Pityriasis

PITYRIASIS (from the Greek pityron-bran), since the time of Willan and Bateman, a morphological term for persistent fine scaling, patchy or diffuse, on dry (without exudation and crusts) skin, which is either unchanged in color and consistency or colored in various shades, inflamed, infiltrated, or, conversely, atrophic. This same term is also applied to denote dermatoses in which scaling is one of the prominent symptoms in all or most of their stages. In modern dermatology, this term is applied to the following heterogeneous dermatoses in terms of clinical picture and etiology: I. P. rosea (Gibert), II. P. rubra pilaris (Devergie-Besnier), III. P. rubra (Hebra), IV. P. simplex capillitii, V. P. simplex faciei, VI. P. versicolor (tinea versicolor), VII. P. tabescentium, VIII. P. lichenoides chronica - a synonym for one type of parapsoriasis (see Psoriasis), IX. P. rubra seborrhoica (Unna), which should be understood as seborrheic eczema complicated by erythroderma. I. Pityriasis rosea ("pink ringworm", Gibert's ringworm, described by him in 1862) - a unique dermatosis which at its height is characterized by the presence of partly "patchy", partly pathognomonic "ring-shaped" elements called medals, scattered without any particular system, mainly on the trunk, to a lesser extent on the limbs and even less on the neck and lower part of the face. The patchy elements are small, juicy, pale pink spots of round or oval shape, from the size of a pinhead to a kopeck. They resemble urticarial, syphilitic roseola, but differ in weakly angular, more blurred outlines and the rapid appearance in the center of sparse plate-like matte scaling, which gradually spreads over the entire surface; simultaneously the eruptive disk fades, flattens, the scales fall off, and a healthy, slightly hyperemic or weakly pigmented surface is exposed (patchy form of Gibert's ringworm). The medals, which are a further stage in the evolution of patchy elements, are larger (up to fifty kopecks and more), ring-shaped, round or oval disks, sharply demarcated, with bright pink raised edges, weakly scaling and paler, sometimes weakly pigmented centers, within which the skin surface is dry and finely wrinkled, as if pleated (which is especially noticeable when stretching the skin). Sometimes on the pink border of the medal, small redder hyperemic spots are noticeable (ring-shaped form of Gibert's ringworm). In some cases, patchy elements predominate, in others, medal-like elements. In some cases, scattered eruptions are preceded by an "incubation period" of 4-20 days, accompanied by the appearance, more often on the front surface of the trunk, less often on the limbs, neck or face, of one or several (clustered) "primary" plaques of the type of especially large medals. The dermatosis is characterized by 1) a seasonal nature, giving the largest number of cases in autumn and spring and coinciding with a decrease in air temperature and an increase in its relative humidity; 2) arbitrary cyclic course with a duration of 4 to 8 weeks; 3) great rarity of relapses. In many patients, 5-15 days before the appearance of scattered eruptions, general malaise with slight fever, aching in joints and muscles, sore throat, etc. is observed. In neurotics or persons with chronic intoxication, itching may be observed. Atypical forms: 1) Acute form with rapid abundant eruption of bright red, mainly patchy elements, and sometimes the face and even the hairy scalp are affected with swelling of the lymph glands; subtypes of this form are: a) vesicular form with irregularly scattered small vesicles on the disks and even in the intervals between them and with possible appearance on the toes and hands, on the palms and soles of vesicular eruptions of the type of dyshidrotic eczema; children are especially prone to this form of dermatosis; b) confluent form - an acute type with closely clustered and in places merging into large disks elements; c) eczematized form with the formation of vesicles, weeping and crusts, usually arising from rubbing irritating ointments; 2) Relapsing form with possible repetition of the dermatosis at different intervals - from several months to several years. 3) Prolonged remitting form - very rare, which can give outbreaks of new eruptions during the reverse development of the rash and drag on for several months. 