(Synonyms: Syphiloderma; Dermatosyphilis; Syphilis of the Skin.)

In what various types may syphilis manifest itself upon the integument?

Syphilis may show itself as a macular, papular (rarely vesicular), pustular, bullous, tubercular and gummatous eruption; or the eruption may be, in a measure, of a mixed type.

In what respects do the early (or secondary) eruptions of syphilis differ from those following several years or more after the contraction of the disease?

The early or secondary eruptions are more or less generalized, with rarely any attempt at special configuration. Their appearance is often preceded by symptoms of systemic disturbance, such as fever, loss of appetite, muscular pains and headache; and accompanied by concomitant signs of the disease, such as enlargement of the lymphatic glands, sore throat, mucous patches, falling of the hair and rheumatic pains.

State the distinguishing characters of the late eruptions.

The late eruptions (those following one or more years after the contraction of the disease) are usually of tubercular, gummatous or ulcerative type; are limited in extent, and have a marked tendency to appear in circular, semicircular or crescentic forms or groups. Pain in the bones, bone lesions and other symptoms may or may not be present.

What is the color of syphilitic lesions?

Usually, a dull brownish-red or ham-red, with at times a yellowish cast.

Are there any subjective symptoms in syphilitic eruptions?

As a rule, no; but in exceptional instances of the generalized eruptions, more especially in negroes, there may be slight itching.

Describe the macular, or erythematous, eruption of syphilis.

The macular syphiloderm is a general eruption, showing itself usually six or eight weeks after the appearance of the chancre. It consists of small or large, commonly pea- or bean-sized, rounded or irregularly-shaped, not infrequently slightly raised, macules. When well established they do not entirely disappear under pressure. At first a pale-pink or dull, violaceous red, they later become yellowish or coppery. The eruption is generally profuse; the face, backs of the hands and feet may escape. It persists several weeks or one or two months; as a rule, it is rapidly responsive to treatment.

How would you distinguish the macular syphiloderm from measles, rÖtheln and tinea versicolor?

Measles is to be differentiated by its catarrhal symptoms, fever, form and situation of the eruption; rÖtheln, by its small, roundish, confluent pinkish or reddish patches, its precursory pyrexic symptoms, its epidemic nature, and short duration; tinea versicolor by its scaliness, peripheral growth, distribution and history.

And, finally, by the absence or presence of other symptoms of syphilis.

Fig. 51.

Macular Syphiloderm.

What several varieties of the papular eruption of syphilis are met with?

There are two forms of the papular eruption—the small and large; those of the latter type may undergo various modifications.

Describe the small-papular eruption of syphilis.

The small-papular syphiloderm (miliary papular syphiloderm) usually shows itself in the third or fourth month of the disease, and consists of a more or less generalized eruption of disseminated or grouped, firm, rounded or acuminated pin-head to millet-seed-sized papules, with smooth or slightly scaly summits, and in some lesions showing pointed pustulation. Scattered minute pustules and some large papules are usually present. The eruption is profuse, most abundant upon the trunk and limbs; and in the early part of the outbreak is of a bright- or dull-red color, later assuming a violaceous or brownish tint. It runs a chronic course, is somewhat rebellious to treatment, and displays a tendency to relapse.

Fig. 52.

Moist Papules. (After Miller.)

How would you distinguish the small-papular syphiloderm from keratosis pilaris, psoriasis punctata, papular eczema, and lichen ruber?

The distribution and extent of the eruption, the color, the grouping, with usually the presence of pustules and large papules and other concomitant symptoms of syphilis, are points of difference. Pustules never occur in the several diseases named, except in eczema.

Describe the large-papular eruption of syphilis.

The large-papular syphiloderm (or lenticular syphiloderm) is a common form of cutaneous syphilis, appearing usually in the first six or eight months, and consists of a more or less generalized eruption of pea- to dime-sized or larger, flat, rounded or oval, firmly-seated,

Small-papular Syphiloderm.

more or less raised, dull-red papules; with at first a smooth surface, which later usually becomes covered with a film of exfoliating epidermis. The papules, as a rule, develop slowly, remain stationary several weeks or a few months, and then pass away by absorption, leaving slight pigmentation, which gradually fades; or they may undergo certain modifications. In most cases it responds rapidly to treatment.

Fig. 53.

Palmar Syphiloderm.

What modifications do the papules of the large-papular syphiloderm sometimes undergo?

They may change into the moist papule and squamous papule.

Describe the moist papule of syphilis.

