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·DIFFERENTIAL
DIAGNOSIS
OF YAWS
CJ. HACKETT, MD, F.RCP,
Rorld ffealth Organization,
Geneva, Switzerland
L.). A. LOEWENTHAL, MD, M.R.C.P., DI M. & H.
Dermatologist.
General Hospital,
Johanneshurg. Union of South Africa
WORLD HEALTH ORGANIZATION
PALAIS DES NATION
GESTVA
1990

·Authors alone are responsible for viens crpressed in the Monograph Series of the
World Health Organization
PINTED IN SWTTZERLAND

·DEDICATION
To the late Dr J Fraisse and the late
Dr M1 Gauthier, who lost their lives in the
service of the World Health Organization,
in appreciation of their contribution to the
eradication of jans

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·CONTENTS 72 9 10 10 33 13 4 14 ננעברת בר 14 Introduction Differentution of the treponematosis Treponemal and other skin lessons Lesions likely to be confused with carly yaws lesions Impetigo contagiosa Lachen spindlosus Ecthyma Pityriasts roses Scabies 1) Psoruns Tungiasis 0 Mycoses Leprosy Phrynoderma Pustulas bacterids Tropical ulcer, chronic vegetating ryoderma, cutaneous Jetsh- Dng criptions 12 Sickle-cell kaamua Chronic furfuraceous impetigo IZ Tuberculous dactyletis Lesions likely to be confused with saws hyperker Palmss and plantar lesions of Palmar and plantar Isions of known uncertain caux ts Cause Patting is Corns and callositses Plantar thickening and fissuning 17 Plantas wants Fussures of the palms Rat bites Other lesions of palms and roles Lesions likely to be confused with late yaus lesions Tropical ukers 21 Derimentation Oranuloma vencreum 31 Pleaked yawy bone ksioni Cutaneous tuberculosis Osteomyelitas Perforating uken 27 Isis of orchocerasus Cutaneous kishmisis Other skin kvont Blantomycout Illustrations IS 13 19 20 20 22 23 Annet References 37

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·INTRODUCTION As progress is made in yaw's eradication in many countries, it becomes Increasingly important to acquire more information on a number of aspects of the disease in order to ensure the effective and economical conduct of the final stages of cradication campaigns One such aspect is the differential diagnosis of certain skin and other lesions not caused by yaws from yaws lesions which they may resemble At all stages of a mass campaign for the cradication of yaws the clinical diagnosis should be as accurate as circumstances permit It is realized, however, that in view of the limited amount of time available at instal treatment surveys and of the simple training of the field staff a certain number of errors in diagnosis are to be expected, under favourable conditions these probably amount to about 10% of all diagnoses or yaws In thc later stages of an cradıcation campaign, ie, after the initial treatment survey and resurveys, the manifestations of yang have largely disappeared as a result of mass treatment with penicillin. It is then that many lesions not due to yaws and not influenced by the treatment gren become prominent, and the accuracy of diagnosis becomes more important both for assessing the achievement of the campaign and for planning further activities. Diagnostic crrors may also be frequent when yaws is in spontaneous regression This monograph has been prepared in response to requests for an illustrated work which would assist field workers in making a differential diagnosis, and it is intended as a companion volume to the monograph entitled an internanional nomenclature of sans lesions (Ilacictt. 1957) Only illustrations of lesions likely to cause confusion with yaws have been selected, no attempt being made to provide cthaustive illustrations of all the conditions referred to Among the skin conditions which may be confused with yaus those causing lesions of the palms and soles seem to be the least well understood and the most troublesome, they have therefore bech dealt with in the most detail It should be noted that in the descriptions which follow references to illustrations in the monograph, An International nomenclature of vows kesions, are given using the abbreviation " Yaxs morrerclature" followed by the number of the figure (eg. I ans comerclature, Fig 9) ·10 DIFFERENTIAL DIAGNOSIS OF YAWS Differentiation of the treponematoses The differentiation, as given in textbooks, of the lesions of yaws from those of endemic and venereal syphilis has at present no great practical application in mass campaigns. Much confusion between these arises from inadequate knowledge and unsound criteria. A point that might give some slight assistance would be residence, especially in childhood, in an area where one of these treponematoses was preponderant or present to the exclusion of the others. Some workers think that a history of having had yaws has some diagnostic value, but this is largely dependent upon personal experience and upon the population concerned. It is possible . sounder criteria will be needed than are available at