4) Chronic form - an extremely rare type of Vidal, where sparse patchy disks, located mainly in large joint folds, slowly turn into especially large medals that can exist for many months and seemingly years. Histologically, the following is noted: 1) parakeratosis with leukocytes among the scales; 2) uneven acanthosis with lengthening and thickening of the interpapillary processes; 3) interstitial, and sometimes intracellular, formation of vesicles in the superficial layers of the prickle cell layer; 4) hyperemia and dilation of vessels of the papillary and subpapillary layers with possible pinpoint hemorrhages on the tops of the papillae; 5) edema of the papillary body; 6) significant perivascular infiltration. In diagnosis, syphilitic elevated roseola, trichophytosis, psoriasis, seborrheids, parapsoriasis and other erythematous-squamous dermatoses should be kept in mind. Pathognomonic are: medals, the presence of a primary plaque, especially a large one, the arbitrary relatively rapid reverse development of eruptions, the cyclic course, the jagged outlines of plaques, sparse "single-layer" scaling, absence of pinpoint bleeding when scraping off scales, absence of fungi in the scales (and in the covering of vesicles), etc. Etiology is not exactly clarified. By the clinical course of Gibert's ringworm - it is apparently an infectious erythema with an unknown causative agent, the introduction and development of which are facilitated by cooling and high air humidity. It is possible that the causative agent is introduced through the skin by trauma, blood-sucking insects or worn underwear by patients (U. Wile). Cases of small household epidemics, development of a primary plaque at the site of smallpox vaccination, wasp bite, near a paronychia, etc. are known. Some authors (du Bois, Benedeck) allegedly found fungi-schizosaccharomycetes in the scales and vesicles. According to Peren (Perm), the skin of patients reacts violently to intradermal administration of streptococcal vaccine, not reacting to staphylococcal vaccine, which is why the author thinks of streptotoxicoderma. Women get sick twice as often as men. The favorite age is from 20 to 30 years. - Treatment. The dermatosis resolves arbitrarily and without a trace. In the period of multiplication of eruptions, rubbing of the skin and baths are prohibited, talcum powder is prescribed, for itching - a mixture for shaking (zinc, talc, glycerin, water in equal parts). For acute forms - sodium salicylate (up to 3 z per day) or intravenously sodium thiosulfate. In the period of reverse development - wiping with warm water with a soft sponge, soap baths with exfoliating soaps (for example ichthyol); careful irradiation with a Bach lamp (Volk, Hazen). In chronic cases - X-rays, reducing ointments, etc. II. Pityriasis rubra pilaris, or follicularis - a type of unique but close to psoriasis dermatosis, which was described under the name of generalized psoriasis in 1835 by Rayer, in more detail in 1857 by Devergie and finally developed in 1889 by Besnier and his student Richaud; often called Devergie's disease and according to the opinion of most modern dermatologists is an analog of lichen ruber acuminatus (Hebra) (although it is quite possible that F. Hebra meant the rare "spiny", i.e. follicular form of lichen planus in persons with pronounced hair loss). The main element of the dermatosis is a small follicular pink-orange papule, usually of irregular angular outline, scaling like bran, with a central follicular spine on the surface. At first, isolated papules scatter diffusely or in groups on the skin, which on palpation produces the impression of a grater. Later, closely clustering, papules merge into uniform psoriasis-like plaques, heavily infiltrated, with a dry and scaling surface, crossed by sharply defined skin grooves, among which pathognomonic depressed areas of normal skin of irregular angular outline, dotted with individual horny spines, are often noticeable. Multiplying in number and size, these plaques merge into wide fields and can occupy the entire surface of the skin. At the same time, the skin of the hairy parts, especially the head, is covered with a uniform compact film of dry bran-like scales, and the intensely red palms and soles are covered with a thick layer of compacted horny covering. The nail plates, dull and longitudinally striated, rise high above their bed with a fibrous horny mass resembling the core of a reed, becoming very sensitive to pressure (see separate table for the article Psoriasis, fig. 3). The lesion is usually symmetrical. Subjective sensations are expressed by a feeling of tension, sometimes slight itching.

