10. PUSTULAR DISEASES – IMPETIGO, ECTHYMA, FURUNCULUS, CARBUNCLE, MALIGNANT PUSTULE


Under the term pustular diseases, thus defined, are usually comprised impetigo, ecthyma, and furuncular affections, -the later term including furunculus, or boil; anthrax or carbuncle; and pustular maligna, or malignant boil….


General Remarks.

In many very different diseases of the skin pus is present, and if the term pustular were used in its widest sense a large number of diseases would have to be included under it; for instance, acne; favus; scabies; pemphigus; variola; farcy; varicella; and so on. But in the diseases just named the presence of pus is often not a primary or even essential condition, and its importance is thrown into the shade by the prominence of other features. In those affections which may more strictly be called pustular, the suppuration is the leading and the primary condition, the particular morbid condition the practitioner has to recognize and to remedy. Now under the term pustular diseases, thus defined, are usually comprised impetigo, ecthyma, and furuncular affections, -the later term including furunculus, or boil; anthrax or carbuncle; and pustular maligna, or malignant boil. Delhi boil would come under this division, but, owing to its rarity in this country, will not be treated of.

Impetigo Contagiosa.

This disease is characterized by the appearance of mild pyrexial symptoms, followed in two or three days by the appearance of one or more small vesicles. They slowly enlarge, but soon dry into thin, light-yellow crusts, or scabs. These lesions may be few or numerous, and successive outbreaks may prolong the affection for several months. The affection is unquestionably contagious, and when it once appears upon an individual, other members of the family, either children or adults, may contract it. In not a few instances the eruption has appeared within a couple of weeks or so after vaccination. If the crust, which has the appearance of being “stuck on”, is removed, a slightly reddened but not eroded surface is revealed, from which but little or no moisture is exuded.

The disease is seen amongst children of the lower orders especially, probably in great measure because the disease spreads by contagion freely amongst them. It occurs also in those who have all the advantages of social position and good hygiene.

The eruption in the disease in the majority of cases appears first of all on the face, sometimes on the top or back of the head, and in the form of “little watery heads” (vesicles) that enlarge into flat bullae if they are not injured by scratching. Sometimes the hands are attacked at the outset, and look as if burnt here and there; phlyctenae may also arise out of and around the remnants of vaccinia, or about cuts or bruises. The disease then extends to other parts, the back of the neck, buttocks, feet, etc. The vesicles are always isolate. In five or six days the bullae may reach the size of a sixpence or shilling unless ruptured, and are then flat and depressed in the centre, their contents becoming turbid. Usually the vesico-pustule is the size of a large split-pea or there -abouts. The secretion consists of lymph-like fluid, granular cells, and subsequently pus-cells.

Scabs commence to form a few days after the appearance of the disease. They are characteristics of the disease, varying in size from that of a split pea to a shilling; they are flat, straw-colored, dry, and granular-looking, and appear as if “stuck on” to the part; they present as a rule, no inflammatory areola around their circumferences, though this is the case in severe instances of the disease. If removed, little sores are observed beneath, more or less filled in by gummy-like secretion, or a little pellet of plastic lymph, and when the scabs fall off there is an erythematous base left behind, the hue of which gradually fades away. The disease may be spread from spot to spot by direct inoculation with its secretion in the act of scratching. The crop of vesicles is to some extent successive, though the majority of the places “come out” in the first week or so.

In some instances the disease resembles vaccinia very slowly. There is always a uniformity about it; it always commences by vesicles; there are no papules present at the height of the disease. On the face the spots may be confluent, and then the disease resembles eczema impetiginodes; but the patches are made up of the elements described above. On the scalp the disease consists of circular, mostly isolated, flat-scabbed spots about the top and back of the head, the hair being matted by the crusts. Usually, no pediculi and no offensive smell are present. Now it is very important to note that an eczema may be readily excited in fair children by scratching or the irritation of the discharge, in connection with impetigo contagiosa-and then the characteristic features of the latter disease are masked. The result of neglecting to attend to this point is that the practitioner regards the disease present as solely and entirely an eczema. The error, too is a very common one.

