CUTANEOUS MANIFESTATIONS OF ACQUIRED SYPHILIS

Synonyms.—Syphilis cutanea; Syphilis of the skin; Dermatosyphilis; Syphiloder-
ma; Syphilid.

Syphilitic manifestations of the skin constitute an important class
of dermatologic cases, and the presence of such lesions, history of their
occurrence, or resulting scars often furnish important clues to the possi­
bility or probability that some existing obscure organic or constitutional
condition may be due to the same cause. The various syphilodermata
can be conveniently considered dermatologically without special division
of the so-called secondary or tertiary stages, incidental mention being
made on this point in connection with each variety of eruption. After
the appearance of the initial lesion of syphilis there is, as is well known,
a variable period of a few weeks or longer, known as the “period of second
incubation,” in which the disease is apparently quiescent, except that
slowly and gradually following the enlargement of the nearby lymphatic
glands there is a general invasion of this glandular system, although
glands in other situations never reach the same development in this
particular as the lymphatic structures connected anatomically directly
with the chancre. In fact, quite frequently this glandular involvement
fails to be general, at least to the degree of special significance. The
adenopathy is usually readily recognized by palpation of the more super­
ficial glands, as the postauricular, occipital, submental, submaxillary,
anterior and posterior cervical, axillary, epitrochlear, inguinal.¹ It

¹ Friedländer (“ The Value of Lymphatic Gland Examination as a Factor in the
Diagnosis of Syphilis,” Jour. Cutan. Dis., 1912, p. 14) contributes an interesting and
analytic paper on this subject with tabulations; he found enlargement, especially
if bilateral, of the epitrochlear, occipital, and posterior cervical glands to be, in the
order named, of the greatest diagnostic significance.

Plate XXI.

Chancre of the lip : a not uncommon type, with but slight to moderate underlying indu­
ration and a quite characteristic pseudo-membranous coating frequently observed.

Chancre of the lip : a common type, with considerable underlying and surrounding
infiltration and induration.

SYPHILIS

771

usually reaches its greatest development at about the time of or during
the outbreak of the secondary cutaneous symptoms. The enlargement
varies, exceptionally being so slight as to be scarcely, if at all, recog­
nizable, and in occasional instances attaining considerable dimensions.
As a rule, however, in the various situations named one or several of
the glands are found pea- to bean- and small-nut-sized or somewhat
larger, and are hard, indolent, and painless, with no tendency, in uncom­
plicated cases, to suppurative action. In scrofulous subjects and in
others where accidental pyogenic inoculation also takes place, the glands,
more especially those anatomically connected with the site of the chancre,
may undergo softening and break down. Such, however, is not of com­
mon occurrence. The adenopathy of syphilis usually persists, more or
less, though the secondary stages of the disease, and often, especially in
those patients untreated, somewhat indefinitely. It is not, however,
a part of a late tertiary cutaneous manifestation, except sometimes in
nearby glands, and more particularly when there is ulceration with sup­
puration—the glandular enlargement or sympathy being then due rather
to the latter process than to the malady itself.

The advent of the secondary stage of syphilis, the most character­
istic symptoms of which are the more or less generalized cutaneous
eruptions, occurs a somewhat variable time after the date of exposure or
inoculation, varying within considerable limits from four or five weeks
to some months. Most authors place the average at about eight weeks,
and this accords with general experience, although the outbreak is not
uncommon about the sixth week, and the possibility of a much longer
period is also to be recognized.¹

Preceding the eruptive outbreak for several days or one or two
weeks certain other symptoms—one or several—are not infrequently
observed, such as rheumatism, especially about one or two joints, severe
persistent headache, neuralgia, bone pains, some loss of weight, a dinginess
or unhealthy-looking skin tint (especially the face and particularly about
the chin and mouth, which often presents a slightly macular, mottled
appearance),² febrile action (syphilitic fever), and a general feeling of
lassitude, and occasionally a distinctly cachectic condition (syphilitic
cachexia). According to White and Martin, examinations of the blood
at this time, and also earlier, usually show a slight increase in the white
blood-corpuscles, a lessening of the red corpuscles, and a marked diminu­
tion in the hemoglobin percentage. These various symptoms, if present,
often persist for days or weeks, or subside measurably or completely
upon the full development of the eruption, or they may show no tendency
to abate until active and energetic treatment is instituted. The syphil-

¹ Bergh’s review (Monatshefte, 1893, vol. xvii, p. 593) of the subject on this point is
of value, naturally, indicating considerable variation, although the period just men­
tioned can be considered the rule. His own statistics of 254 cases in males show that
in 2 cases the general eruption appeared in the fourth week, in 11 in the fifth, 20 in the
sixth, 28 in the seventh, 32 in the eighth, 21 in the ninth, 30 in the tenth, 23 in the
eleventh, 16 in the twelfth, 13 in the thirteenth, 24 in the fourteenth, 27 in the fifteenth,
3 between the twentieth and twenty-fourth, and 4 between the latter and the twenty-
ninth; the extremes being twenty-four and two hundred and four days.

