Report

NUMMULAR ECZEMA OF STATIS ORIGIN

THE BACKBONE OF A MORPHOLOGIC PATTERN
OF DIVERSE ETIOLOGY
BERNARD |, BENDL, M.D,

ABSTRACT: A tota! of / 3 patients with nummufrom the Division of Dermatology,

lar eruptions of unknown origin were collected
University of British Columbia.
Vancouver. Brilish Columbia. Canada
over a period of 8 years. This numberws reduced
to 82 patients by exclusion o known clinical entities which became unmasked during the study.
All 82 patients were found to have varicose veins
and/or edema of the lower extremities. Auciency), infection (bacterial, fungal, viral),
toeczematization may be the common denominator.
neurosis, atopic dermatitis, allergy (food or

Devergie first coined the term nummular

eczema in 1857. He described a patchy eczematous eruption of unusual tenacity which
involved the extremities and trunk. Numerous
articles were written over the succeeding century. These were preoccupied with defining
the morphologic ap[iearance of this condition.
Since 1950 many investigations have been
directed toward elucidating the etiologic factors in this presentation. In general, the varied
and diverse factors held to be responsible for
this condition have followed the vogue of the
times. The following list is impressive only in
its length: nutritional (food or vitamin defiPresenled at the 52ncl Annual Meeting o\ Ihe Canarii.in
Dermatolgica I AssiKiation, Montreal Qucl>ec, lune H,
1977.
Address for reprinls: B, |, Bendl, M.D., 26-3195
Cranville Streel, Vancouver, B, C, Canada, V6H K2.

bacteria), contact dermatitis (primary irritant

or allergic), toxic (bacteria), complex allergens (combinations of bacterial and
cutaneous breakdown products), allergy to
food proteins, internal iocus of infections, and
a mild form of dermatitis herpetiformis.
Many studies in the past have treated nummular eczema as a single well-defined
etioiogic or morphologic entity^neither of
which it is. Some uninformed or misinformed
investigators have taken the term "nummular" literally and have included any coinshaped eczematous patchy eruption under
this diagnosis. The net result o all these investigations has been destruction of the term
tiummular eczema.
Clinical studies in the past have been carried out on a heterogenous group of nummular eruptions. For example, there is no need to
include housewife's eczema, atopic dermatitis, asteatotic eczema, discoid seborrheic

()(jn-9()39/79/()3()()/129/$()U,5 Inlernalional Society of Tropical Dermatology, Inc,

129

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INTERNATIONAL lOURNAL OE DERMATOLOGY

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Vol. 18

Table 1. Ultimate Diagnoses in I 13 Patients Initially Diagnosed as

"Nummular Eczema"
A.

Nummular eczema of stasis origin (82 patients)

B.

Others (31 patients)

Atopic dermatitis
Tinea corporis
Contact dermatitis
allergic
irritatit
Drugs
Parapsoriasis guttata
Dyshidrosis with autoeczematization
Multi|>le factors

''

patients
^^
^

^
'^
^

+ lycra, B. C, cedar oleoresin, rubber.

i carbrital, gold.
1 - atopic dermatitis + allergic contact (sheets)-'^
2 - tinea corporis -I- allergic contact (nickel) + discoid seborrheic dermatitis
3 - dyshidrotic eczema + micosis fungoides
4 - dyshidrotic eczema + irritant dermatitis

dermatitis, or contact dermatitis under the

term nummular eczema.
If we are to derive any useful data from the
analysis of a series of patients with nummular

eruptions, we must first exclude distinct clinical entities. Once the known clinical entities
are excluded, the residual patients may be
scrutinized closely for evidence of similarity.

Table 2. Classilication of Nummular Eczema Patterns

A.

True Nummular Eczema (Intrinsic Eczema, Autoeczematid)

1. Nummular eczema of stasis origin (exudative neurodermatitis of Kreibich- and Ehrmann,^ varicose eczema
with autoeczematization," stasis dermatitis with autoeczem.itization),
2. Dyshidrosis with autoeczematization ("dry type" of nummular eczema of Dowling^).
3. Chronic recurrent recalcitrant pustular eruption of the palms and soles with autoeczematization (pustular
bacterid with acitt)eczemalization).
4. Others: Irritation or edema o a primary cutaneous eruption may result in the appearance of nummular
eczematous lesions distant from the original site. This spread would appear to occur by hematogenous
dissemination, eg. tinea pedis with trichophytid,

