A CASE OF 
DERMATITIS HERPETIFORMIS. 
BY 
George T. Elliot, M. D., 
Professor of Dermatology, 
New York Post-Graduate Medical School, etc. 
REPRINTED FROM THE 
Journal of Cutaneous and Genito-Urinary Diseases 
for April, 1896. [Reprinted from the Journal of Cutaneous and Genito-Urinary Diseases 
for April, 1896.] 
A CASE OF DERMATITIS HERPETIFORMIS. 
By GEORGE T. ELLIOT, M. D., 
Professor of Dermatology, New York Post-Graduate Medical School, etc. 
THE following case of dermatitis herpetiformis is so typical in 
its entire clinical symptomatology and course that it would ap- 
pear worthy of record. The repeated and constant report of 
similar instances of cutaneous disease has in the last few years greatly 
increased our knowledge of the general features which characterize it, 
as well as broadened our conception of its nature. At the same time, 
the diagnostic value of its symptoms is more fully appreciated, the 
disease is more readily and generally recognized, and no longer con- 
founded with those one and other cutaneous processes which at various 
times in its course it may resemble, owing to the individual lesions 
present. 
Male, aged fifty-six, a merchant, consulted me February 1, 1890. 
He had never been ill, and his domestic and business relations were 
entirely free from any such complications as would produce worry, 
anxiety, or lead to any moral or other shocks. Temperate, a moderate 
smoker and not given to any excesses, except indulgence in straw- 
berries whenever obtainable, he could give no clew in his history sug- 
gesting the origin of his disease. The first outbreak was preceded for 
a year or more by a gradual dryness, harshness, and roughness of the 
entire skin, but especially of the hands, and in June, 1889, an intensely 
itchy eruption appeared suddenly over his chest. It was thought to 
be “ prickly heat,” but, as it spread rapidly over the back and extremi- 
ties, a physician was consulted. At that time, the lesions were papules 
and vesicles grouped and arranged in rings, and the diagnosis was 
made of “ ringworm ” complicated with eczema. The application of 
the remedies ordered led to extensive exfoliation of the epidermis, and 
immediately afterward, bullse as large as a pigeon’s egg appeared 
around the wrists, in the axilhu and in the groins. Similar lesions, 
pea to hazelnut in size, developed in crops generally over the body, 
except upon the back. During the succeeding six months, the erup- 
Copyright, 1896, by D Appleton and Company. 2 
Original Communications. 
tion persisted almost continuously, though the type of lesion was not 
stated, relapse succeeding relapse, each separated by only short inter- 
vals of improvement. Intense, agonizing itching was present all the 
time, as well as a severe universal hyperidrosis, and violent clonic 
spasms of the extremities caused him much distress when lying down. 
By December of the same year his condition had considerably im- 
proved, and he went to Old Point Comfort. During the tirst two 
weeks he gained in strength, he slept better, the itching and sweating 
diminished, but he then received accidentally a severe moral shock. 
The following day, the pruritus returned and bulls© cropped out on the 
inner surfaces of the thighs. A few days later, papules appeared over 
the extremities, and the outbreak became progressively severer—pap- 
ules, vesicles, bulls©, and erythematous patches developing in success- 
ive crops over the various portions of the body. Shortly after, he con- 
sulted Dr. Duhring in Philadelphia, who diagnosed the case as one of 
dermatitis herpetiformis, and later he came to New York and under 
my care. 
On examination, the patient was found to be well nourished, his 
appetite and digestion were good, but the bowels for several months 
had been loose, three to four or more stools occurring every day. 
From two and a half to four quarts of urine were passed every twenty- 
four hours, frequent nocturnal micturition being a necessity. The 
amount would be increased whenever the itching was severe, or the 
patient became worried or depressed. The urine was limpid and very 
light in color, acid, and of a specific gravity of 1*019. No albumin or 
sugar. Urea, 1*60 per cent. Yesical and urethral epithelium, a few pus 
cells and small uric-acid crystals were found present under the micro- 
scope. No elevation of the temperature existed or took place while 
under treatment. The pulse was full and regular, but when he ex 
erted himself one beat in about fifteen would be missed—a condition 
which had existed for twenty-five years. As far as could be ascer- 
tained, all the other organs of the body were normal. The mind was 
clear, the brain active, no muscular weakness, no tenderness on pres- 
sure over the spine. The hair had turned very gray since the disease 
existed, but there was no alopecia. The beard had changed from 
brown to white. The nails of the fingers and toes were dystrophic, 
discolored, thickened and split longitudinally, and their growth was 
apparently retarded. 
