The anular lesions of early syphilis in the negro.

By

Howard Fox, M. D. (New-York).

(With plate XVI--XVIII.)

Among the dermatological peculiarities of the negro, I should like to call particular attention to one that has not been recognized to my knowledge, by any except American syphilographers. I refer to the unusual frequency with which the annular forms of the papular syphilide are observed in the negro race. The eruption of which I am writing is not to be confused with the annular lesions of late syphilis which are so characteristic of the disease and which are seen with equal frequen cy in both white and negro races. The eruption has its origin in the fiat papules of syphilis in which a depression of the cen- tral portion takes place, associated with a peripheral exten- sion of the border. This is spoken of as the annular or circinate papular syphilide.

The eruption is described rather briefly in most of the text books on dermatology and syphilis, but little or no mention is made of its frequency in the negro. Good illustrations of this form of syphilis in the white race, are seen in the atlases of W i l s o n , K a p o s i , Morrow~ T a y l o r and P r i n g l e , and a most unusual case is depicted in the text book of Jullien.

A t k i n s o n (1) was the first, I believe, to call attention to the frequency of the annular syphilide in the negro and

316 Fox.

writes ,,In my clinic which includes a large number of persons of negro blood, the eruption appears to especially prevail in colored individuals." G i l c h r i s t (2) says that as. far as his experience extends, ,,It appears to be much more prevalent in the negro race than in the white races." S t e l w a g o n (3) says ,,It is a somewhat unusual manifestation and is seen most frequently in the negro." P u s e y (4) also states that it ,Is most frequent in negroes." J a c k s o n (5) says that the eruption which he speaks of as the circinate, squamous syphilide, ,Seems to be specially apt to affect the negro race." Sir Malcolm M o r r i s (6) gives a well marked illustration of the annular lesions in a colored individual (Patient of G i 1 c h r i s t) but does not refer to their frequency in the negro race. I have failed to find any mention of the annular syphilide in the negro in the text books on dermatology and syphilis by the following authors: B a z i n , B r o c q , C a m p a n a , C r o c k e r , D a r i e r , F i n g e r , F o u r n i e r , G a u c h e r , H a l l o p e a u et L e r e d d e , H a r d y , H u t c h i n s o n , H y d e , J a m i e s o n , J o s e p h , J u l l i e n , K a p o s i , L a n g , L e s s e r , M a u r i a c , MraSek , P i n k u s , R i e c k e , S e q u e i r a , W a l k e r and yon Z e i s s l .

In a comparative study of skin diseases in the white and negro race (7)~ I have concluded that the annular syphilide should be classed with keloid, elephantiasis, and fibroma as affections that are especially characteristic of the negro. Indeed every one who has had occassioa to see many cases of skin disease in the negro must have been impressed with the fre- quency and extent of the annular syphilide in the colored race. This has been our experience at the V a n d e r b i l t Clinic, which is attended by a considerable Lumber of negroes, though unfortunately there are no available statistics upon the subject at this clinic. In my figures obtained from the Johns H o p k i n s Dispensary, in a thousand consecutive cases of skin diseases in white persons there were 72 cases of syphilis, none of them presenting the annular form of the disease. In the corresponding one thousand cases in the negro there were 93 cases of syphilis 11 of which, or 5"7% presented examples of the annular syphilide. In 114 consecutive cases of syphilis in the white race, observed by Dr. P i s k o at the Harlem

The anular lesions of early syphilis in the negro. 317

Hospital there was one well marked case of the annular syphilide, while among 50 consecutive cases oi syphilis in the negro race observed during the same period there were 7 well marked examples of the same type of the disease.

The type of annular syphilide that I have seen most frequently is well shown in an illustration (wood cut) by A t k i n s o n. This consists of delicate elevated circular rims which are smooth or slightly scaly and show a definite infiltration. The lesions may appear as complete circles or portions of circles. They may be discrete or may coalesce and form gyrate patches or at Limes remarkable festoons and" geographic figures. A very unusual case of this variety has been published in my study of skin diseases in the negro . (Patient of Dr. R. B. C a 1" m i c h a e 1.) G i l c h r i s t has also published two well marked cases, one of them showing a decided tendency to form gyrate patches. Illustrations of the annular syphilide in the negro are also given in the text books of S t e l w a g o n , J a c k s o n and P u s e y .

