IMPETIGO HERPETIFORMIS¹

Definition.—An extremely rare disease, occurring in women
almost exclusively, and usually while in the puerperal state, charac-

¹ Literature: Hebra, Wien. med. Wochenschr., No. 48, 1872 (translation in Amer.
Jour. Syph. and Derm., 1873, P. 156); Lancet, March 23, 1872; and colored plates in
Atlas der Hautkrankheiten, H. ix, Taf. ix and x, 1876; Kaposi, Archiv, 1887, p. 273
(based upon 13 cases; 4 colored plates); Dubreuiih, Annales, April, 1892 (a report of
a new case and an analytic review of all authentic previously reported cases, almost
all of which were observed in Germany and Austria). Since this date among other
cases recorded are: Glaevecke, Arch, für Gyn., Bd. ccxi, H. 1, p. 18—abstract in
Jour. Cutan. Dis., 1897, p. 146 (recovery; histologic examination); Hartzell, Jour.
Cutan. Dis., 1897, p. 507 (in a woman aged eighty-four); Whitehouse, ibid., 1898, p.
169 (in a male); Wechselmann, Archiv, 1910, cii, p. 207 (typical Hebra type; bacte-
riologic examination, negative; no eosinophilia); Graham Chambers, Brit. Jour. Derm.,
1911, p. 65 (male patient; case and histologic illustration; comparatively mild case;
bacteriologic examination negative).

IMPETIGO HERPETIFORMIS

407

terized by the appearance of numerous isolated and closely crowded
miliary pustules, with a decided tendency to the formation of circular
groups or patches, and preceded and accompanied by grave systemic
disturbance, and usually ending fatally.

Symptoms.—The eruption is chiefly upon the genitocrural region,
inner and flexor aspects of the thighs, and the anterior surface of the
trunk, although other parts of the body may also share in the disease.
It consists of minute pustules, grouped or arranged in circles, tending
to crowd together into patches; they crust over and new lesions and
circular groups appear at the periphery, the crusts being of a yellowish,
greenish, or brownish color. In this manner the eruption spreads,
the patches coalesce, and large areas are thus involved. The surface
beneath the crusts is red and moist looking, not unlike that of a weeping
eczema. The circular grouping and spreading are more or less charac­
teristic, but in some of the cases reported the lesions were disseminated
and in irregular clusters. The pustules come out in crops, and the malady
goes from bad to worse, so that a great part or almost the entire surface
may become invaded. The mucous membranes of the mouth, nose,
and throat may also show involvement. The crusts fall off as the case
progresses, new epidermis forms, or the surface continues to have the
moist eczematous aspects. In some instances patches similar to those
of pemphigus vegetans are observed. In a few of the cases, too, the
eruption was polymorphous, these being midway in their cutaneous
symptoms between this affection and dermatitis herpetiformis. While
the disease is, as a rule, continuous, there may be intermissions of partial
or complete quiescence. Along with the cutaneous outbreaks there
is grave constitutional disturbance, which persists, increases in severity,
and, with but few exceptions, finally, from exhaustion or some inter-
current organic disease, the patient succumbs.

Etiology and Pathology.—The disease is obscure. It is closely
allied to dermatitis herpetiformis and to pemphigus, cases of apparently
mixed symptomatology having been reported by Heitzmann,¹ Zeisler,²
Fordyce,³ and others. Excepting several cases in males, all of the cases
so far reported were in women, and with but few exceptions in women
in the pregnant state. The pathologic anatomy (T. Du Mesnil and Marx,
Dubreuilh, Glaevecke, and others) shows dilatation of the blood­ and
lymph-vessels, with swollen endothelium and encompassed with embry­
onic cells. The interpapillary processes of the epidermis are widened
and prolonged, there is an abundance of round-cell infiltration in the der­
ma obscuring its structure, and which in the pustular area completely
obliterates the line of demarcation between the pars papillaris and the
rete layer. Contrary to Du Mesnil, Dubreuilh finds that the smallest
pustules are deepest seated. Several micro-organisms have been found
by some observers, while with others the bacteriologic examination
was negative; on this point no conclusion is yet warranted. The disease

¹ Heitzmann, Arch. Derm., 1878, p. 37.

² Zeisler, Monatshefte, 1887, p. 950.

³ Fordyce, Jour. Cutan. Dis., 1897, p. 495 (with colored plate and several histo-
logic cuts).

4o8

INFLAMMATIONS

is evidently an infection, and in some cases its septicemic nature seemed
evident. In autopsies nephritis and pulmonary tuberculosis have been
noted in some instances.

Diagnosis.—Its clinical features, its occurrence in women, and
generally when in the parturient state, are usually sufficiently char­
acteristic to distinguish it from pemphigus, more especially pemphigus
vegetans, and from dermatitis herpetiformis; midway cases between
it and the latter disease are, however, likely to give rise to difficulty,
which a few weeks’ observation will usually solve.

Prognosis and Treatment.—Not much hope can be held out
to the patient, as the disease is usually fatal. With but relatively few ex­
ceptions all have died, some after weeks, some after months, of suffering.¹
Treatment is to be based upon general principles, and the plans advised
in pemphigus and dermatitis herpetiformis seem indicated. Abortion
should be induced. The cases which recovered were, as a part of the
treatment, kept in the continuous water-bath.

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