With the exception of the face, the entire body was deeply pig- 
mented, but here and there were small islands of skin normal in color, 
and standing out in vivid contrast with the dark brown left by former 
outbreaks, with the red hue of the newer erythematous lesions and Case of Dermatitis Herpetiformis. 
3 
with the purplish and cvanotic tinge of those undergoing- involution. 
On the upper arms and on the abdomen were many dirty, grayish- 
white, irregularly shaped spots, evidently superficial cicatrices caused 
by the scratching and wounding of the lesions. The skin in its en- 
tirety was much thickened and indurated, especially over the buttocks. 
Below the knees it was tense and shiny, though not oedematous. The 
lesions distributed over the surface were.of all kinds, forms, shapes, 
and sizes. Vesicles, bullae, papules, and erythematous bands and 
patches occurred alone on a surface, or were grouped together in a 
most peculiar and inextricable manner. On the face, bullae alone 
were present. They were discrete or grouped, the size of a buckshot 
to a hazelnut, round or oval, linear or crescentic, or curving partly 
around a central bleb. Some were angular and stellate, others of uni- 
form outline. 
Over the body, discrete bullae were distributed. They were tense, 
resistant, not rupturing easily, and contained a clear, light-yellow, neu- 
tral fluid. In some places, notably at the navel, a large central bulla 
was seen surrounded by a row of vesicles somewhat larger than a pin- 
head. These bullous lesions arose apparently from the skin, without 
being preceded by any redness or primary change. The vesicles were 
pinhead and a little larger in size and grouped together, the groups in 
some places being a handbreadth in size. Some were deep-seated, as 
though occupying the center of pre-existing papules. Only on the 
backs of the hands had the contents of either bullse or vesicles become 
purulent, and when uninjured by scratching they dried up into thin, 
yellowish crusts. The papules varied in size from a small pea to a 
pinhead, bright or dusky red in color, and resistant. The larger ones 
were discrete, but the others were arranged in groups occupying small 
or large areas. The erythematous lesions were of most varied shape 
and form, and ranged in size from that of a nickel to patches occupy- 
ing, for instance, an entire buttock. They were also represented by 
narrow, elevated bands, ring-shaped and inclosing a sunken-in, viola- 
ceous center, or by segments of circles, or by gyrate or festooned lesions 
of varying length. In their evolution, they began as an erythematous 
solid efflorescence about the size of a nickel; the central portion soon 
subsided, becoming dusky red or cyanotic in color, while the red bor- 
der, a quarter to a third of an inch broad, advanced. As progression 
took place, involution occurred pari passu, until a limit of growth 
seemed to be reached, and then the entire lesion disappeared, leaving 
only some pigmentation, or upon the red elevated margin a row of 
vesicles or papulo-vesicles developed. The lesion would then appear 
as made up of a dusky-red or brownish disk, entirely or partly encircled 4 
Original Communications. 
by a chaplet of distinct vesicles arranged in a uniform or in a more or 
less irregular manner. Separate vesicles never arose in the centers of 
these disks, nor were these latter encircled by more than one row of 
such lesions. Instead of the progressive enlargement taking place, 
sometimes disks appeared which, from the first, were surrounded by a 
vesicular border. There were also crescentic lesions and others repre- 
senting some segment of a circle which appeared as primary efflores- 
cences. In their advance over the surface they would join together 
and thus form gyrate and wreathlike figures of varying contour and 
extent. On the legs below the knees there were many excoriated 
places and superficial ulcerations, due to scratching and the tearing of 
the surface. 
No particular course was followed in the evolution or involution of 
the lesions. They would appear suddenly, singly or in crops, and re- 
main for several days, or they would come out and disappear in a few 
hours or in a day. These latter would leave no trace of their former 
presence, but the bullm or vesicles would dry up into crusts, or, being 
ruptured by scratching, leave an excoriated surface which healed slowly. 
