Chapter 14

Glossy skin is a rare condition following an injury or disease of the nerve. It is usually seen about the fingers. The skin is hairless, faintly reddish, smooth and shining, with a varnished and thin appearance, and with a tendency to fissuring. More or less severe and persistent burning pain precedes and accompanies the atrophy.

Protective applications are called for, the disease tending slowly to spontaneous disappearance.

#Describe general idiopathic atrophy of the skin, and give the treatment.#

General idiopathic atrophy of the skin is extremely rare, and is characterized by a gradual, more or less general, degenerative and quantitative atrophy of the skin structures, accompanied usually with more or less discoloration and pigmentation.

Treatment is palliative and based upon indications.

#Describe parchment skin, and state the treatment.#

Parchment skin (_xeroderma pigmentosum_, _angioma pigmentosum et atrophicum_) is a rare disease, the exact nature of which is not understood. It is characterized by the appearance of numerous disseminated, freckle-like pigment-spots, telangiectases, atrophied muscles, more or less shrinking and contraction of the integument, and followed, in most instances, by epitheliomatous tumors and ulceration, and finally death. It is usually slow in its course, beginning in childhood and lasting for years. It is not infrequently seen in several children of the same family.

Treatment is palliative, consisting, if necessary, of the use of protective applications and of the administration of tonics and nutrients.

#Describe atrophic lines and spots.#

Atrophic lines and spots (_striæ et maculæ atrophicæ_) may be idiopathic or symptomatic, the lesions consisting of scar-like or atrophic-looking, whitish lines and macules, most commonly seen on the trunk. They are smooth and glistening. Slight hyperæmia usually precedes their formation. As an idiopathic disease its course is insidious and slow, and its progress eventually stayed. The so-called _lineæ albicantes_, resulting from the stretching of the skin produced by pregnancy or tumors, and from rapid development of fat, may be mentioned as illustrating the symptomatic variety.

In course of time the atrophy becomes less conspicuous.

#Describe senile atrophy.#

Senile atrophy is not uncommon, the atrophy resulting, as the name inferentially implies, from advancing age. It is characterized by thinning and wasting, dryness, and a wrinkled condition, with more or less pigmentation and loss of hair. Circumscribed pigmentary deposits and seborrh[oe]a, with degeneration, are also noted.

#What several diseases of the skin are commonly followed by atrophic changes?#

Favus, lupus, syphilis, leprosy, scleroderma and morph[oe]a.

#CLASS VI.--NEW GROWTHS.#

#Keloid.# (_Synonyms:_ Keloid of Alibert; Cheloid.)

#Give a descriptive definition of keloid.#

Keloid is a fibro-cellular new growth of the corium appearing as one or several variously-sized, irregularly-shaped, elevated, smooth, firm, pinkish or pale-reddish cicatriform lesions.

#Describe the clinical appearance of keloid.#

The growth begins as a small, hard, elevated, pinkish or reddish tubercle, increasing gradually, several months or years usually elapsing before the tumor reaches conspicuous size. When developed, it is one or more inches in diameter, is sharply defined, elevated, hard, rounded or oval, fungoid or crab-shaped, and firmly implanted in the skin. It is usually pinkish, pearl-white, or reddish, commonly devoid of hair, with no tendency to scaliness, and with, usually, several vessels coursing over it. In some instances it is tender, and it may be spontaneously painful.

The breast, especially over the sternal region, is a favorite site for its appearance. One, several or more may be present in the single case.

#What course does keloid pursue?#

Chronic; usually lasting throughout life. In rare instances spontaneous involution takes place.

#State the etiology of keloid.#

The causes are obscure. The growth usually takes its start from some injury or lesion of continuity; for instance, at the site of burns, cuts, acne and smallpox scars, etc.--_cicatricial keloid, false keloid_; or it may also, so it is thought, originate in normal skin--_spontaneous keloid, true keloid_.

#What is the pathology of keloid?#

The lesion is a connective-tissue new growth having its seat in the corium.

#Is there any difficulty in the diagnosis of keloid?#

No. It resembles hypertrophic scar; but this latter, which is essentially keloidal, never extends beyond the line of injury.

