(Sycosis; So-called non-parasitic sycosis; Mentagra; Folliculitis; barbae; Coccogenic sycosis)
Definition. A chronic, inflammatory disease of the hair-follicles, usually involving the beard and mustache, due to microbic infection, and characterized by the presence of papules, pustules and nodules perforated by hairs.
This affection was termed “non-parasitic” in distribution to the folliculitis caused by the ringworm fungus which is described in this book as tinea barbae. Now that the true nature of these conditions is known the term sycosis should no longer be applied to ringworm of the beard.
Symptoms. Varying greatly in extent and degree, this condition is typically located on the beard and mustache but can occur on the eyebrows, neck, border of the scalp, axillae and pubic regions of either sex. It is usually milder when it occurs in unusual or atypical locations. Beginning on the lips, chin or cheeks the lesions appear as pin-point- to pin-head-sized, conical or flat papules which soon become pustular, each lesion being pierced by a hair. Involving the upper lip, there is often a history of nasal catarrh with an acute eczema arising therefrom. The lesions may be few or many, scattered or grouped, but usually appear discrete, closely aggregated, presenting a resemblance to a fig, whence the name sycosis. They gradually increase in number by the successive involvement of new follicles so that the affected area may exhibit at one time a mingling of all lesions in various stages of involution and evolution. Or the eruption may appear in crops and, as involution occurs in some lesions, a new crop arises. The hair, at first firmly seated in the follicles, cannot be extracted without pain but as the follicular suppuration becomes active, they can be easily and almost painlessly plucked. The hair is reproduced unless the follicle is destroyed, but the actual amount of hair lost is relatively small and positive scarring is scarce. The pustular secretion may appear in small separate crusts marked by a centrally situated hair, but in the severer cases the close aggregation of the lesions produces some infiltration covered with purulent crusts which, on removal, reveal a weeping surface with the hairs that are left implanted in shallow pits caused by the loss of their sheaths.
Sycosis becomes chronic unless cured and gradually involves new follicles until the whole bearded region is symmetrically affected, but it never extends to the non-hairy parts of the face. Atypical lesions such as furuncules, soft fluctuating tumors, vegetations and eczematous inflammations may appear at any time and markedly change the clinical picture; or the inflammation may largely disappear leaving a persistent redness covered with whitish scales with an occasional papule or pustule scattered about; or an eczematous condition, with marked infiltration, may develop in the affected skin, presenting papules, pustules, scales and crusts. Some degree of eczema is nearly always present in chronic cases and those involving atypical locations. Uncomplicated sycosis very rarely causes adenitis and seldom shows the deeply seated nodules common to ringworm of the beard. Sycosis will occasionally run a long course with aggravations and ameliorations but preserve its typical features. A variable degree of burning, itching and pain may be present but as a rule subjective sensations are mild and not troublesome.
Lupoid sycosis (sycosis lupoide, Brocq; ulerythema sycosiforme, Unna) is a term applied to a rare, persistent and chronic condition, the early symptoms of which are those of sycosis vulgaris, probably complicated later by the presence of the tubercle bacilli. This condition is usually limited to the beard, is inclined to be symmetric, and starts as a well-defined erythematous spot on which vesicles, bullae, scales and crusts form. It spreads serpiginously in the line of the beard, slowly and persistently, little affected by treatment until irregular, smooth, white, slightly depressed scar tissue develops. The perifollicular lesions may be papular, vesicular or pustular and, as long as the disease is spreading, pustular lesions which make it resemble sycosis vulgaris may be found at the periphery.
Etiology and Pathology. Sycosis is usually found in males between twenty and fifty years of age, although similar pustular folliculitis of other parts may occur in adults of both sexes. No special condition of the skin, health or mode of living is essential to its development, but the same influences that render the skin vulnerable to suppurative processes in general may act as predisposing causes of sycosis. Externally these may be such mechanical, chemical or thermal factors as derange local nutrition, or cutaneous conditions like seborrhea or eczema; internally, retention of waste products due to their overproduction or faulty elimination may predispose. These etiological factors being present, the invasion of the follicles by the staphylococcus aureus or albus causes a typical inflammation. Sycosis may be contagious in susceptible subjects and can be communicated by shaving or by the common use of combs, towels, pillows, chairs and other articles in public places. The cause of lupoid sycosis is unknown but probably some infective agent is added to the ordinary sycotic process.
Pathological changes are the same as in ordinary vascular connective tissue inflammation due to pyogenic cocci. The follicle is involved secondarily, a perifolliculitis being primary. Before the hair falls out, pus may escape at the follicular opening or through a break in the epidermis near the hair. So the papillae usually escape and the loss of hair is often temporary.