² Trimble, “The Mottled Chin of Syphilis,” Jour. Cutan. Dis., 1911, p. 569, calls
particular attention to this not uncommon symptom.

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itic fever is occasionally sufficiently severe to simulate or suggest other
febrile diseases. Some cases, may, however, remain absolutely free
from any such disturbances, and the eruption be the first sign of con­
stitutional syphilis. In fact, the secondary stage of the disease may be
so extremely mild in all respects that its occurrence is overlooked, and
if the chancre has been slight, or in women and in concealed situations,
it may be that late tertiary eruptions or other syphilitic symptoms may
be the first recognized evidences of the malady. This is not an uncom­
mon observation in married women who have contracted the disease
unknowingly through the marital relation. As a rule, however, sec­
ondary manifestations of the disease are sufficiently pronounced to lead
to seeking of medical advice, even though the initial lesion had escaped
the patient’s notice. A few remarks upon some of the characteristics
of syphilitic eruptions in general may be of value before describing the
various types individually.

General Observations and Diagnostic Characters__

Syphilis, not only in its cutaneous symptoms, but in all its relations, varies
considerably in different cases. It may be benign in character (benign
syphilis), scarcely making any impression, or in occasional instances
extremely severe or malignant (malignant syphilis), striking the patient
with tremendous force, giving rise to profound anemia, marasmus, and
even death. Ordinarily, however, its course is mild or only moderately
severe; in some instances quite pronounced, with a variable degree of
malignancy. Sometimes this severe or malignant character seems to
be mainly shown in the type, persistence, and recurring tendency of the
skin-lesions, the general health remaining fairly good.

Syphilis, in its cutaneous manifestations, at least, can truly be said
to be a great imitator, as there is scarcely an eruption, exclusive of some
of the exanthemata, that cannot, in a measure, and sometimes strikingly,
be simulated. Nevertheless, the syphilodermata in most instances
are sufficiently distinctive in some features to make their recognition
ordinarily a matter of but little difficulty; on the other hand, the resem­
blance to other affections may sometimes be so great as to demand most
careful investigation as well as recourse to blood test, and examination
for spirochetes, or several days’ or one or two weeks’ observation,
before a positive conclusion can be reached.

Distribution.—The earlier cutaneous manifestations—those of the
secondary period of the malady—are more or less general and symmetric
in distribution, although in many instances the different types may show
a preponderance on certain regions, as will be referred to in describing
the individual eruptions. It may be said, however, that in many cases
the upper part of the forehead, just at the margin of the hair, the angles
of the mouth, the nasolabial folds, the palms, soles, region of the anus,
and genitalia are frequently the seat of lesions. The syphilitic eruptions
may be abundant or somewhat scanty, and vary considerably in duration.
In relapses the eruption is much more scanty and usually of less general
dissemination, with a disposition to irregular or ill-defined grouping or
aggregations. The late syphilodermata, those of the declining active
or secondary stage, and particularly those of the tertiary period, are

syphilis                                         773

rarely of wide distribution, but, on the contrary, are commonly confined
to one or several regions, with a distinct grouping tendency.

Configuration and Color.—In the earlier syphilitic eruptions, as
already remarked, there is exhibited but little, if any, tendency to special
grouping or configuration. The lesions are usually rounded or ovalish,
sometimes irregularly so. In occasional cases of the erythematopapular
manifestation, especially in negroes, some of the lesions, more particu­
larly about the mouth, lower part of the face, and neck are distinctly
annular. In the later secondary, relapsing outbreaks irregular grouping
occurs, sometimes with a segmental or circinate tendency, but, as a rule,
these characters are reserved for the later or tertiary eruptions, of which
the tubercular syphiloderm is representative. Here the tendency to
segment, circinate, and serpiginous arrangement is more or less constant,
and, taken together with chronicity, is almost diagnostic

The color of the syphilodermata is a dingy, sluggish, or dull red,
often coppery. In the earliest part of the outbreak, more particularly
of the macular syphiloderm, the hue may be a brighter one, often of a
quite distinctly inflammatory aspect, but this is soon lost, and the dull
red to brownish red soon presents, and which finally amounts to brownish
pigmentation, which, however, eventually disappears. The dull or cop­
pery red is often very suggestive, but color alone is rarely to be depended
upon for positive differentiation—it is simply to be viewed as one of a
group of diagnostic factors, which together are clearly conclusive.

