Fig. 153 – Papulosquamous syphilid of generalized distribution.
Papulosquamous syphilids of the palms and soles (palmar and plantar syphilid) are so unlike other papular syphilids, owing to the structural peculiarities of these parts, as to need a separate description. If they develop in the first year they form a part of the general syphilitic eruption and are easily recognized but, if as usual they appear in the second year, they are most persistent, recur for years and are apt to be difficult to recognize.
On the palm the lesions appear first on the central part, as a slightly colored to a coppery-red spot, pea to cherry in size, covered by firm translucent, scarcely elevated epidermis. They are barely perceptible to the touch at the early stage but when the epidermis becomes thickened, opaque and gradually raised, it splits up into lamellae or is thrown off in one mass, leaving a reddish, round or angular spot bordered by undermined skin. This lesion by serpiginous extension or concentric growth may extend to the border of the palm, creeping up the side of the hand into the interdigital spaces and finally involve the whole palm. The papules may remain discrete but are disposed to coalesce and form patches which tend to heal in the center and extend peripherally by the formation of fresh papules. Fissures may form when the natural lines of the palm are involved and become so tender that the habitual use of the hands or their exposure to ordinary irritations becomes very painful.
Fig. 154 – Annular syphilid presenting figurate and gyrate formations by the coalescence of lesions (courtesy of Dr. Howard Fox)
When the sole is affected, the lesions present the same features but their course is somewhat modified by the constant protection given to the feet. However fissures on the feet may be deeper, corresponding to the thicker epidermis and become sometimes the seat of an obstinate ulceration. In the secondary period palmar plantar syphilids are likely to be symmetrical; in the later or advanced stages they may affect only one palm or sole and are probably often excited by some local irritation.
Diagnosis of the papulosquamous syphilid of the secondary period need only be made from psoriasis which favors the extensor aspects of the body, particularly in its early evolution, the elbows and knees, and the scalp. Psoriasis lesions are seldom uniform in size, are nearly or quite covered with abundant, pearly, adherent scales which, if forcibly removed, leave red and bleeding points.
Fig. 155 – Moist papular syphilid, condylomata, showing cauliflower-like patch, which occupies the entire perineum, and the resulting edema of the vulva.
On the palms and soles, the late papulosquamous syphilid may be easily mistaken for psoriasis or eczema. Psoriasis rarely invades these parts alone and shows no tendency, like the syphilid, to begin in the center of the palm. Squamous eczema of the palm almost invariably begins between or at the roots of the fingers, on the wrist or dorsal surface and thence spreads to the palms. It pursues a slow, more even course, the infiltration merging usually at the periphery into a hyperemic redness of the adjacent skin. It is attended with itching and often presents or gives a history of moisture, discharge and crusting. Dermatitis seborrhoica is commonly associated with other seborrheic lesions on its more usual situations, as the scalp, eyebrows, nasolabial fold, bearded region, interscapular and sternal regions; it is less likely to form segmental, crescentic and serpiginous shapes than the syphilid; and it does not present the distinct infiltration characteristic of the syphilid.
The moist papular syphilid (mucous patch, condylomata lata) is a modification of the papular form due to its location on warm, moist and often unclean surfaces of the skin, usually at or near such mucous out-lets as the anus or vulva or under the anus or vulva or under the breasts, about the genitals, in the inguinal and axillary regions or between the toes. It may be the only outward evidence of the disease, especially in women, is a very contagious form and a common source of infection. Rarely, moist papules originate from an erythematous or eczematous surface without preceding papular formation but ordinarily they arise from papules and may increase to a half inch or more in diameter. The epithelial covering becomes transformed by heat and moisture into a grayish membrane which separates oris accidentally removed, leaving an eroded, moistened and reddened surface.
