Erythema

“ Eczema, especially in its chronic erythematous forms, exhibited in the face of adults in middle and later life, is of much slower development, is productive of itching, is ill-defined in contour, and is not accompanied by fever.
Erythema in all its varieties is a purely hyperæmic affection and unaccompanied by fever. In erythema multiforme there is an exudative process by reason of which various papules, nodosities, and at times even bullæ, appear upon the surface. None of them, however, are accompanied by a diffused area of redness spreading at the periphery. ”

“ If neither the erysipelas disappear on the critical day, nor any abscess form outwardly, nor any pus be spit up, and if the patient fancy himself well, and be free from pain, death, or a relapse of the erythema is to be apprehended. It is much less hazardous when the swelling and redness are determined outwardly; but if determined to the lungs, they superinduce delirium, and frequently some of these cases terminate in empyema. ”

“ Most commonly, the eruption appears in the form of papules and tubercles. Erythema papulosum is the form of the disease usually met with. It consists of discrete or aggregated patches of flat papules, variable as to size and shape. In color they are bright red, violaceous, or purplish, disappearing partly under pressure. They fade rapidly, rarely lasting longer than a few weeks. Erythema tuberculosum is a form of the disease occasionally encountered in which the lesions are larger, but of the same general character as in the papular variety. ”

“ Describe the symptoms of erythema nodosum.
The eruption makes its appearance suddenly, and is usually ushered in with febrile disturbance, gastric uneasiness, malaise, and rheumatic pains and swelling about the joints. The lesions vary in size from a cherry to a hen's egg, are rounded or ovalish, tender and painful, have a glistening and tense look, and are of a bright red, erysipelatous color which merges gradually into the sound skin. ”

“ Describe the erythematous type of dermatitis 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. ”

“ In the later stages haemorrhages into the skin (petechiae) are common.
Trypanosomiasis.—Patchy areas of erythema are often noted in Europeans affected with this disease. These are frequently circinate with fading in the center and tend to appear on the trunk.
In natives a dry skin is more often noted.
Rat Bite Disease.—An eruption of purplish spots may accompany the fever. There is a resemblance to erythema multiforme.
Dengue.—The true eruption of dengue is the one that appears about the fourth or fifth day as a measles-like eruption, starting about wrists or ankles. ”

“ In the latter affection itching and burning are prominent and constant symptoms, the lesions are fugacious, and the duration of the disease shorter. It can scarcely be confounded with eczema, in which disease the lesions are smaller and intensely itchy, and the eruption does not assume the different shapes seen in erythema multiforme. Erythema nodosum and herpes iris are also to be differentiated. The prognosis is always favorable, as the affection runs a definite course, usually disappearing at the end of a few weeks. It is rarely influenced by treatment. ”

“ Describe the symptoms of erythema intertrigo.
The skin of the involved region gradually becomes hyperæmic, but is without elevation or infiltration; a feeling of heat and soreness is usually experienced. If the condition continue, the increased perspiration and moisture of the parts give rise to maceration of the epidermis and a mucoid discharge; actual inflammation may eventually result. ”

“ Erythema may be considered an exceedingly mild form of erysipelas, and yields to gentle treatment, as it is given in measles.
120. ADDITIONAL RULES FOR THE TREATMENT OF ERUPTIVE DISEASES.
In all these eruptive diseases, especially small-pox, all I have said, in speaking of scarlatina, about ventilation, [Pg 84] air, diet, &c., ought to be duly observed. ”

“ Blood or gland-lymph examination, or, if this be negative, hepatic or splenic puncture, should establish the diagnosis.
In pellagra the erythema is of a characteristic type. It is not ringed or fugitive as that of trypanosomiasis, and it affects principally the exposed parts of the body; the disease is of a much more chronic character, and, instead of lethargy, the mental condition, if implicated, is more that of insanity melancholia alternating with mania and terminating in dementia. Further, in pellagra, the symptoms are aggravated at particular seasons spring and autumn. ”