#Give the prognosis.#

The growth is persistent and usually irresponsive to treatment. In some cases, however, there is eventually a tendency to spontaneous retrogression, up to a certain point at least.

#What is the treatment of keloid?#

Usually palliative, consisting of the continuous application of an ointment such as the following:--

[Rx] Acidi salicylici, .................... gr. x-xx Emplast. plumbi, Emplast. saponis, ... [=a][=a] ....... [dram]iij Petrolati, ........................... [dram]ij. M.

An ointment of ichthyol, twenty-five per cent. strength, rubbed in once or twice daily, is sometimes beneficial.

Operative measures, such as punctate and linear scarification, electrolysis and excision, are occasionally practised, but the results are rarely satisfactory and permanent; not infrequently, indeed, renewed activity in the progress of the growth is noted to follow. The _x_-ray can be tried with some hope of improvement. The administration of thyroid has been thought to have a possible influence in some instances.

#Fibroma.# (_Synonyms:_ Molluscum Fibrosum; Fibroma Molluscum.)

#What do you understand by fibroma?#

Fibroma is a connective-tissue new growth characterized by one or more sessile or pedunculated, pea- to egg-sized or larger, soft or firm, rounded, painless tumors, seated beneath and in the skin.

#Describe the clinical appearances of fibroma.#

The growth may be single, in which case it is apt to be pedunculated or pendulous, and attain considerable dimensions; as a result of weight or pressure surface-ulceration may occur. Or, as commonly met with, the lesions are numerous, scattered over large surface, and vary in size from a pea to a cherry; the overlying skin being normal, pinkish or reddish, loose, stretched, hypertrophied or atrophied.

The tumors are painless. The general health is not involved.

#What is the course of fibroma?#

Chronic and persistent.

#What is the etiology of fibroma?#

The cause is not known. Heredity is often noted. The affection is not common.

#State the pathology of fibroma.#

The growths are variously thought to have their origin in the connective tissue of the corium, or in that of the walls of the hair-sac, or in the connective-tissue framework of the fatty tissue. Recent tumors are composed of gelatinous, newly-formed connective tissue, and the older growths of a dense, firmly-packed, fibrous tissue.

#From what growths is fibroma to be differentiated?#

From molluscum contagiosum, neuroma and lipoma; the first is differentiated by its central aperture or depression, neuroma by its painfulness, and lipoma by its lobulated character and soft feel.

#Give the prognosis of fibroma.#

The disease is persistent, and irresponsive to all treatment save operative measures.

#What is the treatment of fibroma?#

Treatment consists, when desired and practicable, in the removal of the growths by the knife, or in large and pedunculated tumors by the ligature or by the galvano-cautery.

#Neuroma.#

#Describe neuroma.#

Neuroma of the skin is an exceedingly rare disease, characterized by the formation of variously-sized, usually numerous, firm, immovable and elastic fibrous tubercles containing new nerve-elements, and accompanied by violent, paroxysmal pain. Their growth is slow and usually progressive. Later they are painful upon pressure. They are limited to one region.

The tumors are seated in the corium, extending into the deeper structure, and consist of nerve-fibres, yellow elastic tissue, blood vessels and lymphoid cells.

In the two cases reported, excision of the nerve-trunk gave, in one instance, permanent relief; in the other the effect was only temporary.

#Xanthoma.# (_Synonyms:_ Vitiligoidea; Xanthelasma.)

#What is xanthoma?#

Xanthoma is a connective-tissue new growth characterized by the formation of yellowish, circumscribed, irregularly-shaped, variously-sized, non-indurated, flat or raised patches or tubercles.

#Name the two varieties met with.#

The macular or flat (_xanthoma planum_) and the tubercular (_xanthoma tuberculatum_ or _tuberosum_). In some instances both varieties (_xanthoma multiplex_) are seen in the same individual.

#Describe the clinical appearances of xanthoma planum.#

The macular or flat variety is usually seen about the eyelids. It consists of one, several or more small or large, smooth, opaque, sharply-defined, often slightly raised, yellowish patches, looking not unlike pieces of chamois-skin implanted in the skin.