The change into the moist papule (also called mucous patch, flat condyloma) is not uncommon where opposing surfaces and natural folds of skin are subjected to more or less contact, as about the anus, the scroto-femoral regions, umbilicus, axillÆ and beneath the mammÆ. The dry, flat papules gradually become moist and covered with a grayish, sticky, mucoid secretion; several may coalesce and form large, flat patches. They may so remain, or they may become hypertrophic, warty or papillomatous, with more or less crust formation (vegetating syphiloderm).

Fig. 54.

Annular Syphiloderm. (After I.E. Atkinson.)

Describe the squamous papule of syphilis.

This tendency of the large-papular eruption to become scaly, when exhibited, is more or less common to all papules, and constitutes the squamous or papulo-squamous syphiloderm (improperly called psoriasis syphilitica). The papules become somewhat flattened and are covered with dry, grayish or dirty-gray, somewhat adherent scales. The scaling, as compared to that of psoriasis, is, as a rule, relatively slight. The eruption may be general, as usually the case in the earlier months of the disease, or it may appear as a relapse or a later manifestation, and be limited in extent.

As a limited eruption it is most frequently seen on the palms and soles—the palmar and plantar syphiloderm. Occurring on these parts it is often rebellious to treatment.

Maculo-papular syphiloderm.

How are you to distinguish the papulo-squamous syphiloderm from psoriasis?

In psoriasis the eruption is more inflammatory, and usually bright red; the scales whitish or pearl-colored and, as a rule, abundant. It is generally seen in greater profusion upon certain parts, as, for instance, the extensor surfaces, especially of the elbows and knees. It is not infrequently itchy, and, moreover, presents a different history.

In the syphilitic eruption some of the papules almost invariably remain perfectly free from any tendency to scale formation; there is distinct deposit or infiltration, and the lesions are of a dark, sluggish red or ham tint; and, moreover, concomitant symptoms of syphilis are usually present.

Describe the annular eruption of syphilis.

The annular syphiloderm (circinate syphiloderm) is observed usually in association with the large-papular eruption, and consists of several or more variously sized, ring-like lesions, with a distinctly elevated solid ridge or wall peripherally and a more or less flattened centre. It is commonly seen about the mouth, forehead and neck. The lesion appears to have its origin from an ordinary, usually scaleless or slightly scaly, large papule, the central portion of which has been incompletely formed or has become sunken and flattened. The manifestation is rare, and is seen most frequently in the negro.

What several varieties of the pustular syphiloderm are met with?

The small acuminated-pustular syphiloderm, the large acuminated-pustular syphiloderm, the small flat-pustular syphiloderm, and the large flat-pustular syphiloderm.

Describe the small acuminated-pustular eruption of syphilis.

The small acuminated-pustular syphiloderm (miliary pustular syphiloderm) is an early or late secondary eruption, commonly encountered in the first six or eight months of the disease. It consists of a more or less generalized, disseminated or grouped, millet-seed-sized, acuminated pustules, usually seated upon dull-red, papular elevations. The eruption is, as a rule, profuse, and usually involves the hair-follicles. The pustules dry to crusts, which fall off and are often followed by a slight, fringe-like exfoliation around the base, constituting a grayish ring or collar. Minute pin-point atrophic depressions or stains are left, which gradually become less distinct. Scattered large pustules, and sometimes papules, are not infrequently present.

Describe the large acuminated-pustular eruption of syphilis.

The large acuminated-pustular syphiloderm (acne-form syphiloderm, variola-form syphiloderm) is a more or less generalized eruption, occurring usually in the first six or eight months of the disease. It consists of small or large pea-sized, disseminated or grouped, acuminated or rounded pustules, resembling the lesions of acne and variola. They develop slowly or rapidly, and at first may appear more or less papular. They dry to somewhat thick crusts, and are seated upon superficially ulcerated bases.

It pursues, as a rule, a comparatively rapid and benign course. In relapses the eruption is usually more or less localized.

How would you distinguish the large acuminated-pustular syphiloderm from acne and variola?

In acne the usual limitation of the lesions to the face or face and shoulders, the origin, more rapid formation and evolution of the individual lesions, and the chronic character of the disease, are usually distinctive points.

In variola, the intensity of the general symptoms, the shot-like beginning of the lesions, their course, the umbilication, and the definite duration, are to be considered.

The presence or absence of other symptoms of syphilis has, in obscure cases, an important diagnostic bearing.

Describe the small flat-pustular eruption of syphilis.