B. False Nummular Eczema

These condtions represent primary cutaneous entities which, on occasion exhibit a nummular pattern.
1. Atopic dermatitisinfantile, childhood and teenage fomis.
2. Lichen simplex chronicus (Vidal).
3. Contact dermatitis
a. Allergiceg. nickel
b. Irritant
1. housewife's eczema
2. eczema craquel (asteatotic eczema)
3. pityriasis alba (chronic superficial dermatitis ol Dowling")
4. Drug eruptionseg. carbrital, gold, fixed drug eruptions.
5. Infectionseg. impetigo, infectious eczematoid dermatitis (Engman"), candidiasis, dermatophytosis.
t>. Othersdiscoid seborrheic dermatitis, Garbe-Sulzberger dermatosis, dermatitis her[>etiformis, mycosis fungoides, neurotic eczema of Brocq" (recurrent eczemaloid infection of Ihe hands of Pollitzer) psoriasis, etc.

No. 2

NUMMULAK ECZEMA

The purpose of this study is the examination

of a group of 82 patients in whom certain
similarities seemed more than a coincidence.
These patients were classified as nummular
eczema of stasis origin.

Bendl

131

20-

10-

Materials and Methods

One-hundred and thirteen patients with
nummular eruptions of unknown origin were
collected over a period of 8 years- Patients
who presented initially with nummular eruptions which eventually proved to be distinct
clinical entities were excluded from the study
group (Table 1). Specific patterns of disease
soon became obvious, and a basis for classification of nummular eruptions was established {Table 2).
A group of 82 control patients, randomly
chosen, but matched for age and sex, were
examined for evidence of varicose veins and
edema of the lower extremities. These patients had presented with culaneous complaints other than nummular eczema.
Fourteen random biopsies were taken from
the trunk and extremities of 11 study patients.
Representative eczematous and scaling lesions were included in this sample. Multiple
hematoxylin and eosin stained sections from
each biopsy specimen were examined.

80

Fig- 1. Nummular eczema of stasis origin. Age and

sex distribution-

men, the median duration was 5 months

(range 1 week to 17 years).
Signs and symptoms: The most common
symptom complained of by patients was
pruritus. Clinical signs (Figs. 2-4) exhibited
by patients include scaling patches (Rayer
eczema)71%, eczematous patches (Willanic eczema)32%, erythema32%, minimal petechiae or hemosiderin 16%. Only 2
patients exhibited hemosiderin pigment in
the skin. Petechiae were thought to be induced by rubbing of the affected areas. It is
noteworthy that none of the 82 patients in the

Results

5ex and age: Of the 82 patients, 45':^ were

women and 55% men. The peak prevalence
in women was in the 41-60 age group
(46%). In men, it was iti the 51-70 age group
(51%). The median age of women was 52
years (range 21 -82 years). The median age of
men was 62 years (range 21-82 years). Fourteen percent of all patients were under 41
years of age and 6% were older than 81
years. The vast majority of fhitients (80%)
were therefore between the ages of 41 and
80 years (Fig. 1).
Duration: The median duration of the
eruption prior to examination in men was 4
months (range 1 week to 10 years). In wo-

Fig. 2. Prominent vari( ose vems, ederna, erythema,

hyjierpigmentation and the patchy etzematotis eruption
<H nummular et^t-m.i ot slasis origin, lateral leg-

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Vol, 18

contained mononuclear cells. The derma!

findings were confined to the upper and mid
dermis atid consisted of vascular ectasia, exIravasation of erythrocytes and a dense
perivascular lymphocytic inflammatory infiltrate,
Conirfb(/(/ng or etiologic factors:

I lg, i, Ec-',eiiia!ou:>
hands (same patient as in Fig. 2).

Mit; doi^a ui the

Study showed vesiculation of the palms or

soles.
Distribution oi lesions: Ninety-eight percent of initial lesion (s) occurred on the lower
extremities. Two patients (one lemaie and
one male) exhibited their initial lesions on
the dorsa of the hands. The distribution of
lesiotis is demonstrated in Figure 2, The extensor surfaces of the limbs are, by far, the
most cotnmonly involved areas.
Pathology: The acuteness of the histopathologic findings paralleled the clinical
appearance of the lesions biopsied. The
usual epidermal findings were those of mild
hyperkeratosis, spotty parakeratosis, intracellular edema, spongiosis, mild to moderate irregular acanthosis, exocytosis ot lymphocytes and intraepidermal vesicles. Vesicles