“ Sometimes only the upper layer is affected, and then the appearance is like that seen in erythema, diffused redness of the skin produced by capillary congestion. There is but slight swelling, and the constitutional symptoms are not severe. ”

“ The fact that the skins of most animals are pigmented and covered with hair, precludes the easy detection of erythema by visual examination, consequently this indicator of possible inflammation is not often made use of in the examination of equine subjects. ”

“ Mention the etiological factors in erythema multiforme.
The causes are obscure. Digestive disturbance, rheumatic conditions, and the ingestion of certain drugs are at times influential. Intestinal toxins are doubtless important etiological factors in some cases. Certain foods, such as are apt to undergo rapid putrefactive [Pg 49] or fermentative change, especially pork meats, oysters, fish, crabs, lobsters, etc., are, therefore, not infrequently of apparent causative influence. It is most frequently observed in spring and autumn months, and in early adult life. The disease is not uncommon. ”

“ When these are reduced, if the hands are contracted, and become trembling, convulsion and delirium seize such a person; but blisters break out on the eyebrow, erythema takes place, the one eyelid being tumefied overtops the other, a hard inflammation sets in, the eye become strongly swelled, and the delirium increases much, but makes its attacks rather at night than by day. ”

“ Sometimes it takes the form of urticaria factitia, in which the skin reacts to every kind of mechanical stimulation, such as rubbing, scratching, or pressure, all of which alike lead to the formation of weals, which may be diffused all over the body. Less often in association with disturbances of menstruation, acute œdema or erythema are observed. ”

“ The latent period is also affected by the dose, temperature, and humidity. The symptoms of the erythema phase are red, painful itching followed by painful necrosis that heals slowly.
(2) In the eyes, vesicants produce intense pain and photophobia. Blistering of the eyelids and mucous membranes can result in temporary blindness. Even after recovery, scars on the cornea can reduce visual acuity. ”

“ Vesiculation will serve to differentiate from erythema multiforme. The absence of neuralgic pain, the distribution, location, and arrangement of the vesicles, are sufficient to exclude herpes zoster. In pemphigus the size, distribution, arrangement, mode of formation, and course of the lesions are different from herpes iris.
The affection tends to spontaneous disappearance in the course of a week or two; nor does treatment seem to influence materially its course. The bowels should be opened with saline laxatives, and other symptoms treated on general principles. ”

“ The pathology of the lesions in this disease is as follows: reacting to some irritant, the blood-vessels dilate, serum is poured out from them into the tissues around, and compressing the vessels from without empties them of blood. This explains the white centre of the urticarial weal, the red margin of which is the clinical expression of the dilated and uncompressed vessels at the border. In those diseases grouped together under the name of erythema, although the majority of authors place them under the heading of inflammation, there is a good deal suggestive of a close relation to urticaria. ”

“ The macules are rounded or ovalish, varying in size from a pinhead to a finger-nail. Both are smooth and glistening, and the skin is thinned and scar-like. They are slightly depressed or grooved, and possess a pinkish, whitish, or bluish-gray color. They may appear upon any region, but the abdomen, buttocks, and thighs are the favorite localities. They pursue a slow course over a period of years or a lifetime, occasioning no inconvenience. The first stage of either variety of the disease is characterized by erythema, the lesion being reddish, hyperæmic, and slightly raised or puffed. ”

“ They appear from a few weeks to a few months after infection, and are among the most frequent early manifestations of secondary syphilis. The inflammatory process begins in erythema, usually diffuse, often punctated, sometimes in patches. It extends from above downward more frequently than in the reverse direction, but may spread in any direction. The lesion commences upon the soft palate and tonsils more frequently than [p. 407] on the pharynx, but may commence in any portion of the oro-guttural cavity. Tumefaction ensues, with lividity of the surface. The epithelial cells become distended ”