The papular and erythematous lesions, however, would change from 
a bright to a dusky red, then purplish, and when entirely gone only a 
brown pigmented area remained. 
The subjective symptoms were intensely severe, and consisted en- 
tirely in intolerable itching and burning. In some degree they were 
always present, but there would be paroxysmal exacerbations of excess- 
ive severity, and more frequently at night, or whenever he removed 
his clothing and his skin became exposed to the air. These symptoms 
and the clonic spasms already referred to prevented sleep for some 
hours after he went to bed. The itching and burning would also be- 
come worse whenever the weather was stormy or rainy, or when the 
bowels were costive, or if any mental worry or anxiety supervened. 
Before the appearance of a crop of lesions, the sites upon which they 
were to appear would likewise itch and burn intensely. There was 
a universal severe hyperidrosis also present, which added to his dis- 
comfort. Always existing on the trunk, it became severe upon the 
extremities only during the pruritic paroxysms. 
While the patient was under treatment, there was progressive im- 
provement, interrupted, however, by a succession of relapses of varying 
extent and intensity, and consisting of a single type of lesion or 
of multiform efflorescences. The occurrence of a relapse could not 
always be traced to any definite cause, though it would take place 
when there was a change from fine to bad weather, when any func- 
tional disturbance of the gastro-intestinal canal arose, or when he Case of Dermatitis Herpetiformis. 
overtaxed himself mentally or physically. Gradually, however, these* 
renewed outbreaks became less frequent and severe, the clonic spasms 
as well as the hyperidrosis ceased, the pigmentation diminished, the* 
skin was less thickened and infiltrated, and, generally and markedly 
improved physically and mentally, the patient went home March 23d. 
He was then entirely free from any lesions, and had only occasionally 
a little itching. At the end of a few weeks, however, the cutaneous 
symptoms returned in some degree, but subsided shortly. In the fol- 
lowing year there were several relapses, and finally he went to Europe 
for a number of months, and has since then remained comparatively 
well. The treatment he received while under my care consisted of 
general dietetic and hygienic measures. Ergot internally up to a 
drachm and a half three times a day, and ichthyol in carron oil exter- 
nally. Besides these, baths of starch and white-oak bark were given 
daily. The ichthyol gave almost instantaneous relief to the burning 
and itching, and enabled him to obtain rest and sleep. 
As I have already stated, this case presented in a most typical 
manner all the symptoms characterizing dermatitis herpetiformis, and 
in this it agreed with the many other examples of the disease which I 
have had under my care. That at times during its course it resembled 
to some extent in its lesions other diseases of the skin, is unquestion- 
able—in fact, that is true in all cases of dermatitis herpetiformis—yet 
when the symptoms developed were taken as a whole, it was readily 
seen that each variation in aspect wTas simply an expression of a part 
of that pathological process now recognized and known in its variable 
and multiform phenomena as Duhring’s disease. The right of distinct 
existence is not, however, accorded to dermatitis herpetiformis by all, 
as only in the last year Kaposi * has denied that it was a disease of 
itself, but rather a sort of collective conception, made up in part of 
erythema multiforme and of other bullous affections, urticaria, etc., 
and in part of pemphigus. As far as pemphigus is concerned, I most 
assuredly can affirm that this patient was not affected with that dis- 
ease. There were at various times during its course bullse on the 
surface, it is true, but these were greatly in the minority ; they were 
distributed here and there, but were relative exceptions in the great 
mass of other lesions with which the surface wras covered. Papules 
and vesicles arranged in groups were the predominant lesions, as well 
as erythematous patches of various shapes. I can not see how a pem- 
phigus could be made out of such a case, nor how its clinical history, 
phenomena, behavior, or course could be reconciled with those of pern- 
* Proceedings of Fifth German Dermatol. Congress. Original Communications. 
pliigus as defined and described by authors. Pemphigus acutus, a 
severe disease, with systemic reaction, fever, etc., and usually ending 
fatally in a few days, does not come into consideration here, nor does 
pemphigus foliaceus or vegetans, but only pemphigus vulgaris chronicus. 