The small flat-pustular syphiloderm (impetigo-form syphiloderm) consists of a more or less generalized, pea-sized, flat or raised, discrete, irregularly-grouped, or in places confluent, pustules, appearing usually in the first year of the disease. The pustules dry rapidly to yellow, greenish-yellow, or brownish, more or less adherent, thick, uneven, somewhat granular crusts, beneath which there may be superficial or deep ulceration; where the lesions are confluent a continuous sheet of crusting forms. The eruption is often scanty. It is most frequently observed about the nose, mouth, hairy parts of the face and scalp, and about the genitalia, frequently in association with papules on other parts.

Are you likely to mistake the small flat-pustular syphiloderm for any other eruption?

Scarcely; but when upon the scalp, it may bear rough resemblance to pustular eczema, but the erosion or ulceration will serve to differentiate. Moreover, concomitant symptoms of syphilis are to be looked for.

Describe the large flat-pustular eruption of syphilis.

The large flat-pustular syphiloderm (ecthyma-form syphiloderm) consists of a more or less generalized, scattered eruption, of large pea- or dime-sized, flat pustules. They dry rapidly to crusts. The bases of the lesions are a deep-red or copper color. Two types of the eruption are met with.

In one type—the superficial variety—the crust is flat, rounded or ovalish, of a yellowish-brown or dark-brown color, and seated upon a superficial erosion or ulcer. The lesions are usually numerous, and most abundant on the back, shoulders and extremities. It appears, as a rule, within the first year, and generally runs a benign course.

Fig. 55.

Rupia. (After Tilbury Fox.) In the other type—the deep variety—the crust is greenish or blackish, is raised and more bulky, often conical and stratified, like an oyster shell—rupia; beneath the crusts may be seen rounded or irregular-shaped ulcers, having a greenish-yellow, puriform secretion. It is usually a late and malignant manifestation.

How would you differentiate the large flat-pustular syphiloderm from ecthyma?

The syphilitic lesions are more numerous, are scattered, are attended with superficial or deep ulceration, and followed by more or less scar-formation. Moreover, the history, and presence or absence of other symptoms of syphilis have an important diagnostic value.

Fig. 56.

Ulcerating Tubercular Syphiloderm.

Describe the bullous eruption of syphilis.

The bullous syphiloderm, (of acquired syphilis) is a rare and usually late eruption, appearing in the form of discrete, disseminated, rounded or ovalish, pea- to walnut-sized, partially or fully distended, blebs. The serous contents soon become cloudy and puriform. In some cases the lesions are distinctly pustular from the beginning. The crust, which soon forms, is of a yellowish-brown or dark green color, and may be thick and stratified (rupia), as in the deep variety of the large flat-pustular syphiloderm. The erosions or ulcers beneath the crusts secrete a greenish-yellow fluid. It is a malignant type of eruption, and is usually seen in broken-down subjects.

It is not an uncommon manifestation of hereditary syphilis (q. v.) in the newborn.

Fig. 57.

Tubercular Syphiloderm.

How is the bullous syphiloderm to be differentiated from other pemphigoid eruptions?

By the gravity of the disease, the accompanying ulceration, the course and history; and by other evidences, past or present, of syphilis.

Describe the tubercular eruption of syphilis.

The tubercular syphiloderm (syphiloderma tuberculosum) may exceptionally occur within the first year as a more or less generalized eruption. As a rule, however, it is a late manifestation, at times appearing many years after the initial lesion; is limited in extent, and shows a decided tendency to occur in groups, often forming segments of circles and circular areas, clearing in the centre and spreading peripherally.

It consists (as a late, limited manifestation) of several or more firm, circumscribed, deeply-seated, smooth, glistening or slightly scaly elevations; rounded or acuminated in shape, of a yellowish-red, brownish-red or coppery color and usually of the size of small or large peas. Several groups may coalesce, and a serpiginous tract result (serpiginous tubercular syphiloderm). The lesions develop slowly, and are sluggish in their course, remaining, at times, for weeks or months, with but little change. As a rule, however, they terminate sooner or later, either by absorption, leaving a more or less permanent pigment stain with or without slight atrophy (non-ulcerating tubercular syphiloderm), or by ulceration (ulcerating tubercular syphiloderm).

Describe the ulcerating tubercular syphiloderm.

Fig. 58.

Ulcerating Tubercular Syphiloderm.

The ulceration may be superficial or deep in character, and involve several or all of the lesions forming the group. The patch may consist, therefore, of small, discrete, punched-out ulcers, or of one or more continuous ulcers, segmented, crescentic or serpiginous in shape. They are covered with a gummy, grayish-yellow deposit or they may be crusted. As the ulcerative changes take place, new

Tubercular Syphiloderm.

