150                                         HYPEREMIAS

ERYTHEMA SCARLATINOIDES

Synonyms.—Erythema scarlatiniforme (Hardy); Roseola scarlatiniforme (Bazin);
Desquamative exfoliative erythema; Erythema scarlatinoides; Erythema scarlatinoides
recidivans; Fr., Erythème scarlatinoïde; Erythème scarlatiniforme desquamatif.

Definition.—Erythema scarlatinoides is a term employed to des­
ignate those cases of more or less diffused erythema followed by partial
or complete desquamation.¹

Symptoms.—There are various grades of this condition, from
those in which but a part of the body is involved, to those in which
the rash is almost continuous over the entire surface; with insignificant
or no constitutional disturbance, to that of severe degree with high
temperature (Besnier, Brocq, Atkinson, and others). Moreover, the
rash is occasionally of a morbilliform character; by far the majority,
however, present a scarlatinous appearance. This latter may in some
instances be punctiform at first, but, as a rule, the redness soon becomes
uniform. The color may vary between a bright pink or red to a sluggish
or livid red. Upon the whole, its color and general appearance are
similar to those of scarlet fever. The rash may be of acute onset, with
more or less constitutional disturbance, or it may be somewhat subacute,
with slight or no systemic symptoms. As a rule, it is ushered in with
the ordinary symptoms of mild febrile disease, with a concomitant de­
velopment of the skin redness; or this latter may not appear for several
hours to a day or so later.

The constitutional symptoms, when present, frequently abate upon
the appearance of the erythema. In extreme cases, however, the sys­
temic disturbance may persist for several days or longer; in fact, this
depends upon the cause responsible for the eruption. In most instances
the rash begins to subside in from twenty ­four hours to three or four
days, with desquamation, which may be branny or may take place in
large thin sheets. Exceptionally, desquamation is scarcely perceptible.
In extreme cases the tongue and throat may share in the eruption, and
exceptionally the nails be shed, and even the hair be lost. These cases,
judged by the reports of French writers (Vidal, Besnier, Brocq), are more
common in France than with us or in other countries.

Recurrences are not uncommon in many cases (recurrent exfoliative
erythema; erythema scarlatinoides recidivans), but the later attacks may
be less severe (Elliot, Hartzell, and others). The course of the eruption
is usually run in from one to three or four weeks. As a rule, there are
no subjective symptoms.

¹ Some important literature: Brocq, Jour. Cutan. Dis., 1885, p. 225, full account
and bibliography to date; I. E. Atkinson, ibid., 1886, p. 295; Ohmann-Dumesnil, ibid.,
1890, p. 293, with bibliography; Besnier, Annales, 1890, p. 1, and Brocq, p. 265; Payne,
Brit. Jour. Derm., 1894, p. 129 (unusual persistent types); Ohmann-Dumesnil (in
typhoid fever), Jour. Cutan. Dis., 1890, p. 293 (with some references), and St. Louis
Med. and Surg. Jour., July, 1893; Elliot, New York Med. Jour., Jan. 11, 1890; Blanc,
International Clinics, Oct., 1891, and Jour. Cutan. Dis., 1893, p. 11; Sligh (Case of
Annual Skin-shedding), Internat. Med. Mag., June, 1893 (with illustrations); Hartzell,
University Med. Mag., Aug., 1895; Luithlen, Dermatolog. Zeitschr., vol. ix, Heft 1, 1902,
p. 39, “Dermatitis Exfoliativa und Erythema Scarlatiforme” (review and references);
Kramsztyk, ibid., 1902, H. 3, and Jahrbuch für Kinderheilk., vol. lv, 1902, No. 3
(3 cases); Gardiner, Brit. Jour. Derm., 1908, p. 245.

