Ringed Eruptions in Skin Diseases, and their

Differential Diagnosis.

JAMES D. GOLD, M.D., BRIDGEPORT.

Mr. President and Members of the Connecticut Medical Society I fully appreciate the difficulty which one, confining his time and study to a single branch of medicine, encounters when he undertakes to present a subject to an audience comprised mostly of those in the general practice of medicine, and not so particularly interested in any one speciality. I have therefore chosen this subject with the hope that there may be something of interest to all.

Ring formations occur in many of the common diseases of the skin and in some of the rarer ones as well. These rings in all, while not so constant or diagnostic a feature as in ringwormthe disease par excellence for ring formations-may, nevertheless, have features so characteristic as to lead us to differentiate them, and to so identify them with the disease to which they belong that a correct diagnosis may be made. Having established this, we are able to proceed with a proper treatment, for a correct diagnosis is half the battle in treating skin lesions. Where one would need a stimulating application or destructive agency, another disease almost similar in appearance would require the most soothing application. Hence you see the necessity for recognizing the disease to be treated, and not taking it for granted that you have either an eczema, syphilis or ringworm, not applying any of the many samples of proprietary remedies with which one's office is fully supplied, and not accepting the list of diseases for which that one sample is a panacea. The following diseases are those in which ringed eruptions are either characteristic or may be found: ringworm, pityriasis rosea, psoriasis, erythema multiforme, syphilis, seborrhoic eczema,

lupus erythematosus, lichen planus, dermatitis factitia, lupus vulgarus, and a few rarer diseases.

Ringworm of the general surface, or tinea circinata, the one skin disease which occurs in rings (as the name implies), in which the perfect rings or circles are truly characteristic of the disease, is caused by the vegetable parasite, tinea trichophytina. There are two distinct forms of the fungus; microsporon andonini, or small-spored fungus, and the trichophyton megalosporon, or large-spored fungus. The small-spored fungus appears under the microscope as irregularly grouped round spores with large branching mycelia threads. In the large-spored fungus the spores are larger, often irregularly rounded, found in chains or lines, and accompanied with the branching mycelia. Ringworm of the general surface is characterized by one or more acute inflammatory, scaling, itching rings, varying in size; they occur at first as small scaling patches, rapidly increasing in size from one-half to two inches in diameter, with a tendency to heal in the center, and the periphery composed of minute vescicles followed by scaling, so that a typical lesion is the clear center, the scaling inflamed ring with the outer border of the minute vesicles. When seen on the scalp, the patches are round, but the distinct ring condition is not so marked, only a general scaliness with broken and falling hairs.

Generally, the diagnosis of ringworm of the body is easily made, when we take into consideration the acute character of the lesion, its location upon the face, scalp, or upper portion of the body more frequently than elsewhere, more commonly seen in children than adults, and its contagious character transmitted from one part to another, or from one person to another.

There is one form of ringworm called eczema marginatum, or tinea circinata cruris, which resembles eczema somewhat in appearance, but is really a ringworm, for it is due to the tinea spores. It occurs in the genital region and axillæ, appearing first as a small, superficial ring and, favored by the heat and moisture of the parts, develops rapidly, taking on a more inflammatory character, and presenting more the appearance of true eczema; but the border is sharply defined, raised and

scaling, it extends from the periphery by the formation of minute vesicles, with a slight indication of a healing center and generally there is more or less redness and scaling. The disease may extend well up onto the abdomen, down the thighs, between and onto the nates; the same condition may be found in the axillæ, either in conjunction with the disease located in the genital region or separate.

Thus we have ringworm, the true ringed eruption, acute and inflammatory in character, with the raised, scaling ring, vesicular border, and clear normal center, usually only a few lesions being found, and not a general eruption all over the body. Ringworm must be differentiated from pityriasis rosea, which is an acute disease, generally found on the trunk and limbs, rarely on the face; it appears first as small, pinkish, or pale red scaling macules, which tend to increase in size, forming irregularly shaped rings, with the scaly pink border, and a peculiarly wrinkled, yellowish, café au lait, colored center. There is usually one initial lesion of several days duration before the general eruption appears; thus we have the difference; pityriasis rosea is more general as a rule, the rings are irregular in shape, lack the vesicular and markedly scaling border, and the center is yellowish and wrinkled, and finally pityriasis rosea tends to spontaneous recovery in the course of a few weeks.