The general condition is usually not affected. Like psoriasis, the dermatosis lasts for many years, giving periods of remission and exacerbation, and may spontaneously disappear for long years. The disease develops insidiously, but sometimes, taking on an acute course from the start, it can cover the entire surface of the skin in 10-20 days. In such cases, the characteristic spines in the form of black funnel-shaped points are noticeable only on the back of the first phalanges of the hands. The onset is most often in childhood or adolescence. The intensity of redness, infiltration, and scaling, as well as the size, thickness, and shape of the follicular spines, are subject to wide variations. Some authors have noted the appearance of small pointed nodules on the hard palate. As a common complication, especially with irritating local treatment, secondary erythroderma is observed, in which the diagnostic signs of the dermatosis are lost and the general condition is disturbed. Richter (Schichter, 1928) described an arthropathic form of the disease, as in psoriasis (see).-The histological picture of epidermodermatitis: stratified hyperkeratosis of the hair follicles with a spine containing a hair in the center; preservation, sometimes thickening, of the granular layer; the spinous layer is either normal or thinned; hyperemia of the papillae with moderate diffuse cellular infiltration. The etiology and pathogenesis are unclear. Clinically, P. rubra pilaris is close to psoriasis. Some authors (Wigley, Gr? Little, Mgebrov, etc.) have noted in the same patients alternating eruptions of both psoriatic and P. rubra pilaris types. Milian and others defend a tuberculous etiology: sometimes a positive reaction to tuberculin, coincidence with tuberculous lesions of the skin (Schaffer), glands, lungs, bones (Gavrilova), improvement and even recovery from tuberculous antigens (Gougerot, Ogo, etc.). However, in most patients, the absence of signs of tbc and fruitless skin inoculations in guinea pigs (Pautrier) are noted. Americans, noting a decrease in basal metabolism, speak in favor of the endocrine nature of P. rubra pilaris, citing success from thyroidin and other endocrine preparations. More and more cases of familial-hereditary P. rubra pilaris are being described, which further brings the dermatosis closer to psoriasis. The diagnosis is not difficult. In torpid cases, the diagnosis is difficult with acute course: simulation of lichen planus, Wilson-Broc dermatitis, psoriasis, etc. The spines, especially on the back of the first phalanges of the hands, hyperkeratosis of the nail bed, intense pityriasis of the hairy scalp, and islands of healthy skin among continuous psoriatic fields are typical.-Treatment in general is the same as for psoriasis (see). Of internal remedies, arsenic and thyroidin are especially indicated; in acute course, intravenously ¹/₂% solution of quinine (Lebedev) or 20% solution of sodium thiosulfate. III. Pityriasis rubra (Hebra). Since the time of Bateman, this term has designated the clinical picture of persistent diffuse redness of the skin, scaling like bran, regardless of whether such a condition arises primarily or secondarily during some inflammatory dermatosis, but in 1868 F. Hebra under this term, to which only this author's name can be applied, described a unique picture of a chronic dermatitis developing primarily in adults, characterized, in addition to universal dense redness and bran-like scaling, by slowly progressive pigmentary atrophy of the skin and its appendages and gradually increasing cachexia, leading patients to death either from marasmus or from an intercurrent disease. To characterize P. rubra Hebra, F. Hebra and Kaposi emphasized the absence of papules, i.e., clinically noticeable infiltration of the skin, vesicles, pustules, crusts, etc. According to Kaposi, the beginning of the disease is red scaling disks developing in the area of large joint folds, gradually expanding and covering the entire surface of the skin. Later, students and followers of Hebra expanded the symptomatology of this dermatosis, including large-plate scaling, infiltration of the skin, benign course without clear atrophy of the skin and disturbance of the general condition, the possibility of remissions and even complete recovery, etc., from which the difference between various forms of primary dermatoses of both definite and unclear etiology was smoothed out and lost, against which many dermatologists rightly protested. From the analysis of the case reports of P. rubra Hebra, it is clear that under this name are described: 1) dermatoses as a symptom of visceral or glandular tbc; 2) premycotic erythrodermas, or parapsoriasis en plaques of Brocq; 3) dermatoses in diseases of the blood-forming organs (malignant lymph¹ogranulomatosis, leukemia, leukosarcoma, etc.); 4) erythrodermia ichthyosiformis congenita of Brocq, etc. Therefore, some authors, such as U. Wile, even advocate for the abolition of the term P. rubra Hebra. However, although very rarely, the type of atrophic dermatitis, proceeding according to Hebra's description, is observed, and only to it is this name applicable.