The British Journal of Dermatology, April 1905
Footnotes have been collected at the end of the text, and arelinked for ease of reference.
The British Journal of Dermatology, April, 1905
By H. RADCLIFFE-CROCKER.
The above provisional clinical title was suggested to me by mycoadjutor at University College Hospital, Mr. George Pernet, for awell-defined affection of the skin, of which I have met with teninstances during the last three years, all but one of them in privatepractice. I am not aware that the disease in question has beendescribed before, unless it can be brought under Brocq’s “erythrodermiespityriasiques en plaques disseminées,” with which it will beclosely compared when the cases themselves have been considered.
A case which I showed at the Dermatological Society of London inOctober, 1904, when Drs. Hallopeau, Gastou, Jacquet and Pautrierwere present, was not regarded by them as a case of Brocq’s disease,with which they were presumably familiar, but as an entirely newaffection in their experience.
The following description is drawn up from nine of the cases, allmales, which, in the main features, closely resemble each other.The remaining case, a lady, had some important differences whichwill be discussed later.
So far, all the cases have been adults, though some of them wereyoung. The lesions are evolved in patches of a pale pink or yellowishhue on the limbs and trunk, the uncovered parts, such as the faceand hands, being free or very slightly affected. Generally, thepatches come out very gradually and in small numbers and, in themain, symmetrically, but as the older patches never go away spontaneously,while fresh ones are continually evoluting at short or long120intervals, large areas are involved, and in the course of years (in onecase, months) the whole trunk and limbs are crowded with lesions,though there are always spaces of normal skin intervening, or sometimescompletely enclosed by the diseased process, where the originalpatches have coalesced. For the most part the original patches arediscrete and enlarge but little after their formation, unless theymerge into adjoining patches, when hand-sized or larger areas maybe formed.
With regard to individual patches, they are usually of oval orelongated form, arranged symmetrically in oblique lines on the backin the direction of the ribs, probably in the lines of fission, more orless horizontal in direction in front, and often, but not always, invertical lines on the limbs. On the latter, especially the thighs, theynot infrequently present the appearance of streaks formed by thefinger, the upper part of the stroke being abrupt, and the lower shadingoff. This may sometimes also be seen on the trunk. The majorityof the single patches range from one to three inches in their longestdiameter; the borders are not very well-defined nor raised above therest, but there is no difficulty in discerning the morbid from the healthyskin. They are not raised above the surface, but may be rather deepin the cutis. Infiltration can often be distinctly felt when the patchis pinched up in comparison with the adjoining healthy tissues, but inthe more recent and smaller patches it is imperceptible, and occasionallythey look like mere stains. Their colour is either pale pink oryellowish; in some cases the yellowish hue is pronounced, in othersabsent or nearly so; on the lower limbs the pink hue predominates.The surface is smooth on the trunk, but is often slightly rough on thearms and thighs, and below the knees maybe distinctly rough or even inbranny scales. The patches are never so marked on the upper as onthe lower limbs, the palms are always free, and the backs of the handsare generally unaffected, but sometimes there are a few small patchesbelow the wrist. The face is nearly always free, though I have seenfaint patches in one case. There is very little to suggest that thedisease is inflammatory, and itching is quite absent in most of thecases; a few patients said they had some itching when hot, but only inone case was it really complained of, and that only in the early evolutingstage of the patches. The initial site for the lesions varies; the thighsare the most frequently first affected, the legs next in frequency, and121then the trunk. The lower limbs, too, are generally more crowdedwith lesions than other parts.
The duration of the disease may be very long. My first case hadbeen developing for over ten years, others had been only for a fewmonths; but in the case of a medical man, over 50 when I saw him,he said that patches first appeared on his legs when he was a house-surgeon,and had been slowly evolving ever since, so that after thirtyyears he was pretty thickly covered, as none as far as he knew hadgone entirely away, though they had temporarily disappeared whenhe had rubbed in chrysarobin ointment, but had gradually returnedto their old site.
The disease is compatible with perfect health; and even whenthere was any departure from the normal there was no reason tosuppose that the abnormality was in any way connected with the skinlesions, while the majority of the patients had above the averagehealth for their age.
While there appears to be no tendency in the disease to spontaneousinvolution, they are not, as the case narratives show, altogether rebelliousto treatment, and in at least two cases a cure appears to havebeen effected and in others some improvement, while in a residue noimprovement could be noted. The agents which appeared to have a goodeffect are salicin in 15-grain doses at least three times a day, which byitself entirely cured a recent case (Case 5) of only two months’duration and of rather acute development, and vasogen iodine 10 percent. rubbed in is a useful supplement and materially aided in thecure of Case 4. In some cases, salicin has failed to make any markedimpression on the lesions, while in others the patient has not gone onwith it sufficiently long to test its merits. As might be expected, ithas been most successful when the disease has been present for a shorttime.