1. Varicosities of the lower limbs: 88^/( of

all patients exhibited moderately severe or
severe varicositie'^ of the lower extremities. In
15'7( of all patients, the varicosities were unilateral. Ten patients (12'";i) had no evidence
of varicosities (Table 3) it is perhaps relvent,
that whenever one limb exhibited more severe varicosities than the other (56'7( of patients), the initial cutaneous eruption always
appeared on this limb.
2. Edema of the lower limbs: 87'i of all
patients exhibited pitting edema of the involved lower extremities. Eleven patients
(13'/f) did not demonstrate edema of the involved lower extremities. Of this latter group
of patients, no information was available in
one patient, four patieiits were on diuretics at
the time of the examination, two patients declared that they did not experience edema,
although they had not been examined for this
sign. Four patients had no evidence of edema
at tlie time of examination.
3. Previous vascular surgery or trauma:
Thirty-two patients (39%) had a previous history of vascular surgery, severe trauma,
sclerotherapy or phlebitis of the involved
lower extremities.
4. Seasonal prevalence: Fifty-three patients (65%) first presented with their problem during the winter or spring. The median
duration of the eruption was 4-5 months.
This would indicate that in a majority of patients, the eruption first appeared in the Fall
or Winter,
5. Other factors: In contrast with other
studies, a small number of patients (13%)
were encountered under the age of 41 years.
It was thought that this group of patients
might be different from the over 40 age

No. 2

NUMMULAR ECZEMA

133

Bendl

Fig, 4. Miiipiiologic lesicjns ot nummular ec/ema ot stasis origin. A, lett. scaling patch (Rayer eczema) on
dorsuni of wrist. B, ngfif, eczematous patch iWillanic eczemal on anterior tibia.

group. Table 4 summarizes the relevant data

in the under 41 age group of patients.
The control group of 82 patients exhibited
some very striking differences from the study
group. Twenty-one percent of control patients exhibited moderately severe to severe
varicosities of the lower extremities (as compared to 88% of the study group). Twelve
percent of control patients showed pitting
edema greater than 1 + (as compared to 87%
of the study patients). Thirty-otie percent of
control patients had a previous history of
Table 3.

I'alieiit

1
2
i
4
5
b
7
8
9
10

vascular surgery, severe trauma or phlebitis

of the lower extremities (as compared to 39%
of study patients).
A most striking and unexpected discovery
in the control group was the finding of 4 men
with classical nummular eczema of stasis origin. These patients had presented with complaints unrelated to their nummular eczema,
A considerable difference exists between
the study and control patients due to the
presence of edema and varicose veins. From
the raw data, this difference is so significant

l'crlinenl Liinicjl D.ila on Patients V^ithoul

the Lower Limb--

of

Clinical Features
Aching ot loth legs with intermittent claudication
P,ira|)legic with multiple fractures and edema of both legs
Bilateral pitting edema of legs
On diuretics tor edema of legs
P,ira|ilegic with heart failure; on ctiuretics with gross edema of legs
Fractured hip i years previously and persislent edema of involved leg
Edema ol involved leg at end of day
Ischemia of legs with edema of involved limb
Persistent edema of ankles and hands of unkown origin
Diabetic with persistent edema of lou'er legs

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INTERNATIONAL JOURNAL OF DERMATOLOGY

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Vol. 1H

pletely to even the most aggressive topical

therapy. Potent topical corticosteriods combined with the use of a diuretic, however,
result in a very favorable response. This latter
therapy is used by the author in eruptions of
limited distribution. Fxtensive rapidly spreading eruptions are treated with long acting corticosteroids, intramuscularly, topical potent
corticosteroids, and diuretics. Once the eruption clears, it is controlled with diuretics and
topical corticosteriods.
Surgical treatment of the varicose veins
occasionally resulted in cutaneous remissions of many years. However, this usually
occurred only where the involved varicosities were localized. Surgical treatment of
extensive moderately severe or severe varicose veins was often followed by a remission
of many months. Fventually, maintenance
therapy with diuretics and topical corticosteriods became necessary.
Fig, 5. Nummular eczema of statis origin. Distribution of lesions.

to a very high degree that a statistical analysis

would serve no useful purpose.
Treatment: The recurrent and recalcitrant
nature of "nummular eczema" is a very prominent part of the clinical pattern. A persistent
problem of stasis may be the underlying
problem responsible for the historically poor
response to therapy and the high relapse rate.
I believe that nummular eczema of the
type described in this study responds incom-

Comment
Autoeczematization is a clinical term
which has been used to describe a clinical
event. It has been noticed over the years that
an eczematous lesion may be induced to
spread to other areas of the body if it is irritated. This irritation may be induced by a
secondary bacterial infection, by rubbing, by
application of irritant or sensitizing chemi-

Table 4, Relevant Data on Palfe/iLs in the Forty and under Age Croup
Patient

Sex

Age

1
2
3
4
5
6
7

F
F
F
F
F
F
F

20
21
35
32
34
40
30

8
9
10

F
M

11

26
29
22
20

Clinical Features
Klippel-Trenaunay syndrome with edema of the involved lower limb.
Paraplegic with multiple fractures and eczema of legs.
Varicose veins of many years duration requiring vein stripping at age 21 years.
Severe varicose veins of left leg of several years duration.
Varicose veins since age 15 years requiring vein stripping in past.
No varicose veins; edema of legs and hands of unknown cause.
Severe varicose veins of many years duration; worse with each pregnancy;
spontaneous rupture of vein during last pregnancy.
Severe varicose veins bilaterally of several years duration.
Severe varicose veins since childhood. Complete vein workup at age 21 years.
Very severe varicose veins of right leg.
Severe bilateral varicose veins of 4 years' duration.