This disease is defined by Hebra* as characterized by repeated out- 
breaks of India?, and no other lesion is described or mentioned by him 
in the whole article. Erasmus Wilson,f Tilbury Fox, Hardy,* 
Simon,| Crocker,A Brocq,() Zeisler, J and any number of others, have 
not deviated from this, Ilebra’s definition, beyond mentioning the 
occasional presence of some erythematous patches or urticarial wheals 
upon which bullae subsequently developed. Kaposi $ himself, in his 
book (1883), and again in its newer edition (1893), defines pemphigus 
as a “ bullous eruption, characterized by outbreaks of bullae,” men- 
tioning that erythematous phenomena of various kinds accompany it. 
Ko other lesions are described, and in the article devoted to the sub- 
ject he agrees with those other writers mentioned. When the descrip- 
tion of pemphigus as obtained from the works of these eminent writers 
is compared with that of dermatitis herpetiformis as given by Duhring, 
Brocq, and others, and also as observed by myself in many cases, it 
is certainly difficult to understand a failure to recognize Duhring’s 
disease as distinct from pemphigus: on the one hand, a process of 
which the essential symptoms—the sine qua non—are bullae ; on the 
other hand, a disease in which bullae do occur, but only as one of 
many other types of lesions, and, moreover, one which in my expe- 
rience at least, is more uncommon than anv other of the eruptive 
phenomena seen in the process. Besides these, in dermatitis herpeti- 
formis the subjective symptoms are intense, the itching, burning, and 
paraesthesia always severe; in pemphigus they are very slight, and 
often entirely wanting. The latter disease is accompanied bv severe 
systemic symptoms, the patients become emaciated and prostrated, 
while in the former the individual is in a relatively good condition of 
health, even though the process runs a long and chronic course. The 
mortality of pemphigus is certainly very high, and it has always been 
considered a serious disease; that of dermatitis herpetiformis is infini- 
* Hebra. Hebra and Kaposi, Hautlcrankh., 1872. 
\ Wilson. Diseases of the Skin, 1867. 
% T. Fox. Skin Diseases, 1873. 
* llardy. Traite des maladies de la peau, 1886. 
|| Simon. Hauthkrankheiten, 1861. 
A Crocker. Diseases of the Skin, 1888. 
() Brocq. Traitement des maladies de la peau, 1890. 
$ Zeisler. Morrow’s System of Syph., etc., 1894. 
X Kaposi. Pathologic und Therapie d. llautk., 1883 and 1893. Case of Dermatitis Herpetiformis. 
7 
tesimal. I do not remember more than one case of pemphigus vulga- 
ris which I have seen, which has not ended fatally, while in over forty 
of dermatitis herpetiformis which I have treated only one died, and 
then from septicaemia, the origin of which was very doubtful.* 
In view of these striking differences between the two forms of erup- 
tion, differences which have repeatedly been stated, it is therefore not 
surprising that the consensus of opinion has accepted and substantiated 
Duhring’s description, and that dermatitis herpetiformis has become 
recognized, with few exceptions, as a distinct entity. It may, however,, 
be advanced that such cases are nevertheless examples of pemphigus 
•vulgaris, being of the type pemphigus pruriginosus. Still, this latter 
is now separated from pemphigus, and certainly clinically it bears no 
resemblance to it. Kaposi f specifically states that the picture pre- 
sented by pemphigus pruriginosus is entirely different from the usual 
one of pemphigus vulgaris (ein von dem gewohnliohen ganz abweick- 
endes Krankheitsbild), explaining the absence of bullae by the fact that 
the erythematous lesions are scratched before the bullae can form. I 
most certainly would agree with him that it bears no resemblance to 
pemphigus vulgaris, but, being so markedly representative of dermatitis 
herpetiformis, it is not surprising that it has come to be generally re- 
garded as belonging in this latter category. 
It is hardly necessary to make a differential diagnosis between this 
case of dermatitis herpetiformis and erythema multiforme bullosum, 
or of other type, or to take urticaria bullosum into consideration. 
Only careless observation could allow these eruptions to be confounded 
with the former one; and I wrnuld only state, in conclusion, that the 
case reported here was neither a pemphigus, nor an erythema multi- 
forme, nor an urticaria, but a most typical and characteristic example 
of dermatitis herpetiformis. 
I//. West Thirty-third Street. 
* Elliot. American Journal of the Medical Sciences, 1895. 
f Kaposi, loc. cit.