Description

Erythematous Lupus first appears as a small, reddish macule, in its earliest beginning, presenting no features that are sufficiently characteristic to enable its true nature to be distinguished. It slowly increases, and when it attains a diameter of a quarter of an inch or so, it can be readily made out as a very slightly elevated patch of peculiar color, dry, and sometimes a little scaly. The fine scales are not imbricated like those of psoriasis, nor loosely attached like those of pityriasis. On the contrary, a small speck of the stratum corneum partly loosens, presenting a free and unattached edge; but if traction be made, it will be found that the remainder of the scale is quite adherent. These partly detached scales may be found all over the patch, in some cases more freely developed than in others, but never heaped up in strata, as in psoriasis. The patch continues to extend, and in four or five years, sometimes sooner, may reach an inch in diameter. As a rule, before it quite reaches this size, a change commences in the centre; the color becomes less marked; the elevation subsides, and the skin looks thinner even than normal. In other words, atrophic changes in the skin are going on, and the ultimate result is the replacement of what was once normal skin by a white, depressed cicatrix. As these alterations proceed, the lesion still extends at its periphery, and we have presented an annular infiltration slightly raised above the normal skin outside it, and above the cicatrizing skin within. These processes may go on from year to year until the patch has involved a large extent of surface, half the face for instance, and during the entire period there may be no ulceration. Meantime, other patches may form and blcrease in size for an indefinite period. Sometimes the extension of the patch ceases spontaneously, and, after undergoing the atrophic changes mentioned, its seat is occupied by a blanched, depressed scar. This cessation of morbid action is rare, and can never be predicted beforehand.

* Exceptions to this statement noted later.

When two or more patches are present, they usually appear in succession, but often exhibit a decided tendency to symmetry. The affection is essentially chronic, and the description given presents the principal features that appear in the majority of cases. Occasionally there appears to be special involvement of the sebaceous follicles, and the appearances are slightly modified accordingly.

There is, however, a second form of erythematous Lupus, apparently more common in Germany than here, and sometimes characterized, according to Hebra and Kaposi, by an acute course, and by the appearance of a large number of primitive macules scattered over an extended surface, or in some cases confluent. This variety, like the other, usually commences on the face, and the different spots may succeed each other slowly, or, occasionally with rapidity, giving the affection a somewhat acute character, and involving the trunk and extremities with hundreds of macules in one or two weeks. This form is further liable to certain complications. These are first, painful subcutaneous nodes of temporary duration; second, painful oedematous swellings of the skin and tissues about the joints; third, severe nocturnal osteocopic pains; fourth, hemorrhagic bullae, adenites of the parotid, submaxillary, and axillary glands; fifth, erysipelas, which may be mild, or, on the contrary, severe and fatal. Diagnosis. - The principal points on which to rely are the color, the slight scaliness, the chronic course, and the tendency to scarring. The only affections liable to be mistaken for it are chronic erythema, chronic scaly eczema, and syphilis. The absence of infiltration in the first of these should be sufficient to distinguish it from Lupus. In eczema the history of the eruption and its special features, together with the total absence of all tendency to the formation of cicatricial tissue, should make the diagnosis clear. A papulo-squamous syphilide might somewhat resemble an erythematous Lupus, but the lesions in the former disease would be far more numerous, they would not have lasted any great length of time, and the history of the case and concomitant symptoms would probably be sufficiently distinct to clear up any doubts.

Prognosis

The prognosis of erythematous Lupus is good so far as any given lesion is concerned, provided it is not already too extensive; as in the majority of cases it can be controlled. A much more difficult undertaking, however, is to prevent the appearance of fresh lesions at other points.

Histology

A few words concerning the histology of this affection will throw a certain amount of light on the course of the lesions, as well as give a clue to their successful treatment. On microscopical examination, the upper portion of the corium is found to be densely infiltrated with small cells. These, together with the normal connective tissue of the part, occupy more space than did the connective tissue alone, hence the alight elevation of the surface. This infiltration is undistinguishable microscopically, from many infiltrations occurring under other circumstances, but the cells of which it is composed resist change for a very much longer period than the cells found in simple inflammatory or in syphilitic infiltrations. In the former they may be present for a few days or weeks only, and in the latter for a few weeks or months only, but in Lupus they may persist apparently unchanged for months or years. Their presence, of course, causes pressure on the connective tissue, and this pressure leads to its atrophy. After an indefinite period, however, the cells begin to disappear, probably through fatty degeneration and absorption, and when they have entirely disappeared, we, of course, will not be surprised to find the integument thinner than normal, as a portion of its own particular structure had already been destroyed. The indica-tion for treatment is, of course, to banish the infiltration at as early a date as possible, and before it has, to any great extent, interfered with the integrity of the normal tissues of the part.

The treatment of erythematous Lupus will be deferred until the other varieties of Lupus have been described.