Dermatitis Exfoliativa Neonatorum

DERMATITIS EXFOLIATIVA

NEONATORUM : RITTER'S

DISEASE.

By KEDARNATH DAS, M.D.,

Registrar, Medical College Hospital, Calcutta.

This rare acute disease of the new-born

characterized by hyperemia and excessive epi- dermic exfoliation, and accompanied at times by the formation of vesicles or bullae, has received scant recognition in text-books. The disease, as far as I know, has never been recognised in this country: at least no case has been recorded in

the Indian Medical Gazette. I am sure that cases do occur here, but they are thought to be cases of pemphigus neonatorum. The following case, which came under my observation only a few days ago, supplies the text for this paper:? A Hindu male infant, twelve days old, sud-

denly developed patches of diffuse redness over the face and neck. On the next day the trunk got affected, and there were large blebs here and there, the temperature rising above 103?F. The

day after the extremities were red, but the

temperature came down. I saw the case now, and the large-blebs gave me the impression that the case was one of pemphigus neonatorum.

When seen next, after two days, I found large flakes of epidermis peeling off. The eyes were

red. This exfoliation led me to the recognition of the true condition. There was slight bronchial catarrh with irritation of bowels. Father and mother healthy ; no history of syphilis. The

infant recovered in a week's time. Treatment consisted of the application of Vinolia cream

and putting the infant on a large pad of cotton wool. The child is now suffering from an

attack of furunculosis. The following description of the disease will,

I hope, be useful to the profession in recog- nising it:?

Ritter first described it carefully, and to him belongs the credit of establishing the existence of the disease. It is claimed that Herieuz, Huetter, Bille and others have described it, but

they had confounded it with pemphigus. Ritter observed 279 cases from 18G8?1878.

Since 1878 only a few more cases have been

reported in Germany. In America only 6 cases have been reported by Dr. Elliot till 1892.

Hallopeau presented an example of it before

the Dermatological Society of Paris in 1892. Little is known with regard to its etiology; the disease is probably parasitic. Symptoms and clinical course.?The disease

generally occurs between the second and fifth week of life, rarely before the end of the first week. The process develops suddenly under the form of a diffuse redness, usually located upon the lower half of the face about the mouth, but it

may occur on some other portion of the body or even be universal. The hyperemia generally spreads rapidly and continuously, but it may appear in patches, becoming ultimately univer- sal in a short-time. As a rule, the extremities are attacked the last of all. With the exten- sion of the hyperemia, exfoliation of the epi- dermis begins upon the surface first attacked. The exfoliation may occur without any exuda- tion, the epidermis being slightly thickened, wrinkled, dry and fissured into pieces of all sizes, loosened at the edges and removable by any slight mechanical action, and underneath them a thin layer of new epidermis will bo found. On the other hand, the exfoliation may be pre- ceded by an outbreak of small vesicles or large irregularly shaped flaccid bullre. These may burst or being rubbed off, leave a raw-looking surface. In such cases the baby, at the height of the disease, presents a most pitiable appear- ance, as though it had been scalded?the epider- mis on some portions wrinkled and sodden-look- ing, on others peeling off in large ragged flakes, while large areas may be entirely denuded, the rete alone remaining. The buccal and nasal cavi-

ties are affected, and fissures are very apt to form at the corners of the mouth. The conjunctivae are usually injected, and in a case there was deep ulceration of both cornea. The process of re-

generation is very rapid. Usually the disease runs its course in from 7?10 days. Unless some

internal complication exists, the process is un-

accompanied by either fever or systemic distur- bance. Relapses are occasionally observed but are usually mild. As sequela3, furunculosis may be mentioned as the most common, but abscesses with consecutive sepsis and gangrene may occur.

Pathology and morbid anatomy.?Hitter held that it was a form of pysemic infection, but his opinion is apparently untenable. Bolin held

that it was a dermatitis. Caspary regards it as an epidermolysis of unknown nature with

secondary h}7pera3mia of the cutis?possibly an acute disturbance of nutrition in those external

layers of the skin which do not contain blood- vessels. Kaposi and Bolin think that it repre- sents a great increase in the physiological desquamation; but while the latter regards it as a pemphigoid eruption, the former agrees with Ritter in separating it entirely from pem-

phigus. Brocq considers it to be a peculiar form of pemphigus; but more recently Riehl has discovered a fungus with long thin mycelium,

August 1899.1 CEREBELLAR ABSCESS?MAYNARD. 283

and concludes tliafc it is its cause. This parasitic theory is the most satisfactory, but requires corroboration.

Diagnosis.?When once the disease is studied, the diagnosis offers no difficult}'. The only disease with which it can be mistaken is pemphi- gus simplex acutus neonatorum. Though pem- phigus appears during the first few weeks of life, it usually develops earlier, commonly between 4th and Sfcli day, rarely after the 14th. It does not

begin with diffuse redness but with an eruption of discrete bullae upon an uninfiltrated erythema- tous base. These appear in successive crops for a week or more, but rarely after the first month of life.

Prognosis.?Ts unfavourable. The mortality of Hitter's cases was 4882?/. The cause of

death in some cases is the intensity of the at- i

tack ; in others exhaustion, secondary septi- | cfemia, marasmus or loss of animal heat. Inanition is a frequent cause, as also the

development of some secondary or complicating disease.

Treatment. Sustain the vital powers of

the infant by proper nourishment and tonics.

Externally fats and oils with some antiseptic, as boric acid, resorcin or icthyol are recommended as well as enveloping the patient in wadding or in absorbent cotton. Icthj'ol being a parasiti- cide and also a keratoplastic agent would be peculiarly indicated.