No. 2

NUMMULAR ECZEMA

cals, etc. It is this induced-spread of lesions

to which the term autoeczematization refers.
Hypothesize that the primary lesion in
nummular eczema of stasis origin is usually a
patch of varicose eczema. I feel that factors
which induce edema of the lower limb result
in autoeczematization of the varicose
eczema lesions to other parts of the body. In
nummular eczema of stasis origin, the factor
which induces edema is usually a varicose
vein. However, in this study, trauma, heart
failure, dependency of the limbs, ischemia,
uremia and endocrine problems have all
been shown to result in lower leg edema and
subsequent flare or spread of the nummular
eruption.
The generic term "nummular eczema"
used to describe a specific condition can
only cause confusion unless the term is qualified. I feel that nummular eczema whether
of stasis origin, dyshidrotic origin, associated
with pustular bacterid or whatever, must always represent an example of autoeczematization.
The confusion regarding nummular eczema
patterns is compounded by the usage of illdefined diagnostic terms coined many years
ago, investigative studies carried out on
heterogenous groups of patients, loose diagnostic grouping, and a contituiingdu|jlicatioti
and proliferation of nomenclature.

Bendl

135

A careful review of all pertinent literature

available to the author has resulted in the
classification in Table 2.
References
1. Devergie, M. G. A.: Traite Pratique des Maladies de
La Peau, 2nd ed, Paris, V. Masson, !H57, p. 223.
2. Panaccio, E., and Adam, J. E.: Eollicular contact
dermatitis due to coloured permanent-pressed
sheets. Can. Med. Assn. J. 109i23, 1973.
3. Wilkinson, R. D.: Sheet dermatitis Can. Med. Assn.
j . 109:14, 1973,
4. Kreibich, C: Ekzeme und dermatitiden. In: lacfassohn, |.: EHandkich der EHaut und Geschlechtskrankheiten, Berlin, lulius Springer, 1927.
5. Ehrmann, S.: Klinik und histologie der hautkomplikalionen ausschlieblich des uicus cruris.
Handbuch der Haut und Geschlechtskrankheiten.
429, 1927.
6. FHaxthausen, H,: Generalized "ids" ("autosensilization") in varicose eczemas. Acta Derm. Venereol.
35:271, 1955,
7. Calnan, C. D., and Meara, R. EH.: Discoid
eczemadry type. Trans. St. John's EHosp. Dermatol. Soc. 37:26, 1956.
8. Calnan, C. D., and Meara, R. EH.: Parapsoriasis en
plaque and chronic superficial dermatitis. Trans. St.
|t)hn's Hosp. Llermatol. Soc. 37:12, 1956.
9. Engmann, M. E.: An infectious form of an eczematoid dermatitis. Am. |, Med. 4:769, 1902.
10. Sulzberger, M. B., and Garbe, W.: Nine cases of a
distinctive exudative discoid and lichenoid chronic
dermatosis. Arch, Dermatol. Sphilol. 36:247, 1937.
11. Brocq, L., quoted by Besnier, E., Brocq, L,, and jacquet, L.: La Pratique Dermatologique. Paris, Masson
and Gie, 1900, p. 91.
12. Pollitzer, S.: A recurren! eczematoid affection of the
hands. |. Cutan. Dis, 30:716, 1912.

The Term "Virus"

For centuries after Celsus, the term 'virus' was used casually as a synonym for poison
orvenotTi, until with the grcjwing awareness of transmission uf disease in the eighteenth
and nineteenth centuries it eventually acquired the meaningof an infectious agent. The
gradual acceptance of this usage in medical literature ran parallel to thedevelopment of
the twin concepts ni infection and contagion, and both owed much to another virus
disease of exceptional historical interest. Unlike rabies, smallpox through the centuries
has had a marked influenceun the ( ourse of scxial and politic al history.WattTson.A.
P., and Wilkinson. L.: An Introdui in>nU)lht'History of Virology. Nf^w York, Cambridge
University, 1978, p. 3.