The sites of predilection of the annular syphilide in the negro, are the corners of the mouth, chin, the upper lip near the junction of the nose, the supraorbital region and the forehead. Less frequently it is seen upon the back of the neck, the trunk and extremities, especially the arms. I do not remember having seen the eruption upon the legs.

The period of the disease at which the eruption may appear varies according to A t k i n s o n , from three to eighteen months, while according to G i l c h r i s t it may be delayed as late as the third, fourth or fifth year. In the majority of cases that I have observed, the lesions appeared within six months after infection.

That the size of the lesions may vary considerably is seen by a glance at the accompanying illustrations. The individual circles may at times be as large as a silver dollar, while larger patches are formed by the coalescence o f a number of lesions.

In the differential diagnosis, two diseases of the skin, tinea circinata and erythema multiforme must be considered. The annular syphilide is most likely to be mistaken by an in- experienced observer for tinea, especially when the elevated margins are thin and delicate in appearance. The infiltration

318 Fox.

of the elevated borders, the failure to demonstrate the fungus and the presence of other symptoms of early syphilis, including a positive W a s s e r m a n n reaction would readily clear up the diagnosis. While the appearance of annular patches of erythema multiforme might simulate an annular syphilitic, the sites of predilection in the two diseases are somewhat different. The former affection is most often seen upon the face and neck, upon the backs of the forearms and hands, and about the feet, while the latter is most frequently observed upon the face, trunk and arms. The presence of itching or burning, the transitory duration, and the absence of other evidences of syphilis would aid in making a proper diagnosis. The annular syphilide could hardly be mistaken for psoriasis, a disease which is not commonly seen upon the face and one which occurs with extreme rarity in the full blooded negro. The eruption should finally be distinguished from the annular lesions of late syphilis in which the patches are formed by grouping of individual tubercles.

The annular syphilide in the negro responds to treatment as favorably as does the flat papular type of the disease. Like other forms of cutaneous syphilis in the dark races its disap- pearance is apt to be followed by greater deposition of pigment than is usually seen in white persons.

I am indebted to Dr. George T. J a c k s o n for the privilege of photographing some of his cases and to Dr. John A. F o r - d yc e for one of the illustrations (fig. u

References. 1. A t k i n s o n , I. E. Syphiloderma papulosum circinatum. Jour.

Cutan, & Vener. Diseases. 1883. Vol. I. p. 15. 2. G i l c h r i s t , T. C. Two unusual cases of annular syphilides in

Negroes. Maryland Med. Jour. 1909. Vol. XLIIL p. 200. 3. S te iwa 'gon~ H. W. Diseases of the Skin. 1905. p. 736. 4. P u s e y , W. A. The Principles and Practice of Dermatology.

1911. p. 538. 5. J a c k s o n , G. T. Diseases of the Skin. 1908. p. 693. 6. M or r is, Sir Malcolm. Diseases of the Skin. 1909. p. 483. 7. F o x , H. Observations on Skin Diseases in the Negro. Trans.

VI. Internat. Dermat. Congress. 1907. Vol. I. p. 198.

hrehiv f. Dermatologie u. Syphilis, Bd. CXIII. Tar, XVI.

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H. F o x : Syphil is in the negro. Lichtdruckv. Max Jai~d, Wien.

Archly f. Dermatologie u. Syphilis, Bd. CXIII. Tar. XVII.

Fig. 4

H . F o x : S y p h i l i s in the negro . Lichtdmck v. Max Jaffd, Wien.

Archiv f. Dermatologie u. Syphilis, Bd. CXIII. Taf. XYIII.

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H. F o x : Syphi l i s in the negro. Lichtdruckv. Max Jaffd, Wien.