The mucous membranes of the eye and the nose are sometimes implicated; then inflammation is produced by the development of little ulcers, that take their origin in the formation apparently of vesico-pustules, identical with those seen on the surface of the skin. The eye may look as though affected by slight purulent ophthalmia, but soon recovers itself.

The disease may complicate eczema, scabies, and other affections, and vice versa.

Diagnostic features are-its apparently epidemic character in many cases; the antecedent febrile condition; its attacking children; the origin from isolated vesicles, which tend to enlarge into blebs and to become pustular, the bleb having a depressed centre, and, it may be, a well-defined, slightly raised, rounded edge; the isolation of the spots; the uniform character of the eruption, and its general and scattered condition; its frequent seat and commencement about the face or head; the circular, flat, granular, yellow crusts looking as if stuck on; its contagious nature and inoculability; its frequent following in the wake of vaccination; the absence of pain, and especially troublesome itching at night.

Contagious impetigo may be confounded with eczema; but the history is altogether different, and the isolation, the small scabbed patch, the characters of the crusts, and the facility of cure at once distinguish it. Impetigo sparsa does not arise from a vesiculation, but is primarily pustular, made up of aggregated pustules; it does not phlyctenoid; it is not contagious nor inoculable; it does not run a definite course; it is not confined to the young; it is not so amenable to treatment.

Pemphigus.

In this disease the blebs are larger, more persistent, oval, and distended; the contents are watery and acid. Pemphigus is non-contagious; it does not occur especially on the face or the head; it is less inflammatory, and wants the characteristic scabs. Ecthyma.-This is primarily a pustular disease; it is seen also in adults; there are more induration and swelling, and a good deal of pain in connection with the formation of pustules; it is non-contagious; the scabs are heaped-up and dark. Pustular scabies.-This is the disease with which contagious impetigo is at times confounded. It must be remembered that the two diseases may coexist. In children both attack the buttocks frequently; both may exist about hands and feet; but the distinctions are really very clear.

In scabies there is no febrile condition; the eruption is multiform. If there be ecthymatous pustules, like impetigo contagiosa, they are covered by dark thick crusts; there are plenty of characteristic vesicles, with cuniculi and papules. If the impetigo contagiosa begins about the buttocks, it appears presently on the face or the head, or both. There is no irritation, nor are the effects of scratching visible about the body as in scabies; the bullous origin of the disease is distinct, and the scabs are characteristic. The hands are not specially affected in scabies in the child, but even impetigo contagiosa may attack the hands and feet markedly; still there is no multiform eruption, and there are no cuniculi in the latter.

When a correct diagnosis is made, the treatment is easy. The natural course of the disease is a short and definite one. The secretion is an active agent, by means of inoculation self- practiced by the patient in scratching, in transmitting the disease from one part to another. Therefore it is of first importance to destroy the activity of the pus, and to alter the behavior of the surface that secretes it. A very active agent in procuring this result is an ointment containing five grains of the ammonio-chloride of mercury, and apply it to surface beneath the scabs, which must be removed by poulticing or fomentation with warm water. A sulphur ointment is also beneficial. The patient must be well-nourished, and strict hygienic treatment adopted. Cleanliness is all-important.

The old-school rely principally upon the external applications.

The indications for the internal remedies are:

Antimon. crud-This is the principal internal remedy. Eruption forming thick, heavy yellow crusts, with burning; eruption about face; worse from bathing the parts; better in open air; chronic cases.

Arsen. alb.-Black pustules, filled with black blood and fetid pus; painful sensation on scalp and face, as from cutaneous ulceration; worse from cold and touch; better from warmth.

Baryta carb.-Especially old people; thick crusts behind the ears; fat dumpy children, with swollen lymphatics,; sore throat, with swelling of tonsils after the least cold; worse at night and when thinking of it; better in open air.

Calcarea carb.-During dentition; dry crusts; sweat of forehead, particularly in the evening; sensitiveness of the root of the hair.

