LICHEN SCROFULOSUS³

Synonym.—Lichen scrofulosorum.

Definition.—A chronic, mildly inflammatory disease, usually
occurring in scrofulous subjects, characterized by millet-seed-sized,
rounded or flattened, reddish or yellowish, more or less grouped, slightly
desquamating papules.

In recent years many contributions having in view the grouping

¹ Macleod, Brit. Jour. Derm., 1902, p. 220; Civatte (of Brocq's service) (“note
pour servir a l‘etude des tuberculides papulo-squameuses; trois cas de tuberculides a
forme de parapsoriasis.” Annales, 1906, p. 209), from his investigations and review, be­
lieves that parapsoriasis might be an atypical tuberculosis of the skin.

² Engman, “Discussion,” Jour. Cutan. Dis., 1911, p. 559.

³ Méneau, “Du lichen scrofulosorum,” Jour. mal. cutan., 1899, p. 6, gives an
admirable account and review of this subject, with bibliography. See also papers and
discussion on the same, Trans. Internal. Derm. Congress, London, 1896, and those
referred to in the course of the text.

228

INFLAMMATIONS

together of several cutaneous diseases which are more or less peculiar
to scrofulous individuals have been made by Hallopeau (toxi-tuber-
culides), Darier, Hyde, Boeck (érythèmes tuberculeux), and Johns-
ton¹ (cutaneous paratuberculoses), and others, diseases of which the
lesions, while not due directly to the presence of tubercle bacilli, are
attributed to their toxins, the organisms having their seat in some
other part of the body, either close to the skin or in the deeper organs.
The various maladies thus included are lichen scrofulosus, lupus erythem-
atosus, erythema induratum, acne varioliformis (acne necrotica), hidra-
denitis suppurativa, and a few other affections. That these affections
are commonly seen in the tuberculous or those of tuberculous history
cannot be doubted, and that, moreover, some present suggestive his-
tologic features. That the explanation advanced (tubercle toxins) is
the correct one, requires, I believe, greater substantial evidence, however,
before it can be accepted unreservedly. For this reason I have preferred,
for the present, to consider these affections separately, and in their cus­
tomary places, and not under a general class heading. It is true that
accumulating facts are almost conclusive as to the tuberculous relation­
ship of lichen scrofulosus, but with the other affections named, the
evidence is as yet too scanty to warrant a definite decision.

Symptoms.—This malady is, as a rule, free from subjective symp­
toms and insidious in its development, so that it is generally not noted
until well-defined patches have formed. The lesions are small, at first
scarcely more than a pin­point in size, but which later usually attain
that of a pinhead. They almost always arise close together, in irregular
bunches or groups, rounded or segmentel in configuration; at first bright
or dull red, they later assume a livid or brownish tone, and often become
fawn-colored or yellowish, which in some instances closely approaches
the tint of the normal skin. Not infrequently new lesions arise in the
interspaces of the older papules, and between the patches or groups, so
that in some cases considerable surface is covered, and if the lesions are
yellowish or near the skin hue, the eruption presents some resemblance
to goose-flesh (cutis anserina). As a rule, however, the malady is usually
represented by but a limited number of patches or areas. The lesions
become capped by minute scales, and although they may be close together,
never actually coalesce. The older, usually central, papules of the
patch often undergo involution, flatten down, and thus results the
crescentic or segmental outline often observed; minute yellow stains mark
the site of lesions which have disappeared. The eruption is commonly
limited to the trunk, especially the lower two-thirds, and more frequently
toward the lateral aspects. Less frequently it may also be found upon
the arms and legs, and in the latter situation occasionally slight hem-
orrhagic extravasation may be noted in the lesions, giving them a livid
aspect—lichen lividus. Exceptionally some of the papules are of a
larger size, and may contain centrally a yellowish sebaceous plug, and

¹ J. C. Johnston, “The Cutaneous Paratuberculoses,” Phila. Monthly Med. Jour.,
February, 1899, p. 78 (an extremely valuable exposition, with résumé and bibliography);
Riecke, article ‘‘Lichen Scrophulosorum,” in Mrâcek‘s Handbuch der Hautkrankheiten.
vol. iv, p. 521 (also gives a complete exposition with bibliography).

