ECTHYMA

405

ECTHYMA

Definition.—Ecthyma is characterized by the appearance of one
or several or more discrete, finger-nail-sized, flat, usually markedly
inflammatory pustules.

Symptoms.—The eruption is seen commonly upon the legs,
sometimes upon the shoulders and upper back and the forearms, but
rarely elsewhere. The lesions begin as small, usually pea-sized pus­
tules, without a prepapular or prevesicular stage. They increase some­
what in size, and when fully matured attain about the area of a small,
or sometimes a large, finger-nail. They are slightly elevated, flattened,
and have a markedly inflammatory base and areola, with usually con­
siderable infiltration and induration of the underlying tissue. In color
they are at first yellowish, but soon become, from the admixture of
blood, reddish or brownish. They gradually, in the course of several
days to several weeks, dry to brownish or blackish crusts, beneath
which will be found, in the earlier stages of this process, superficial
excoriation. If a maturing pustule is pricked or accidentally ruptured,
the fracture may close by drying of the exuded pus and the lesion fills
up again. The individual pustules usually last ten days to a few weeks;
but new lesions may continue to appear from day to day or week to week
for a period of several months or longer. As a rule, not more than five
or ten are present at any one time. Occasionally, however, they are
more numerous, small and less deep, and may be limited to one or both
legs below the knees. More or less persistent pigmentation, and, in
some instances, superficial scarring may remain to mark the site of the
pustules. The subjective symptoms are never marked, and rarely con­
sist of more than slight pain and tenderness; itching is occasionally com­
plained of, but is never severe.

Etiology.—Ecthyma is distinctly a disease of the lower walks
of life, and occurs in those debilitated from any cause whatsoever.
It is therefore more commonly seen in poor-houses, prisons, and in the
slums districts. Improper food, living under bad hygienic conditions,
are predisposing. Its common subject is the adult tramp or the low-
class tenement lodger. It is not uncommon, according to Hallopeau,
in those working in sugar-refineries. It occurs infrequently in children.
The exciting cause of the disease must be considered, from the stand­
point of our present knowledge, to be a specific micro-organism. The
malady is mildly contagious. Nor can it be doubted that the slight
breaks in the continuity of the cutaneous tissues produced by scratching
and by vermin—the bites of lice and bedbugs—in those whose other con­
ditions and surroundings predispose, are in many cases potential factors
in the production of the disease. It is to be borne in mind also that
exceptionally the ingestion of certain drugs, as iodids and bromids, may
produce somewhat similar lesions.

Pathology.—The disease is allied to impetigo, and by many is
considered identical. Experiments with direct inoculations (Vidal,
McCormick) and cultures, it is alleged, always produce the same affec­
tion; further confirmation is, however, needed on this point. Various

406

INFLAMMATIONS

investigators (Mathieu and Netter, Wickham, Thibiérge, Unna, and
others) have found a streptococcus in the lesion. Studies (Leloir, Unna)
of the pathologic anatomy show that the process begins as an inflamma­
tion in the lower epidermal layers, fibrinous centrally and edematous per­
ipherally, and which invades the derma superficially or deeply; minute,
intercellular cavities form, which melt together and are filled with a
fibrinous and purulent fluid. The fluid cavity involves the upper corium
and exceptionally the entire corium. The pus, which is inoculable and
auto-inoculable, usually contains staphylococci and streptococci.

Diagnosis.—Ecthyma is to be differentiated from the impetigos
(q. v.) and the large, flat, pustular syphiloderm.

The flat pustules of syphilis are ordinarily sluggish, much less in­
flammatory, and usually lacking the extensive, hard, and bright-red
base and areola of ecthyma; moreover, the ulceration of the syphilitic
lesion is deeper and more sharply cut, and the secretion is thicker,
drying to greenish or greenish-brown crusts, which are more bulky
and inclined to be heaped up like an oyster-shell. The flat pustular
syphiloderm is also of more extensive distribution, frequently with
other syphilitic lesions intermingled, and almost invariably accompanied
with other symptoms of syphilis.

Prognosis and Treatment—Ecthyma is rapidly amenable to
treatment. It is to be kept in view that the affection occurs, as a rule,
only in those in a depraved state of health and those who have been
exposed to bad hygienic conditions, and these possible factors should
be met with proper measures and tonics.

Cleanliness is necessary, and frequent washings, with the use of the
ordinary toilet soap, or alkaline baths, are to be advised; these, together
with remedial unguent applications, soon remove the crusts. If they
are firmly adherent, and if the process appears to go deeply, water
dressings or starch poultices can be used temporarily, but in ordinary
cases this is not necessary, and the crusts may be permitted to become
detached gradually, healing taking place beneath. Applications are
to be made twice daily, and applied spread on lint or any suitable ma­
terial. The local treatment is similar to that employed in impetigo
contagiosa.

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