The further course of the moist papule is influenced by local irritation, friction and other influences incident to location and habits, as well as the treatment employed. It may rapidly disappear under proper care or, if left to itself, may take on a diphtheroid covering or become crusted with dried secretions, followed by ulceration, or it may become depressed and give off an offensive secretion. Again, it may take on a papillary growth, especially about the arms and genitals, and become elevated from 1/10 to 1/5 of an inch above the surface (condylomata lata). These vegetating lesions may coalesce, forming irregular, cauli-flower-like patches, furrowed or fissured and yielding a brownish and foul secretion (vegetating syphilid). Moist papules are usually seen in the secondary period but they may appear later, even in the later tertiary stage. In all cases, they tend to persist and relapse for weeks and months, continuing indefinitely if untreated and, unlike other syphilitic eruptions, they may itch if exposed to friction and pressure.
Fig. 156 – Vegetating syphilid of the axilla.
Fig. 157 – Vegetating syphilid of the genitocrural region.
The diagnosis of moist papules and condylomata is rarely attended with difficulty. Their situation in certain regions, mode of development and form, together with ther lesions and concomitant symptoms of syphilis make their nature painly apparent in most cases. Non-syphilitic venereal vegetations (verruca acuminata) usually overlap their base and are distinctly branched or pedunculated. The syphilitic vegetations are as broad at their bases as on their outer surfaces. Rarely when subject to pressure, the non-syphilitic papillary growths may present a closer resemblance to the syphilitic, and the associated symptoms and history of the case will be needed to establish a positive diagnosis. At the margin of the anus, a condyloma may be mistaken for simple anal fissure, but the former has more rounded and fuller edges and is often covered by a grayish film or pellicle.
A syphilitic lesion which occurs on a mucous surface is known as a mucous patch and is looked upon as a flattened, abraded papule whose peculiar form is influenced by its location. Patches of diffused but well-defined erythema commonly appear upon some of the mucous outlets of the body as early as the second month after infection but, unless they give rise to soreness or are subjected to some form of irritation, they may be easily overlooked. there are usually present two or three of these patches, of a grayish-white color with a pinkish-red periphery. After the epithelia are cast off, the spots will appear smooth, eroded or superficially ulcerated. They may be found on any part of the mucous membrane of the mouth and throat and on the lips. They also occur in the nose, on the mucous surfaces of the genitals in both sexes and less commonly in the larynx. Mucus patches on the tip and sides of the tongue may be annoying and painful, especially if irritated, and combined with the effects of hyperemia the dorsum and sides of the tongue may become irregularly fissured. More or less epithelial hyperplasia may also occur in plaques which have been variously termed leukoplakia, psoriasis and ichthyosis of the tongue. These lesions are obstinate in their course. Mucous patches vary in appearance with their location, the use or abuse to which the parts are subject, and the vital resistance of the tissues.
Tertiary ulcerations are most likely to attack the gums, soft and hard palate. On the gums the process is apt to assume a serpiginous form, gradually extending along the line of the teeth. On the soft palate deep ulcers may develop and cause an irregular destruction of tissue if not arrested by timely treatment. When the hard palate is invaded the bone may became necrosed. The power of replacement and repair in the tissues under medication, however, even when a large amount of tissue has been eaten away but perforation has not occurred, is remarkable.
Syphilitic erythema and mucous patches are not generally in themselves sufficiently characteristic to be a diagnostic except in association with other evidences of the disease. A bluish-red color of the erythema and a whiter line of sodden epithelium at the border of a mucous patch are suspicious signs of their syphilitic nature. Rarely the origin of a mucous patch or ulcer from a papular formation can be determined and is then in favor of syphilis. The lesions of the latter are also free from the sensitiveness and signs of inflammation at the border of the non-specific mucous sore unless made so by irritation; but mucous plaques often simulate objectively the common canker sores or aphthous ulcers so closely as to make differentiation impossible without the presence of concomitant symptoms, which fortunately are nearly always present or soon appear. Owing to the contagiousness of mucous patches, the same precautions should be taken in doubtful cases as in unmistakable syphilis until the latter can be excluded.
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