(Delhi boil; Aleppo evil; Endemic boils; Biskra button; Gafsa button; Natal sore; Oriental boil)
Definition – An endemic, specific granuloma of the skin, characterized by a papule which enlarges peripherally with scaling or crusting and finally develops into an indolent ulcer.
Symptoms – One, several or sometimes many lesions may appear usually on the face (especially in the young) or on the hands, arms, feet and legs. The scalp, trunk, palms and soles are usually exempt. The initial lesions is a small, itchy, red papule which peripherally enlarges to the size of a pea and is usually covered by smooth, shining, red, slightly elevated and unbroken skin. Later a scale develops in the central portion of the papule and a slightly depressed opening may be seen from which a serous fluid oozes which dries into an adherent crust. This crust gradually increases by segments until it covers the whole papule or nodule which may be surrounded by a red zone on which other papules develop. Beneath this crust, disintegration goes on for weeks, until a round, suppurating, superficial or deep ulcer is formed, showing an irregular, sharply defined border and an uneven floor partially covered with fungating granulations. This ulcer may reach the size of a silver dollar or, from the coalescence of two or more lesions, form irregular patches. These continue to secrete an offensive seropurulent fluid which forms bulky, adherent crusts. After a variable period of some months, reparative granulations spring up on the floor of the ulcer which gradually heals at the borders, causing a scar which is as variable in appearance as the disease is in its character and course. It may be very slight or sunken or pigmented and markedly deforming when occurring on the face. The duration of the disease varies from six to twelve months and, while erysipelas, lymphangitis, phlebitis and abscesses rarely complicate, there is ordinarily a lack of painful sensation and no systemic involvement.
Fig. 170 & 171 Oriental sore is depicted in these illustrations which were taken in Syria. The “buttons” are readily discernible (courtesy of Dr. Howard Fox).
Etiology and Pathology – This disease varies in certain tropical countries and is limited to some localities as the synonyms mentioned under the title would imply. It may be said to be contagious, inoculable and autoinoculable. Both sexes and all nationalities are affected and, while it may occur at any age, it is more common in childhood and adolescence. The autumn months furnish the greatest number of cases. Infection probably takes place through a break in the surface of the skin, due to slight traumatisms, insect bites, blisters, vaccination and other cutaneous eruptions but a lowered vitality may predispose to it. One attack usually furnishes immunity. Some microorganism is undoubtedly the causal factor, probably a protozoa-like organism similar to or identical with the Leishman-Donovan bodies. Just what insect carries the parasite, whether it is the sand-fly, the mosquito or some other species, is not known but it is generally admitted that such a performance takes place. Microscopic findings show pronounced granulation changes in the corium beneath and around the ulcer, due to the reaction against some virus.
Diagnosis – The endemic nature, location on exposed parts, slow evolution, absence of marked local or general disturbances and the itchy primary papule which slowly becomes a desquamating and crusting nodule followed by ulceration, should easily differentiate this disease from the ordinary furuncle or carbuncle or from the ecthymatous, rupial or ulcerative lesions of syphilis, lupus vulgaris or yaws.
Prognosis and Treatment – While relapses may occur and the formation of disfiguring scars result, recovery always takes place. Cleanliness and soothing applications, attention to sanitary and hygienic principles of living and avoidance of all sources of infection are usually sufficient. Excision, cauterization and mild antiseptics have been advocated. Iodin tincture painted on the lesions, mercurial applications and daily forcible spraying with boiled distilled water at a high temperature have also been recommended.