Diagnosis. Eczema itches, is seldom confined to the bearded region, is more superficially seated at first and usually less intense. Eventually it is attended with a continuous exudation, forming extensive crusts which are not limited to the hair-follicles. It is well to remark that the two condition often co-exist, either being primary in the order of occurrence.
Tinea barbae often begins in scaly, circinate, well-defined patches with broken-off, stubby and easily extracted hairs. Lumpy, nodular, non-suppurative tumors, multiple foci, and a comparatively acute course are characteristic. However, a microscopic examination may be necessary to establish the diagnosis.
Pustular syphilid will show ulceration on removal of the crusts, is rarely confined to the follicles, the beard or the surfaces supplied with large hairs and there are usually other symptoms, past or present, of syphilis.
Acne is not confined to the beard but occurs on the nose, forehead and cheeks and its lesions are frequently marked with comedones, not pierced with a hair. It usually begins before adult life.
Lupoid sycosis may be recognized by its usual limitation to the beard, its well-defined, slow, progressive, centrifugal extension, vesicular and bullous formations, atrophic scarring and resistance to treatment.
Prognosis. While life is never endangered, sycosis is usually obstinate to treatment and relapse are common. The duration, extent and type of lesion should be borne in mind in promising a cure or cosmetic effect, but most cases are curable under persistent careful treatment. Lupoid sycosis is even more rebellious to treatment than the ordinary type.
Treatment. Predisposing factors of any type demand primary consideration. This may be accomplished by dietetic and other hygienic measures and especially reference to the improvement of the assimilative and eliminative organs. Local treatment which is naturally antiparasitic is much more effective if the general tone of the tissues is good. Simple external measures are most important and embrace the removal of crusts, first softened by some simple oil or fat and then washed off with hot soap and water or hot borax water. Shaving should be insisted upon although it is painful the first few times and patients object to it. Cutting the hair short or plucking it out with epilation forceps present no advantages over shaving. Cleanliness may be obtained by the methods suggested, with or without the addition of a hot saturated solution of boric acid, dilute solution of hydrogen peroxide or corrosive sublimate or creolin soap followed, in cases of the mild type, by dusting the affected area with boric acid powder during the day and applying at night, tincture of iodin, guaiacol or weak boric acid or salicylic acid ointment.
The average case needs more severe treatment and, although protection and antisepsis are desired, it is better to avoid further inflammation and wise to gradually increase the strength of the prescription. Facial applications conspicuous in color or odor are to be avoided if possible. Any of the following substances may be used in ointment form: betanaphthol (15 to 25 grains), resorcin (20 to 30 grains, ammoniated mercury (10 to 30) grains), calomel (30 grains), mercuric chlorid (1 grain), europhen (15 to 30 grains), sulphur (60 grains), to an ounce of fresh lard, vaseline or cold cream. The following formulas may also be used if necessary but their conspicuous color should be remembered.
Rx Hydrarg. sulph. rubri.,
M. Sig. Apply constantly.
Rx Sulphuris precipitati,
M. Sig. Apply constantly.
Lotions containing the above may be used in individual cases but are less often useful. Occasionally acute cases may be benefited by the continued application of sodium bicarbonate solution or a 5 per cent. creolin in glycerin, while long standing, obstinate indurated cases may be aroused by painting a small area at a time with liquor potassae, which is washed off in half a minute and a zinc oxid or other mild protective ointment applied.
I believe the X-rays present the best treatment for all persistent and obstinate cases. A medium soft tube may be used for five to ten minutes at eight to ten inches distance, every three or four days, until a slight erythema develops and falling of the hair ensues. Eight to ten exposures usually suffice and I have followed this procedure in about thirty cases, including one of lupoid sycosis, with nearly perfect results. Massive dose X-raying presents some advantages over the fractional method and may be used if the proper technic is possible. In milder forms the unipolar X-ray tube or mild fulguration are equally successful. Pyoktanin in 10 per cent. solution may be applied by cataphoresis, the positive electrode being placed on the lesion and the cathode held in the hand. A vaccine (staphylococci) may be administered in selected cases. Any of these means suggested may be followed or accompanied, to a certain extent, by the ointments before mentioned.
No matter what local treatment may be selected, the internal remedy, particularly as it applies to the general condition, should be carefully selected. See indications for Arsen. iod., Graphites, Hepar., Kali brom., K. mur., Mercurius, M. biniod., Nat. sulph., Viola.