Erythema

ERYTHEMA (erythema), a diffuse inflammatory patchy rash on the skin or on mucous membranes, often arising from the merging of smaller spots. Multiple exudative erythema of Hebra (erythema exsudativum multiforme Hebrae), an acute cyclic disease characterized by the sudden appearance or occurrence after prodromal phenomena (general malaise, headache, chills, elevated temperature, sometimes joint pains) of a symmetrical rash, mainly on the extensor surfaces of the limbs; often the process involves the skin of the neck and face, less often the trunk [see separate table (pp. 399-400), Fig. 1]. In some cases, the mucous membrane of the mouth and lips is affected. The rash consists of light red and livid, round, firm papules 0.3-1 cm in diameter. During 3-4 days these eruptions increase, and their central part sinks in and takes on a cyanotic color (erythema exsudativum annulatum or circinatum). With the merging of eruptions, various polycyclic figures are formed (erythema exsudativum marginatum, gyratum). In some cases, a new nodule develops in the center of the eruption, which then forms the same concentric circle as the first papule (erythema iris). With pronounced exudation, vesicles and blisters form on the eruptions (erythema exsudativum vesiculosum, bullosum; hydroa vesiculosa). Sometimes the central blister is surrounded by a bright red roller, behind which is a row of vesicles, and then again an inflammatory roller (herpes iris, herpes circinatus). The blisters on the mucous membrane of the mouth and lips quickly burst, exposing bleeding, dirty-looking erosions; the lips swell, the red border is covered with bloody and dirty crusts and cracks. Due to severe pain, food intake is difficult. Usually multiple exudative erythema lasts 2-3 weeks; general phenomena, including fever, usually last only a few days, but there are severe cases with longer duration. The outcome is always favorable. A characteristic feature of multiple exudative erythema is relapses; there are patients who annually once or twice, more often in spring and autumn, suffer from multiple exudative erythema. The disease occurs mainly in young age, both sexes are affected equally. Histologically, the papular form is characterized by significant edema of the papillary layer and inflammatory infiltration (mainly lymphocytic) around the vessels of the papillary and subpapillary layers. - Etiology is unknown. The infectious nature of the disease is indicated by its cyclic course, development more often at a certain time of year (spring and autumn) and the described epidemics. The causative agent of this disease, however, has not yet been found. Clinical observations suggest the so-called hidden microbism in multiple exudative erythema: frequent development during other infectious diseases, after the use of medications (salvarsan, mercury, antipyrine, etc.), after cooling, etc. Hypotheses about the connection of multiple exudative erythema with tuberculosis and syphilis are not confirmed. The theory of focal infection attracts somewhat more attention. - Prevention for persons suffering from recurrent multiple erythema consists in the need to avoid cooling of the body. - Treatment: with widespread eruptions, bed rest is necessary. Internally - salicylic preparations (Natrii salicylici 4 times a day 0.5 each) or quinine bromide (3 times a day 0.5 each). Locally: indifferent powders and pastes. The covers of blisters are cut off. For eruptions in the oral cavity - astringent rinses (Alumini crudi pulver., Ac. tannici aa 15.0, 1/2 teaspoon per glass of water). Solar erythema (erythema solare) occurs several hours after strong insolation, accompanied by severe itching or burning. The skin is bright red, swollen, sharply painful on touch; the boundaries of the lesion strictly correspond to the area of excessive insolation. If blisters do not then form, the process in 4-5 days develops back by large-plate peeling, leaving a brownish pigmentation. The same course is taken by erythema photochemical from ultraviolet and other rays. - Erythema from embarrassment (erythema from shame, fleeting erythema, erythema pudoris, erythema fugax). In persons with increased excitability of vasomotors of central origin, mainly in women, when embarrassed, quickly passing red spots appear on the skin of the face, neck, chest and buttocks. - Erythema scarlatiniforme (scarlatinoid erythema, erythema scarlatiniforme) is relatively often of medicinal origin (from salvarsan, mercury, morphine, quinine, atropine, etc.) (see Dermatitis), as well as infectious (in influenza, septicemia, etc.). - Recurrent scarlatiniform erythema (dermatitis scarlatiniformis recidivans) - see Dermatitis. - Infectious erythema (erythema infectiosum) - see Fifth disease. - Erythema intertrigo - see Intertrigo. - Erythema induratum Bazin - see Bazin's indurative erythema. - Erythema neonatorum toxicum - see Leiner's disease, Newborn. - Erythema pernio - see Chilblains.

