Definition. – A secondary tubercular infection of the skin, caused by the direct extension of the process from affected glands or other deep foci of tuberculosis and characterized by infiltration, softening, ulceration and scarring.
Symptoms. – This is probably the commonest form of tuberculous infection. Formerly the term scrofuloderma was applied to many conditions of the skin occurring in strumous subjects but it is now limited to a condition showing well-defined subcutaneous nodules which gradually enlarge, degenerate, ulcerate and terminate in typical scar tissue. The lesions are commonly observed about the face and neck and months and even years are required to produce a pronounced development, though the lymph glands may have been tumid, dense or doughy for a long time. The affected glands may vary in size form a small nut to an orange. The superimposed skin may at first be movable and normal in color but ultimately softening occurs, the skin becomes thin, first red, then of a bluish or purplish hue by pressure from the upward growth, and epidermal rupture takes place, giving exit to a watery pus mixed with caseous material and blood. Fistulous cracks and sinuses develop, resulting in a chronic discharge and characteristic ulcers. The ulcers are linear or oval in shape with a grayish, uneven floor covered with flabby granulations. The base is soft or firm but never densely indurated. The edges are generally undermined, thin, pale, soft, bluish or yellowish, sharply cut or ragged, usually inverted so as to quite or nearly hide the ulcer beneath. The crusts, like the ulcers, are often linear, rarely bulky, thin, tenacious, reddish or brownish in color, while the scars are linear or irregular, often corded, sometimes net-like and isolating portions of diseased tissue or small areas of sound skin. These scars may be of diagnostic value in later years.
Fig. 136 – Scrofuloderma of ten years’ duration. Other lesions scattered about, especially on one leg which shows marked increase in size.
Rarely scrofuloderma may involve large areas of subcutaneous and muscular tissue about the neck or on the extremities. In this form enormous ulcers may develop as described in the simpler type. Another rare form of scrofulous gummata presents subcutaneous nodules on the back or extremities of scrofulous children and only differs from the common lesions because of its relationship to deeply distended lymphatic vessels. Strumous dactylitis, usually found in children, is characterized by bulbous extremities of the fingers and toes, due to tubercular infiltration. There may be present in these cases fistulous openings, papillary and fungating growths and even bone caries. There are many other indefinitely described forms of tuberculosis of the skin, due either to the direct action of the bacillus or to the action of some toxin derived from the germ, that might be properly described as varieties of scrofuloderma and often have been in the past. However, for the sake of simplicity and because of their etiology is not well understood, the chief of these, erythema induratum and lichen scrofulosus, are separately described under their respective headings, while the rare conditions known as the small pustular scrofuloderm (Duhring), folliclis and acnitis are here considered synonymous with acne varioliformis.
Fig. 137 – Scrofuloderma, superficial variety, of fifty years’ duration in a man of sixty. The scars of old lesions may be seen, mingling with the active lesions. Cured by mercuric chlorid in collodion and Arsenicum iod. 2x.
Fig. 138. – scrofuloderma of ten years’ duration in a girl of fourteen. The active cutaneous lesions and elephantiac appearance of the right leg and the scars resulting from scrofulous abscesses on the left leg are plainly evident.
Fig. 139. – Scrofuloderma of fifteen years duration. The scar represents an ulceration which took five years to heal. The eruption at the elbow consists of superficial pustules and warty nodules and was cured by painting the lesions with mercuric chlorid 2 grains and resorcin 10 grains in an ounce of collodion, plus Arsenicum iod. 3x.
The course of scrofuloderma is always slow and the ulcer formation rarely tends to heal, on the contrary it may spread. However, before ulceration occurs, the infected tissue may become encapsulated and remain stationary for a long time, while with great rarity absorption takes place.
Etiology and Pathology. – Scrofuloderma is undoubtedly a secondary form of tuberculosis and the tubercle bacillus is the sole efficient cause as in other varieties of the disease. The well-known scrofulous physique or other signs of scrofula will often be found in patients exhibiting some of the scrofulodermata, although the general health may appear fairly good and the skin symptoms give rise to little or no suffering. The bacilli are generally more numerous than in lupus but less abundant than in tuberculosis orificialis. The microscopic changes are similar to tuberculosis of the internal organs. The subcutaneous tissue is the seat of small round and epitheloid cellular growths which undergo degeneration and, breaking through the thin and tense layer of the epidermis, cause a characteristic ulcer. Large masses of necrotic and softened tissue are usually found and the degeneration is regarded as more pronounced than lupus.