present, Treponemal and other skin lesions The skin has a limited number of reaction patterns, so that similar lesions may result from different causes. This concept, so clearly expounded by ---.... all the sharestare of an eruption, ils method of symptoms, in addition to Only a few lesions are truly diagnostic of yaws and often the repetition of the same pattern in an endemic area tends to be taken as evidence of yaws. Two diagnostic aids are frequently employed; the first is the serological tests used in all treponematoses, and is of little value in the individual case in an area where either yaws or syphilis is endemic and where sera from more than half the population may be reactive. The second is the response to antitreponemal therapy, chiefly in the form of penicillin. This may be of some practical value but is of little scientific value because penicillin is effective in all treponemal and in certain non-treponemal diseases. The possibility of more than one disease being present in the same patient should be kept in mind, ·DIFFERENTIAL DIAGNOSIS OF YAWS LESIONS LIKELY TO BE CONFUSED WITII EARLY YAH'S LESIONS Impetigo contagiosa is a pyogenic infection characterized by discret. thin-walled vesicles and bullae which become pustular; the exudate or drying forms darkish yellow crusts (Fig 1). When these crusts are removed the lesions seem to be eroded but not clevated. Healing occurs without Jeaving scars. The face is the most frequent site. The onset and course of impetigo are more rapid than those of yaws papillomata. Yaus papilomala (Yaws nomenclature, Fig. 11 B) are larger discrete lesions, more aised above the skin, and are often present on other sites than the face. The surface of the hypertrophic yaws papilloma is more coarsely granular Lan that of impetigo In impetigo some flaccid vesicles are usually present Jout the edge of the lesion. The infection readily erlends to any skin abrasion. Ecthyma may complicate impetigo or appear de noro at the site of abrasions or insect bites It extends into the corum (Fig. 2) and consequcntly leaves scars (Fig. 3) There is a resemblance between ccthyma and the early yaws papilloma (Yaw's nomenclature, Fig 11 A), but on removal of the crusts the former shows ulceration (1.e, loss of dermis) instead of raised vegetations. Furthermore, purulent exudate is often present in ecthyma and is absent in yaws papillomata, this is an important diagnostic point. Scabies is characterized by tortuous burrows in the horny layer of the epidermis made by the female mite, and into which shc Lays her CESS, and by small papular and pustular lesions which may outnumber the burrows. Intense itching, especially at night, leads to a wide range of appearances due to scratching, secondary infection and pustules (Fig 4) Diagnosis may be confirmed by finding the Sarcoptes scabiei or its products in the burrow's. Except in rare cases in infancy, scabies does not affect the face and scalp The most commonly affected sites are skin folds such as between the digits, the wrists and forearms, the points of the elbows, the anterior aullary folds, the genitals and the buttocks (Fig. 3), and nipples The skin below the internal mallcole 13 often involved in children The papillomata of yahs are usually Larger and more granular than the late confluent lesions of sabies and have a different distribution. Tungiasis, caused by Tiga penetrans (synonyms paper and chigoc), since it may occur in children as well as adults, is likely to be confused with planlar papillomata, especially since in both conditions the lessons are moist and tend to be circular (Fig 6.cf Yaxs nomenclature, Fig ·12 DIFFERENTIAL DIAGNOSIS OF YAWS It is prevalent in South America, the Caribbean Islands, Africa, and the west coast of India and does not occur in Asia, South East Asia or the Pacific. T. penetrans in Africans is nearly always multipic. If many contiguous parasites are present the lesion may resemble a dryish papilloma. The uniformity of the size of the individual lesions, whether active or healing, is of help (Fig. 7) Diagnosis will be confirmed by removal of the parasite or by observation of the posterior cutremity of the parasite extruding small pellets of reddish brown faeces or batches of eggs amid the debris. T. penetrans tends to occur most frequently on parts of the sole not in direct contact with the ground and thus between the toes and on the borders of the feet. Since the Tunga occupies the dermis it causes pain, and secondary infection is usual. The female parasite remains in the sole until she has laid her eggs and then is shed. The impregnated female is 3-5 mm in diameter and produces a cavity in which she lies, On healing. only slight scarring remains. The Tunga lesion starts as a small irritable point, while the plantar papilloma starts as a decper, very painful swelling which ruptures through the normally thick cuticic. In plantar or palmar papillomata the