Cicuta vir.-Impetigo sparsa; eruption on chin and lower part of face, forming thick yellow crusts; honey-comb-like crusts, which fall off and leave a bright-red smooth surface; painful eruption on scalp.

Clematis.-Psoric constitution; pimples on forehead, root and sides of nose; pustules about lips, tender to touch; large pustules about loins; eruption changes character during the changes of the moon; worse in bed, washing, and towards morning; feels exhausted on waking.

Conium.-Sero-purulent eruption in aged people, old hypochondriac maids; vertigo when turning over in bed, looking up; old weak, and feeble men; scrofulosis, with engorgement of lymphatics; eruption around mons veneris.

Croton tigl.-Pustular eruption upon an inflamed base, with itching and stinging pain upon septum nasi, plugging the nostril; eruption on abdomen; sore nipples of nursing women.

Euphorbium is indicated when there is an irritable skin, with swelling of the face and pea-sized yellow vesicles.

Graphites.-Scabby eruption, with excessive oozing;eruption around mouth and nose or the whiskers; hair falls out; corrosive blisters about extremities, toes, and fingers; dry skin; very sensitive to cold; cold hands and feet, with scanty menses; rhagades.

Hepar.-Eruption after mercurialism; sensitive to touch; tendency to ulceration; humid scabs and pustules upon the head, oozing a fetid substance; swollen cervical glands; cracks behind ears; hands cracked dry.

Iris vers.-Impetigo capitis, with gastric complaints, nausea, and vomiting.

Kali bichrom.-Dry eruption; pustules disappear without bursting. Stands next to Antim cr. as a remedy.

Kreasotum.-Painless pustular eruption all over body, especially on chin and cheeks; sticking pain, especially on points; sad and weeping; worse in open air.

Lycopodium.-After abuse of mercury; itching and suppurating eruption on head and face; full of deep cracks; abundant and fetid discharge; fetid and moist scabs behind ears; humid tinea capitis.

Mercurius.-Swelling and suppuration of glands; gastric derangement; moist scabs, with excoriation of the scalp and destruction of the hair; yellowish scabs on face, with fetid discharge; yellowish scabs, especially around mouth.

Mezereum.-Deep inflammatory redness of face; eruption fat and moist; ichor from scratched places excoriates other parts.

Nitric acid.-Eruption on head, pricking on being touched; pustular eruption on face, with large red margin and heavy scabs; mercurio-syphilis.

Rhus tox.-Small pustules on back base; greenish pus, with violent itching at night; humid eruption, with thick scabs on face and head, destroying the hair, with fetid smell; eruption on nose, extending to face.

Silicea.-Eruption resembling varicella; violent itching of scalp; moist scald head; growing pains; better warmth, worse from cold.

Sulphur.-Dry, thick, yellow scabs on scalp, with profuse discharge; great itching relieved by scratching; purulent eruption on elbows.

Tartar emet.-The remedy when the disease is exceedingly pustular.

Thuja.-Eruption all over the body; itching and shooting, especially at night; pustular eruption about the knee; better from gentle rubbing.

Viola tricolor.-Pustules and scabs upon face, with burning and itching, and discharging fetid pus; sensation as of tension of the integument of face; urine smells like cat’s urine worse at night. Recent cases.

Ecthyma.

This disease is described as consisting of isolated phlyzacious pustules-namely, those which are “large, raised on a hard base, of a vivid red color, and succeeded by thick, hard, dark-colored scabs, beneath which there is ulceration.” The pustules are generally distinct round, and isolated; they are mostly general, but may be partial, and leave cicatrices behind. The shoulders, buttocks, and limbs are the parts usually attacked. There are two chief forms described-acute and chronic.

Acute general ecthyma is rare. The ordinary scattered ecthyma is practically always the result of the action of some irritant upon the skin, in an unhealthy or badly nourished subject; and so ecthymatous pustules frequently occur in connection with scabies and phthiriasis, and more rarely in pruri, or eczema, and other diseases.

