(Lupus superficialis; L. sebaceous; L. erythematodes; Ulerythema)
Definition – A chronic, superficial, inflammatory new growth, characterized by persistent, red scaly patches covered with adherent grayish or yellowish scales and which terminate in atrophy.
Symptoms. – A number of forms occur, showing marked clinical differences. The chief varieties are: (1) discoid; (2) disseminated; (3) telangiectatic.
The discoid type is commonly found upon the bridge of the nose and the adjoining surface of the cheeks where it assumes a symmetrical form resembling a butterfly. Less commonly the scalp, where it produces permanent baldness, arms, hands and other portions of the body may be affected. The disease begins as one or more pin-head- to pea-sized, isolated or grouped, reddish spots which soon become covered with a tightly adherent, grayish or yellowish horny scale. when this is removed there is seen upon its under surface small peg-like projections which correspond to small pits in the skin and which are, in reality, sebaceous casts of the follicular ducts. The spots gradually increase in size to that of a quarter of a dollar, and by peripheral extension and coalescence, larger patches may be formed. Involution may occur centrally with an active peripheral border or the lesion may disappear completely. In any case, the atrophied surface present small pin-head-sized depressions that are white, shining and smooth. The borders are often active, deep red in color and studded with patulous or enlarged sebaceous orifices or horny plugs, while the center of the patch has ceased its activity.
The disseminated variety is an acute and more generalized form and, although it usually begins in the same locality and in the same manner as the discoid form, it is prone to spread to the extremities and other parts. The lesions may be numerous, from ten to one hundred, and subjective sensations, vesiculation and pustulation may occur. Exceptionally systemic symptoms develop to such an extent that the disease ends fatally. Fortunately this type is rare and is seldom seen in this country.
A telangiectatic form has been described as characterized by pin-head or much larger sized patches appearing on the face and showing a pinkish or deep red color. It is attended by thickening of the skin and some elevation of the border. ‘Itching and burning may be felt but there is never any moisture unless eczema complicates. Scaling and patulous orifices, seen in the other forms, are absent.
Fig. 144 – Lupus erythematosus, discoid variety, involving both cheeks and ears. Cured by the high-frequency currents, solidified carbon dioxid and Nat. mur. 12x.
Lupus erythematosus of the mucous membranes is usually secondary to that of the skin and may be found on the lips, in the mouth or on the conjunctiva. The lesions are usually superficial but well defined with slight thickening and may be the color of the surface or violaceous.
The course of lupus erythematosus is chronic, remaining stationary for a long time and often lasting ten or twenty years or longer. Fortunately subjective sensations are mild or absent in these commoner types and the general health is little affected. Even the cases of long duration do not show any tendency to cancerous degeneration as is noticed in lupus vulgaris.
Etiology and Pathology – The disease usually develops in the third decade of life and attacks females twice as often as it does males. It has been known to follow acne, rosacea, seborrheic dermatitis, variola, erysipelas and undue exposure to heat or cold. In fact over half of my cases have been secondary to these conditions. I dislike to say that the cause of this disease is unknown but the opinions of investigators are so at variance as to whether the condition is essentially a tubercular infection, or due to the toxins of the tubercle bacillus, or a chronic eczematoid condition, that it is impossible to say with any certainty what the true nature is.
Pathologically we find the same difference of opinion but the conclusions of Robinson, from his own observations and from a review of those of others, seem reasonable. He concludes that “lupus erythematosus is a chronic inflammatory disease of the cutis with special histologic characters, as shown by the changes in the blood vessels by the new formation of an adenoid-like tissue, reticular tissue, by the presence of mononuclear and absence of polynuclear cells in the cell infiltration; and these changes must depend upon the presence of a poison generated in loco. In other words lupus erythematosus is a local infective process, a granuloma.”
Fig. 145 – Lupus erythematosus of many years’ duration in an uncommon location. Much improved by applications of guaiacol and Arsenicum brom. 3x internally.
Diagnosis – Eczema is not so sharply defined; it will often show moisture and pronounced itching; its scales and crusts do not have prolongations on their under side; it is more acute or rather recurrent, and does not leave scars.
Dermatitis seborrhoica presents greasy or oily scales and is usually associated with a primary seborrhea of the scalp, but it should be mentioned that lupus sometimes develops from seborrheic diseases.
Psoriasis is uncommon on the face without positive signs of the disease elsewhere, its scales do not fit into pit-like depressions; it does not produce scars not, as a rule, cause baldness when situated on the scalp.
