[Reprinted from the Journal of Cutaneous and Genito-Urinary Diseases 
for May, 1896.] 
IMPETIGO CONTAGIOSA ANNULATA ET SERPIGINOSA. 
JAY F. SCHAMBERG, A. 8., M. D., 
Dermatologist to the Union Mission Hospital; Instructor in Skin Diseases, Philadelphia 
Polyclinic. 
IN Rayer’s Atlas of Skin Diseases * published in Paris, in 1835, are 
two plates representing impetigo annulata. 
The term u pustular ringworm ”is added in parenthesis. In 
the descriptive text Rayer says : 
“ Impetigo is characterized by small, inflamed, yellowish pustules ; 
by honeylike crusts when the lesions are recent, and grayish or green- 
ish ones like old plaster when the lesions are old. Sometimes impetigo 
exhibits certain peculiar appearances; impetigo scabida when the 
crusts are grayish, lamellar, and occupy a large portion or the whole of 
an extremity; pustular ringworm when the crusts are arranged in an 
annular manner.” 
The conclusion that the above illustrations are not those of pustu- 
lar ringworm is, I believe, justified by the fact (1) that Rayer applied 
this term indiscriminately to crusts arranged annularly ; (2) that the 
disease occurred in an adult female; and (3) that profuse crusting and 
high-grade inflammatory reaction were present. 
A search of the literature in the more modern text-books of skin 
diseases gives us but little information in reference to this interesting 
form of impetigo. The treatises on dermatology in the English lan- 
guage contain nothing on the subject. The same may be said of most 
of the French works. Kaposi, in speaking of impetigo, says: 
“ Impetigo faciei contagiosa is characterized by the acute outbreak 
of pinhead to lentil-seed sized superficially seated vesicles in the region 
of the face, scalp, and neck. These appear in crops, discrete at first, 
* Atlas des maladies de la peau. Par P. Rayer, medecin consultant du roi, medecin de I’ho- 
pital de la Charite, chevalier de la Legion d’honneur, membre des Academies royales de m6de- 
cine de Paris et de Madrid. Public par J. B. Bailliere, Paris, 1885. 
Copyright, 1896, by D. Appleton and Company. 2 
Original Communications. 
later coalescing and drying rapidly to gumlike crusts, under which epi- 
thelial regeneration takes place. Some reach the size of a thaler in 
the form of concentric rings of vesicles resembling herpes tonsurans or 
pemphigus serjpiginosusUnna, in his Histopathologic der Haut- 
Tcrankheiten, says; “In contradistinction to impetigo vulgaris, im- 
petigo circinata forms flat, thin crusts which spread peripherally and 
sink in the center. The following is a typical case of the latter in an 
elderly man : A. L. Eight days ago there appeared upon the nose, 
chin, forehead, cheeks, and beard an eruption of vesicles. The ma- 
Fig. 1 (Plate YII of Payer’s Atlas).—“ A variety of impetigo remarkable for the annular 
arrangement and the swelling of the skin under the crusts in an individual of strumous diathe- 
sis.” Impetigo annulata (pustular ringworm). 
jority of these were soon converted into brownish translucent crusts 
that spread peripherally, their centers becoming depressed and des- 
quamating.’'’ 
The arrangement of impetiginous vesicles in concentric rings, or in 
a circinate manner at all, is certainly a rare occurrence in this coun- 
try. From the descriptions of Kaposi and Unna, it would seem that 
in Germany such an arrangement is not uncommon. The following 
case is, in my opinion, a remarkable instance of this unusual form of 
impetigo contagiosa: Impetigo Contagiosa Annulata et Serpiginosa. 
3 
B. K., a lad of ten years, presents upon the face, near the angle ot 
the month, several pea sized pustules covered with profuse crusts. 
Fig. 2.—“lmpetigo annulaire (pustular ringworm)” (Plate VII bis of Atlas). “This plate 
represents the crusts of impetigo arranged in irregular rings. This variety is very rare. The 
hairs between the crusts have been cut short. This affection developed in a woman who sev- 
eral months previously had a similar eruption around the left eye.” 
Upon the lateral and posterior aspects of the neck are similar though 
larger lesions, and also a few vesico-pustules. The axillary and pubic 
regions are the seats of a most remarkable condition. In the axillae 
are symmetrically arranged gyrate patches the size of the palm of 
the hand, the centers of which are almost but not entirely clear. The 
border is serpiginous and made up of yellowish-brown, greasy, loosely 
attached crusts, which project a quarter of an inch above the surface of 
the skin. Large fragments of crust hang here and there from the bor- 
der as if attached but by a thread. The centers of the patches show a 
number of round, crusted lesions, such as are seen upon the neck. The 
skin is not perceptibly reddened except when the crusts are removed. 
No ulceration is present. A large plaque the shape of a butterfly, 
the penis representing the body, involves the pubic and inguinal 
regions and the inner sides of the thighs. The crusts upon the borders 
are here even more prominent than in the axillas. Upon the upper 
part of the right thigh is a round patch about one inch in diam- 
eter, which shows distinct concentric crusting, as in rupia. The fall- 
ing out of the central crusts would, of course, produce a typical 
circinate plaque. Other lesions are present upon the arms, neck, and 
back. 4 
Original Communications. 
The accompanying photograph (Tig. 3), although an excellent one, 
might suggest to some an affection other than impetigo contagiosa. 
The involvement in this manner of the axillae and pubis certainly con- 
jures up the arrangement of eczema marginatum. The configuration of 
Fig. 3. 
the patches and their localization are, however, the only points of simi- 
larity. Microscopical examination of the crusts proved the absence of 
any fungous elements. The pubic patch, with the outlying rupialike Impetigo Contagiosa Annulata et Serpiginosa. 
5 
crust, might suggest the possibility of syphilis. Examination of the case 
clinically would have shown that the dermatosis was exceedingly super- 
ficial. The crusts lay upon the skin. There was no infiltration and 
no ulceration. It is scarcely necessary to repudiate the diagnosis of 
tinea favosa. It might be here added that the affected regions were 
in this individual still hairless. 
That this case is one of impetigo contagiosa is, I think, beyond 
reasonable doubt. The long duration (eight weeks) and the extensive 
involvement are, I believe, due to the unusual activity of the exciting 
organism. It is more than probable that future research will discover 
a number of varieties of impetigo contagiosa produced by different 
bacteria. Unna to-day recognizes an “impetigo staphylogenes,” an 
“impetigo streptogenes,” etc. 
Microscopic examination of the crusts showed the presence of 
micrococci, most of them in groups of twos. The pus from an un- 
ruptured vesico-pustule gave a similar result. 
Under the use of an ointment of red oxide of mercury and white 
precipitate the affection rapidly improved. The patient was on the 
road to recovery when he disappeared from observation.