Tuesday, September 2, 2008

Lupus Vulgaris (Synonyms: Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the Skin.)

Lupus Vulgaris (Synonyms: Lupus; Lupus Exedens; Lupus Vorax; Tuberculosis of the Skin.)

What do you understand by lupus vulgaris?

Lupus vulgaris is a cellular new growth, characterized by variously-sized, soft, reddish-brown, papular, tubercular and infiltrated patches, usually terminating in ulceration and scarring.

Upon what region is lupus vulgaris usually observed?

The face, especially the nose, but any part may be invaded. The area involved may be small or quite extensive, usually the former.

At what age is the disease noted?

In many cases it begins in childhood or early adult life, but as it is persistent and tends to relapse, it may be met with at any age.

Describe the earlier symptoms of lupus vulgaris.

The disease begins by the development of several or more pin-head to small pea-sized, deep-seated, brownish-red or yellowish tubercles, having their seat in the deeper part of the corium, and which are somewhat softer and looser in texture than normal tissue. As the disease progresses, variously-sized and shaped aggregations or patches result, covered with thin and imperfectly-formed epidermis.

What changes do the lupus tubercles or infiltrations undergo?

The lesions, having attained a certain size or development, may remain so for a time, but sooner or later retrogressive changes occur: the matured papules or tubercles, or infiltrated patches, slowly disappear by absorption, fatty degeneration, and exfoliation, leaving a yellowish or brownish pigmentation, usually with more or less atrophy or cicatricial-tissue formation—lupus exfoliativus; or disintegration and destruction result, terminating in ulceration—lupus exedens, lupus exulcerans. This latter is the more usual course.

Describe the clinical appearances and behavior of the lupus ulcerations.

They are rounded, shallow excavations, with soft and reddish borders. In exceptional instances exuberant granulations appear— lupus hypertrophicus; or papillary outgrowths are noted—lupus verrucosus. The ulcerations secrete a variable amount of pus, usually slight in quantity, which leads to more or less crust formation; later, however, cicatricial tissue, generally of a firm and fibrous character, results.

In what manner does the disease spread?

The patches spread by the appearance of new tubercles, or infiltrations at the peripheral portion. New islets and areas of disease may continue to make their appearance from time to time, usually upon contiguous parts.

Are the mucous membranes of the mouth, throat and larynx ever involved?

In some instances, and either primarily or secondarily.

Is the bone tissue ever involved in lupus vulgaris?

No.

What course does lupus vulgaris pursue?

It is slowly but, as a rule, steadily progressive. Several years or more may elapse before the area of disease is conspicuous.

What is the cause of lupus vulgaris?

It is now known to be due to the invasion of the cutaneous structures by the tubercle bacillus; in short, a tuberculosis of the skin. It is not infrequently observed in the strumous and debilitated. It is entirely independent of syphilis.

What is the pathology of lupus vulgaris?

According to recent investigations, the infiltrations of lupus are due chiefly to cell-proliferation and outgrowth from the protoplasmic walls and adventitia of the bloodvessels and lymphatics. The fibrous-tissue network, vessels and a portion of the cell infiltration are thus produced, the fixed and wandering connective-tissue cells of the inflamed stroma of the cutis being responsible for the other portion of the new growth (Robinson).

State the diagnostic features of lupus vulgaris.

In a typical, developed patch of lupus are to be seen:—cicatricial formation, usually of a fibrous and tough character; ulcerations; the yellowish-brown tubercles and infiltration; and the characteristic soft, small, yellowish or reddish-brown, cutaneous and subcutaneous points and tubercles.

How does the tubercular syphiloderm differ from lupus vulgaris?

The tubercular syphiloderm is much more rapid in its course, the ulceration is deeper and the discharge copious and often offensive; the scarring is soft, and, compared to the amount of ulceration, but slightly disfiguring; and it is, for obvious reasons, a disease of adult or late life. The history, together with other evidences of previous or concomitant symptoms of syphilis, will often aid in the differentiation.

How does epithelioma differ from lupus vulgaris?

