instances, however, the neuralgic pains may be persistent, and in zoster of the supra-orbital region the eye may suffer permanent damage.

How would you treat herpes zoster?

_Const.i.tutional treatment_, usually tonic in character, is to be based upon general principles; moderate doses of quinia, with one-sixth grain of zinc phosphide, four or five times daily, appear in some cases to have a special value. The accompanying neuralgic pain may be so intense as to require anodynes. _Local treatment_ should be of a soothing and protective character. A dusting-powder of oxide of zinc and starch (to the ounce of which twenty to thirty grains of camphor may be added) proves useful; and over this, in order that the parts be further protected, a bandage or a layer of cotton batting. Oxide-of-zinc ointment, and in those cases in which there is much pain, ointments containing powdered opium or belladonna, or orthoform, may be used. A mild galvanic current applied daily to the parts is often of great advantage, both in its influence upon the course of the eruption and upon the neuralgic pain. The plan, so often advised, of painting the parts with flexible collodion is not to be commended.

Dermat.i.tis Herpetiformis.

(_Synonyms:_ Hydroa Herpetiforme (Tilbury Fox); Herpes Gestationis (Bulkley); Pemphigus Prurigiuosus; Duhring's Disease.)

Give a definition of dermat.i.tis herpetiformis.

Dermat.i.tis herpetiformis is a somewhat rare inflammatory disease, characterized by an eruption of an erythematous, papular, vesicular, pustular, bullous or mixed type, with a decided disposition toward grouping, accompanied by itching and burning sensations, with, as a rule, more or less consequent pigmentation, and pursuing usually a chronic course with remissions.

Describe the erythematous type of dermat.i.tis herpetiformis.

The character of the eruption in the erythematous type resembles closely that of erythema multiforme and of urticaria, especially the former. The efflorescences usually make their appearance in crops, and are more or less persistent; fading sooner or later, however, and giving place to new outbreaks. Vesicles are often intermingled, developing from erythematous and erythemato-papular lesions or arising from apparently normal skin.

It may continue in the same type, or change to the vesicular, bullous or other variety.

Describe the papular type of dermat.i.tis herpetiformis.

This is rarely seen as consisting purely of papular lesions, but is commonly a.s.sociated with the erythematous and vesicular varieties. In a measure it resembles the papular manifestations of erythema multiforme, with a distinct disposition toward group formation. The papules tend, sooner or later, to develop into vesicles, new papular outbreaks occurring from time to time; or the whole eruption changes to the vesicular or other type of the disease. It is not a common type.

Describe the vesicular type of dermat.i.tis herpetiformis.

This is the common clinical type of the disease, and is characterized by pin-head to pea-sized, rounded or irregularly-shaped, distended or flattened and stellate vesicles, occurring, for the most part, in irregular and segmental groups of three or more lesions, seated either upon apparently normal integument or upon hyperaemic or inflammatory skin. They exhibit no tendency to spontaneous rupture, but after remaining a shorter or longer time, are broken or disappear by absorption. The lesions tend to appear in crops. It may, as it not infrequently does, continue in the same type, or it may become more or less erythematous or bullous in character. In not a few instances pustules, few or in numbers, are at times intermingled.

Describe the pustular type of dermat.i.tis herpetiformis.

This is rare. It is similar in its clinical characters to the vesicular type, except that the lesions are pustular. It is met with, as a rule, in a.s.sociation with the vesicular and bullous varieties of the disease.

Describe the bullous type of dermat.i.tis herpetiformis.

The bullous expression of the disease is usually of a markedly inflammatory nature, often innumerable blebs, small and large, appearing almost continuously, and in some instances involving the greater part of the surface. The lesions arise from erythematous skin, from preexisting vesicles or vesicular groups, or from apparently normal integument.

There is a marked disposition to appear in cl.u.s.ters. A change of type to the erythematous or vesicular varieties is not unusual.

Describe the mixed type of dermat.i.tis herpetiformis.

In this type the eruption is made up of erythematous patches, vesicles, bullae, and often with pustules intermingled, appearing irregularly or in crops, and with a tendency to patch or group formation.

Describe the characters of the vesicles, pustules and blebs.

As a rule, these several lesions, especially the vesicles and blebs, are somewhat peculiar: they are usually of a strikingly irregular outline, oblong, stellate, quadrate, and when drying are apt to have a puckered appearance. They are herpetic in that they show little disposition to spontaneous rupture, occur in groups, and are usually seated upon erythematous or inflammatory skin--in some respects similar to the groups of simple herpes and herpes zoster.

What is to be said in regard to the subjective symptoms?

The subjective symptoms are usually the most troublesome feature of the disease, consisting of intense and persistent itching and a feeling of heat and burning.

Are there any const.i.tutional symptoms in dermat.i.tis herpetiformis?

As a rule, not, excepting the distress and depression necessarily consequent upon the intense itchiness and loss of sleep. In the pustular and bullous varieties there may be mild or grave systemic symptoms, but even in these types the const.i.tutional involvement is, in most instances, slight in comparison to the intensity of the cutaneous disturbance.

What is the course of dermat.i.tis herpetiformis?

Extremely chronic, in most instances lasting, with remissions, indefinitely. The skin is rarely entirely free. From time to time the type of the disease may undergo change. From the continued irritation and scratching more or less pigmentation results.

What is to be said in regard to the etiology?

The disease is in many instances essentially neurotic, and in exceptional instances septicaemic. Pregnancy and the parturient state are factors in some instances (so-called herpes gestationis). It is possible in some instances that the eruption may be an expression of a mild toxemia of gastro-intestinal origin. In some cases no cause can be a.s.signed. In the majority of patients the general health, considering the violence of the eruptive phenomena, remains comparatively undisturbed.

Nervous shock and mental worry are factors in some cases. Polyuria, with sugar in the urine, has occasionally been noted. Eosinophile cells have been found both in the vesicles and the blood. In some instances--exceptionally, it is true--the disease has appeared shortly after vaccination.

Mention the diagnostic features of dermat.i.tis herpetiformis.

The multiformity of the eruption, the characters of the lesions, the disposition to grouping, the absence of tendency to form solid sheets of eruption (as in eczema), the intense itching, history, chronicity and course. In doubtful cases, an observation of several weeks will always suffice to distinguish it from eczema, erythema multiforme, herpes iris and pemphigus, diseases to which it at times bears strong resemblance.

Give the prognosis of dermat.i.tis herpetiformis.

An opinion as to the outcome of the disease should be guarded. It is exceedingly rebellious to treatment, and relapses are the rule.

Exceptionally the bullous and pustular varieties prove eventually fatal.