#Describe the clinical appearances of xanthoma tuberosum.#

The tubercular variety is commonly met with upon the neck, trunk and extremities. It occurs as small, raised, isolated, yellowish nodules, or as patches made up of aggregations of millet-seed-sized or larger tubercles. The lesions may be few or they may exist in great numbers.

#What is the course of xanthoma?#

Extremely slow; after reaching a certain development the growths may remain stationary.

#State the etiology of xanthoma.#

The causes are obscure. Jaundice not infrequently precedes and accompanies its development, especially in the tubercular variety. The disease is uncommon, and is usually seen in middle and advanced life, and more frequently in women. In some cases (_xanthoma diabeticorum_) of general xanthoma diabetes is the causative factor.

#What is the pathology of xanthoma?#

It is a benign, connective-tissue new growth, with concomitant or subsequent, but usually partial, fatty degeneration.

#Give the prognosis of xanthoma.#

The condition is persistent, and usually irresponsive to all treatment save destructive or operative measures.

#What is the treatment of xanthoma?#

Treatment consists, in suitable cases, of excision; in some instances, electrolysis is serviceable. Applications of trichloracetic acid cautiously made are sometimes of value. In that form of general xanthoma due to diabetes the treatment of this latter condition will materially and sometimes completely remove the eruption.

#Myoma.# (_Synonyms:_ Myoma Cutis; Dermatomyoma; Liomyoma Cutis.)

#Describe myoma.#

The disease is rare, and consists usually of one or several (exceptionally numerous), variously-sized tumors of the skin, made up of smooth muscular fibres. They are flat, rounded, oval or pedunculated, and have a smooth surface and a pale-red color; as a rule, they are painless.

The growth is benign, and consists essentially of a new formation of unstriped muscular fibres; but it may also be composed largely of connective tissue (_fibromyoma_); or it may contain an abundance of bloodvessels (_myoma telangiectodes_, _angiomyoma_); or there may be lymphatic involvement (_lymphangiomyoma_).

#Angioma.# (_Synonyms:_ Nævus Vasculosus; Nævus Sanguineus.)

#Give a definition of angioma.#

Angioma is a congenital hypertrophy of the vascular tissues of the corium and subcutaneous tissue. Exceptionally it makes its appearance a few weeks or a month after birth.

#Into what two classes may angiomata be roughly grouped?#

The flat (or non-elevated) and the prominent (or elevated).

#Describe the flat, or non-elevated, variety of angioma.#

The flat, or non-elevated, angioma (_nævus flammeus_, _nævus simplex_, _angioma simplex_, _capillary nævus_) may be pin-head- to bean-sized; or it may involve an area of several inches in diameter, and, exceptionally, a whole region. It is of a bright- or dark-red color, and is met with most frequently about the face. In some instances it extends after birth, reaches a certain size and then remains stationary; occasionally, when involving a small area, it undergoes involution and disappears.

The so-called _port-wine mark_ is included in this group.

#Describe the prominent, or elevated, variety of angioma.#

The prominent variety (_venous n[oe]vus_, _angioma cavernosum_, _n[oe]vus tuberosus_) is variously-sized, often considerably elevated, clearly-defined, compressible, smooth or lobulated, and of a dark, purple color; it may, also, be erectile and pulsating. The growth is usually a single formation, and is met with upon all parts of the body.

#What is the pathology of angioma?#

It is a new growth, consisting of a variable hypertrophy of the cutaneous and subcutaneous arterial and venous bloodvessels, with or without an increase of the connective tissue.

#Give the treatment of angioma.#

In some instances, especially in infants, painting the parts repeatedly with collodion or liquor plumbi subacetatis will act favorably. For well-established, small, capillary nævi electrolysis or puncturing with a red-hot needle or with a needle charged with nitric acid may be employed; for "port-wine mark" frequent and closely contiguous electrolytic punctures are occasionally followed by a slight diminution in color. For the _prominent growths_, vaccination, the ligature, puncturing with the galvano-cautery, and excision are variously resorted to.

In recent years applications of liquid air and carbon dioxide have proved of service in some cases.

#Telangiectasis.#

#Describe telangiectasis.#

Telangiectasis consists of a new growth or enlargement of the cutaneous capillaries, usually appearing during middle adult life, and seated, for the most part, about the face.

