Skin Diseases of Children/Lupus and other Tuberculides

by George Henry Fox

PLATE X.

Lupus Vulgaris.

From the collection of Photographs of Dr. George Henry Fox

 

LUPUS AND OTHER TUBERCULIDES.

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Many years ago the fact was noted by dermatological clinicians that lupus vulgaris was frequently associated with pul-

Fig. 36.—A group of tubercles.

monary phthisis, and recent microscopical research has demonstrated that in both affections the same bacillus may be found. Lupus vulgaris is therefore one of the clinical forms of cutaneous tuberculosis and may be properly described as a tuberculide. There are other affections of the skin which are commonly associated with the varied symptoms of scrofula and in which the bacillus tuberculosis may be found, but they are clinically distinct, though pathologically related to lupus. The term tubercular, as applied to lupus, was originally used only in a morphological sense, indicating the nodular character of the eruption. It is a singular fact that, while the old term is still

Fig. 37.—Tubercles forming a ring.

retained in use, science has invested it with a deeper and more definite significance since the discovery in the nodule of the tubercle bacillus.

Lupus vulgaris is an affection which is often seen in childhood, and which, indeed, begins in most cases before the age of puberty. It usually appears in the form of one or more dull red papules upon the cheek or elsewhere. These slowly increase in number and tend to coalesce (Fig. 30). Frequently the older or central lesions disappear by interstitial absorption and an irregular ring is formed (Fig. 37), or an infiltrated patch with one or two outlying nodules (see plate). Upon the neck the disease often assumes a serpiginous form, spreading at the margin and enclosing a cicatricial area, dotted, perhaps, by a few recently developed nodules (Fig. 38). This form of the disease may have a somewhat acute character, and, though spreading slowly, may increase in extent much more rapidly than does the nodular form seen upon the cheeks.

Upon the ala nasi, which is a frequent site of lupus, a scaly

Fig. 38.—Serpiginous lupus with central cicatrix.

or crusted patch is often seen, with more or less ulceration, and in time a marked deformity as the result of cicatricial contraction (Fig. 39).

The nodules of lupus, when well developed, have a characteristic translucent, jelly-like appearance, and, though feeling firm and resilient to the touch, are much softer than the normal cutaneous tissue. In an advanced stage the nodules and patches of lupus become somewhat scaly and not infrequently soften and ulcerate. In chronic cases seen in adult life the disease is often found to have spread over the greater portion of the face, producing a marked ectropion and a partial disappearance of the nose and ears. Such an extensive development of the disease is rarely if ever observed in childhood. Although the face is the most common site of lupus, the trunk and extremities may also be affected, either independently or with the face.

Fig. 39.—A favorite site of lupus.

Another tuberculide, or affection in which the bacillus tuberculosis is invariably present, is often met with in childhood as well as in adult life, and is known as tuberculosis verrucosa or lupus verrucosus. This consists of dry, warty, or papillomatous patches (Fig. 40), which may develop upon the back of the hand, especially over the knuckles, the wrist, the popliteal spaces, and other portions of the body, and is commonly regarded as the result of local infection. The development of the disease is slow. Ulceration rarely occurs, but the centre of the patch may undergo a spontaneous cure, leaving cicatricial tissue.

Still another form of cutaneous tuberculosis is that commonly described under the name of scrofuloderma. This appears in the form of suppurating or crusted ulcers of the skin in children who usually present other evidences of the scrofulous taint. It is most frequently observed upon the neck over

Fig. 40.—Lupus verrucosus (tuberculosis verrucosa cutis).

lymphatic glands which have undergone caseous degeneration and softening, although it may occur in multiple discoid lesions over the buttocks, thighs, and other portions of the body. When lupus or scrofuloderma attacks the hand or fingers of a child the bony tissue is frequently involved and a strumous dactylitis may develop, or caries with resulting atrophy and a considerable subsequent deformity (Fig. 41).

Lupus erythematosus, though allied in name to lupus vulgaris and often bearing a strong resemblance to it, cannot be considered as a tuberculide. The bacillus tuberculosis has not been found in this affection, and all attempts at inoculation of animals have given negative results. It may be remarked in passing that this disease, like lupus vulgaris, is most commonly seen upon the face (Fig. 42), but, unlike the common form of lupus, it is rarely seen in childhood.

Fig. 41.—Ulcerating lupus with atrophy of bone.

In the treatment of lupus and the other tuberculides much may be done to improve the general health of the patient and thus to modify to a limited extent the spread of the disease; but to effect a cure a resort to surgical measures is necessary. The palliative treatment by means of ointments and plasters, so frequently employed, need only be mentioned for the sake of condemnation. The morbid tissue must be destroyed, and it matters little how this is done provided it is thoroughly done. The knife, the cautery, and caustic pastes I have used and discarded, believing that by the skilful use of the curette and burr the disease can be removed with the least amount of pain and discomfort and the least resulting disfigurement. For many years I have used the dental burr of varying size, dipped in carbolic acid, for the destruction of lupus nodules, and ever with increasing satisfaction. This instrument readily penetrates the

Fig. 42.—Lupus erythematosus.

gelatinous lesions, and when the handle is rolled between the fingers, and the burr pressed in various directions, it bores out the softened lupus tissue as it does the carious substance in a dental cavity and leaves the normal skin uninjured. In diffused patches of lupus, in scrofulous ulcerations, and in verrucous tuberculosis (after the warty surface has been removed by a salicylic-acid plaster) nothing can be more serviceable than the dermal curette.