LICHEN SCROFULOSUS                                     229

sometimes several or more are distinctly pustular and acne-like. In
rare instances this latter feature is quite pronounced. In occasional
cases, more especially in the older patients, there is noted an associated
small nodular eczematoid eruption about the scrotum, sometimes a veri­
table eczema.

The course of the malady is exceedingly chronic, often lasting for
years, new lesions and patches arising from time to time, and some
gradually disappearing; in other instances the eruption, after a variable
time, fading away, and later recurring. While the minute yellow stains
usually left by the papules remain for a shorter or longer time, eventually
there is not observable a trace of the previous eruption; very exception­
ally, however, minute atrophic scars, but rarely more than few in num­
ber, are observed. Evidences of scrofula are usually found associated
with the eruption.

Etiology.—The disease is extremely rare in this country,¹ less so
in France, not uncommon in England,² and most frequent throughout
Germany, especially Austria. The malady is one of childhood and
adolescence, rarely observed under two or three years, and seldom above
twenty or twenty-five. Sex does not seem to exert much influence,
although it is somewhat more common in males, markedly so in Germany.
It is a disease of the scrofulous, and the positive evidence at hand,
though scant compared to the negative, gives it a place, I believe, among
the tuberculoses of the skin, although with one or two, but not abso­
lutely conclusive, exceptions (Jacobi, Wolff)³ bacilli have not been
found in the lesions (Riehl, Darier, Lukasiewicz, Jadassohn, and others).
Animal inoculations have failed (Leredde, Jadassohn, Hallopeau, Lafitte,
and others) in almost all trials, although in a few instances they have been
followed by tuberculosis (Pellizari, Jacobi). In 14 cases out of 16 in
which Jadassohn injected tuberculin there was the characteristic reac­
tion. Schweninger and Buzzi saw, apparently as a result of tuberculin
injections in a tuberculous subject, lichen scrofulosus develop; and
recently Nobl⁴ records 5 cases, clinically typical, which were in reality
examples of reaction of the skin after inunction of a tuberculin ointment.

¹ Bronson, Archives of Derm., 1875, p. 137 (case demonstration); Shepherd, Canada
Med. and Surg. Jour., 1880-81, vol. ix, p. 283 (a case); Gottheil, Jour. Cutan. Dis.,
1886, p. 133 (with cut and some literature references); Currier, Jour. Cutan. Dis., 1892,
p. 403 (case demonstration—doubtful); Hyde, ibid., 1897, p. 453 (a case); Gilchrist,
Johns Hopkins Hosp. Bull., 1899, p. 84 (negro child). Professor Duhring (Diseases of
Skin, third edit., 1882) states that he has not met with a case in this country. My ex­
perience, including services at two institutions at which children form a large propor­
tion of the patients, is the same—not a single case has come under my observation.

² In England cases have been observed by Tilbury Fox (Trans. London Clin. Soc'y,
1879, P. 190 (6 cases, with colored plate); Crocker, ibid., p. 195, and Diseases of Skin,
second edit. (15 cases); and Brit. Jour. Derm., 1899, p. 38 (case demonstration);
Pringle, Brit. Jour. Derm., 1894, p. 218 (case demonstration); Perry, ibid., 1895, p. 156
(case demonstration); Colcott Fox, ibid., p. 153 (case demonstration); Little, ibid.,
1900, p. 167 (case demonstration); and others.

³ Jacobi, Verhandl. der deutsch. dermatolog. Gesellschaft, III. Congress, 1891, p. 69
(with histologic plate); Wolff, ibid., VI. Congress, 1899; Haushalter, Annales, 1898,
p. 455, found bacilli in lesions of 2 cases described by him, but in these cases the lesions
were quite large, discrete, disseminated, and also upon the face, and represent more
closely cases of disseminated tuberculosis of the skin.

