In some instances there is a tendency toward the maculopapular type and although this may embrace the entire eruption, it is quite common to find a few of these lesions on the palms and soles and about the genitals and anus, even when they are not found elsewhere. This form may have a tendency to develop into circles or parts of circles. It is apt to be preceded by more severe constitutional symptoms, is more rapid in its invasion, more persistent in its course and exhibits more desquamation than the purely macular type.
Fig. 151 – Macular syphilid with a tendency toward maculopapular formation.
A diagnosis may be based upon the presence of remains of the initial lesion, on constitutional symptoms and the exemption of the exposed surfaces. The more frequent occurrence of the eruptive fevers in children and the syphilids in adults, the different onset, and the absence of the catarrhal symptoms of rubeola or the throat symptoms and strawberry tongue of scarlatina will serve to exclude the two last mentioned diseases. Drug erythemas from copaiba, cubebs, mercury, belladonna, coal-tar products, etc.,. disappear after the causal drug is suspended, leaving no trace. They are much more vivid in color, often of a scarlet red, itch and are of short duration. Tinea circinata presents one or few lesions, lack of symmetry, great scaliness, usually occurs in children and the ringworm fungus may be discovered by the microscope. Tinea versicolor may resemble the macular syphilid in color and location but its lesions can be rubbed or scraped away readily and its causal fungus can be found by the microscope. Its usual history of long duration, together with an absence of any syphilitic concomitants, should be conclusive. Pityriasis rosea has a like distribution and duration as the macular syphilid but its lesions are larger, more scaly, slightly itchy and do not leave stains.
Papular Syphilid – The papule is the most important and may be the earliest manifestation of cutaneous syphilis, either alone or combined with the macule or it may follow the latter and constitute the chief recurring eruption of the entire secondary period. If it persists into the third stage, it may merge into the tubercular syphilid by an intermediate papulotubercular form. Commonly, papules do not occur before the fourth month or recur before the end of the second year. They are apt to be disseminated in the earlier stage but later tend to form circular groups and show a marked preference for certain regions. Thus, on the scalp they become crusted; on the general surface, scaly; at the angles or in the folds of the skin, present fissures; on the palms and soles they are persistent and simulate psoriasis; but the genital and anal regions they often become moist, extensive and vegetating. Four forms are commonly described, the miliary, lenticular, squamous and moist varieties.
The miliary papular syphilid (syphilitic lichen) is not so common as the flat papular form and is follicular in type, involving the hair-follicles. Smaller and larger varieties are described, varying in size from a pin-head up to double or treble that size. The smaller variety is quite rare, consists of minute, bright-red conical elevations which soon fade to a fawn or coppery hue and leave a brownish-red stain. This eruption, occurring in the first or secondary years of the disease, is generally distributed in groups of from four or five up to forty lesions, commonly situated about the sternal region, neck, face and back of the shoulders. The eruption often appears rapidly, is persistent and new lesions may continue to appear for several months. Sometimes a minute vesicle forms at the apex of the papule (miliary papulovesicular syphilid) which dries in a few days, leaving a superficial crust. In other cases the process may be intense enough to form a minute pustule (miliary papulopustular syphilid) which results in the formation of a minute crust. The larger miliary syphilid is more common than the smaller variety and is usually seen on the back, neck, upper part of the chest and extensor surfaces of the extremities. The lesions are larger, more round, fewer and occur in less regular groups than in the smaller form. Secondary exfoliation may take place leaving a fringe of whitish scales around the papules.
Diagnosis of this form may need to be made from lichen scrofulosus but the latter occurs in childhood, its eruption is nearly always confined to the trunk and is associated with other evidences of scrofula. Rarely, there may be some resemblance to keratosis pilaris, psoriasis punctata, lichen ruber, lichen planus or papular eczema.
The lenticular papular syphilid (flat or large papular syphilid) is the most common, extensive and persistent eruption of the secondary period. It may occur before the macular form has disappeared or follow closely and, in successive crops, continues to recur during the first and second years, or rarely in the tertiary period. The lesions are at first pin-head to bean-sized but gradually increase until they reach the diameter of a large coin. They are round, flatly convex, well-defined, only slightly elevated and, as they develop, the color changes from a bright red to a shining coppery hue. The epidermic covering desquamates, leaving the same fringe-like scaling about the base as is seen in some of the large miliary lesions. With each succeeding exfoliation, the papules become flatter and gradually disappear, leaving grayish or brownish persistent stains. In the early stage the lesions are often numerous and widely distributed, but are not usually grouped, though they may be closely situated about the genitals, forehead and mouth. Occasionally when numerous or near together, they may coalesce to form broad patches. They show a predilection for the forehead (constituting along the margin of the hair a form of corona veneris), lower part of the face, back of the neck and shoulders, flexor aspects of the elbows and knees, genitoanal regions and the palms. Fresh crops may appear before the preceding lesions have resolved, and sometimes papules may be seen in all stages of evolution and involution. With each successive crop the lesions diminish in number and increase in size until the latter outbreaks may consist of only a few grouped papules within limited regions.
The diagnosis of this characteristic syphilid should be readily made although some of the larger lesions may resemble the flat maculotubercles of leprosy, but the different origin, development, concomitants and behavior under treatment should serve to differentiate the syphilid.
The papulosquamous syphilid (squamous syphilid) is in reality a common modification of the large papular form showing distinct scaly tendencies. A papular syphilid of any type may exhibit a scaly formation at any point in its development or decline. the mildest form is rare, presenting a furfuraceous desquamation of rounded, slightly elevated patches (syphilitic pityriasis). The commoner and more pronounced form will present dry, dirty, grayish and friable scales (syphilitic psoriasis). Rarely, the scales may be dense, horny or adhesive. A form, frequently observed in the larger and deeper papules of the secondary period, appears in crops, tends to persist for months but finally resolves in the same manner as the non-scaly papule and leaves the same kind of pigmentation. The favorite sites for the more marked scaly papules are along the eyebrows, at the margin of the hair, about the mouth, nose and chin, on the palms and soles, and the flexor aspects of the limbs and trunk. No part of the surface, however, is exempt from this syphilid. The lesions are usually discrete but occasionally coalesce on the lower part of the face and in the neighborhood of the genitals.
Fig. 152 – Lenticular or flat papular syphilid, showing a tendency in some lesions to become pustular (ecthymiform).
Another modification is characterized by progressive peripheral enlargement until it reaches the size of a coin (nummular syphilid). If these lesions become scaly they often leave a fringe at the border and frequently present well-defined and elevated margins which, together with a slight depression in the central portion, give an umbilicated appearance. If the process of involution is completed in the central portion, a hard scaly ring of infiltration bounds the atrophic and depressed center (annular or circinate syphilid). If these ring-shaped lesions meet and fuse, figurate or gyrate shaped patches often covered with thick, whitish scales will strongly resemble the lesions of psoriasis. The circinate syphilid (orbicular syphilid) is occasionally formed by a linear mergence of smaller papules arranged in circles or segments of a circle. The union of such patches will form variously festooned or figured lesions. A large papule may be surrounded by a row of smaller papules known as the stellate syphilid. In fact the mingling and union of the primary and transitional forms of the papular and papulosquamous syphilid are as remarkable as they are rare. To some extent the co-existence of seborrhea may be responsible for the more common circinate syphilids. Their location on the hairy parts of the face, about the mouth, alae of the nose and genitals bears this out. Occasionally, papillary hypertrophy producing warty vegetations may be noted in these localities.
American homeopath, he directed several hospitals in New York.
Professor of dermatology.
Served as Lieut. Colonel during the 1st World War.
See his book online: American homeopathy in the world war