Large-pustular Syphiloderm.

lesions, especially about the periphery of the group or patch, may appear from time to time.

In some instances, more especially about the scalp, the surface of the ulcerations becomes papillary or wart-like, with an offensive, yellowish, puriform secretion (syphilis cutanea papillomatosa).

From what diseases is the tubercular syphiloderm to be differentiated?

From tubercular leprosy, epithelioma and lupus vulgaris, especially the last-named.

What are the chief diagnostic characters of the tubercular syphiloderm?

The tendency to form segments, crescents and circles, the color, the pigmentation and ulceration, the history, and not infrequently marks or scars of former eruptions.

Fig. 59.

Tubercular Syphiloderm.

Describe the gummatous eruption of syphilis.

The gummatous syphiloderm (syphiloderma gummatosum, gumma, syphiloma) is usually a late manifestation, showing itself as one, several or more painless or slightly painful, rounded or flat, more or less circumscribed tumors; they are slightly raised, moderately firm, and have their seat in the subcutaneous tissue. They tend to break down and ulcerate. The lesion begins usually as a pea-sized deposit or infiltration, and grows slowly or rapidly; when fully developed it may be the size of a walnut, or even larger. The overlying skin becomes gradually reddish. At first firm, it is later soft and doughy. It may, even when well advanced, disappear by absorption, but usually tends to break down, terminating in a small or large, deep, punched-out ulcer.

Fig. 60.

Tubercular Syphiloderm.

Does the gummatous syphiloderm invariably appear as a rounded well-defined tumor?

No. Exceptionally, instead of a well-defined tumor, it may appear as a more or less diffused patch of infiltration, leading eventually to extensive superficial or deep ulceration.

From what formations is the gummatous syphiloderm to be differentiated?

From furuncle, abscess, and sebaceous, fatty and fibroid tumors. Attention to the origin, course, and behavior of the lesion, together with a history, must all be considered in doubtful cases.

Fig. 61.

Large Pustular Syphiloderm.

What is to be said in regard to the character and time of appearance of the cutaneous manifestations of hereditary syphilis?

In a great measure the cutaneous manifestations of hereditary syphilis are essentially the same as observed in acquired syphilis. They are usually noted to occur within the first three months of extra-uterine life. The macular, papular, and bullous eruptions are most common.

Describe these several cutaneous manifestations of hereditary syphilis.

The macular (erythematous) eruption begins as large or small, bright- or dark-red macules, later presenting a ham or cafÉ-au-lait appearance. At first they disappear upon pressure. The lesions are more or less numerous, usually become confluent, especially about the folds of the neck, about the genitalia and buttocks; in these regions resembling somewhat erythema intertrigo.

The papular eruption is observed in conjunction with the erythematous manifestation, or it occurs alone. The lesions are but slightly elevated, and seem to partake of the nature of both macules and papules. They are usually discrete, and rarely abundant; they may become decked with a film-like scale, and at the various points of junction of skin and mucous membrane, and in the folds, they become abraded and macerated, developing into moist papules.

The bullous eruption consists of variously-sized, more or less purulent blebs, and is usually met with at or immediately following birth. It is most abundant about the hands and feet. Macules and papules are often interspersed. There may be superficial or deep ulceration underlying the bullÆ.

What other symptoms in addition to the cutaneous manifestations are noted in hereditary syphilis in the newborn?

Mucous patches, and sometimes ulcers, in the mouth and throat; hoarseness, as shown by the peculiar cry, and indicating involvement of the larynx; snuffles, a sallow and dirty appearance of the skin, loss of flesh and often a shriveled or senile look.

What is the pathology of cutaneous syphilis?

The syphilitic deposit consists of round-cell infiltration. The mucous layer, the corium, and in the deep lesions the subcutaneous connective tissues also, are involved in the process. The infiltration disappears by absorption or ulceration. The factor now believed to be responsible for the disease and the pathological changes is the SpirochÆta pallida, discovered by Schaudinn and Hoffmann, and usually found in numbers in the tissues.

Give the prognosis of cutaneous syphilis.

In acquired syphilis, favorable; sooner or later, unless the whole system is so profoundly affected by the syphilitic poison that a fatal ending ensues, the cutaneous manifestations disappear, either spontaneously or as the result of treatment. The earlier eruptions will often pass away without medication, but treatment is of material aid in moderating their severity and hastening their disappearance, and is to be looked upon as essential; in the late syphilodermata treatment is indispensable. In the large pustular, the tubercular and gummatous lesions, considerable destruction of tissue may take place, and in consequence scarring result. Ill-health from any cause predisposes to a relapse, and also adds to the gravity of the case.