moist base is either discoid or, if there is a central dry raised area, annular. Leprosy, especially its macular lesions (Fig. 8), may be confused with macular (You's nomenclature, Fig. 3A) or maculo-papular yaws (Davey, 1957) The presence of other manifestations of either discase would resolve some uncertainty. In lepromatous lesions Mycobacterium leprae can usually be readily demonstrated. In tuberculoid leprosy involvement of nerves should be sought by testing for loss of sensation to heat and cold and to light touch and for absence of sweating. More difficulties may anise with the factish "macules" (Fig. 9) of early indeterminate leprosy, in which nerve damage may be difficult to detect and the range of the lesions may be wide. (cf. Yaw's momenclature, Fig. 9, 11 F, 11 G.) Tropical ulcer (see also page 21) may resemble the ulcero-papillomatous initial yaw (Yaws nomenclature, Fig. 2). Among other conditions which may be difficult to distinguish from the initial yaw on clinical grounds are various forms of chronic vegetaling p) oderma and cutaneous leishmaniasis. The last condition, one of whose numerous synonyms, "forest yaws": may cause confusion, can appear as single or multiple nodular or ulcerative lesions on the exposed parts. Clinical differentiation may be difficult and a search for leishmania or treponemes in deep scrapings may be necessary. Chronic furfuraceous impetigo (synonyms: impetigo pityroides, pytiriasis alba, erythema streptogenes, pityriasis simples faciei, dartre volante) is very frequent and ubiquitous and may give rise to diagnostic difficulties with squamous macular carly yaws. It is practically confined 10 children. The earliest lesions often consist of grouped, minute, hyperkeratotic papules resembling lichen spinulosus.

·DIFTERENTIAL DIAGNOSIS OF YAWS Lichen spinatosus is probably best regarded as a common reaction type, for although it may occur as a distinct entity, it may also orur as an unusual manifestation of other diseases, such as lichen planus, Acuminate micropopular carly yaws (Smith, 1932, Fig. 23-25; and Yous nomenclature, Fig. 7 and 8), is clinically indistinguishable from lichen spinulosus. Thus two manifestations attributed to carly yaus arc duplicated by an extremely common and geographically ubiquitous skin disease of children. Chronic furfuraccous impetigo is a superficial inflammation of the skin. The macular lesions, which afc usually discoid, are sharp-edged and ascrage 3 cm in diameter. Their surface is only slightly scaly. In the carlier stages the lesions are faintly crythematous, but they are usually noticed only when the erythema has disappeared and hypopigmentation (not complete depigmentation) is apparent. Brand & Tass (1952) found It present in about a half of the schoolchildren they examined in Israel and quote Wise as saying that it could be found on the skin of all North American Negro children if they were carefully examined This applies to a great extent to white and Bantu children in South Africa, where all Slages from lichen spinulosus to furfuraceous impetigo ore frequent and where yaws does not occur. Pityriasis rosen is another dermatosis of world-wide distribution. It produces round or oval, scaly plaques (Fig. 10), with a tendency to form "collarettes", or peripheral fringes (Fig 11) The greatest diameter of the plaques is in the direction of the cleavage lines of the skin The discase is confined to the trunk and proximal parts of the limbs and usually lasts It wecks or less. rsorlasis, though relatively infrequent in the coloured races, may, however, cause confusion, especially when the palms and soles are affected. The distinctive type of desquzmation (rig 12) in psoriasis, with dry, silvery scales, its well-known distribution on the ottensor surfaces of the Timbs, especially the knees and clbow's, and above all its chronicity, help 10 distinguish it from the lesions of annulsr, circinate or sertiginous fapillomata (Pans momenclatwo, Figur and 11 G) When the scales are removed from a lesion, the glistening smooth surface with bleeding points is characteristic, as is getting of the nails when present. Mycoses of the hands (Fig 13), feet (ris 14), and body may cause confusion and require microscopic examination of scales for the presence of fungal hyphac, They may occasionally be confused with cuminate Npillomata or hypericratoses. Hoxescr, the thickening of the skin ih the mycoses is rarcly as great as in the sans lesions. In the papillomaua there is less desquamation and less surrounding inflammation of the skin (Hans nomenclature, fig. 13 G and 15 D) In myroses of the palms islets of healthy skin may k isolated in the lesion and pompholyx lesions may ·14 DIFFERENTIAL DIAGNOSIS OF YAWS occur, especially along the fingers. These palmar and plantar mycoses do not respond to anti-yaws treatment and are probably some of the yaws hyperkeratoses that do not respond to penicillin". Phrynoderma