Acute ecthyma commences with slight febrile disturbances, and occasionally sore throat; locally, there is first a sense of heat and burning, followed by the appearance of reddish raised points, with hard, indurated bases, and distinct vivid areolae; these points, which very size from that of pea to that of a shilling, quickly pustulate, and are often accompanied by acute, sharp pain. In two or three days the pustules give exit to discharge, which dries into hard, adherent, dirty, discolored scabs, covering over circular ulcerations; the crusts fall off in a week or so, leaving behind dark stains. The ecthymatous spots may be few or many; in the latter case a good deal of irritation is set up; the patient may be unable to sleep from pain and the glands and lymphatic vessels may become inflamed, small abscesses forming subsequently. The disease is generally protracted by successive crops of pustules or it may relapse into a chronic state. The limbs, shoulders, and trunk are chief seats of the disease.

Chronic ecthyma generally results from the action of some irritation, as in scabies, in connection with pediculi, and from scratching and badly nourished subjects. The ecthymatous pustules in the chronic disease are of similar character to those of acute ecthyma. They are painful, with hard, inflammatory bases and a small central collection of pus. When they occur on the limbs, especially the legs, in old people they are followed sometimes by troublesome ulcers.

In ecthyma the seat of disease appears to be the uppermost layer of the derma, not unlikely about the glands of the skin, the depth of surface involved being less than in furunculus, and there is no “core”, otherwise ecthyma would be well classed with boils. The tendency to ulceration and sloughing, the lividity of the inflammatory areola, the disturbance of the general system, all point to a cachectic condition.

Causes.-The predisposing causes are always such as lead to debility and an impoverished state of blood. They are, in infants, bad nursing, suckling by mothers much out of health, scabies, bad clothing, damp dwellings; in adults and others, over-work, fatigue, convalescence from acute diseases, bad food, privations, various occupations that induce irritation of the skin, as bricklaying, excesses of all kinds, debauchery, uncleanliness, night-watching, overcrowding in public institutions-work houses, jails, and such like. The immediate exciting causes are scabies, phthiriasis, the use of acrid medicinal applications, and scratching.

Prognosis is to be made according to the general condition of the patient. The ecthyma, per se, is of little gravity, save when it is accompanied by sloughing, as in old people; then it is grave. Diagnosis.-The distinct, large isolated pustules, with an inflamed areola and hard base, disturbed over the body, are very distinctive of the disease. It may be confounded with impetigo sparsa, but in this disease there are rather sero-pustules, which are very superficial; the discharge is viscid, yellowish; these are as dark scabs, no indurated, inflamed, and painful bases. Furunculus is deeper, it runs a slower course, and contains a central “slough” or “core”, as it is called. It is more circumscribed, and there is little scabbing.

Treatment.-Locally a good application is an ointment made by rubbing together an ounce of lard, and half a drachm or so of Friar`s balsam. The crusts may be removed after soakings with oil, and affected parts dressed with an ointment made by adding five to ten grains of white precipitate to the ounce of cosmoline. After the pustules burst, if the ulcers show but little tendency to heal, a weak carbolized wash may be used.

The patient should be well hygiened and given a good generous diet.

The appropriate internal remedy may be selected from the following:

Anacardium.-Hard, red pustules, itching worse after scratching; crossness and irritability with weakness of mind; sensation of a hoop around the affected part.

Antimon crud.-Pustules on the face in fat people; yellowish or brownish scabs on the face; desire for acids.

Arsen, alb.-Red or white pustules, with intense burning; painful black pustules, gnawing, burning, and itching; eruption on the scalp, forehead, around the eyes, cheeks, arms shoulders, and upper part of the chest, terminating in thick crusts, and leaving well-marked scars.

Aurum.-Pustules on the face, neck and chest, with irritability and melancholy.

Bellad.-Pustules surrounded by a whitish areola. Burning and itching with great sensibility to touch.

Caladium.-White pustules with red areolae, sore to the touch and itching; better from sleep in the day time.

Calcarea carb.-Heat, thirst and loss of appetite accompany the eruption. Scrofulous children and during dentition.

Cantharis.-Tendency to ulceration and gangrene, after or with the exanthemata; debility and emaciation.

