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Crazy pavement skin eruption
291 TRANSACTIONSOF THE ROYALSOCIETYOF TROPICAL MEDICINE AND HYGIENE. Vol. XXXIV. No. 3. November,1940.
CRAZY P A V E M E N T
SKIN ERUPTION.
BY
LUCIUS NICHOLLS, M.D. (CANTAB.), Bacteriological Institute, Colombo, Ceylon.
There is a tendency at the present time to attribute certain types of skin changes in the malnourished to pellagra, or to refer to them as pellagroid. An example of this occurs in the January issue of these TRANSACTIONS, under the title " Infantile Pellagra." In this paper H. C. TROWELL (1940) reviews a number of publications in which certain types of malnutrition in children have been described from many parts of the world. Apparently the commonest sign in these types is oedema ; but many, if not all, of the children show a skin eruption, which being irregularly fissured was first described by WILLIAMS (1933) as resembling crazy pavement. Some of these publications state that other signs, such as xerophthalmia, stomatitis, polyneuritis and diarrhoea also occur in some of these children. But the diagnosis of " infantile pellagra " appears to be founded mainly on the crazy pavement eruption. The nomenclature of malnutrition is a difficult matter, because unlike the infections, there is seldom a single etiological factor, a deficient diet almost always being deficient in more than one factor. Oedema is not a characteristic of pellagra, and when it is present in the malnourished it is mainly due to protein deficiency, and it is appropriate to refer to it as nutritional oedema.
~92
CRAZY PAVEMENT SKIN ERUPTION.
Skin changes, which may be likened to crazy pavement, are far from uncommon among patients in the wards of the general hospitals in the tropics. The following are two examples : - CASE I. The patient, age 35, was a fairly well-to-do trader. He had suffered from chronic nephritis for about 2 years. He had had oedema of the legs, and this had subsided on a high protein diet. The skin over the anterior surfaces of the legs was somewhat rough, and was finely and irregularly fissured (vide Fig. 1). He stated that his skin had alwa"ys been somewhat rough, but only recently had been fissured. T h e face, back of the hands, upper surfaces of the ankles, and the rest of the body was free from these changes. His description of his diets before and after his illness started indicated that they had always been adequate, and had included ample of the protective foodstuffs, such as milk and eggs. CASE I I .
The patient, age 30, was of the labouring classes, 'and was suffering from phthisis. He had patches of superficial epithelium which were darker than the normal skin and were separated by fissures (vide Fig. 2). The skin changes occurred only on the legs below the knee ; the upper surfaces of the ankles were not affected. He had lived on the usual curry and rice diets before entering hospital 6 weeks previously, and his descriptions of his diets did not indicate any marked deficiencies. It may be that in such cases as these there has been deficient absorption or faulty metabolic utilization of certain vitamins, but in the present state of our knowledge we are not justified in making assumptions of this kind, still less to diagnose all such cases as pellagra mainly on the existence of a crazy pavement eruption. REFERENCES. TROWELL,H. C. (1940). Infantile pellagra. Trans. R. Soc. trop. Med. Hyg., 83, 389. WILLIANIS,C.D. (1933). A nutritional disease of childhood associated With a maize diet. Arch. Dis. Childh., 8, 423.
FIG. I.
FIG. II.
CRAZY
PAVEMENT
SKIN
ERUPTIOX.
CRAZY P A V E M E N T
SKIN ERUPTION.
BY
LUCIUS NICHOLLS, M.D. (CANTAB.), Bacteriological Institute, Colombo, Ceylon.
There is a tendency at the present time to attribute certain types of skin changes in the malnourished to pellagra, or to refer to them as pellagroid. An example of this occurs in the January issue of these TRANSACTIONS, under the title " Infantile Pellagra." In this paper H. C. TROWELL (1940) reviews a number of publications in which certain types of malnutrition in children have been described from many parts of the world. Apparently the commonest sign in these types is oedema ; but many, if not all, of the children show a skin eruption, which being irregularly fissured was first described by WILLIAMS (1933) as resembling crazy pavement. Some of these publications state that other signs, such as xerophthalmia, stomatitis, polyneuritis and diarrhoea also occur in some of these children. But the diagnosis of " infantile pellagra " appears to be founded mainly on the crazy pavement eruption. The nomenclature of malnutrition is a difficult matter, because unlike the infections, there is seldom a single etiological factor, a deficient diet almost always being deficient in more than one factor. Oedema is not a characteristic of pellagra, and when it is present in the malnourished it is mainly due to protein deficiency, and it is appropriate to refer to it as nutritional oedema.
~92
CRAZY PAVEMENT SKIN ERUPTION.
Skin changes, which may be likened to crazy pavement, are far from uncommon among patients in the wards of the general hospitals in the tropics. The following are two examples : - CASE I. The patient, age 35, was a fairly well-to-do trader. He had suffered from chronic nephritis for about 2 years. He had had oedema of the legs, and this had subsided on a high protein diet. The skin over the anterior surfaces of the legs was somewhat rough, and was finely and irregularly fissured (vide Fig. 1). He stated that his skin had alwa"ys been somewhat rough, but only recently had been fissured. T h e face, back of the hands, upper surfaces of the ankles, and the rest of the body was free from these changes. His description of his diets before and after his illness started indicated that they had always been adequate, and had included ample of the protective foodstuffs, such as milk and eggs. CASE I I .
The patient, age 30, was of the labouring classes, 'and was suffering from phthisis. He had patches of superficial epithelium which were darker than the normal skin and were separated by fissures (vide Fig. 2). The skin changes occurred only on the legs below the knee ; the upper surfaces of the ankles were not affected. He had lived on the usual curry and rice diets before entering hospital 6 weeks previously, and his descriptions of his diets did not indicate any marked deficiencies. It may be that in such cases as these there has been deficient absorption or faulty metabolic utilization of certain vitamins, but in the present state of our knowledge we are not justified in making assumptions of this kind, still less to diagnose all such cases as pellagra mainly on the existence of a crazy pavement eruption. REFERENCES. TROWELL,H. C. (1940). Infantile pellagra. Trans. R. Soc. trop. Med. Hyg., 83, 389. WILLIANIS,C.D. (1933). A nutritional disease of childhood associated With a maize diet. Arch. Dis. Childh., 8, 423.
FIG. I.
FIG. II.
CRAZY
PAVEMENT
SKIN
ERUPTIOX.