Fig. 140 – Strumous dactylitis in a tuberculous child, showing the typical bulbous extremities of the fingers.
Diagnosis. – Its origin from lymphatic glands or to her deeper tubercular foci, the absence of outlying tubercles and infiltration, together with the knowledge of its history and superficial course should differentiate scrofuloderma from lupus vulgaris, although the two types occasionally coexist. These points, together with other signs of struma, should distinguish this condition from the ulcerating syphilid which generally appears in adult life and is more rapidly destructive.
Prognosis is favorable, in that the local lesions may be made to heal, and the scrofulous habit greatly modified by physiological, hygienic and remedial measures.
Treatment of Tuberculosis Cutis. – Existing and active tuberculosis of the skin is treated from an external and internal standpoint, the former including all local measures and the latter all internal remedial measures, plus general hygiene and prophylaxis.
External treatment should aim to destroy or limit the action of the efficient cause to such an extent that the bacilli may be removed and a cure accomplished. inasmuch as this is a destructive disease attended with inflammation and scarring, it may be necessary to excite artificial inflammation, destroy tissue and promote fibrosis. In any of these procedures the attempt is made to follow nature’s course. Latent or inactive cases seldom call for local care but the moment activity begins, treatment should be inaugurated and continued with judicious persistency. The local measures range from soothing, mild and stimulating to the mildly caustic and even destructive measures. Antiseptic treatment is especially indicated in the ulcerating and crusting forms because here the staphylococcus is to be removed. Often many forms of treatment are essential in the cure of any one case but the choice will ordinarily lie between the parasiticides, caustics, X-rays or refrigeration. Many of the more severe methods of local treatment are nearly or quite obsolete but will be briefly referred to, especially under the treatment of lupus vulgaris.
The ulcers of orificial tuberculosis may be made to heal by cleansing with hot water, drying the surface with antiseptic cotton and immediately painting it with a solution of mercuric chlorid, 2 to 8 grains in an ounce of compound tincture of benzoin or Tolu. It has been my habit to use 10 per cent. aristol powder between and after the applications of the above-mentioned mercuric lotion. Curetting or the application of the silver nitrate stick or dilute lactic acid may be advisable.
Tuberculosis verrucosa may be treated with the solution of mercuric chlorid above named or with a strong salicylic acid plaster with or without creosote. As the growths diminish, iodin may be freely applied alone or in collodion. Individual growths may call for the curette, knife, X-rays, Finsen light or caustics, of which solidified carbon dioxid is the best. This last mentioned agent may be applied firmly for one to two minutes.
Lupus vulgaris has been treated in so many fashions that to enumerate any but the most successful methods would be confusing. If the lesions are hyperemic and irritated, the constant application of diachylon ointment or the sedative calamin-zinc-oxid lotion may be recommended. Usually the object is to destroy the granuloma with as little scarring as possible and, although the treatment may be gentle and stimulating at the onset, it invariably must become destructive. Brooke’s formula is the most satisfactory of the milder preparations:
Acidi salicylici, gr. xv; 1@
Hydrarg. oleatae, gr. xx; 1@2
Ichythyolis mxx; 1@2
Zinci oxidi @
Pulv amyli aa 3j; 4@
Paraffin mollis. q.s.ad.3j; 30@ M.