on the extensor surfaces of the limbs (Fig. 15) closely resembles umbilicate papular early yaws (Yaws nomenclature, Fig. 6), and other signs of vitamin A deficiency, such as night blindness and Butot's spots, should be sought. Recalcitrant, symmetrical palmar and plantar pustular eruptions, sometimes called pustular bacterids or pustular psoriasis, and probably related to acrodermatitis continua, may resemble yaws hyperkeratosis, but they are rare. Drug eruptions are rare in communities where yaws is endemic, but the papillomatous and fungating lesions of bromoderma and iododerma may occasionally closely resemble the papillomata of early yaws. Sichle-cell anaemia in infants (Lambotte-Legrand & Lambotte-Legrand, 1958) may cause characteristic swellings over one or more metacarpal or phalangeal bones (Fig. 16). These are warm, painful and tense, and resemble an infective osteomyelitis or dactylitis. These lesions are most frequent during the second six months of life and after one or two weeks disappear spontancously. Faint periosteal shadows and occasionally arcas of necrosis within the bone resembling those of osteomyelitis may be seen in radiographs. Suppuration is rare. Swelling in the long bones of the limbs may occur in older patients. Enlargement of the liver or spleen, jaundice, cranial bossing or other characteristic changes of sickle-cell anaemia may be present (Hendrickse, 1960). Dactylitis in yaws (Yau's nomenclature, Fig. 18 E) is exceptional during the first year of life, and then papillomata would probably also be present. Tuberculous dactylitis may closely resemble the polydactylitis of early yaws (Yaws nomenclature, Fig. 18 E). In children, in the carly stage of infection (Lambotte & Legrand, 1953), swelling of the fingers of short duration (Fig. 17) without radiographic changes may occur; these may be associated with other early tuberculous lesions, such as adenitis, keratoconjunctivitis, rheumatic pains or erythema nodosum, cither at the same time or later. Spina ventosa in which the phalanges and metacarpals are cxpanded and the cortex is rarefied is occasionally seen.

·DIFFERENTIAL DIAGNOSIS OF YAH 15 LESIONS LIKELY TO BE CONFUSED WITHI YAWS HYTERKERATOSES Palmar and Plantur Lesions of Uncertain Crose Palmar and plantar lesions not due to yaws are likely to be confused with those due to yaws whether the prevalence of active yans is high or low. The yaws lesions of the palms and soles present a fairly consistent pattern in all yaws endemic areas and such lesions do not occur where yaws is absent The first well-illustrated deseripuion is by Baermann (1911). The undoubted yaws lesions of the palms and soles include the plantar papillomats and the early and late hyperkeratoses, which have been illustrated again recently (Hackett, 1957) Lesions of the palms and soles not due to yans form a conſusing group, of which a few are rare but ubiquitous. Some appear to be chiefly limited to the coloured races; it is probable that this racial prevalence as the result of environmental factors. The lesions may be classified conveniently as (1) those with pitting, with or without plugs, and (2) those with diffuse hyperkeratosis, with or without fissuring. Palmar and plantar lesions occur in many parts of the world, regardless of the presence of any endemic treponematosis. Most of these lesions do not resemble yaws lesions and are not allected by therapy to which yaws lesions rapidly respond. Turner (1959) also refers to these non-yaw's lesions Some of these lesions have been recognized for many years but their recognition has become of more practical importance in the later stages of the present effective yaw's cradıcation campaigns. Mistales most often anse from the erroneous belief that all palmar and planlar changes, in a population where yah's is frequent, arc due to yans. The recognition of this error is immediately followed by more accurate diagnosis. Pitting Without plugs larger pits, up to 3 mm in diameter. These start on an apparently normal sole, especially on the heel, as punctate cxcavations. They form shallow, round or 0131 depressions (Fig. 18) up to 3 mm in diameter. buch do not extend below the stratum corneum, and the porillary ridges may remain vissble across the bases (Fig. 19). The piis occur on points of pressure on the fact but the pressure points of the tocs are spared in the carly stages Usually all or most of the depressions are of about the same sue. They may coalesce to form lincar depressions or ſurrous (Fig. 20), and may be contiguous over a large area but remain discrete with cach depression separated by narrow ridges. The depressions may ·14 DIFFERENTIAL DIAGNOSIS OF YAWS occur, especially along the fingers. These palmar and plantar mycoses do not respond to anti-yaws treatment and are probably some of the " yaws hyperkeratoses that do not respond to penicillin". Phrynoderma on the extensor surfaces of the limbs (Fig. 15) closely resembles umbilicate papular early yaws (Yaws nomenclature, Fig. 6), and other signs of vitamin A deficiency, such as night blindness and Bitor's spots, should be sought. Recalcitrant, symmetrical palmar and plantar pustular cruptions, sometimes called pustular bacterids or pustular psoriasis, and probably related to acrodermatitis continua, may resemble yaws hyperkeratosis, but they are rare. Drug eruptions are rare in communities where yaws is endemic, but the papillomatous and fungating lesions of bromoderma and iododerma may occasionally closely resemble thc papillomata of early yaws. Sickle-cell anaemia in infants (Lambotte-Legrand & Lambotte-Legrand, 1958) may cause characteristic swellings over one or more metacarpal or phalangeal bones (Fig. 16). These are warm, painful and tense, and resemble an infective ostcomyelitis or dactylitis. These lesions are most frequent during the second six months of life and after one or two weeks disappear spontaneously. Faint periosteal shadows and occasionally areas of necrosis within the bone resembling those of osteomyelitis may be seen in radiographs. Suppuration is rare. Swelling in the long bones of the limbs may occur in older patients. Enlargement of the liver or spleen, jaundice, cranial bossing or other characteristic changes of sickle-cell anaemia may be present (Ilendrickse, 1960). Dactylitis in yaws (Yaws nomenclature, Fig. 18 E) is exceptional during the first year of life, and then papillomata would probably also be present. Tuberculous dactylitis may closely resemble the polydactylstis oſ carly yaws (Yaw's nomenclature, Fig. 18 E). In children, in the carly stage of infection (Lambotte & Legrand, 1953), swelling of the fingers of short duration (Fig. 17) without radiographic changes may occur; these may be associated with other early tuberculous lesions, such as adenitis, keraloconjunctivitis, rheumatic pains or erythema nodosum, either at the same time or later. Spina ventosa in which the phalanges and metacarpals arc expanded and the cortex is rarefied is occasionally seen.

·DIFFERENTIAL DIAGNOSIS OF YAWS 15 LESIONS LIKELY TO BE CONFUSED WITH YAWS HYPERKERATOSES Palmar and Plantar Lesions of Uncertain Canse Palmar and plantar lesions not due to yaws are likely to be confused with those due to yaws whether the prevalence of active yaws is high or low. The yaws lesions of the palms and soles present a fairly consistent pattern in all yaws endemic areas and such lesions do not occur where yaws is absent The first well-illustrated description is by Baermann (1911) The undoubted yaws lesions of the palms and soles include the plantar papillomata and the early and late hyperkeratoses, which have been illustrated again recently (Hackett, 1957) Lesions of the palms and soles not due to yaws form a confusing group, of which a few are rare but ubiquitous Some appear to be chiefly limited to the coloured races; it is probable that this racial prevalence is the result of environmental factors. The lesions may be classified conveniently as (1) those with pitting, with or without plugs, and (2) those with diffuse hyperkeratosis, with or without fissuring. Palmar and plantar lesions occur in many parts of the world, regardless of the presence of any endemuc treponematosis. Most of these lesions do not resemble yaws lesions and are not affected by therapy to which yaws lesions rapidly respond. Turner (1959) also refers to these non-yaws lesions. Some of these lesions have been recognized for many years but their recognition has become of more practical importance in the later stages of the present effective yaws eradication campaigns Mistakes most often arise from the erroneous belief that all palmar and plantar changes, in a population where yaws is frequent, are due to yaws The recognition of this error is immediately followed by more accurate diagnosis Pitting Without plugs Larger pits, up to 3 mm in diameter These start on an apparently normal sole, especially on the heel, as punctate excavations. They form shallow, round or oval depressions (Fig 18) up to 5 mm in diameter, which do not extend below the stratum corneum, and the papillary ridges may remain visible across the bases (Fig. 19). The pits occur on points of pressure on the foot but the pressure points of the toes are spared in the early stages. Usually all or most of the depressions are of about the same size. They may coalesce to form linear depressions or furrows (Fig. 20), and may be contiguous over a large area but remain discrete with each depression separated by narrow ridges The depressions may ·16 DIFFERENTIAL DIAGNOSIS OF YAWS be less than 1 mm and up to 2-3 mm below the surface (Fig. 21). When the changes are extensive some resemblance to crepe rubber may be noted on casual inspection (Fig. 22). These depressions may become filled with soil or debris, which is easily removed with water, when the bases of the pits are