438 MEDICAL MYCOLOGY 



The lesion begins as a round, red, elevated spot with intense pniritus. 

 Soon the center becomes paler and pigmented brown; only the margin shows 

 the characters of the active lesion. This normally consists of small vesicles, 

 filled with a serous liquid. These open spontaneously, leaving a slight crust 

 and scales. By this time the pruritus has usually caused extensive scratching 

 followed by punctiform excoriations and black or brown crusts in which blood 

 from scratching is mingled with the exuded liquid. Unless secondary infec- 

 tion sets in, healing begins in the middle, leaving brown normal skin which 

 gradually fades. As it spreads, growth is more variable ; the circular appear- 

 ance is lost and it gradually becomes polycyclic and irregular in outline. New 

 lesions may have started from autoinoculation by scratching, which spread 

 and fuse with the original lesion. Rarely the red border is lacking, and the 

 lesion remains red and furfuraceous for some time. It suggests pityriasis 

 rosea but it is more inflammatory (Arzt & Fuhs, 1924). Another type, still 

 rarer, shows a more inflammatory lesion elevated 2-3 mm. above the healthy 

 skin with its surface full of small vesicopustules. The disease may become 

 chronic without treatment, lasting a year or more, with recurrence after ap- 

 parent healing unless properly treated. Karrenberg (1928) reports an eryth- 

 rasmoid type. 



In the interdigital folds (usually confined to the toes), perhaps because 

 of the higher and more constant moisture content of the epidermis, the skin 

 of the fold is dark grayish red, the horny layer thin, dry and shining, or moist 

 and eroded, soon disappearing over part of the lesions. Deep in the fold are 

 found white, macerated scales or larger swollen membranous sheets of epi- 

 dermis. The margins are distinct and curved, the homy layer separating, 

 allowing large flakes to be pulled off. Commonly, but not always, some 

 vesicles may be found. Rarely does the lesion extend to the dorsal part of 

 toe or foot, and it usually does not extend much beyond the area in which 

 the toes are in contact with the plantar surface. Pruritus may be present and 

 intense or it may be absent. The interdigital spaces of the hands are rarely 

 infected, perhaps owing to lower moisture content. Various species of 

 Monilia seem to be the common occupants of this site, producing lesions 

 quite similar to those of the feet. Cleveland "White (1928) reports a case of 

 inguinal lymphadenitis accompanying interdigital lesions, in which he was 

 able to isolate Epidermophyton interdigitale from the inguinal lymph nodes. 



When the palmar and plantar surfaces are attacked, usually a dysidrosi- 

 form or a hyperkeratotic lesion results. The principal symptom of this lesion 

 is translucent gray red to steel blue vesicles in the horny layer, suggesting 

 grains of sago and varying in size from that of a pinhead to that of a lentil. 

 Where the horny layer is thick, as on the soles of the feet, the vesicles are 

 below the level of the surface, but where the homy layer is thinner, as on the 

 hands and toes, the vesicles are raised slightly above the surface. Frequently, 

 especially on the feet, the vesicles appear yellowish milky from pus formation. 

 The vesicles or pustules seldom open spontaneously to produce a moist eczema. 