Mercurial plasters constantly applied, mercuric chlorid (1 to 2 grains to the ounce of lotion or ointment), sulphurous acid, guaiacol (pure or with equal parts of glycerin or sterile olive oil), iodoform (5 to 10 per cent. in ointment) and lactic acid (10 per cent. solution) have all been recommended. When a more active remedy but one not exactly destructive is desired, choice may be had of salicylic acid, resorcin or pyrogallic acid. Salicylic acid is prescribed as follows: in collodion, 30 to 60 grains to the ounce; mixed with glycerin to make a paste; in a plaster mass made with petrolatum and resin plaster, 1 to 2 drams to the ounce; or as an ointment, 2 to 3 drams to the ounce. Resorcin may be used in the same way and in the same strengths and is often less painful. Pyrogallic acid, however, is the most certain in its action and may be used in a 10 to 25 per cent. ointment made up with resin cerate and vaseline. This remedy is deservedly the most popular and may be applied twice daily. After a superficial slough has formed in ten days to three weeks, carbolized boric acid ointment or a 2 per cent. pyrogallic acid may be applied until healing ensues. A safe application in new and superficial forms of lupus is a 5 to 10 per cent. solution of potassium permanganate applied daily until the nodules are softened. A 1 to 2 per cent fuchsin solution and pyoktanin-blue have likewise been recommended. These last three agents are particularly valuable preceding the use of pyrogallic acid.
Arsenic in the form of ointment or paste is mildly destructive and is the most efficient of the older methods. These applications produce pain and can only be applied to small areas because of the danger of absorption. The formula recommended by Hebra, consisting of arsenious acid 20 grains, cinnabar 1 dram in an ounce of cold cream to which cocain muriate (5 to 10 grains) may be added, is a practical prescription. This is spread thickly on lint and changed twice daily for two to five days. The after treatment consists in poulticing until the sloughs come away, with the subsequent application of a mild antiparasiticide. Various other caustics, such as lactic acid applied on a cotton wool pad once or twice daily from ten to thirty minutes with a 5 to 10 per cent. aristol ointment used in the interim, Vienna paste (caustic potash and unslaked lime), fuming nitric acid, chlorid of zinc paste, nitrate of silver stick, galvanocautery, Paquelin cautery, Hollander hot-air cauterization, and sparking with the high-frequency currents have been reported as beneficial, but with the exception of the last-named agent are hardly worth considering. Curetting, scarification, excision and electrolysis are no doubt useful in selected cases but the advent of the Finsen photo-therapy, X-rays and refrigeration have largely superseded these measures.
Fig. 141 – Electrolytic knife.
Fig. 142 – Irido-platinum needle.
Fig. 143 – Scarifying spud.
Phototherapy, as scientifically demonstrated by Finsen and his followers in Copenhagen, is the ideal method for the dry-non-ulcerative cases. The advantages of the treatment are the excellent cosmetic results, no anesthetic is necessary, no injury to the general health is noted and the proportion of cures or pronounced improvements runs as high as ninety-four per cent. The greatest disadvantages are the great length of time required because it is often necessary to keep the patient under observation for one to four years, the tediousness of the individual treatment which varies from three-quarters of an hour to one and a half hours, the discomfort and pain during and after the applications and the expense of the treatment, together with the impossibility of procuring properly trained attendants. It is probable in our country that few cases can be treated by this agent. However no judgment is sound that is based upon the use of modification of the Finsen lamp because the original variety exceeds in the depth and activity of its action any other type yet produced. Many cases are unable because of their means or residence to receive the Finsen light treatment and these may be benefited by the X-rays, especially if they present extensive pigmentation, thick scars, deep infiltration or are so situated that pressure and direct radiation are impossible. The X-rays may produce just as good cosmetic effects and destroy the nodules as thoroughly as the Finsen rays but, to be effective, it is often necessary to produce a dermatitis which may persist for weeks causing pain and the suspension of treatment. A much larger area may be treated by the X-rays at one sitting than by phototherapy and it causes no pain or inconvenience.
The action of radium, which Wickham and others have reported as little less than phenomenal in the treatment of lupus, is similar to the X-rays but cannot be said to present many advantages over this more common and easily procurable agent. My own experience has been that the X-rays give the best results in cases of circumscribed lupus of the forehead, ears and back, and that radium is more effective in extensive superficial lesions of the trunk. Radium applications will vary from 5 to 30 in number and from 20 to 50 minutes in duration. The so-called radioactive preparations in ointment and lotion form which have flooded and the market in the last few years, purporting to accomplish new-growth destruction by their radioactive properties, do not present any marked radioactivity but rather owe their partial success to the Cauterization by solidified carbon dixoid has been a favorite method in my hands for the last four years. If the area to be treated is small, the application may be made without a general anesthetic. The time of application varies from 1/2 to 3 minutes and the degree of pressure necessary must be judged in each individual case according to the duration, location and character of the lesion. The X-rays may be applied during the time that the necrotic mass is separating.