⁴ Nobl, “Zur Pathogenese des Lichen Scrophulosorum,” Dermatolog. Zeitschr.,
1909, vol. xvi, p. 205 (with some references).

230

INFLAMMATIONS

The almost invariable association of the malady with evidences of scrof­
ula, such as glandular enlargements, ulcers, caries of the bones, phthisis,
and tuberculous family history (Hebra-Kaposi, T. Fox, Duhring, Crocker,
Hyde, and almost all others), considered with the other facts just pre­
sented, indicate that it is to be considered a tuberculous eruption, the
failure to find bacilli leading some observers (Hallopeau, Hyde, Brocq,
Johnston, and others) to attribute it to the toxins of the organisms seated
at near or remote parts.

Pathology.—The disease has its seat about the pilosebaceous folli­
cles. Anatomic investigations (Kaposi, Sack, Jacobi, Leredde, Unna,
and others) show that the papule is made up of an infiltration of lym-
phoid, epithelioid, and giant-cells, the inflammatory changes beginning
first around the vessels, in and about the hair-follicles, sebaceous glands,
and about the papillae surrounding the follicular opening. The cutis
beneath the degenerated epidermis undergoes caseous degeneration.
Gilchrist¹ states that in his case (a negro) the microscopic sections pre­
sented two striking features: (I) Semiglobular-looking masses, situ­
ated in the horny layer, and especially around the hair-follicles; (2)
marked pathologic changes in the upper portion of the corium beneath
these masses, and also about the hair-follicles, especially the deepest
portion; the latter was characterized by its tuberculous structure.
There is, therefore, in the histologic picture a similarity to the struc­
ture of miliary tubercle, and a further support to the belief in the tuber­
culous character of the disease; Jacobi,² Sack,³ Hallopeau and Darier,⁴
and Lesselier,⁵ from their findings, speak most strongly to this effect.

Diagnosis.—The disease is to be differentiated chiefly from
the miliary papular syphilid, keratosis pilaris, and papular eczema.
The first is an eruption of the active stage of syphilis, and, in addition
to the eruption being widely distributed, other symptoms of this disease
can always be found. The usual regions for keratosis pilaris are the
limbs, most commonly the thighs, especially the outer surface; there
is practically no tendency to form groups or patches. Papular eczema
is rarely seen on the trunk alone,—a favorite region for lichen scrofulosus,
—and it is decidedly itchy, and frequently some of the lesions are vesicu­
lar or papulovesicular. These various characters suffice ordinarily to
distinguish these several eruptions from lichen scrofulosus. In this
latter the patchy and sluggish features, together with the usual presence
of scrofulous symptoms, will also serve to prevent error.

Prognosis and Treatment—The malady readily responds to
treatment; if let alone, it persists an indefinite time. The classic treat­
ment of Hebra, which rapidly cures, consists of cod-liver oil internally
and externally; small or moderate doses should be administered. Ameri­
can and English patients would seriously object to oleum morrhuæ as
a local application, and experience teaches that mildly stimulating oily

¹ Gilchrist, Johns Hopkins Hosp. Bull., 1899, p. 84.

² Jacobi, loc. cit.

³ Sack, Monatshefte, 1892, vol. xiv, p. 437.

⁴ Hallopeau-Darier, Annales, 1892, p. 45.

⁵ Lesselier, ibid., 1906, p. 897 (out of 17 cases, found in 14 the structure of the
tubercle).

PITYRIASIS RUBRA PILAR IS

231

applications or ointments will act as effectually. Crocker found that
inunctions of plain vaselin, or with 15 drops of the solution of subacetate
of lead, or 5 grains (0.35) of thymol to the ounce (32.), were quite as
efficient as cod-liver oil applications.

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