#To what extent may telangiectasis develop?#

It may be limited to a red dot or point, with several small radiating capillaries (_nævus araneus_, _spider nævus_), or a whole region, usually the face, may show numerous scattered or closely-set capillary enlargements or new formations (_rosacea_). The latter is frequently associated with acne (_acne rosacea_).

The etiology is obscure.

#What is the treatment of telangiectasis?#

Destruction of the vessels by electrolysis or by the knife. (See treatment of acne rosacea.)

#Lymphangioma.# (_Synonym:_ Lymphangiectodes.)

#Describe lymphangioma.#

Lymphangioma is a rare disease, consisting of localized dilatations of the lymphatic vessels, appearing as discrete or aggregated pin-head or pea-sized, compressible, hollow, tubercle-like elevations, of a pinkish or faint lilac color, and occurring for the most part about the trunk. It is of slow but usually progressive development, and is unaccompanied by subjective symptoms.

A rare condition, Kaposi described as lymphangioma tuberosum multiplex, characterized by more or less solid, somewhat cystic, pearly to pinkish red, sometimes crowded lesions, is now known to be "benign cystic epithelioma"; its most common site is the face. While called "benign," ulcerative action may eventually ensue.

Treatment, when demanded, consists of operative measures.

#Rhinoscleroma.#

#Describe rhinoscleroma.#

Rhinoscleroma is a rare and obscure disease, slow but progressive in its course, characterized by the development of an irregular, dense and hard, flattened, tubercular, non-ulcerating, cellular new growth, having its seat about the nose and contiguous parts. The overlying skin is normal in color, or it may be light- or dark-brown or reddish. Marked disfigurement and closure, partial or complete, of the nasal orifices gradually results. It is met with chiefly in Austria and Germany.

Treatment, consisting of partial or complete extirpation, is rarely permanent in its results, the disease tending to recur.

#Lupus Erythematosus.# (_Synonyms:_ Lupus Erythematodes; Lupus Sebaceus; Seborrh[oe]a Congestiva.)

#What is lupus erythematosus?#

Lupus erythematosus may be roughly defined as a mildly to moderately inflammatory superficial new-growth formation, characterized by one, several, or more circumscribed, variously sized and shaped, pinkish or dark red patches, covered slightly, and more or less irregularly, with adherent grayish or yellowish scales.

#Upon what parts is lupus erythematosus observed?#

Its common site is the face, usually the nose and cheeks, with a tendency toward symmetry; it is often limited to these parts, but may occasionally be seen upon other regions, more especially the lips, ears, and scalp. In rare instances a great part of the general surface may become involved.

#Describe the symptoms of lupus erythematosus.#

Usually the disease begins as one or several rounded, circumscribed, pin-head- to pea-sized lesions; slightly scaly, somewhat elevated, and of a pinkish, reddish or violaceous color. They slowly, or somewhat rapidly, increase in area, and after attaining variable size remain stationary; or they may progress and coalesce, and in this manner sooner or later involve considerable surface. The patches are sharply defined against the sound skin by an elevated border, while the central portion is somewhat depressed and usually atrophic. More or less thickening and infiltration are observed. _There is no tendency to ulceration_. The scaliness is, as a rule, scanty. The gland-ducts are enlarged, patulous or plugged with sebaceous and epithelial matter.

The subjective symptoms of burning and itching are usually slight and often wanting.

#What course does lupus erythematosus pursue?#

As a rule, the disease is persistent, although somewhat variable. At times the patches retrogress, involution taking place with or without slight sieve-like atrophy or scarring.

#State the causes of lupus erythematosus.#

The etiology is obscure. Some observers believe it to be a variety of cutaneous tuberculosis. It is essentially a disease of adult and middle age; is more common in women, and more frequent in those having a tendency to disorders of the sebaceous glands. It may, in fact, begin as a seborrh[oe]a.

#What is the pathology?#

It was formerly considered a new growth, but recent opinion tends toward regarding it as a chronic inflammation of the cutis, superinducing degenerative and atrophic changes. Variable [oe]dema of the prickle layer and of the cutis is found. There is no tendency to pus formation.