L. Moshvillaison. Erythema nodosum, an eruption of painful, distinctive reddish infiltrates, which upon regression take on a violet-brown color, ranging in size from a pea to a plum, accompanied by an acute febrile condition. The disease primarily affects preschool and school-age children. The incidence significantly decreases after puberty, although adults also contract it, mainly women. E. nodosum is to some extent a seasonal disease, with the peak incidence falling in the spring months. Etiology and pathogenesis. The etiological connection between the overwhelming majority of E. nodosum cases and tuberculosis is currently almost universally recognized as a fact. Pathomorphologically, E. nodosum does not exhibit the specific picture characteristic of tuberculous tissue, and bacteriological studies also fail to detect tubercle bacilli in the nodules. E. nodosum, like blisters and serous pleuritis, belongs to the paratuberculous manifestations; not being a pathognomonic symptom of tuberculosis, it at the same time is so rarely caused by other etiological factors (rheumatoid form) that practically it must be considered as a symptom accompanying active tuberculosis. Developing in the vast majority of cases in the period immediately following tuberculosis infection, at the end of the pre-allergic period, or in a tuberculous child during the period of fluctuation and shift of his allergy after acute infectious diseases (measles, whooping cough, etc.), E. nodosum should be regarded as a para-allergic manifestation arising and caused by a sharp shift and fluctuation of allergy in the tuberculous child. There is no basis for classifying E. nodosum among the rheumatic diseases, even the form often observed in adults with painful symptoms from the joints, since neither endocarditis nor chorea is ever noted in its course. There is somewhat more reason to consider the view that also denies the tuberculous etiology of E. nodosum, regarding it as an infectious disease sui generis, sometimes accompanied, like rheumatic diseases, by painful symptoms from the joints (Comby, Kisel). In favor of this view, denying the etiological connection with tuberculosis, reference is made to endemic outbreaks of E. nodosum in children's groups, the absence of typical recurrences of E. nodosum as proof of the development of immunity after an episode of E. nodosum, and the rare occurrence of E. nodosum in infants despite the presence of tuberculin allergy fluctuation in them. These arguments are still disputed: endemic outbreaks often upon careful investigation prove to be the result of fresh tuberculosis infection of many children from one bacillary patient, recurrences of E. nodosum are also noted; young children, although rarely, do contract E. nodosum. Despite the possibility of reconciling the existing contradictory views on E. nodosum by considering it as an allergic or para-allergic manifestation caused by both tuberculous and non-tuberculous etiology, much in the etiology and pathogenesis of this disease remains controversial and unclear. Symptomatology. The characteristic eruption of E. nodosum nodules is preceded by a febrile period lasting several days, in rare cases up to 2-3 weeks, which continues even after the eruption appears; in very rare cases, nodules appear during the period of falling temperature. The onset of the disease is acute, with high temperature, often preceded by a short prodromal period manifested by malaise, pallor, subfebrile temperature, etc. The characteristic eruption is usually localized on the front surface of the calves in the form of red with a violet tint, painful on pressure infiltrates ranging in size from a small pea to a small plum, less frequently and in smaller numbers on the outer surfaces of the forearms and shoulders. The number of elements varies considerably: from single nodules on one or both calves to densely scattered infiltrates of various sizes on the calves and upper extremities. In addition to the usual localization, atypical, sharply defined reddish nodules may occasionally appear on the dorsal surface of the feet, buttocks, face, and trunk, somewhat resembling urticaria or erythema multiforme. On the face, the rash sometimes takes the form of a butterfly, as in lupus erythematosus. The typical E. nodosum infiltrates undergo changes several days after their appearance: becoming flatter, they take on a violet, then brown color, in places their color resembling subcutaneous hemorrhages, subsequently remaining for days and weeks as characteristic pigmented spots. In the febrile period, usually before the eruption, in the vast majority of cases in children, a strongly positive tuberculin reaction, accelerated erythrocyte sedimentation rate, and shadows detectable on X-ray at the lung roots, interpreted as pericoronal and perihilar infiltrates, are noted. In children with E. nodosum examined for tuberculin sensitivity before the onset of the febrile period, a weakly positive tuberculin reaction or more often a negative reaction (hypo- or anergy) is sometimes noted. In exceptionally rare cases in children, more often in adults, no positive reaction is noted throughout the entire period of E. nodosum illness. In adults, however, pain is noted significantly more often than in children, and very rarely changes in the joints, which previously gave reason to classify E. nodosum among rheumatic diseases (see pathogenesis above). The infiltrates at the lung roots, occurring in a large number of children with E. nodosum in the febrile period, even before the appearance of typical nodules, have a characteristic course for these lesions (see Tuberculosis, pulmonary, in children). Arising acutely, they regress very slowly, sometimes over months. The development of infiltrates at the pulmonary hili with simultaneously a strongly positive tuberculin reaction, as well as the appearance of E. nodosum itself, indicates an immunobiological shift in the body toward a strongly expressed allergic (hyperergic) reaction. Subsequent observation of a child who has had E. nodosum should therefore take into account the further course of the tuberculous disease in him and the possibility of the development of further phases of the hyperergic reaction, especially miliary tuberculosis and tuberculous meningitis. Therapy. During the febrile and the immediate subsequent period, bed rest and careful care are necessary. It is not E. nodosum that requires treatment, but the tuberculous child, in whom the appearance of E. nodosum often indicates fresh tuberculosis or an exacerbation of a previously latent tuberculous process. The painfulness of the erythematous eruptions requires protective dressings in some children. Children who have had E. nodosum require the creation of the most favorable environmental conditions for them and careful observation; in many cases, with special indications, sanatorium treatment, the more frequently the younger the child. In cases of E. nodosum with negative tuberculin reaction and no signs of active tuberculosis, treatment is limited to bed rest and careful care; the use of salicylate preparations is unnecessary. The appearance of E. nodosum, especially in a preschool child, often gives rise to the discovery of patients with open tuberculosis in the child's environment and the sanitization of the bacillary focus.

i. Tsimbler.