The edges of the epitheliomatous ulcer are hard, elevated and waxy; the base is uneven, the secretion thin, scanty and apt to be streaked with blood; the ulceration usually starts from one point, and is often painful; the tissue destruction may be considerable; there is little, if any, tendency to the formation of cicatricial tissue; and, finally, it is usually a disease of advanced age.

In what respects does lupus erythematosus differ from lupus vulgaris?

Lupus erythematosus has no papules, tubercles or ulceration.

How does acne rosacea differ from lupus vulgaris?

Acne rosacea is characterized by hyperæmia, dilated vessels, papules, pustules, the absence of ulceration, and a different history.

State the prognosis of lupus vulgaris.

Lupus vulgaris is always a chronic disease, often exceedingly rebellious to treatment, and one that calls for a guarded opinion. Relapses are not uncommon.

The general health usually remains good, but in some instances death by tuberculosis of the lungs has been noted.

Is external or internal treatment called for in lupus vulgaris?

Always external, and not infrequently constitutional also.

What is the constitutional treatment?

The general health must be cared for; good, nutritious food, fresh air and out-door exercise, together with, in many cases, the administration of such remedies as cod-liver oil, potassium iodide, iron and quinine, are of therapeutic importance. Tuberculin may be tried in severe and obstinate cases, but its use is not without danger.

State the object of local treatment.

The destruction or removal of the diseased tissue.

May milder methods of treatment sometimes prove beneficial and even curative?

Exceptionally, mercurial plaster, corrosive-sublimate lotion and ointment (gr. j to ℥ j), a plaster containing five to fifteen per cent. of salicylic acid and creasote, repeated paintings with carbolic acid, and the constant application of lead plaster containing twenty per cent. of ichthyol, are valuable.

Of the milder methods, those most in vogue to-day are the Finsen light and x-ray. Either proves extremely valuable in some cases, but the Finsen method is the favorite method.

What methods are commonly employed for the rapid removal or destruction of lupus tissue?

Cauterization, scarification, erasion and excision are variously practised; the particular method depending, in great measure, upon the extent of the disease, the part involved, and other circumstances.

Name the several caustics, and state how they are employed.

Pyrogallic acid, used as an ointment:—

  ℞ Ac. pyrogallici, ................................. ʒij
Emplast. plumbi, ................................. ʒj
Cerat. resinsæ, .................................. ʒv. M.

It is applied for one or two weeks. Every several days the parts are poulticed, the slough thus removed, and the ointment reapplied, and so on until the diseased tissue has been destroyed. It is useful in those cases in which a mild and comparatively painless caustic is advisable. In most cases several repetitions of this plan are necessary. Arsenious acid, employed as an ointment—

  ℞ Ac. arseniosi, ................................... gr. xx
Hydrarg. sulphid. rub., .......................... gr. lx
Ungt. aquæ rosæ, ................................. ℥i. M.

It is painful but thorough; it is spread on lint and renewed daily. The action is usually sufficient in three days, and the parts are then poulticed until the slough comes away, after which a simple dressing is employed. Its application is advisable for a small area only—not more than four square inches—as absorption is possible.

Galvano-cautery.—The diseased tissue is destroyed by numerous punctures with a red-heated point or by linear incision with a red-heated knife. It is often a practicable and satisfactory method. The Paquelin cautery and liquid air and carbon dioxide also have their advocates.

Describe the operative measures employed in the removal of lupus tissue.

Linear Scarification.—The parts are thoroughly cross-tracked, cutting through the diseased tissue, and subsequently a simple salicylated ointment applied. The operation is repeated from time to time, and as a result the new growth undergoes retrogressive changes, and cicatrization takes place.

Punctate Scarification.—By means of a simple or multiple-pointed instrument numerous closely-set punctures are made, and repeated from time to time, usually with the same action and result as from linear scarification.

Erasion.—The parts are thoroughly scraped with a curette, and a supplementary caustic application made, either with caustic potash or several days' use of the pyrogallic-acid ointment. The result is usually satisfactory.

The dental-burr is also useful in breaking up discrete tubercles.

Excision.—This is an effective method if the disease consists of a small pea- or bean-sized circumscribed patch.

Of these various operative methods those now most favored are erasion and excision, punctate and linear scarification methods are now rarely employed.

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