ERYTHEMA SCARLATINOIDES                          151

The various cases of shedding of the skin (skin-shedding, deciduous
skin) are apparently related to this malady. The erythematous ele­
ment is, however, seldom so pronounced. In these cases there is often
a tendency to periodicity, the most remarkable in this respect being
that reported by Sligh (loc. cit.), in a man, aged thirty-seven, who had
shed his skin annually since birth, the beginning evidences of recur­
rence always showing on the same date. Indeed, in these cases there
is a suggestive resemblance to “molting’‘ observed in some animals,
and to the periodic shedding of the cuticle in serpents. A case recently
came to my own notice, through Dr. Harmon, of Phillipsburg, Pa., of a
boy of fifteen who had been “shedding his skin” twice yearly—July and
December—for the past five years; there was but slight redness, and no

Fig. 26.—Erythema scarlatinoides in a frail young woman of thirty years, and of
generalized distribution, the trunk showing branny exfoliation, the extremities that of a
thin, flake-like or lamellar character. There was no infiltration, the earliest stage being
a faint or moderately defined scarlatiniform erythema. An attack annually for several
years, lasting about four or five weeks. No general symptoms except mild and evan­
escent prodromal febrile action and slight malaise.

subjective symptoms except a preliminary feeling of dryness of the skin;
the process required about two weeks to run its course.

Etiology and Pathology.—There are doubtless many causes
for this form of erythema, which also demands, perhaps, a peculiar
individual idiosyncrasy. The various toxemias, general or intestinal,
are probably most frequently responsible. Septic infection seems at
times causative. The condition is also seen in association with albu-
minuria, rheumatism, gonorrhea, etc, and may likewise result from
the eating of certain foods, especially “shell­fish” and spoiled meats, or
from the ingestion of certain drugs. External irritation may also be the
starting-point of the erythema—as, for instance, after operation and
from the use of mercury and iodoform. The rash produced by this
latter is, however, usually more inflammatory and belongs more properly

152

HYPEREMIAS

under dermatitis exfoliativa (q. v.). Other causes mentioned are sewer-
gas poisoning (Crocker), digestive derangements (McCall-Anderson)
following injuries and operations (Atkinson), obscure changes of tissue
or secretion about wounds (Hoffa), malaria (Cheadle), prolapsed and
enlarged ovary (Elliot), auto­intoxication with ptomains (Lépine and
Molière). The manner in which the eruptive phenomena are produced
is unknown; this may be from disturbance of the nerve-centers, direct
irritation on the peripheral blood-vessels or nerves, or of reflex origin.
Brocq considers the disease a mild form of dermatitis exfoliativa.

Diagnosis.—At times there is considerable difficulty the first day
or two in reaching a positive opinion. It resembles closely scarlet
fever, but the intensity of the constitutional symptoms of this latter,
the peculiar strawberry tongue, and the swollen fauces are wanting.
Moreover, the erythema is rarely so general in its distribution as the
rash of scarlatina. Occasionally, also, it presents some resemblance
to measles, but the peculiar associated symptoms of measles would be
absent, and, moreover, the eruption of erythema rarely begins on the
face, and not infrequently spares this region. From rötheln it may be
distinguished by the absence of the glandular enlargement and the lack
of a history of contagion. This latter can also be utilized in differen­
tiating from scarlet fever and measles. It must be admitted, however,
that in the beginning of a tolerably well-marked case of erythema scarlat-
inoides the diagnosis cannot always be made with certainty, and the
case should be in such instances isolated; one or two days’ observation
will usually clear up any doubt.

Prognosis.—This is always favorable; in ten days to three or
four weeks the patient is usually entirely over the attack. It may,
however, recur; and, in exceptional cases, recurrences may follow some­
what rapidly one after another, partaking more of the nature of derma­
titis exfoliativa (q. v.). In one case (Tilbury Fox) there had been 100
attacks.

Treatment.—The systemic treatment depends upon the cause
which may have provoked the erythema; when this is ascertainable,
the appropriate remedies should be advised. In many cases, however,
the treatment must necessarily be based upon general principles. A
saline laxative, occasionally repeated, along with moderate doses of
sodium salicylate, quinin, salol, charcoal, and other intestinal anti­
septics, is to be prescribed. In debilitated subjects strychnin is of value,
and later other of the well-known tonics. To guard against recurrences,
patients should be carefully advised as to diet, avoiding all questionable
foods. The possibility of certain drugs being at times responsible is to
be borne in mind.

External treatment is rarely called for. If necessary, dusting-
powders may be used; in fact, the same applications as advised in ery­
thema hyperæmicum.

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