#Is there any difficulty in the diagnosis of lupus erythematosus?#

As a rule, not, as the features of the disease--the sharply circumscribed outline, the reddish or violaceous color, the 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 (usually the nose and cheeks)--are characteristic.

#State the prognosis of lupus erythematosus.#

The disease is often capricious and extremely rebellious to treatment; some cases, up to a certain point at least, yield readily, and occasionally a tendency to spontaneous disappearance is observed; a complete cure is, however, it must be confessed, rather rare. The disease in nowise compromises the general health. In those rare instances of generalized disease the patient has usually died from an intercurrent tuberculosis.

#How is lupus erythematosus to be treated?#

The general health is to be looked after and systemic treatment prescribed, if indicated. As a rule, constitutional remedies exert little, if any, influence, but exceptionally, cod-liver oil, arsenic, phosphorus, salicin, quinine, or potassium iodide proves of service.

Locally, according to the case, soothing remedies, stimulating applications and destruction of the growth by caustics or operative measures are to be employed. (_Try the milder applications first._)

#Mention the stimulating applications commonly employed.#

Washing the parts energetically with tincture of sapo viridis, rinsing and applying a soothing ointment, such as cold cream or vaseline.

A lotion containing zinc sulphate and potassium sulphuret thoroughly dabbed on the parts morning and evening:--

[Rx] Zinci sulphatis, Potassii sulphurati, .... [=a][=a] ... [dram]i-[dram]iv Glycerinæ, ........................... [minim]iv Aquæ, ................................ f[Oz]iv. M.

The calamine-and-zinc oxide lotion used in acute eczema is also often extremely valuable.

Lotions of ichthyol and of resorcin, five to sixty grains to the ounce; ichthyol in ointment, five- to twenty-per-cent. strength, is also useful.

Painting the patches with pure carbolic acid; repeating a day or two after the crusts have fallen off.

The continuous application of mercurial plaster.

Sulphur and tar ointments, officinal strength or weakened with lard, and also the following:--

[Rx] Ol. cadini, Alcoholis, Saponis viridis, ..... [=a][=a] ...... [dram]iiss. M.

(This is to be rubbed in, in small quantity, once or twice daily, and later a soothing remedy applied.)

In recent years both the _x_-ray and Finsen light have been used with variable success. Repeated applications of the high-frequency current, with the vacuum electrode, have also proved serviceable. Cautious applications of liquid air or carbon dioxide have also been used with some success in the past few years.

#When are destructive and operative measures justifiable?#

In obstinate, sluggish, and long-persistent patches, and then only after other methods of treatment have failed. (Remember that a patch or patches of the disease _may_ disappear in course of time spontaneously, and occasionally _without leaving a scar_.)

#State the methods of treatment commonly used in obstinate, sluggish and persistent patches of lupus erythematosus.#

Cauterization--with nitrate of silver, with applications of pyrogallic acid in ointment or in liquor gutta-perchæ, fifteen to thirty per cent. strength, and with solutions (cautiously employed) of caustic potash, and exceptionally with the galvano-cautery.

Operative--scarification, either punctate or linear, and erosion with the curette. (See treatment of lupus vulgaris.)

#Lupus Vulgaris.# (_Synonyms:_ Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the Skin.)

#What do you understand by lupus vulgaris?#

Lupus vulgaris is a cellular new growth, characterized by variously-sized, soft, reddish-brown, papular, tubercular and infiltrated patches, usually terminating in ulceration and scarring.

#Upon what region is lupus vulgaris usually observed?#

The face, especially the nose, but any part may be invaded. The area involved may be small or quite extensive, usually the former.

#At what age is the disease noted?#

In many cases it begins in childhood or early adult life, but as it is persistent and tends to relapse, it may be met with at any age.

#Describe the earlier symptoms of lupus vulgaris.#

The disease begins by the development of several or more pin-head to small pea-sized, deep-seated, brownish-red or yellowish tubercles, having their seat in the deeper part of the corium, and which are somewhat softer and looser in texture than normal tissue. As the disease progresses, variously-sized and shaped aggregations or patches result, covered with thin and imperfectly-formed epidermis.

#What changes do the lupus tubercles or infiltrations undergo?#