206

INFLAMMA TIONS

DERMATITIS EXFOLIATIVA NEONATORUM¹

Synonyms.—Ritter's disease; Dermatitis exfoliativa infantum; Keratolysis neo-
natorum.

Under this name Ritter first (1878) thoroughly described a disease
occurring in the newborn in which the cutaneous symptoms were
closely similar to those of dermatitis exfoliativa in older patients, with
now and then a case presenting some analogy to pemphigus foliaceus.
Since then cases have been recorded by other observers (Caspary, Boeck,
Elliot, and others), although the disease is a rare one. According to
Ritter and others, the disease usually begins between the second and the
fifth week; the symptoms vary somewhat, although there is always the
essential character, sometimes at the beginning or at other times later,
of thin epidermic exfoliation, leaving here and there, or in the grave cases
more or less generally, the red exposed rete or corium, and occasionally in
parts presenting a distinctly moist surface. In other instances there is dis­
played a tendency to scattered vesicobullous formation or serous under­
mining, with exfoliation, the former being more properly cases of this
disease, some of the latter probably related to or examples of pemphigus
neonatorum.² It frequently begins in one region, often about the chin,
and is then followed by general involvement. Buccal, nasal, and con-
junctival mucous membranes show invasion, and at the juncture with
the integument at the commissures show slight crusting or fissuring.
The eruption usually appears without systemic symptoms. In some
patients the body-temperature tends below the normal, and maras-
mic symptoms supervene and death frequently results. On the other

¹ Literature: Ritter, Central-Zeitung für Kinderheilkunde, Oct. 1, 1878; Archiv,
1879, p. 129; Archiv für Kinder heilkunde, 1880, p. 53; Boeck (described as pem­
phigus foliaceus), Archiv, 1878, p. 17; Bohn, in Gerhardt's Handbuch der Kinder-
heilkunde; Caspary, Archiv, 1884, p. 122; Elliot, Amer. Jour. Med. Sci., Jan., 1888,
p. 1 (a good review of the subject, with references); Dorland, Philada. Polyclinic,
1896, p. 385; Escherich, Verhandlungen der Deutschen dermatolog. Gesellschaft, V.
Congress, 1896, p. 65; Pagliari, La Pediatra, Nov., 1897, p. 317—abstract in Annales,
1898, p. 820; Winternitz, Archiv, 1898, vol. xliv, p. 397; Luithlen, ibid., vol. xlvii, 1899,
p. 323; Patek, Jour. Cutan. Dis., 1904, p. 269; Burnside Foster (loc. cit.), 4 cases;
Skinner (review, case report, histology, with case and histolcgic illustrations, and
references), Brit. Jour. Derm., 1910, p. 75; Hazen (“Pemphigus Foliaceus and Derma­
titis Exfoliativa Neonatorum”), Jour. Cutan. Dis., 1912, p. 325, with case and histo-
logic illustrations and bibliography.

² Hedinger (Archiv, 1906, vol. lxxx, p. 349) discusses the relationship of dermatitis
exfoliativa neonatorum and pemphigus acutus neonatorum, and concludes that the two
conditions differ in degree rather than in kind; he reports 2 cases, 1 presenting predomi­
nantly symptoms of the former and the other predominantly of the latter. The further
interesting fact is that both the cases came from the practice of the same midwife, and go
to indicate that both these conditions are probably variants of impetigo contagiosa.
Hazen is of the opinion that the exfoliation is secondary to a generalized cutaneous
infection, probably with the staphylococcus albus.

Leiner (ibid., 1908, vol. lxxxix, p. 65, with colored case illustration), and Brit.
Jour. Children's Diseases, June, 1908, p. 244, describes under the name erythrodermia
desquamativa an affection occurring in breastfed children, usually in the first months
of life, with cutaneous symptoms very similar to those of a more or less generalized
eczema seborrhoicum. Most of the cases run a benign course, recovering in a few
weeks; in a third of the cases, however, intestinal symptoms supervene, with severe
diarrhea, fever, marasmus, and finally death. Leiner has observed 43 cases in the
past five years in the Carolinen Children's Hospital in Vienna; he considers it distinct
from Ritter's disease and of the nature of an autotoxic erythema.

DERMATITIS EXFOLIATIVA NEONATORUM             207

hand, after persisting one to three weeks or longer, recovery ensues.
Suppurative processes—furunculous and phlegmonous in character
—have been noted as sequelae (Ritter). A single case has come under
my observation, in which the malady presented, a week or so after
birth, with a reddening of the skin and more or less general exfoliation,
with here and there a tendency to slight serous exudation; the tempera­
ture was a trifle below the normal; the infant presented a marasmic
appearance, but finally, after two or three weeks, recovered. The
eruption began in the flexures, especially about the genitocrural region.

The nature of the disease remains still obscure. The process has
been variously regarded as a dermatitis of pyemic origin (Ritter); as
an epidermolysis (Caspary, Skinner), with consecutive hyperemia of the
cutis; as a peculiar pemphigoid eruption (Behrend, Brocq), as a dermati­
tis due to a fungus found (Riehl¹) in one or two instances; and as merely
an exaggeration of the physiologic epidermic desquamation noted in
the newborn (Kaposi). In one instance Winternitz found the staphy-
lococcus pyogenes aureus and albus in the blood. Hazen found the latter
in the fresh vesicles. Its occurrence in institutions, notably in Ritter's
cases, suggests that the disease is contagious or infectious. The view
sometimes expressed that it is a sequence of some form of intra-uterine
exanthem is negatived by those cases in which the eruption has not pre­
sented until four or five weeks after birth. The pathologic anatomy has
been investigated by Winternitz, Luithlen, Skinner, and others, but the
conditions found are not especially different from the average cases of
dermatitis exfoliativa, except that there is usually more serous exudate.
The principal conditions noted are: Hyperemia of the skin and other
signs of inflammation; dilatation of the vessels; edema, etc.

Prognosis and Treatment—The prognosis is always grave, a
fatality of about 50 per cent, being recorded. In Ritter‘s 297 cases
150 recovered, 145 died, the remaining 2 were still under observation
at the time of his report. The loss of body-heat, the gravity of the
attack, marasmus, and secondary septicemia are factors in various
cases directly responsible for the fatal issue. Treatment consists in
sustaining the strength of the patient by appropriate means, the char­
acter of the nourishment receiving special attention; the child should
have its natural nourishment—recovery is scarcely to be expected
unless this is possible. The maintenance of the body-heat is likewise
of essential importance. For this and other purposes fats or oils should
be freely used externally, medicated with 0.5 to 1 per cent, of boric
acid or ichthyol, and the patient wrapped in cotton wadding. The
crusts at the corners of the mouth, when present, should be frequently
anointed with olive or almond oil, and softened and gently removed,
as their presence, together with the resulting fissuring, restrains the
child from taking sufficient nourishment.

¹ Riehl, cited by Elliot, Morrow‘s System, vol. iii (Dermatology), p. 321.

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