Lupus vulgaris is an affection of childhood or youth, is rarely symmetrical and its lesions are deep-seated papules or tubercles without involvement of the sebaceous system. Ulceration with scarring is usually present and the latter is irregular and very noticeable as compared with the smooth and fine scarring of lupus erythematosus.
Tinea circinata is unusual in adult life, does not show the characteristic scales or scars of lupus erythematosus and will show the presence of the causal fungus on microscopic examination.
A scaly syphilid is more rapid in its evolution, associated with other signs of syphilis, is much less hyperemic and does not exhibit the peculiar peg-like projections of the lupus scale.
Fig. 146 – Lupus erythematosus in the usual location. The lesions were superficial and of four years’ duration.
Fig. 147 – Showing the cure of the lesions depicted in Fig. 146 by application of guaiacol and solidified carbon dioxid plus Nat. sulph. 6x.
Prognosis – While this is guarded and scarring must always be expected and relapses are frequent possibilities, the health is now wise harmed except in the acute disseminated variety. Hence it is the cosmetic discomfort which makes treatment so imperative and which is responsible for the number of cases that are partially or wholly relieved or cured. It is impossible to state any time within which relief may be expected because temporary improvement is common from even simple treatment, while recurrences may show themselves after a so-called complete cure.
Treatment – Local applications are to relieve hyperemia and superficial cell infiltration, hence they vary widely in degree from mild sedatives to caustic destructive measures. Superficial hyperemic patches must be treated mildly while deep-seated infiltrated areas need stimulation and cauterization. The patches of this disease are so easily stimulated into activity that great care is necessary if local agents are to be used at all. Simple mechanical methods consist in frequent anointing with some bland oil or fat. If a small amount of stimulation is needed, the tincture of green soap may be used to remove the scales. For their effect upon the blood vessels in hyperemic cases, plain collodion or adrenalin chlorid (1:000) may be applied to the surface and repeated as often as necessary. For a combined effect of relieving hyperemia and removing scales, a 3 to 10 per cent. salicylic acid in collodion or a 10 per cent. resorcinal collodion may be employed.
A host of stronger local applications may be used, such as tincture of iodin; caustic potash solution 1 part to 10 of water; 1 per cent. betanaphthol; 5 to 50 per cent. resorcin; 10 to 30 per cent. sulphur; 5 to 10 per cent. salicylic acid in solution or ointment; saturated or dilute carbolic acid solution; ammoniated mercury or pyrogallic acid in 5 to 10 per cent. ointment; guaiacol pure or diluted with equal parts of olive oil. Linear scarification, electrolysis, galvanocautery, thermocautery, curetting or excision are seldom resorted to in these days although they may be rarely useful. Solidified carbon dioxid is of great value and should be applied with moderate or firm pressure for from 20 to 60 seconds according to the location and degree of infiltration of the lesion. The amount of surface covered at one treatment usually should not be more than two square inches of contiguous area. If the lesions be extensive but superficial, I dissolve the snow in ether and paint it over a much larger surface.
Phototherapy, while not achieving the notable results in the treatment of lupus erythematosus that it has in lupus vulgaris, has proven serviceable in some cases of a pronounced vascular type. The X-rays seem better suited to the deeper cases in which the follicles and glands are markedly involved. In a large number of cases the combination of both photo- and radiotherapy has worked well. It has been my experience that the high-frequency currents, using a flat vacuum electrode almost, but not quite, in contact with the skin for from three to fifteen minutes twice weekly, are more satisfactory than either of the above methods. However, some authorities believe that their chief sphere is to complete a cure already started by actinic rays or X-rays or that they should even precede photo- or radiotherapy or be used intercurrently. Mild lotions or ointments such as boric acid or calamin may be applied between these physical applications.
My personal observation in the treatment of nearly one hundred and fifty cases of this disease leads me to favor solidified carbon dioxid, the high-frequency currents and the X-rays in the ordered named, with guaiacol, adrenalin chlorid and calamin as simple adjuvants.
Internal treatment includes the necessary tonic measures, laxatives, intestinal ferments and a strict regulation of diet, based on each individual case after careful observation on the part of the physician, including repeated examinations of the urine. Most patients need more water between and less with their meals and all need to omit stimulating food and drink. Exercise, bathing, clothing and all other elements which regulate physiological living may need attention. These methods, combined with a carefully prescribed remedy, will usually suffice in a simple case without any radical external treatment and are of immense value in even the severe types. Almost any remedy may be properly prescribed on a totality of symptoms, but the virtue of the following I can personally affirm: Apis, Arsenicum, Arsenicum iod., Fluor. acid, Hydras., Hydrocot., Kali mur., Ledum, Natrum mur., Rhodo., Rhus tox., Pet., Sepia and Sulphur.