Syphilitic Pigmentation. 
By A. H. Ohmann-Dumesnil, M. D., of St. Louis. 
[Reprinted from The Tri-State Medical JOURNAL and Practitioner, St. Louis, August, 1897.J 
AMONG the signs which attest to the existence of a former eruption of 
syphilis and, consequently, as evidence that the disease has existed, 
is the syphilitic pigmentation. Every practitioner of medicine and 
every surgeon places much reliance upon this sign and, unfortunately, too 
much in some cases. For it must not be forgotten that quite a number of 
non-venereal cutaneous troubles but too often leave traces behind them in 
the form of pigmentations, and it often requires a well-trained eye coupled 
with experience to establish a positive differential diagnosis. For this, 
among other reasons, it has seemed proper to me to dwell at some length 
upon a subject which might, under ordinary circumstances, seem rather 
trivial to the reader. Cases do arise in which it is necessary to make out a 
history of syphilis in order to cure some condition present which may be 
due to the disease. If the objective lesions of the skin negative the former 
presence of lues, much unnecessary experimenting is avoided; and if the 
lesions which are present are pigmentations, care must be taken to recog- 
nize them and their cause in order not to fall into an error which might 
ultimately lead to irreparable consequences. I have seen freckles of large 
size mistaken for syphilitic pigmentation, and flea-bites taken for a small 
papular syphilide in the same individual. One symptom was apparently 
confirmatory of the other, and but for timely interference the patient would 
have been subjected to a long course of useless medication. Not only is 
such a consequence to be feared from a purely medical point of view, but 
the social consequences are apt to become quite disastrous to the individual 
from a social standpoint. For instance, a young man who has matrimonial 
intentions presents pigmentary stains and is told that he is suffering from 
an old syphilis may strenuously and very correctly deny that he ever had 
the disease. But when he is told by his uninformed medical adviser that 
he has suffered from "ignored" syphilis and that he presents indubitable 
signs of the disease, he will in the majority of instances simply abandon 
all thoughts of getting married and fall into a state of utter 
always a prey to anxiety in a fear of what will never happen and continu- 
ally on the alert to see that which it is impossible should occur. It is the 2 
avoidance of such consequences which should lead the practitioner to care- 
fully consider the subject of cutaneous pigmentation, its different varieties 
and manifestations, as well as its various phases in different cutaneous 
troubles, in order to be able to avoid making what might prove to be a 
serious mistake. 
It may be stated, in general terms, that it is an almost inevitable con- 
dition, or rather sequence, for syphilitic cutaneous manifestations to be 
followed by more or less marked pigmentation. A peculiarity in connec- 
tion with this pigmentation is that it is more marked in color and outline 
in those cases in which but little or no attention has been paid to the 
employment of external applications to the syphilides which have occurred. 
In those cases in which there has been complete neglect in regard to the 
local treatment of the eruption, it will be found that the pigmentation is 
most intense, and the color is still more heightened if the individual be 
one having a dark complexion. It will require very little observation to 
demonstrate that blondes do not exhibit as marked pigmentary changes of 
the skin as brunettes do in ordinary cutaneous troubles, and the same 
holds true in syphilis. A very small amount of observation will readily 
demonstrate the fact that blondes do not show dark pigmentations, and 
care should be taken not to overlook them on account of their apparently 
mild character; nor, on the other hand, should it be supposed that because 
syphilitic pigmentation is dark in a brunette it is necessarily of a severe 
type or an indication that the primary lesions were of a particularly severe 
or malignant type. In any event, the very presence of the pigmentation 
is a matter of some interest, as it is a sign which plainly indicates the im- 
portance as well as necessity of giving the proper care and attention to all 
cases of syphilitic eruption, in the way of appropriate external applica- 
tions, and also shows, in great part, the reason why the more careful 
writers on syphilology generally insist upon local treatment as a necessary 
adjunct to the internal remedies which are administered. 
It may not be inappropriate to give a sort of general classification of 
the various forms of syphilitic pigmentation which are observed. In the 
first place, all may be divided into two general classes-the idiopathic and 
the symptomatic. The idiopathic are such as follow simple non-destruct- 
ive lesions, such as the roseola, papules, etc. These have a tendency not 
to be as deeply pigmented as in the other class. The traumatic syphilitic 
pigmentation embraces those stains which follow lesions that destroy a 
whole or part of the cutaneous tissue, such as deep pustules, ulcers, cuts, 
burns, etc. It must not be forgotten that traumatisms inflicted upon a 
syphilitic, more especially during the early secondary period, are followed 
by marked pigmentation. Another peculiarity of traumatic syphilitic pig- 
mentation is that it is more deeply colored than the idiopathic. 