The only female case, a lady aged 47 years, resembled the othercases in its gradual evolution, long duration, absence of itching, in thepersistence of the old patches with continual evolution of new ones, inits limitation to the covered parts, and in the general good health ofthe patient. The differences were in the patches being distinctly scalyall over the body; though the scales were small and even powdery inmost parts of the body, they were, as usual, rather larger and moreabundant on the legs. The patches were also more decidedly red than122in the other cases; while there was some spontaneous improvement inthe summer, in winter the patches cracked and smarted. This patient,who had been affected with the disease for ten years, had had the mostvaried drug and spa treatment, including cacodylate of soda injectionsfor three months without any material effect; but after nineexposures to the Röntgen rays, the part exposed entirely cleared up,while the disease was unchanged on the inner side of the leg whichthe rays had not reached. I intend, therefore, to make use of therays wherever practicable.
As regards to etiology, it is chiefly negative. There is a large preponderanceof males, and all the cases have been over 20 years old,while 56 years is the oldest I have met with. In no case could anexciting cause be made out; two of the patients had had syphilis,but it did not appear to have any etiological importance, and in one ofthem antisyphilitic treatment was tried vigorously for twelve monthswithout effect.
Case 1.—Mr. O——, draper, aged 30 years, was first seen by me onMarch 5th, 1902. The disease had been present ten years. From thecommencement none of the patches had gone away. They appearedsimultaneously inside the arms and thighs. They increased in numbersvery slowly for a long time, and were confined to the limbs until threeyears ago, when they attacked the trunk, and during the last yearhave greatly increased in number; in fact, most of them have appearedin the last twelve months. His father was drowned and his mother diedof fatty heart at the age of 51 years. When first seen by me the diseasewas in yellowish patches which commenced four inches above thenipples, but were not abundant till the line of the nipples, and theywere less numerous below the umbilicus than above it. They wererather thickly arranged in horizontal elongated patches from 1 to3 inches long, and 1/2 inch wide, as if streaked by the finger, pale,pink, or yellowish in tint, rather well-defined, but the edges were notsharp, and when the patch was pinched up a slight infiltration orthickening could be felt in the skin. The longer patches were formedby coalescence of some of the smaller ones. The surface was quitesmooth. On the sides, the patches inclined slightly downwards andforwards, but they were practically horizontal in front. On the backthey were sparse, and faintly developed in the interscapular region,123and not nearly so numerous as in front; but on the lower half of theback and sides they were in the form of yellowish red stains, withoutelevation or roughness, and they were more numerous than on theupper part of the back. Forearms: The patches were on the innerside chiefly, more numerous on the right side than the left, and thicklyarranged between the wrist and elbow. They were not elongated,but roundish, oval, or irregular, about three quarters of an inch in diameter,and somewhat brighter in tint than on the trunk. The surfacewas faintly rough, and on pinching up a patch it was slightlythicker than usual. There were about eight to ten patches on theright upper arm, while the left was almost free, and there were notnearly so many patches on the left forearm as there were on the right.On the thighs: They were most abundant on the inner side, andmany more on the right side than on the left. There were scarcelyany patches on the front of the thigh, but there were a few on theouter side. The patches sloped downwards and inwards, were oval andbroader than the trunk patches, but still like finger-streaks. Thelegs were much more densely covered with coalesced irregular patches,some enclosing healthy skin, and the surface was rougher than thelesions on the rest of the body. On the neck, there were a few ill-definedspots about one inch square in area. There was slightblotchy redness of a not very obvious kind on the face, scarcelyperceptible on the forehead. There was some seborrhœa capitis,but not so much as formerly, as he uses brilliantine. The patchesseldom itched unless he got very hot. No illness preceded theeruption; in fact, he has never had any illness; his tongue was clean,and he looked and has always been perfectly healthy. The generalaspect was somewhat that of a general orbicular seborrhoic eczema,except that for the most part the surface was smooth.
He has consulted dermatologists and others, but nothing he hastaken or used has done him any good. I only saw him once.
Case 2.—Mr. H——, aged 37 years, manager of a factory, came to meon April 2nd, 1902. His general health was very good. The diseasehad been present five years, and began on the right fore-arm and alittle later attacked the left. He has never been free since it firstappeared, but thinks some patches have faded and others come out.In the last winter he had been decidedly worse, for the patches had124certainly increased during the last few months. On the fore-arms,they were nearly symmetrical, and were quite so at an earlier stage.The lesions were yellowish or pale red patches; the simple ones wereelongated, but the compound ones irregular in outline; they were from3/4 to 1-1/2 inches long. The surface, with a lens, could be seen to bevery slightly roughened, but this was not perceptible to