The circinate syphiloderm of the secondary period of syphilis may be confused with ringworm, as it occurs especially in the region of the mouth, forehead and neck; the rings are distinct, half an inch to one inch in diameter, but the center is normal, and the border is raised and thickened, sharply defined, slightly scaling, and of dull reddish color; often the lesions coalesce, forming gyrate figures, but with the same distinct borders; accompanying this circinate lesion there may be found over the body typical flat papules of syphilis, which confirms the diagnosis. You will observe this ring is thicker, more indurated, lacks the vesicular border and less scaling than ringworm, and other signs of syphilis present.

Psoriasis may sometimes be mistaken for ringworm. This disease is a decidedly chronic and inflammatory one, character

ized by dry, scaling, indurated patches, few or many in number, and irregular in shape. It is found anywhere upon the body, but the favorite locations are the knees, elbows and scalp. The scales are characteristic of the disease, silvery white, abundant, easily removed and, after removal, leaving the base of the lesion a bright red, with minute bleeding points; that is, the typical psoriasis lesion, the condition to which our attention is called, is caused by the enlarged patch undergoing involution, invariably starting from the center, leaving that perfectly clear and a normal skin; surrounded by this scaling inflamed ring, spoken of as psoriasis circinata, it may happen that several of these rings may run together, forming irregularly shaped rings called psoriasis gyrata; again, these rings may develop as such from the very first, especially so if the patient has had attacks of the disease before; in that condition the rings are broken and incomplete in formation, and few in number.

The only condition of psoriasis which would be confused with ringworm lacks the vesicular border, has abundant silvery scales and is more chronic in character. This ringed form of psoriasis may be confused with pityriasis rosea, but the border is more indurated, the scales larger and silvery and more abundant, and the center of the ring a normal skin, and not the wrinkled yellowish center of pityriasis rosea.

Seborrhoic eczema is a mildly inflammatory scaling disease, primarily having its origin from seborrhoea of the scalp. It presents itself along the hair border of the forehead, or behind the ears, upon the chest, or on the back between the scapula, in the form of solid patches or in broken ring-shaped or gyrate lesions, which are covered with greasy, yellowish scales, mildly inflamed, and the border distinctly marked.

This condition must be differentiated from psoriasis. Both are found along the hair border of the forehead and neck. The chest and back are favorite locations for seborrhoea, not so diagnostic of psoriasis. Seborrhoea has the yellowish scale instead of the silvery, dry scale of psoriasis-finally, the general seborrhoea of the scalp, which is almost invariably present, and the starting point of seborrhoeal eczema. Ringworm and pity

riasis rosea must be considered in observing seborrhoeal eczema, but the vesicular border of one and the yellowish, wrinkled center of the other shows clearly what you have to deal with.

There is in the tertiary period of syphilis the tubercular syphilid which simulates a ring formation, but is irregular in outline; the ring is made up of several closely grouped tubercles, the surface of which is smooth and glistening, or covered with thin scales, the color of a brownish red or coppery, and decidedly indurated around the tubercles; the older tubercles disappear, new ones forming on the outer edge. Thus the circle increases in size, but irregularly so; on absorption of the tubercle, there is left a staining of the skin, and if the tubercle ulcerates, the typical smooth atrophic scar is found after healing. This syphiloderm is slow of development and very chronic in character. Its favorite location is the face about the nose and mouth, but it is often seen upon the trunk and limbs, usually only one or two areas being affected.

The tubercular syphiloderm must be differentiated from lupus vulgaris; the common site for lupus is the face, and when occurring upon other portions of the body, is usually on the face also; the syphiloderm occurs upon any part of the body independently of the face, and as it is a late manifestation of the disease, hence would be seen in middle or late life. Lupus, on the other hand, starts in childhood or early adult life, rarely beginning after thirty years of age. The color of the syphilid is a dark red, while in lupus it is spoken of as the apple jelly color. The syphilid is more rapid in its growth, and the crescentic or circinate groups are characteristic of that disease, and in lupus uncommon. If there has been ulceration and healing, the cicatrix of lupus is thick and tough, while of syphilis the thin papery scar tissue is characteristic.

Psoriasis may possibly be confused with the tubercular syphilid, but the silvery scales, more rapid development and brighter color usually makes it quite distinct.

Dermatitis factitia denotes an eruption or lesion artificially produced, by the application of some irritant for the purpose of gaining sympathy, or malingering. The lesions are of any shape,