Definition. An inflammatory disease of the skin, consisting of large, discrete, flat pustules on an indurated base surrounded by a pronounced hyperemic areola.
Symptoms. Ecthyma seldom represents a distinct disease but usually describes a clinical type of cutaneous inflammation. The eruption begins as reddish or yellowish, pea-sized or slightly smaller pustules which rapidly enlarge often reaching the size of a quarter-dollar. They are located on a distinctly inflammatory base and surrounded by an area of congestion, the color of which gradually disappears into the surrounding skin. The intensity of the process directly under the center of the pustule may result in superficial distruction of tissue and the formation of a small, shallow, circular, pit-like ulcer. If the crust is removed, the surface will be found bathed with a purulent often sanious substance which, if carefully wiped away, will show reddish or grayish granulations. The quantity of the discharge will determine the size of the resulting crusts which are usually bulky, rough, firm, brownish or blackish, although occasionally lighter. Individual lesions will pursue an acute course, covering ten to twenty days, and only a few may appear. In other cases, pustules continue to arise for a few days and the disease may be prolonged for months. Pigmentations often follow the pustules and rarely may be permanent. In colored people the opposite condition of partial or complete absence of pigmentation has been observed to follow the disease. While the eruption is usually limited to the lower extremities in adults of either sex, it may occur upon any portion of the body or at any age. Occasionally, there are slight prodromata which may persist during the early stages of the disease. Heat or soreness may be felt but itching is very slight and only noticed during the healing process.
Etiology and Pathology. Cachexia, debility, poor food and unsanitary surroundings are the underlying factors, while slight traumatisms such as the bites of insects or excoriations, made in an effort to relieve itching from any source, are the acute influences. The essential cause is probably the streptococcus acting on tissues deprived for the time being of their normal resisting power and naturally such tissues would be more readily affected if scratching wee to take place.
The typical pustule of ecthyma does not present any difference from the similar lesion of impetigo or eczema except that it is deeper and shows a lower grade of inflammation. It involves the entire thickness of the epidermis and the papillary layer of the corium and occasionally invades the deeper parts of the corium, so that scars result.
Diagnosis. Ecthyma may be confused with the ecthymatous form of lesions of any cutaneous disease. Impetigo contagiosa is primarily vesicular, its pustules are always superficial without an inflammatory areola, it is more common on the face or hands of children and is distinctly contagious. The pustules of eczema are small, round or acuminate, usually grouped, often coalescent, indefinitely localized, lacking an inflammatory areola, and are more common in children. The pustular syphilids are less inflammatory and do not possess the extensive hard and bright red base of ecthyma. It is also more sluggish and slower in course and its ulceration is larger, deeper and more sharply defined, while its greater secretion causes conical or oyster-shell-like crusts.
Prognosis and Treatment. Ecthyma always responds to proper treatment within a short time. Predisposing and contributing factors should be removed as far as possible. Suitable diet and healthful surroundings, including a daily cleansing bath, are advised. The crusts should be removed with vaseline or any simple fat or oil, and then a plain soap, alkaline or saline bath prescribed. In most cases, a mild antiseptic will be found of service, such as boric acid (20 to 40 grains), resorcin (15 to 30 grains), calomel (5 to 15 grains), betanaphthol (10 to 20 grains), or ichtyol (20 to 40 grains) in an ounce of fresh lard or cold cream. Adrenalin chlorid (1:1000 aqueous solution) or equal parts of alchohol and glycerin, applied twice daily, may be used for mild cases. In suggesting internal symptomatic medication, I must again urge that the whole symptoms picture be studied and not the cutaneous manifestations alone. The following are suggested: Argentum nit., Kali bich., Mercurius, Mercurius cor., Mercurius biniod., Mercurius protoiod, Murex acid, Phosphorus, Psorinum, Secale, Sl., Sul., and Thuja.