The ulcers of early pustular syphilodermata are superficial, and, as
a rule, have no special characteristics; those of the later forms are seg-
mental, rounded, or kidney shaped. The scars resulting from syphilis
are usually soft, pliable, and somewhat insignificant, commonly showing
minute puncta or perforations, the sites of former follicles. Those
resulting from the later eruptions take the shape of the lesions or groups
giving rise to them, and the segmental or horseshoe-shaped scar or scars
will often serve as the key to the past or associated present trouble.
Such scars are commonly soft, and relatively insignificant compared to
the preceding ulceration; they are rarely tough or striated, as frequently
noted in lupus cicatrices, although this tendency and a keloidal disposi­
tion are sometimes observed when at the joints.

Polymorphism.—While the generalized or secondary syphilodermata
can rarely be said to be, to any large extent, polymorphous, the type
being usually more or less uniformly papular, pustular, etc, yet it is
just as true that in most cases several or more characteristic lesions
of another variety than those which chiefly make up the eruption are
to be found when the surface is carefully inspected, and this fact is often
of value in the diagnosis—as, for example, in differentiating the papular
syphilid from lichen planus and the papulosquamous syphilid from psori­
asis, etc, two diseases which are always uniform. In the macular syphilo-
derm will often be found some scattered lesions with a papular tendency
—maculopapules, and commonly also clearly defined papules, especially
about the anal and genital regions; in the small papular syphilodermata
several or more well-developed scattered pustules are not unusual, and
more frequently, especially in the miliary papular syphilid, many of the

774                                   NEW GROWTHS

papules often show a pustular tendency at the summit. The pustular
syphilodermata generally exhibit, here and there, typical papules and so
on; commonly, too, there is an admixture of several or more lesions of a
larger or smaller type than those of which the eruption is chiefly made
up, as some large pustules in the miliary pustular syphilid, some large
papules in the miliary papular eruption, etc. Occasionally, also, the
eruption may be composed of lesions of intermediate type, as in the
papulopustular syphiloderm and papulotubercular syphiloderm.

Subjective Symptoms.—The syphilitic eruptions are usually unac­
companied by subjective symptoms, and this factor can sometimes be
utilized as a differential point in some instances. An exception must be
made to this statement as to the negro, if we are to accept his word for it,
inasmuch as in this race slight or moderate itching is usually complained
of, although it is rarely sufficiently severe to give rise to active scratching
and resulting excoriations. The miliary papular and miliary pustular
syphilodermata seem to be most troublesome in this respect, and these
forms occasionally give rise to insignificant pruritus in the white race
as well. Pain likewise is rarely noted in the early syphilodermata,
although about the anus and genitalia, where they are subjected to con­
siderable heat, moisture, and friction, not only may the lesions become
somewhat painful, but be also itchy to a varying degree. The state­
ment of many patients with such eruptions, either voluntarily or upon
interrogation, that they are or have recently been suffering with an attack
of what they think hemorrhoids is not an uncommon one, and is, indeed,
often a suggestive one. In the later ulcerating syphilodermata there
may or may not be more or less pain; as a rule, however, it is rarely
sufficiently great to give rise to complaint.

Course and Duration.—The syphilodermata of the active or sec­
ondary stage usually appear somewhat rapidly and attain full develop­
ment in one or two weeks, after which, except generally in the macular
syphiloderm, it is not uncommon for a few new lesions to show them­
selves irregularly for a short time. In some cases there is but a scanty
scattered outbreak at first, followed in several days or one or two weeks
with a more or less profuse outburst. Exceptionally the eruption re­
mains scanty throughout. After several weeks the macular syphilid
has generally pretty well declined; in the other types there is often a
somewhat stationary period for a month or so, with now and then, in
some cases, a slight recrudescence. Disappearance gradually takes
place, however, in a few months in some instances, much longer in
others, occasionally leaving more or less persistent lesions on certain
regions, as the palms. The papular eruption is quite prone to slight
relapses for some months. In the late, or tertiary, eruption there is but
little tendency to spontaneous disappearance.

Concomitant Symptoms.—Along with the cutaneous manifestations
of the active or secondary stage of syphilis other symptoms of the
malady are usually associated. The chancre, as is well known, often
persists, or its mark or scar is found. The anatomically connected
glands are noted to be enlarged, and general adenopathy is likewise
usually readily recognized. Sore throat, mucous patches, or superficial

SYPHILIS

77S

ulcers on the inner aspects of the lips, in the mouth, pharynx, etc., are
commonly observed, in some cases to considerable extent, in others
slightly, and exceptionally scarcely at all. Iritis, cephalagia, bone
pains, etc., are also sometimes noted. The skin is commonly sallow or
dingy looking, and the patient anemic, and with a tendency at first to
lose flesh. It is seldom, however, that all of these symptoms are observed
in one case—sometimes but one or two. In the late, or tertiary, syphilo-
dermata concomitant symptoms are often wholly wanting, although
sometimes bone lesions, bone pains, alopecia, superficial glossitis, leuko-
plakia—one or more—may be present. Much more frequently, how­
ever, only evidences of former disturbances are to be found, such as scars,
the effects of iritis, etc.