clearly seen. In the early stages there is little or no thickening of the skin but with more marked changes there may be some thickening; however, the skin remains comparatively soft and pliable. Inflammation and abnormal desquamation are absent. When the changes are marked, the skin has a yellowish colour. These lesions do not affect the palms. Pain is not marked, but may follow much walking. The changes start in later childhood, when the prevalence may be much higher than in adults ; this suggests that spontaneous healing is frequent as do reports that the lesions are more prevalent during the rainy season and that they resolve during the dry season. Furnell (1943) observed these lesions develop after one week's unaccustomed exposure to wet conditions, and other observers report that resolution has followed removal from wet working conditions to dry ones and the adoption of footwear at the same time. Rest and local application of salicylic acid are reported to produce marked improvement. In patients with this condition scrological tests for syphilts are not reactive in the absence of treponemal infection. There is no response to treatment with arsenical or penicillin preparations. The condition occurs in Ceylon, India, Taiwan, Africa and Indonesia, but its distribution and prevalence are not uniform. The lesions are practically confined to the wet tropics and are rare or absent in and areas. Until the condition is better defined, it and its variations as seen in Fig. 18-22 should be called "tropical plantar pitting"; it may comprise more than one pathological entity. The term “keratoma plantare sulcatum" (Castellani, 1910) 15 misleading, but refers to the same condition, this problem is discussed more fully in the Anner (sce page 77). A somewhat similar infrequent cribriform lesion, so far scribed only in white patients, is seen in the late stages of " Pernet's symmetrical lividity of the soles " The weight-bearing areas of the sole are most affected. The horny layer becomes soft and offensive through maceration. Hyper. hydrosis is always present, and is possibly the most important cause. Smaller pits, I mm in diameter. There is another type of plantar pitting of which no published description could be found, in which the skin is slightly thickened and dry and in it are numerous pin-point perforations (less than 1 mm), from which may extend some short, finc fissures. These have been seen in and, but not in humid localities. They have been observed only in the soles. For the present, this lesion might be referred to as "punctate plantar pitting" (Fig. 23). The cause is unknown and the condition is not limited to the tropics.

·DIFFERENTTAL DIAGNOSIS OF YAWS Although somewhat similar lesions have occasionally been seen in the centre of macular or plantar hyperkeratosis of early yaws, punctate plantar pitting is not treponemal. Tiny pits are also seen in apparently normal skin adjacent to plantar warts (see page 20). With plugs There is a rare hereditary disorder which is characterized by small horny plugs in localized thickenings of the epidermis. Palms (Fig. 24) are most frequently involved but the soles may occasionally be affected. The plugs eventually separate, leaving pits, each of which is surrounded by a narrow horny rim This condition appears to have been originally described by Brauer (1912) and has been named " keratoma dissipatum hereditarium palmare et plantare " (Kiess, 1930). The keratodermia of Buschke-Fischer, which is not hereditary, and that of Besnier and the keratodermia punctata of Chalmers & Kamar (1917) (see Annex) are probably identical with the keratoma of Brauer Pits, a few millimetres in diameter, resulting from the separation of horny plugs together with fine desquamation in the skin creases on the palms and soles have been reported in lichen ruber planus (Kiess, 1930, hus Fig. 6) but is rare. The palmar lesions illustrated in Fig 27 A of Yaws nomenclature are probably due to Brauer's keratoma, while the changes on the fingers are due to yaws. Plantar thickening and fissuring Thickened and fissured soles have been seen in many parts of the world. Fissures about the heels occur in moist and in dry countries, thickening and fissuring of the soles is frequent probably in and areas only These changes start in late adolescence and marked lesions are seen only in adults who do heavy work They are usually not very painful but deep vertical fissures of the heel may be Several rare types of familial and sporadic hyperkeratosis of the palms and soles have been described in patients of different races but will not be referred to here Congenital or acquired dryness of the skin (xeroderma) may be associated with hyperkeratosis of the palms and soles and with vertical fissures at the margins of the heel (Figs 35-37) These changes are seen in ichthyosis vulgaris. They also occur with greater seventy in the dry season, both in ichthyotics