The varieties just mentioned may be subdivided, each one, into the 
small and large. The small pigmentation varies in size from a small pin's 
head to the small finger-nail, whereas the large varies from the size of the 
small finger-nail to that of a silver dollar, or even larger-that of the palm 
of the hand. The size is, of course, governed by that of the lesion which 
preceded the pigmentation, so that no fixed rule can be given in regard to 
the size attained or shown. This can only be determined by an examina- 
tion of a case while the eruption or lesions are present. Of course, the 3 
pigmentation present, its color, size, and length of persistence, may give a 
certain more or less distinct idea of the condition which pre-existed. The 
distribution of the lesions in syphilitic pigmentation may be discrete, dis- 
seminated or confluent. In the discrete form the stains occur here and 
there, and, as a usual thing, are not numerous. This is, perhaps, the 
most common, or, at least, that which is. most frequently seen. Not more 
Fig. i. Disseminated Syphilitic Pigmentation. 
than from two to six finger-nail size stains may exist. In the disseminated 
form we have a condition characterized by the presence of numerous stains 
Which vary in size. A good example of this is shown in Figure 1. A 
limb, a portion of the trunk, or the entire body, may be involved. In the 
confluent syphilitic pigmentation we have a condition presented which is 4 
far from being a common one. In this form a large area is involved, but 
it is the rule that certain portions of the skin remain normal. In fact, 
upon a superficial glance it would lead an unpracticed eye to pronounce 
the trouble one of vitiligo. The peculiarity of the contour of the healthy 
Fig. 2. Confluent Syphilitic Pigmentation. 
skin will readily dispel any such idea, and a careful examination will 
readily show that, instead of a loss of pigment declaring itself, the color- 
ing matter is, in reality, encroaching upon the normal skin. A representa- 
tion of a case of this rather rare condition is shown in Figure 2, which 5 
shows very plainly the difference in tint of the normal and of the pig- 
mented skin in a syphilitic whose complexion was quite dark. In this 
form of the trouble care must be taken not to mistake it for other forms of 
extensive pigmentation. Thus, for instance, we have so-called "vaga- 
bond's disease,'' which is due to filth and parasites causing an intense 
pruritus, and the efforts to relieve this by scratching cause a black discol- 
oration of the skin by reason of the dirt on the surface and under the nails 
being deposited under the upper layers of the skin. Again, we have an 
extensive pigmentation occurring in Addison's disease, and, although not 
quite so dark as in syphilitic pigmentation and having the peculiar bronzed 
tint so characteristic of the disease, it may prove deceptive to one who has 
not closely studied these colors; and this very fact of the possibility of 
making an error should make observation more keen and discriminating. 
It is by no means an unusual thing to find, in a case of syphilis in 
which an extensive eruption of papular, pustular or papulo-pustular syph- 
ilides have occurred, large and well-marked pigmentations such as 
are delineated in Figure 1. This is the class of cases which should be 
studied in order to be able to master the various peculiarities which go to 
make such a condition characteristic and enable the observer to pronounce 
his views definitely in regard to any given case. The apparent lack of 
attention which has been devoted to the subject renders it positively im- 
perative to devote some study to it, and it will be found profitable to do 
so. As has been stated above, these pigmentations occur in cases in which 
there has been but little or no internal treatment, or one which has been 
entirely inadequate to the condition present, and, in addition, no external 
treatment at all. Nor must it be forgotten that even efficient treatment 
will not be successful unless it be followed for a certain length of time, 
such as the exigencies of the case may call for. A specific treatment for a 
few months is certainly not sufficient, and taking remedies spasmodically 
will never succeed. Whatever treatment is taken must be prolonged over 
a sufficiently long period of time-one and a half or two years-and then 
there is good ground to expect an immunity from all danger of any tell- 
tale pigmentation. 