Under this head affections of the appendages of the skin—the hair
and nails—due to syphilis, which are also incidentally referred to under
diseases of these parts, can be here conveniently briefly described before
taking up the individual eruptions proper. Alopecia,¹ or hair loss,
consisting of a general falling of the hair (defluvium capillorum), more
particularly the scalp hair, is noted in the early period of the secondary
stage, but rarely amounts to visible baldness, but is more of a simple
thinning. The amount varies in different cases, in some the loss daily
being considerable, in others slight, and frequently scarcely enough to
attract the patient’s notice. It is not only due directly to the infection
itself, but sometimes indirectly also to the seborrheic condition, which
the disease not infrequently engenders. Exceptionally, but usually
later in the course of the disease, instead of a general thinning it occurs
in ill-defined and incomplete small and irregular, sometimes coalescent,
patches—not the clearly cut patches of true alopecia areata—which give
the scalp a “moth-eaten or mangy appearance,” its common region being
the posterior half of the scalp. The hair also shares in the general
“dinginess” which the disease often produces, becoming dry, more or.
less lusterless and lifeless looking, associated with the sallow or dingy
appearance of the skin, especially of the face. As a rule, in hair loss
due to this disease, full or tolerably complete regrowth takes place if the
patient is not advanced in years or has no family tendency to baldness—
in such the loss is not usually replaced. In cases where ulcerative lesions
occur upon the scalp, as occasionally in the late or tertiary stage, and
exceptionally earlier, the follicles are destroyed, and in such spots or
areas the loss is permanent.

The nails of fingers or toes (syphilis of the nails) are also occasionally
involved, either one, several, or more. Both onychia and paronychia are
met with, usually in the active secondary stage, in acquired syphilis, as
well as in hereditary syphilis, referred to later. The usual initial factor
is the presence of syphilitic lesions, generally papules or ill-defined infil­
tration, of the bed, matrix, or nail-folds. There is commonly observed
resulting nutritive disturbance, as shown by thickening, brittleness or fri­
ability, and opacity, and often furrows, depressions, or other irregulari­
ties; if the underlying infiltration is marked and inflammatory, sometimes

¹ Klotz, “Remarks on Syphilitic Alopecia,” Jour. Cutan. Dis., 1907, p. 99, con­
tributes an interesting paper on this greatly overrated symptom.

776

NEW GROWTHS

with a tendency to ulceration, the nail is usually uplifted, but, as a rule,
more or less incompletely, at first at least, becoming more detached later,
and not infrequently dropping off. Generally the nails are replaced,
although at first may be ill formed. In other instances there are no
visible traces of distinct irritation or infiltration of the bed, matrix, or
surrounding parts, the nails showing merely the effect of the general
impaired nutrition produced by the disease and its exacerbations; they
become somewhat opaque, brittle, tend to break at the free edges, and
occasionally exhibit furrows or other evidences of nutritive disturbance.
Instead of chiefly limiting itself to the bed and matrix of the nail,
the inflammatory or infiltrating process may extend to the surround­
ing parts, or it may begin at the latter, and a somewhat variable grade
of paronychia results, with the usual symptoms of this condition. The
skin surrounding the nail is reddened, swollen, the tissues infiltrated, and
suppuration or ulceration may result, and give forth a fetid discharge.
If severe, the finger-end may show club-like enlargement, but this is
never so well marked as in infants in hereditary syphilis. In fact, cases
vary considerably; Taylor divides paronychia into three forms: ulcera-
tive, indolent, which is, as a rule, non-ulcerative, and the diffuse; the non-
ulcerative form, usually starting as a more or less continuous band of
infiltration; the ulcerative form, beginning as a papule or pustule at the
lateral edge or as an ulcer or fissure at the border of the lunula; and the
diffuse variety, as a hyperemia, involving the surrounding parts, and
later the end of the terminal phalanx, and followed by infiltration and
bulbous swelling. The nail is frequently discolored, and also often
exhibits other changes, such as just referred to, and may fall off. In
the usual grade of cases met with, however, this does not result. One
or several may be involved, and either of the fingers or toes. As a rule,
there is not sufficient pain to give rise to actual discomfort, and not in­
frequently, unless knocked, the affected part is practically painless.¹

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