Lupus of the mucous membranes will often need the application of a 2 to 5 per cent. cocain solution before local cauterization. the latter may be accomplished by solidified carbon dioxid, galvano-cautery, Paquelin cautery, daily applications of a compound solution of iodin and potassium iodid, or pure or dilute lactic acid. Cataphoresis with a 2 to 4 per cent. zinc chlorid solution is efficacious and the X-rays may be used in individual cases.
In my opinion, the local treatment of lupus which has for its purpose the removal of the cause, destruction of the growth and promotion of healthy repair is best attained in the majority of cases by the employment of pyrogallic acid, guaiacol, X-rays and solidified carbon dioxid, one or all, without reference to the order in which they are used. As in many other diseases, the closer the adoption of these methods to the needs of each individual case, the better will be the result.
Scrofuloderma calls for external treatment according to the extent, location and stage of the lesions. Physiological and internal remedial treatment, together with local non-interference, is the most sensible course when the disease is latent; as soon as activity is manifested and deep glandular involvement is evident, enucleation, curetting, followed by lactic acid applications, or complete removal of the diseased parts under the strict methods of antiseptic surgery are the most satisfactory. When the skin is not involved but large scrofulous glands are in evidence, excision is also the best treatment and leaves a minimum of scar tissue. Scrofulous ulcers are treated on the same basis as lupus vulgaris with an accent on the mild antiseptic methods. My own habit is to cleanse the lesion thoroughly with dilute hydrogen peroxid or hot boric acid solutions, applying the same to gauze dressings which will keep moist for a time. Some simple powder like aristol may be applied between the thorough washings. Destructive agents are not often needed but unhealthy granulations may be scraped away with a curette followed by the application of the tincture of iodin or a 50 per cent. solution of carbolic acid. Finsen phototherapy is well thought to for these cases but my personal experience has been limited to the successful use of the X-rays and refrigeration among the newer methods.
Internal treatment of all forms of tuberculosis cutis includes every effort made to improve physiological living and is as valuable from a prophylactic as from a curative standpoint. All methods that improve hygiene should be used to increase bodily vigor and prevent the inroads of tuberculosis. No strict or uniform dietary is advisable for these cases because the requirements of no two patients are alike. The same may be said about clothing, climate, exercise, sleep, etc., but in general a nourishing, easily digested diet, with plenty of fresh air and enjoyable exercise may be recommended. It has been truly said that the patient as well as the cutaneous disease should be treated, hence I wish to emphasize the so-called constitutional treatment, although the limitations of this book prevent a long dissertation on the subject.
There are no internal specifics for tuberculosis of the skin but such tonic remedies as cod-liver oil and other oils, hypophosphites, iron, and quinin may be beneficial. No enthusiasm can be aroused from the reports of remedies prescribed empirically for their physiological action although the usefulness of some few remedies as adjuvants has been clearly demonstrated. Of these I believe the new tuberculin (tuberculin R-TR), if carefully prescribed, may be beneficial in a few cases, when regulated by the study of the opsonic index. Injections of thiosinamin (4 to 15 drops in a 15 per cent. alcohol solution) every two or three days, or calomel (3/4 of a grain in 1 c.c. of sterile oil) injected into the buttocks every week or ten days, are in the same class with tuberculin injections. The power of a potentized drug, carefully prescribed to relieve symptoms, thus acknowledging the individuality of each case of cutaneous tuberculosis, is well known to most of my readers. A host of remedies have been reported as giving good results, but only those which I have seen act, or those whose reported action has been authenticated, are appended. Tuberculinum 6 to 12x might be added to this list, especially for the slow, persistent, generalized types of lupus. See indications for Arsen., A. iod., Aurum mur., Baryta carb., B. iod., Calcarea phos., c. sulph., Fluor. acid., Graphites, Hydrocot., Kali bich., K. brom., K. mur., Kreosotum, Lyco., Mez., Nat. mur., Phosphorus, Phyto., Psorinum, Silicea, Staphysagria, Stilling., Thuja.