LW of Dei Tnatitis I lerpetiformis Re- sc*ml)lini»* Krvthcma M ultiformc Louis A. Duhring, M.D. Philadelphia Reprinted from THE MEDICAL RECORD April 2, 188 7 Case of Dermatitis Herpeti- formis Resembling Ery- thema Multiforme BY LOUIS A. DUHRING, M.D. I'KOK KSSUK OK SKIN DISEASES IN THK LNI\ KR&ITY OK PENNSYLVANIA KefriHltdfrom Thb Mbuical. Kkcoro, April*, 1887 NEWYORK WILLIAM WOOD & COMPANY 1887 CASK OK DKRMATITIS HERPETIFORMIS RESEMBLING ERYTHEMA MULTI FORM K. In January, 1884, I was requested by Dr. Mitchell, of Klkton, Md., to see a case of chronic cutaneous disease, exhibiting peculiarities which made the diagnosis difficult. The patient was a man seventy years of age, a lawyer by profession, neurotic, and in poor general health. The disease had existed a year or longer, and was characterized by a profuse, multiform, general eruption, with violent itching and burning. None of the various plans of treatment previously employed had afforded any lelicf. From his physician I further learned that the lesions of the skin had varied in character from time to time, having been sometimes vesicular, and on other occasions erythematous ; while more frequently there had existed a combination of these elementary forms. Itching had always been a marked feature. When I first saw the case the whole general surface was the seat of an abundant, diffuse eruption, character- ized by ill-defined, marginate, annular, and circinate ery- thematous patches, upon which, in many places, were more or less well-formed, variously sized and shaped papulo- vesicular and vesicular lesions. The skin showed, more- over, signs of subacute and chronic inflammation, in the form of thickening, pigmentation, excoriations, and blood- crusts, as well as lesions in all stages of development. Ihe erythematous patches predominated, and had coa- 4 lesced to such an extent that their outline was only in places defined, but everywhere could be seen a disposition to form marginate shapes, as in erythema multiforme. The patches were on a level with the surrounding skin or were slightly elevated, and were acutely congested and infiltrated with inflammatory products, partly plastic and partly serous in nature. In color they were bright-red or violaceous-red, according to their age, and were mottled, owing largely to the fact of their having run together. The whole general surface, but especially the trunk, was affected in this manner ; in addition to which, seated upon these patches were, for the most part, flat, small and large papulo-vesicular and vesicular lesions, here and there well defined, elsewhere imperfectly developed or abortive. The picture, as might be imagined, suggested an extensive diffuse or generalized “chronic” erythema multiforme, with papulo-erythemata, papulo-vesicules, and vesicules. The herpetic element was striking, as shown by the grouping and by the marginate peripheral extension of the process. Here and there the lesions were grouped in an ill defined circinatc form, as in tinea circinata, some of the patches being small, others large. In most localities they were so multiform and had merged one with another so extensively that the elementary characters were to be noted only on close inspection. Scratch-marks, excoriations, and small and large blood- crusts were everywhere present, testifying to the intense itching which had been experienced. The patient stated that this had always been a distressing symptom, was subject to exacerbations, and that it was always at its height during the time a new crop of lesions were develop- ing, occupying usually about a week. The pigmentation was of a dirty-yellowish, muddy, or dusky hue, and was both localized and general. It called to mind that seen 5 in the later stages of extensive pityriasis rosea of the trunk. From a diagnostic stand-point the eruption resembled diffuse, aggravated erythema multiforme of long stand- ing. Herpes iris was not suggested, the erythematous element prevailing. It possessed a history, however, as well as features which precluded it from being classed here. The chronicity of the process, the tendency to re- peated relapses, the obstinacy of the disease, together with the violent itching and burning, would not permit it to be considered as a case of this disease, at least as this affection is now defined. At the same time, I would state that the case possessed certain features in common with this disease, and certainly bore more resemblance to it than to any other well known cutaneous disease. And this brings me to a question that has presented itself on several occasions in studying dermatitis herpetiformis, namely, where (in certain cases) shall the line be drawn separating this disease from other well-defined diseases ? Shall, for example, the case I have just cited be regarded as erythema multiforme or shall it be grouped under the title dermatitis herpetiformis, where I have placed it ? Shall a new definition be framed for erythema mulliforme, to include also a chronic process, in order that this and similar cases may be grouped under this title ; or shall we regard such instances as too far removed from ery- thema multiforme to be classed here, and relegate them to another group ? The line separating one disease of the skin from another in some instances is ill-defined, and there are cases occasionally encountered which may as properly be classified under one head as another. Instances of the kind are met with from time to time with eczema and psoriasis, pityriasis rubra and psoriasis, and, to pass to more chronic forms of inflammation, with 6 lupus erythematosus and lupus vulgaris. They exhibit symptoms common to both diseases and defy precise, schematic classification. The case under discussion, however, I think, may more properly be regarded as an example of the erythem- atous variety of dermatitis herpetiformis than of ery- thema multiforme, especially if we take into considera- tion the history of the disease. In some respects it resembles that reported by Jarisch as “ herpes iris,” and referred to by me in the article entitled “ Preliminary Note on the Relation of Dermatitis Herpetiformis to Herpes Gestationis and other similar Forms of Disease ” {Medical News, November 22, 1884). I saw the patient on several occasions during the sub- sequent six months, his condition having somewhat im- proved, although he still suffered much. It is not neces- sary to enumerate the various internal and external remedies that were employed ; suffice it to say that they were such as might have been prescribed for chronic universal erythematous eczema. Notwithstanding the treatment the disease persisted, and relapses, though milder in form, occurred as before. I report the case, because it is interesting as portray- ing an unusual manifestation of the disease, namely, one bearing a resemblance to erythema multiforme. In a former paper I alluded to the possible relationship be- tween these two diseases, and this case would go to show that the causes at work in these diseases are capable of giving rise to similar cutaneous lesions. Additional clinical information, however, is needed concerning un- usual forms of both diseases before definite views can be expressed, and it is to be hoped that the experience on this point of other dermatologists will be forthcoming.