As has been already mentioned, the syphilitic pigmentation may vary 
considerably in size and color. In form it may be roundish or ovalish, or 
of the form assumed by lesions which are confluent, or that characteristic of 
the trauma immediately preceding. It is of a brownish color, somewhat 
resembling that of copper which has been exposed to the air. Of course, 
the intensity of the tint varies a great deal. In the negro it looks black, 
in light blondes it is of a light tan color. The contours of these pigmenta- 
tions are sharply defined and the borders are clean cut. There are no sub- 
jective symptoms whatever connected with these pigmentations. It is this 
very absence of any subjective symptom which will best serve to differen- 
tiate syphilitic pigmentation from the cutaneous trouble which most closely 
resembles it-tinea versicolor. The latter, which is of vegetable parasitic 
origin, and this is easily determined by the microscope, itches and des- 
quamates to a certain degree, both of which are symptoms not met with in 
pigmentation. In chloasma we have a marked pigmentation whose color dif- 
fers essentially from that of syphilitic origin, and there is, moreover, no his- 
tory whatever of the existence of any previous lesion or eruption. By care- 6 
fully considering these points and establishing the presence or absence of 
any concomitant syphilitic lesions, either primary or consecutive, a differen- 
tial diagnosis can be arrived at with comparative ease. The pigmentary 
syphilide is one which might be taken for the pigmentation under consid- 
eration; more especially as it is a comparatively rare manifestation of syph- 
ilis. In this the pigmentation is not consecutive to some primary lesion 
and is not the result of any destructive process. It appears as such from 
the beginning and is an eruption per se. It is found to occur most gener- 
ally in women, and it makes its appearance upon the back and side of the 
neck. There seems to be no record of its occurring upon the anterior aspect. 
The color of the pigmentation is very light, and it might at first glance be 
taken for an eruption of light freckles. Its peculiarity in distribution, how- 
ever, would show that this is not the condition. It is at best a very unusual 
and even a rare condition. 
Syphilitic pigmentation is rather irregular in its distribution. It is by 
no means necessarily limited to the trunk and extremities. It will show 
itself upon the face and hands, if those parts have been the seat of a syph- 
ilitic eruption. It is for this reason that there attaches some degree of im- 
portance to the prompt recognition of these lesions, more especially when 
in visible portions of the body, in order that there may be accomplished a 
rapid disappearance of. these tell-tale marks of a syphilitic infection, which 
are to-day so readily recognized by the laity as indisputable signs of a former 
infection, and it happens very often that these disguises by the vulgar miss 
their mark. 
The usual course followed by these stains, if they be permitted to take 
their own way, is for them to disappear gradually and ultimately pale in 
the center. This disappearance of pigment progresses slowly towards the 
periphery until there remains nothing but a narrowing of colored pigment 
which seems quite marked. This in its turn also becomes paler, and after 
the lapse of a longer period of time the whole discoloration disappears in its 
entirety. If there has been any considerable destruction of tissue, a white 
scar, either thin or thick, will remain and will become prominent on account 
of being much paler than the normal skin. The entire disappearance of 
the pigmentation is a consummation, however, not as readily attained as 
the patient could desire. It requires quite some time, many months in 
some cases, to arrive at this much-desired result. 
From what has been said, it is quite apparent that the recognition of 
syphilitic pigmentation is a comparatively simple matter, and its treatment 
is equally so if the proper measures be adopted. The treatment of syph- 
ilitic pigmentation is preventive or curative. In the former instance 
energetic general treatment is, of course, essential; and if there be any 
eruption present, local measures are to be applied; and the prevention of the 
appearance of the brownish stain depends entirely upon the faithfulness of 
the patient in making the applications. Among the eligible preparations 
which will be found of value are the following: 
Hydrarg. oleatis, 5%gss. 
1. olivae, opt 
M. Sig. Rub in well once daily. 7 
If an oily preparation be objected to, the following may be employed: 
$ Hydrargyri bichloridi gr. v. 
Ammon, muriat gr. x. 
Spts. coloniensis 
Aquae destillat aa giij. 
M. Sig. Apply twice a day. 
If the curative plan must be employed, much more radical measures 
are necessary. In the case of old pigmentations the following will be found 
of service, remembering that a 1 to 500 bichloride solution must be ap- 
plied finally. Of course, active internal treatment must be given. The 
method is that of Barthelemy, and is a very good one, although somewhat 
troublesome. 
Resorcini 1 5X- 
Zinci oxidi * 5fi8s* 
Glycerini ss 
Adipis Jv. 
Ol. olivae gij. 
M. Sig. Apply several times a day. 
After using this for three days the skin becomes parchment-like and 
peels off. The following is then applied: 
Grenetinalb 5j. 
Zinci oxidi gr. xlv. 
Glycerini 51ss' 
Aquae destillat gij. 
M. Sig. Apply twice a day for two or three days. 
In all cases of syphilitic pigmentation the prognosis should be guarded. 
The pigmented areas, when once established, will persist for a very long 
time, and all the internal treatment administered will fail to procure a good 
result or have any influence in bringing about its disappearance if not aided 
by external measures. Of course, the pigmentation will eventually dis- 
appear spontaneously, but may occupy years in its fulfillment. Energetic 
internal and external measures, however, will enable the physician to give 
not only reasonable hopes but a fair degree of assurance to the patient that 
the spots will disappear in a comparatively short space of time.