DERMATITIS PAPILLARIS PAPILLITII¹

Synonyms.—Acne keloid or acné cheloidienne (Bazin); Sycosis frambœsiformis
(Hebra); Dermatitis papillomatosa capillitii; Folliculitis nuchæ sclerotisans (Ehrmann).

Definition.—A frambesiform disease of the nucha, and usually
extending upward toward the occiput, presenting mixed sycosiform,
nodular, and keloidal aspects.

Symptoms.—The disease begins at the lower occipital region, or
just at the border of the hair, with the appearance of a number of isolated
cutaneous tubercles or sycosiform or acne-like lesions, pin-head to small
pea in size, but which grow larger, and, with the accession of new lesions,
soon become closely grouped or bunched. They are then frequently
pea- to small cherry-sized, red, pale red, or whitish in color, and some­
times contain pus; or pus may form beneath the mass here and there,
and tend to undermine; the nodule, upon incision, emits a creaking sound.
In some instances the surface becomes raw, and then may later present
a papillomatous granulation tissue growth, the whole being occasionally
covered with crusts, and secreting a gummy or seropurulent fluid, and
emitting an offensive odor.

There is more or less scar-tissue with hair loss, and here and there are
seen small projecting tufts of hair; some of the hairs are atrophied and
crooked. In some or many of the lesions, or at many points in the dis­
ease mass, keloidal changes are noted; and in the milder cases the erup-

¹ Literature: Kaposi, Pathologie und Therapie der Hautkrankheiten, Wien, 1880,
and subsequent editions; Morrant Baker, Trans. London Path. Soc‘y, 1882, vol. xxxiii,
p. 367 (with colored plate); Williams, ibid., 1884, vol. xxxv, p. 397 (with histologic
plate); Hyde (2 cases), Jour. Cutan. Dis., 1883, pp. 33 and 78; Marcacci, Giorn. ital.,
1887, p. 295; Eve, Illus. Med. News,. London, June 8, 1889 (with colored plate) ;Du-
breuilh (histology), Annales de la Policlinique de Bordeaux, 1889, p. 107; Heitzmann,
Jour. Cutan. Dis., 1889, p. 450; Crocker, Diseases of Skin, second edit., p. 624; Leloir
et Vidal, Traitê Descriptif; Melle, Giorn. ital., 1891, p. 181; Mibelli, ibid., 1893, p. 469;
Ullmann, Archiv, 1893, vol. xxv, p. 727; Ehrmann, ibid., 1895, vol. xxxii, p. 323;
Porges (with 4 colored histologic cuts and bibliography as to histology), ibid., 1899,
vol. lii, p. 323; Stelwagon (brief report of case with photo.), Jour. Cutan. Dis., 1893,
p. 230; Secchi, Monatshefte, 1896, vol. xxiii, Nov. 15; Ledermann (histology), Ver-
handlungen der Duetsche,n Gesellschaft, V. Cong., 1896, p. 443; Van Harlingen, Trans.
College of Physicians, Phila., 1897, p. 208; Dyer, Amer. Jour. Derm, and Gen.- Urin.
Dis., July, 1899; Tryb, “Ueber Nachenkeloid or Dermatitis nuchæ sclerotisans,”
Dermatolog. Wochenschr., Dec 7, 1912, lv, p. 1491 (5 cases, review and col‘d histolog.
cuts; believes it to be a folliculitis followed with an associated perifolliculitis and keloi-
dal tissue formation); Vörner, Archiv, 1912, cxi, No. 3, reports a case with histology
(reviews the literature of the subject; he regards the process as a local injury leading
to “hemorrhagic abscess” in the cutis; that there is no genuine keloid or fibroma but
rather a simple cicatricial hypertrophy of an inflammatory nature; he found in many
of the giant-cells in the tissue acid-fast rods resembling tubercle bacilli, but in smears,
however, he was only able to demonstrate cocci).

644

NEW GROWTHS

tion presents a decidedly keloidal and tubercular, acne-like appearance.
It is this keloidal tendency which distinguishes it from an ordinary syœ-
siform inflammation. The disease develops slowly, and in some cases,
after several months or years, halts, and remains apparently stationary.
Rarely retrogressive changes are observed in some parts. On the other
hand, the malady may progress and reach considerable dimensions, both
in area, extending up to the vertex, and forming somewhat massive pro­
jections. The cases coming under my observation were moderately
developed, constituting the average case met with.

Etiology and Pathology.—The cause of the disease is not
known. It is infrequent. It may occur in either sex, but is much
more common in males, and is most frequently seen during early adult
and middle age.

There is some difference of opinion among investigators as to whether
the process begins about the follicles (Leloir and Vidal, Dubreuilh,

Unna, Ehrmann) or as
an inflammatory proc­
ess in the cutis (Kaposi,
Ledermann). Clinically
its origin seems certainly
connected with the fol­
licles, and it appears as
if due to some infection.
Besnier and Doyon con­
sider it a papillomatous
growth developing from
acne lesions, etc, and
traumatism. The forma­
tions in the earlier stages
are of the nature of
highly vascular papillary
growths, with structure
somewhat similar to
granulation tissue; later
they undergo sclerosis,
with atrophy of the
hair-follicles. Round-
cell infiltration is noted
in the corium; hyper­
trophy of the epidermis and enlargement of the papillæ and blood-vessels
are also observed. Hyalin corpuscles are seen (Mantegazza, Secchi),
which the latter observer considers to be blastomyces. Ehrmann found
staphylococci. Vörner found in the tissues acid-fast rods resembling
tubercle bacilli. In my cases the sclerotic or keloidal element was
quite a marked feature; all were men—the majority being negroes;
2 of the negroes were brothers.

Diagnosis.—Its features are so peculiar that it can scarcely be
confounded with any other disease. In its beginning sycosis and acne
nodules are suggested.

Fig. 150.—Dermatitis papillaris capillitii; man aged
thirty-nine, of five years’ duration; some slight under­
mining, keloidal aspect predominant.

MOLLUSCUM CONTAGIOSUM                               645

Prognosis and Treatment.—No tendency to spontaneous cure
is noted, but in some instances, as already remarked, the process halts
after a variable time; it may, however, be progressive. The general
health is not influenced by it. It is extremely rebellious to treatment,
commonly resisting all measures; moderate improvement is, however,
not unusual.

The treatment used is similar to that employed in sycosis. The
hairs are to be extracted, the parts frequently cleansed, and any pustules
or pus-accumulation evacuated. A sulphur and ichthyol ointment is
the most valuable: 1 to 2 drams (4.-8.) of the latter to an ounce (32.)
of sulphur ointment full strength or weakened, according to inflammatory
conditions. The object is not irritation, but mild antiseptic stimulation.
Resorcin and boric acid lotions are also at times of some service. Of the
operative methods commended as of some benefit may be mentioned
electrolysis (Ehrmann), linear scarification (Hallopeau and Leredde),
and excision (Ledermann). Van Harlingen states that he has cured
several cases in the incipient stage by thorough destruction by the electro-
cautery; in one case in which complete excision had been made by a
surgeon there was a return of the growth. Judging from its favorable
influence in sycosis, the x-ray treatment should be of value in this dis­
ease.

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