In hereditary infantile syphilis, the prognosis is always uncertain: the more distant from the time of birth the manifestations appear the more favorable usually is the outcome.

How is cutaneous syphilis to be treated?

Always with constitutional remedies; and in the graver eruptions, and especially in those more or less limited, with local applications also.

What constitutional and local remedies are commonly employed in cutaneous syphilis?

Constitutional Remedies.—Mercury and potassium iodide; tonics and nutrients are necessary in some cases.

Local Remedies.—Mercurial ointments, lotions and baths, and iodol in ointment or in (and also calomel) powder form.

Give the constitutional treatment of the earlier, or secondary, eruptions of syphilis.

In secondary or early eruptions mercury alone in almost every case; with tonics, if called for. If mercury is contraindicated (extremely rare), potassium iodide may be substituted.

How is mercury usually administered in the eruptions of secondary syphilis?

By the mouth, chiefly as the protiodide, calomel and blue mass, in dosage just short of mild physiological action; by inunction, in the form of blue ointment; by hypodermic injection, usually as corrosive sublimate solution. The method by fumigation, with calomel or bisulphuret, is now rarely employed.

The method by the mouth is the common one, and it is only in rare instances that any other method is necessary or advisable.

What local applications are usually advised in the eruptions of secondary syphilis?

If the eruption is extensive, and more especially in the pustular types, baths of corrosive sublimate (?ii-?iv] to Cong. xxx) may be used; and ointment of ammoniated mercury, twenty to sixty grains to the ounce, blue ointment, and the ten per cent. oleate of mercury alone or with an equal quantity of any ointment base.

The same applications or a dusting powder of calomel may also be used on moist papules.

How long is mercury to be actively continued in cases of early (secondary) syphilis?

Until one or two months after all manifestations (cutaneous or other) have disappeared, and then, as a general rule, continued, as a small daily dose (about one-quarter to one-third of that prescribed during the active treatment) for a period of two or three months; then another cycle of the active dosage for a period of four to six weeks; then a resumption of the smaller daily dose for another two or three months; and so on, for a period of at least two years.

(Almost all authorities are agreed as to the importance of prolonged treatment, but differ somewhat on the question of intermittent or uninterrupted administration.)

Give the constitutional treatment of the late, or localized, syphilodermata.

Mercury always, usually in small or moderate dosage, as the biniodide or corrosive chloride, and potassium iodide; the latter in dose varying from two grains to two drachms or more, t.d., depending upon its action and the urgency of the case.

How long is constitutional treatment to be continued in cases of the late syphilodermata?

Actively for several weeks after the disappearance of all symptoms, and then (especially the mercury) continued in smaller dosage (about one-third) for several months longer.

What applications are usually advised in the late, or localized, syphilodermata?

Ointment of ammoniated mercury, twenty to sixty grains to the ounce; oleate of mercury, five to ten per cent. strength; mercurial plaster, full strength or weakened with lard or petrolatum; a two to twenty per cent. ointment of iodol; resorcin, twenty to sixty grains to the ounce of ointment base; and lotions of corrosive sublimate, one-half to three grains to the ounce.

The following is valuable in offensive and obstinate ulcerations:—

Ointments are to be rubbed in or applied as a plaster; lotions, employed chiefly in ulcers and ulcerations, are to be thoroughly dabbed on, and usually supplemented by the application of an ointment. Iodol may also be applied to ulcers as a dusting-powder, usually mixed with one to several parts of zinc oxide or boric acid.

Give the treatment of hereditary infantile syphilis.

It is essentially the same (but much smaller dosage) as employed in acquired syphilis. Attention to proper feeding and hygiene is of first importance.

Mercury may be given by the mouth, as mercury with chalk (gr. ss-gr. ij, t.d.); as calomel (gr. 1/20-gr. 1/6, t.d.); and as a solution of corrosive sublimate (gr. ss-?vj, ?j, t.d.). If mercury is not well borne by the stomach, it may be administered by inunction; for this purpose, blue ointment is mixed with one or two parts of lard and spread (about a drachm) upon an abdominal bandage and applied, being renewed daily. Treatment by means of baths (gr. x-xxx to the bath) of corrosive sublimate is, at times, a serviceable method.

Potassium iodide, if exceptionally deemed preferable, may be given in the dose of a fractional part of a grain to two or three grains three times daily.

What local measures are to be advised in cutaneous syphilis of the newborn?

If demanded, applications similar to those employed in eruptions of acquired syphilis, but not more than one-third to one-half the strength.