Cicuta.-Burning suppurating eruption about face, with yellowish crusts.

Croton tigl.-Confluent pustules with oozing and burning; greyish-brown crusts on the abdomen; pustules with scarlet redness of the skin; itching followed by painful burning; pains relieved after sleep; intense itching, but cannot bear to scratch on account of the pain it causes.

Cyclamen.-Pustules on the feet and toes.

Hepar.-Great sensitiveness of the pustules to the slightest touch; redness or little pimples around the ulceration.

Kali bichr.-Pustules all over the body, in the early stage having a small brown scab on the top; pustules at the root of the nails spreading over the hands; pustules, with violent itching which dry without bursting, forming scabs which sting and burn; pustules resembling small-pox, with a hair in the middle, leaving after the scab comes off a small dry ulcer, which heals in about a fortnight, leaving a colorless depressed cicatrix; eruption more in hot weather. Light-haired children inclined to grow fat.

Kali hyd.-The eruption is profuse, over the body. Great desire for the open air. Catarrhal fever with violent thirst.

Kreasotum.-Large fat greasy pustules, with violent itching towards evening; sensation in the skin as from ulceration, especially on face and chin.

Lachesis.-Eruption more on the arms and left side; constitutional taint; feels worse after sleeping.

Mercurius.-Suppurating pustules, which either run together, discharging an acrid humor, or which remain sore, become hollow, afterwards raised and cicatrized; pustules bleed easily and are painful to the touch; itching and burning from the warmth of the bed; sweats easily without relief.

Nitric acid.-Feeling as of a splinter sticking into the pustules when touching them.

Petroleum.-Itching and burning pustules, with great weakness on exertion; great lassitude; worse in fresh air.

Piper nigrum.-Large pustules leaving marks on the face.

Rhus tox.-Pustules seated upon a red base; black pustules, forming hard scabs, with burning and itching; worse at night and in cold and stormy weather.

Secale corn.-Cachectic females, with rough skin; pustules on the arms and legs, with tendency to gangrene.

Silicea.-Pustules all over the body, especially on the back part of the head, sluggish, and do not suppurate or dessicate; sensitive to contact; burning and soreness after scratching; aversion to warm food; worse in cold. Scrofulous diathesis.

Sulphur.-Dry, thick, yellowish scabs all over the body, especially on the scalp; always attended with great itching; painful to touch; aversion to washing.

Tabacum.-Eruption most on neck and upper limbs; weariness, languor and debility; death-like paleness, nausea worse on least motion. Tartar emet.-Eruption over the whole body. Pustules are full, large, round, burning and painful with red areolae, soon drying up and leaving deep malignant ulcers. Pale, livid, blackish, depressed pustules filled with blood or bloody serum collapsing on bursting and changing to broad, deep ulcers.

Thuja.-Suppurating pustules, especially on lower extremities,; worse from touch; relieved by gentle rubbing.

Furuncle.

A furuncle, or common boil needs little in the way of description, the features being so familiar to all. Pathologically considered, it may be described as an acute and painful localized inflammation, differing, however, from a simple abscess by the fact that in the furuncle we find a central core of necrosed cutaneous and connective tissue, around which the inflammation is developed. Modern investigation leads us to the supposition that a micro-organism, having gained an entrance into one of the follicular openings, set up changes which result in the death of the tissue in the immediate vicinity. This necrosed tissue acts as a foreign body and excites inflammation, as would a thorn, and after a few days the hard, painful, red tubercle exhibits a drop of pus at its summit, which gradually increases until the entire lesion softens, and finally breaks, with exit of pus together with the core referred to.

The pus which is discharged from a furuncle appears to be capable of exciting new lesions of a similar nature, and crops of boils may follow each other in an extremely persistent and disagreeable manner.

Melford Eugene Douglass
M.E.Douglass, MD, was a Lecturer of Dermatology in the Southern Homeopathic Medical College of Baltimore. He was the author of - Skin Diseases: Their Description, Etiology, Diagnosis and Treatment; Repertory of Tongue Symptoms; Characteristics of the Homoeopathic Materia Medica.