Vesicular Syphilid (varicelliform syphilid) – This is a rare form occurring in the secondary period. Its actual existence is frequently questioned because all syphilitic vesiculation is transitory and invariably becomes pustular in a short time. It may occur in one of several forms. Thus, the lesions may be minute, disseminated or grouped like eczema; larger, irregularly scattered similar to varicella; or they may occur in ill-defined, herpetic groups (herpetiform syphilid). The vesicles are usually dusky-red with a solid papular base, soon become seropurulent or purulent and, drying, leave small papules which disappear and give way to dark stains of some duration. The diagnosis of this form is based on other secondary eruptions usually present.
Pustular Syphilid – This variety is less common than the macular and papular syphilids but important from their variety, size, number, mode of evolution, time of appearance and in their resemblance to similar non-specific lesions. They vary in size from a pin-point to a dime, are round or oval, surrounded by a coppery zone, may be primary or follow papules or vesicles, may be generalized or limited to certain regions, superficial, leaving no trace behind, or deep with ulceration and scarring. The crusts which form from the small pustules are greenish-brown in color and beneath there is little or no suppuration; the crusts of the larger lesions are greenish-black and cover well-marked ulcers, secreting thick, dark yellow pus. The pustular syphilids commonly appear as secondary manifestations but they may be prolonged into a recur in the tertiary period. Their early occurrence may be indicative of a severe type of the disease or some condition of the patient favoring suppuration. Pustular syphilids may be divided into small acuminated, large acuminated, small flat and large flat syphilids.
The small acuminated or miliary pustular syphilid is an infrequent form, often the evidence of syphilids in a filthy skin. It usually appears within the first six or eight months of the disease and while its onset is slow, it runs an acute course generally without an increase in size or coalescence of the lesions. The lesions are connected with the hair-follicles, being minute pin-head- to millet- seed-sized pustules upon a dull-red papular base. They have a tendency to be profusely generalized, to group in clusters and favor the arms, chest, thighs and back. Crusts soon form which, falling off, leave a fringe-like exfoliation about the base known as the “collaret”. This form is so characteristic that a mistake in diagnosis can hardly be made.
The large acuminated pustular syphilid (acneiform syphilid; varioliform syphilid) occurs in a more or less generalized eruption, usually within the first eight months of the disease and consists of pea-sized or larger, grouped or disseminated, well-rounded, somewhat distended pustules. The eruption prefers the scalp, face and extremities, runs a rapid course and somewhat resembles the lesions of acne and variola. When the crusts form, superficial ulceration may take place underneath and scarring will naturally ensue. Although the duration of this syphilid is from eight to ten weeks, it may be prolonged for months by successive crops.
The diagnosis of this syphilid must be made from the following: Acne vulgaris appears at or about puberty, is limited to the face, neck and shoulders, shows no evidence of constitutional involvement, presents comedones and some follicular abscesses whose contents can be pressed out. Iodid and bromid eruptions will give a history of the use of these drugs or their compounds with the absence of constitutional and other signs of syphilis. The eruption of variola is preceded by pronounced fever and prostration for two or three days before its appearance. Its papules are shotty, its vesicles much firmer than those of of syphilis and its evolution from papules to crusts much more rapid.
Fig. 158 – Large accuminated pustular syphilid (acneiform syphilid); the remainder of the eruption was papulopustular in character.
The small flat pustular syphilid (impetigiform syphilid) is a common form of pustular eruption occurring during the first year after infection and is characterized by irregularly grouped, discrete, flat, pea-to small-finger-nail- sized pustules. While they may be generalized, they show a preference for the nose, mouth, beard, scalp and genitals. when the lesions are abundant, there is a tendency to coalesce. This form is often associated with macular and papular eruptions elsewhere. Crusting may be profuse (pustulocrustaceous syphilid), may occur early, being of a yellow, greenish or brownish hue, and deep or superficial ulceration may take place beneath the crusts. In neglected or debilitated subjects, this syphilid may progress superficially at the periphery while repair goes on in other parts of the patch (serpiginous syphilid). the course and duration of this form is nearly always chronic.