-Histologically - a banal picture of atrophic dermatitis.-The etiology is completely unclear. If in some cases patients died from tbc, the question always arose whether tbc was not a consequence of the progressive cachexia of the patients. In diagnosis, especially in cases with enlarged glands, it is necessary to keep in mind diseases of the blood-forming organs or premycotic erythroderma and to search for tbc.-Treatment is fruitless. According to Kaposi, phenol in pills may be useful. < ' IV. a) Pityriasis simplex, s. sicca capillitii, incorrectly called by the Vienna school 'dry seborrhea' - a banal lesion of the hairy parts of the skin, especially the scalp, called in common parlance 'dry dandruff' and representing more or less abundant accumulation on the surface of apparently unchanged skin of whitish-gray dry thin bran-like scales, forming with greater or less speed after washing and easily falling off like dust when using a brush or comb. The hair is dry, often split at the ends, but does not thin out. Absent in younger children, P. simplex capillitii usually arises at the age of 6-10 years in the form of vague small disks, which gradually multiply, expand, merge and can cover all hairy parts. The dermatosis is sometimes accompanied by itching, scratching and often 'eczematizes', i.e., the skin under the scales turns red, becomes moist, even weeps, covering with loose, often impetiginous crusts.-Histologically - epidermitis with thickening and loosening of the horny layer without parakeratosis, with thinning of the other epidermal rows, especially the keratohyalin. In the scales, Pityrosporon Malassez (spores of Malassez) - a frequent parasite of the hairy skin of healthy people - is almost always present (in 96% according to Templeton). Its role in the etiology of P. simplex capillitii is controversial. However, both clinical data (the appearance of dry dandruff in healthy people after using brushes and other items used by the patient) and the experiments of McLeod and Dowling in 1928 - the rapid appearance of an erythematosquamous disk after rubbing into scarified skin or intradermal injection of an emulsion of the fungus culture - give reason to think of an infectious nature of the dermatosis, which other authors consider a congenital dystrophy of the skin associated with the function of sex hormones. In the pathogenesis of some types of eczema and especially male baldness, P. simplex capillitii plays a prominent role (see below P. crassa). - The diagnosis is in general not difficult: the vague contours of the initial fine-scaling disks, the complete preservation of the hair, the normal appearance of the underlying skin, the absence of pathogenic fungi in the scales and hair with the almost constant presence of Malassez spores are characteristic. The dermatosis is incurable, but systematic washing, especially with tar or sulfur soap, with previous rubbing in ointments containing a small percentage of precipitated mercury, resorcinol, salicylic acid, etc., is a successful preventive measure against 'seborrheic' eczema, tinea amiantacea of Alibert and male baldness. b) Pityriasis crassa capillitii, 'oily dandruff' - a frequent further stage in the evolution of P. simplex capillitii, more rarely - at 15-20 years of age it arises immediately as such. Usually, at the time of puberty or immediately after it, dry dandruff changes its character: the scales gradually become oily from dry - covering the skin with a grayish-yellow sticky paste-like film, easily scraped off from apparently unchanged skin in the form of a paste-like mass, which impregnates cigarette paper in the form of a spreading greasy spot; the hair becomes oily and shiny, especially in its lower part, begins to fall out and thin out - in men on the crown, in women diffusely and especially on the temples.

