HST000001

## PEMPHIGUS

Three forms of pemphigus are recognized—P. vulgaris, P. foliaceus, and P. vegetans. Pemphigus vulgaris is a non-contagious, chronic skin disease characterized by the formation of bullae in uninter- rupted sequence, or more often in crops. Premoni- tory symptoms such as fever, chilliness, anorexia, and nausea, may be present for a day or two before the appearance of the first eruption or before each successive outbreak. As a rule only in children, the debilitated or the aged do the constitutional disturb- ances persist throughout an attack, and then only when the eruption is widespread and profuse. The lesions appear as irregularly disseminated, pin-head- sized vesicles that develop in a few hours into tense, hemispherical bullae, one-half to three inches in di- ameter. The number varies from one or two to sev- eral hundred. The lesions show no predilection for particular regions nor any tendency to occur in groups. The bullae contain clear serum that be- comes turbid or puriform in two or three days. Not until then does an inflammatory areola develop. In- dividual bullae persist two to eight days. They do not tend to burst, but dry to thin yellow crusts that fall off and leave light brown spots or no trace at all. When a bleb is ruptured accidentally a red excoria- tion is exposed which heals from the periphery. The raw spots are very tender and unless properly pro- tected make the wearing of clothing almost im- possible. Unruptured bullae cause a feeling of slight burning or tension. While one crop is dry- ing new lesions appear; the course of the disease is thus prolonged for months or years. Some- times there are intervals of weeks or months be-

tween the outbreaks. The rare cases in which recovery or death ensues within a few months are often described as pemphigus acutus. The mucous membranes are frequently affected in pemphigus and erosions in the mouth and pharynx may render mastication and deglutition exceed- ingly painful. Mild cases of pemphigus vulgaris, without constitutional symptoms, usually get well. In all others the prognosis should be guarded. Pem- phigus foliaceus is a very rare and grave variety of the disease in which the bullae are flaccid and thin-walled and appear so rapidly and in such profu- sion that the whole epidermis becomes undermined. Pemphigus vegetans is another rare and malignant form that occurs usually in syphilitics. The excori- ated surfaces, instead of healing, send out persistent papillomatous granulations that spread slowly at the periphery. **DIAGNOSIS:** *Erythema bullosum* is to be differentiated by the presence of other le- sions of erythema multiforme, the development of the bullae from erythematous macules, the distribu- tion and comparatively acute course. In *urticaria bullosa* the blebs arise from wheals. **TREATMENT:** Arsenic given to the limit of tolerance and long continued, often, but not invariably, produces good results. The greatest effort should be directed to- ward improving the patient's general health. The bullae are to be evacuated, covered with pulvis talci salicylatis N.F. and protected with dry compresses. Or a 2 per cent boric acid wet dressing may be em- ployed. In severe, extensive cases the continuous warm bath gives the patient the most comfort.