Fig. 159 – Pustulocrustaceous syphilid.
The diagnosis of this syphilid may be made from pustular eczema and impetigo contagioso. The former invariably itches, does not ulcerate and lacks all of the typical symptoms of syphilis, while the latter usually occurs on the face or hands, is superficial, mild in character, without ulceration and runs a short, acute course.
The large flat pustular syphilid (ecthymiform syphilid) is a type of pustular eruption which occurs in superficial and deep forms. The marked resemblance to non-specific ecthyma. It is found most abundantly on the legs but may be distributed about the neck, buttocks, inguinal regions and on the trunk. The pustules are small and conical at first, but increase by peripheral extension until they become finger-nail-sized or larger and progressively dry into yellowish-brown or brown crusts. As the crusts grow in size with the base of the pustule, they become flat and sometimes depressed in the center. Beneath the crust, superficial ulceration takes place, so that when the crust is thrown off, there remains a red and slightly papillated surface which may become recrusted or remain scaly until the reparative process is completed. However, a dark-red or ham-colored, slightly infiltrated areola may take a long time to fade.
Fig. 160 – Serpiginous syphilid.
The deep variety of the large flat pustular syphilid is usually indicative of precocious or malignant syphilis and is attended with marked cachexia. It may be generally distributed or limited to the face, scalp, neck or flexures of the extremities. It is rarer than the superficial form. The lesions are the same size as the superficial variety and are flattened with uneven surfaces, but the ulceration is distinct. Crusting is more bulky, being reddish-brown, black or green in color and if heaped up or stratified (rupia), may present extremely noticeable features. Ulceration of a deep punched-out character may be the main point (pustuloulcerative syphilid).
The diagnosis of this syphilid is seldom difficult. Non-specific ecthyma may be excluded by the absence of a bright red inflammatory areola and pruritic sensations, presence of more extensive ulceration, darker and thicker crusts, greater variation in the size of the lesions and other evidences of syphilis. Ecthyma cachectica with a livid areola can be distinguished from the deep ecthymaform syphilid, in the absence of other signs of syphilis, by their superficial though perhaps more extensive character, more distinct inflammatory type and wider areola. Varicose ulcers may be mistaken for the deep variety but attention to the history of development, presence of varicosis, pains, and an absence of other evidences of syphilis will help to differentiate. The ulcerations sometimes found in chronic pediculosis corporis may be known by the presence of blood crusts due to the bites of the insects, as well as by the discovery of the latter in the seams of the underclothing.
Bullous Syphilid (pemphigoid syphilid; pemphigus syphiliticus). – The occurrence of this syphilid in acquired syphilis is very rare. This fact coupled with its ephemeral character, gives it an uncertain place in the classification of the syphilids. It is usually present as discrete, disseminated, round or oval, pea- to walnut-sized bullae; at first filled with cloudy serum which is soon transformed into pus. The lesions are surrounded by a deep-red areola and the pus dries into adherent greenish-black crusts with underlying ulceration. The process is similar to the rupial development of the large syphilitic pustules. While the eruption may be generalized, it shows a marked preference for the lower extremities, soles, palms, and forearms. A diagnosis of this syphilid may be made by its characteristic bullae, crusts and ulcers and the presence of concomitant symptoms of syphilis.
Tubercular Syphilid (nodular syphilid) – This lesion occupies anatomically an intermediate position between the large papule and the gumma but, unlike the former, it involves the whole thickness of the skin, and does not penetrate the subcutaneous tissue like the gumma. It may develop within the first year but is more commonly seen between the fourth and tenth years, and even later. Hence, like the gumma, it is a part of the tertiary period which may be termed the unnecessary, uncertain and chronic stage of syphilis. The eruption is more copious and generalized the earlier it appears, but when it occurs as a late manifestation, it is often localized and scanty.
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