In the first type, senile-type baldness subsequently develops, with greater or lesser speed, through the gradual transformation of adult hairs into vellus hairs and the subsequent loss of the latter. Histologically: in addition to the picture described in P. simplex capillitii, the follicular infundibula are filled with layered horny plugs impregnated with fat; atrophy of the cellular follicular wall and hair papilla; marked hypertrophy of the sebaceous glands; in the dermis, especially around the follicles, cellular infiltration with mast cells. In the horny layer and follicular infundibula, in addition to Malassez spores, myriad Sabouraud microbacilli, as if gradually displacing the former. The significance of this flora is unclear: according to some, it is the basis of the process, while according to others, they are merely saprophytes. Pathogenetically, it is a combination of P. simplex capillitii and seborrhea, which gradually replaces the former. Consequently, the factors contributing to seborrhea (see) also dominate here. The dermatosis is incurable. Prevention in the sense of preserving hair comes to the forefront: washing with soap and hot water, rubbing with alcohol, ether, and other fat solvents, massage of the hairy scalp. Ultraviolet radiation. V. Pityriasis simplex faciei (circumscripta), a frequent skin lesion of children and adolescents in the form of round or oval disks of pityriasis-like dry scaling on normal or slightly pinkish skin, located on the cheeks, nose, chin, front surface of the cheeks, and less commonly on the trunk. They are particularly noticeable for their white color on the surrounding tanned skin. Initially small, they slowly expand and may merge into large scalloped disks. They tend to spontaneous healing, disappearing in one place and appearing nearby, hence the French name 'flying ringworm' (dartre volante). There are no subjective sensations. With frequent washing, irritating ointments, etc., the disks can easily become eczematized and may become foci of stubborn nummular eczema: A number of authors have described epidemics of flying ringworm among schoolchildren. For example, according to Hartmann, out of 49 children in a school, 43 became ill. Sabouraud first established the streptococcal nature of P. simplex faciei, which was later confirmed by others, hence the names 'streptococcal epidermitis,' 'dry impetigo' (Sabouraud), 'streptococcal pityriasis' (Haxthausen), etc. Frequent washing with insufficient drying of the skin and all conditions that cause degreasing, thinning, and loosening of the horny layer favor the development of the dermatosis. P. simplex faciei on slightly pinkish skin can simulate trichophytid or favus. It is necessary: 1) examination of the hairy scalp; 2) examination of scales for fungi. - Treatment gives quick results: discontinuation of washing and especially soap, ointments with a low content of white precipitate mercury, sulfur, resorcinol, etc. VI. Pityriasis (or tinea) versicolor, epidermomycosis furfuracea, etc., pityriasis versicolor - an epidermomycosis caused by the fungus Malassezia (or Microsporon) furfur. Clinically: sharply delimited, most often from pale orange to dense coffee-brown, less often pinkish-orange in color, spots of various sizes and shapes on the skin, sparsely and finely scaling, lying level with the surrounding skin, less slightly elevated. After washing, their surface, which is matte from mycelial-like scaling, becomes shiny upon losing the scales. It runs chronically without subjective sensations, rarely causing slight itching. The usual localization is the trunk, less commonly the extremities, neck, face, and extremely rarely the forearms and shins, and never the feet and hands. Nesting in the follicular infundibula, the fungus penetrates the horny layer, loosening and delaminating its layers, and initially produces numerous small follicular spots that gradually expand and merge with neighboring ones into continuous or reticulated fields of any size and bizarre outlines. Under the influence of sunlight, the affected areas, which do not tan, appear white against a bronze background (leucoderma solare postparasitarium). P. versicolor, one of the frequent epidermycoses, is characteristic of people of all races in middle age and is extremely rare both before puberty and in old age. The virulence of the fungus is very weak: transmission within the same family is extremely rare. Increased sweating, infrequent washing, wearing flannel, undershirts, common baths, etc., favor infection. The pathogen is a fungus discovered in 1846 by Eichstedt in the scales, consisting of: 1) hyphae of mycelium 3 μ thick, twisted, unbranched, solid or jointed; 2) round bodies clustered in nests, 3 to 5 μ in diameter. The spores are located mainly in the superficial layers of the horny layer, while the hyphae are in its deep layers. The hair is never affected. Recognition is not difficult. Especially characteristic are: 1) easy separation of the horny layer plate under the nail; 2) dense staining of the affected areas compared to the healthy periphery with any colored solution - tincture of iodine, methylene blue, etc. - Treatment with any exfoliating ointments (Wilkinson's, 2-3% resorcinol, 5-10% salicylic, 0.1% chrysarobin, etc.) or solutions (tincture of iodine, 5-10% salicylic alcohol, etc.). To prevent recurrences, apply the same exfoliating agents 2-3 times a week, keep the skin and clothing clean, and wear undershirts over a linen shirt. VII. Pityriasis tabescentium - an obsolete term for that physiological-like scaling of the horny layer which is observed on the skin, especially on the extensor surfaces of the limbs, in bedridden patients who are ill for a long time and severely, and which depends mainly on the lack of proper skin care. In elderly people with senile atrophied skin, this process is particularly pronounced.