“ We may now consider the other symptoms of the secondary period in the child.
Coryza is one of the most characteristic, and at the same time one of the most important, of these in its influence on the health of the child. It is due to the same condition of the mucous membrane lining the nasal fossæ as manifests itself simultaneously or soon afterward on the skin in the shape of erythema, roseola, or papules; in other words, it is a hyperæmia with papillary infiltration. ”

“ The pulse is soft, and tends to remain abnormally rapid even when the temperature falls nearly to normal.
The face is flushed, and wears a drawn, anxious expression, and the eyes are bright. A characteristic sweetish odour, which has been compared to that of new-mown hay, can be detected in the breath and may pervade the patient. The appetite is lost; there may be sickness and vomiting and profuse diarrhœa; and the patient emaciates rapidly. The skin is continuously hot, and has often a peculiar pungent feel. Patches of erythema sometimes appear scattered over the body. ”

“ One or more recurrences in succeeding years are not uncommon. Those rare cases in which vesicular or bullous lesions are also seen on the lips and in the mouth, are more prone to longer duration and to more frequent recurrences.
What remedies are commonly prescribed in erythema multiforme?
Quinin, and, if constipation is present, saline laxatives. Calcined magnesia is valuable as a laxative. Intestinal antiseptics, such as salol, thymol, and sodium salicylate, are valuable in cases probably due to intestinal toxins. ”

“ Oedema of genital regions is less marked than in nephritis or cardiac disease. We may also have localized areas of oedema 3 or 4 inches in diameter.
Ship beriberi, which has points in common with both beriberi and scurvy, shows oedema which may be limited to the lower extremities [556] or generalized. Epidemic dropsy is a type of beriberi in which there are fever and an erythema over the dropsical areas.
Calabar Swellings.—These seem connected with infections with Filaria loa. The swellings originate suddenly and disappear in three or four days. They are hard and do not pit on pressure. ”

“ In some of the lower animals a usual feature is redema of certain parts of the body, especially the sheath of the penis, the under surface of the abdomen, and the neck. Similar though less extensive œdemas ccur in man, in whom they are most apparent about the face and about the site of the erythema. In many instances there is a general fullness of the features, which, together with concomitant flushing of the face, is apt to convey a false impression of sound health. ”

“ As a rule, it inclines to chronicity. Relapses are common, especially in adults and elderly persons. There are many cases on record, however, where, recovery having taken place, the individual remains free of the disease. The several varieties may now be considered.
Eczema Erythematosum.—This begins as an erythematous spot or macule, or as a patch, variable as to color, size and outline. It is most frequently met with upon the face, occupying a portion or the greater part of this region, usually in the form of several discrete or confluent patches. ”

“ The majority of persons are not affected by these plants, but in many contact, or in some mere proximity to the plant, will be followed by a dermatitis, variable as to degree. The inflammation may simply be of an erythematous character with slight swelling, or, on the other hand, it may be vesicular, pustular, or bullous, with marked hyperæmia, oedema, and swelling. ”

“ Within twenty-four hours the disease is fully developed; the skin is tense, smooth, and shiny, scarlet and swollen, and feels hot, and is often covered with small blisters. The pain is more or less intense, burning or itching occurs, and there is a sensation of great tightness or tension. On the face the swelling closes the eye and may interfere with breathing through the nose. The lips, ears, and scalp are swollen, and the person may become unrecognizable in a couple of days. Erysipelas tends to spread like a drop of oil, and the borders of the inflammatory patch are well marked. ”

“ Symptoms.—The disease usually begins at the ear or one side of the nose, and redness and swelling extend over that side of the face; more rarely it crosses over the median line and affects the whole of the upper part of the face. Pain and tingling precede the inflammation, and when the latter has reached its height, the eyelid is so swollen that it cannot be opened; the ear is large, red and flabby, while the skin adjacent is swollen, red and painful. Erysipelas is, in fact, an inflammation of the skin, and it is severe according to the depth to which this tissue is implicated. ”