and in those whose skins have become excessively dry as the result of advancing age. Xeroderma may occur in cachexia and in malnutrition, and plantar hyperkeratosis and fissuring of the heels have been attributed to pellagra It is possible, therefore, that the condition under discussion results from several factors, among which the most important may be xeroderma due to malnutrition. A dry climate and ·18 DIFFERENTIAL DIAGNOSIS OF YAWS injury from walking barefoot on hard ground may thus be contnbuti The lesions referred to here as "plantar thickening and fissuring not treponemal in origin and may well, on further study, be found comprise several pathological entities. The following clinical types ! be recognized. Plantar folding and fissuring along the skin creases in the anterior 1 of the soles. The folds and fustows tend to point away from where heads of the metatarsals press the skin of the sole upon the ground dui walking. When folds alonc are present the skin does not appear m thickened and it has nearly normal elasticity. The folds are seen in Fig. from a young man with no active yaws. The fissures alone are seen Fig. 26, from a woman about 18 years of age who also had papilloma ninc months later, after ncoarsphenamine treatment, there were no act yaws lesions and the soles showed little change except a tendency for fissures to become folds. The serum was then non-reactive to the Ka test When fissuring alone is present the skin is often thickened and di than normal and some desquamation may be present. This is illustra in Fig. 27, from a man with palmar papillomata. Eleven months 13 there were no active yaws lesions but the lesions of the soles and he were practically unchanged. Selliſſe & Humphreys (1952) describe simi lesions. Sometimes it is difficult to be certain if fissures or folds are the p dominant change. This is seen in Fig. 28. Furnell (1943) describes simi lesions. This suggests that these lesions may be the same in origin a that the differences seen may be due to the seasonal differences of wetni and dryness. In some and countries extensive fissuring, almost to tessellation to with little desquamation of the soles, may be frequent. Threc degre of this are seen in Fig. 29 to 31 These lesions are most marked who the sole is in contact with the ground. Murray et al. (1956) in their Fig. illustrate the soles of a small boy in Bochuanaland who had mucous patch in the mouth and anal condylomata of endemic syphilis. Marked tessell tion was present on the soles which was probably not treponemal in origi Hudson (1936) in his Fig. 1 describes identical lesions 35 cxtren hyperkeratosis in endemic syphilis in Syria. Fissures of all surfaces of the heel often commence as superficial arbo escent fissures which may later become deeper (Fig. 32 and 33). In Fig. (same foot as Fig. 27 and 33) and Fig. 35 (same foot as Fig. 25) the relatii freedom from changes of the under part of the heel is seen, These lesions start in childhood, when there is little or no cpiderm thickening, and do not cause much discomfort except in the wet seasor when presumably the swelling of the thickened cpidermis of advance lesions may extend the fissures into the dermis. The plantar skin of th ·DIFFERENTIAL DIAGNOSIS OF YAWS heel may appear as if the thickened cpidermis has been wom down walking (" onion skin" effects of Furnell, 1943) These lesions of accompany the folding and fissuring of the soles referred to under preceding heading. Vertical linear fissures of the heel may occur on the lateral, poster and, to a lesser extent, the medial surfaces Some desquamation may present (Fig 36). The more advanced lesion (Fig 37) consists of de lincar crevices, and the medial part of the skin of the instep may be involv These lesions of the lateral part of the heel in the patient illustrated h undergone considerable spontaneous healing during the previous months, while those on the medial surface had become more extensi The lesions occur on the margins of the heels, above that part of the si which comes into pressure contact with the ground. They occur in pendently of the fissures of the sole. Jelliffe & Humphreys (1952) a describe these lesions. The illustrations (Fig. 25-37) referred to in the preceding paragraf were all taken during the dry season. These fissures and folds may occur in patients with early or late act yaws lesions, in those with no yaws lesions, or in persons whose scra non-reactive to the reagın serological tests for syphilis , further stud are needed into what causes them It should be stressed that the soles of healthy persons who walk ba footed on dry, soft, sandy soil are thun, smooth and supple. While cu and scratches may be inflicted on soles by rough, rocky surfaces or cor one would not expect to see any signs of wear on healthy soles unl they were subjected to unaccustomed use. Fissores of the palms Fissures of the palms not due to yaws are occasionally seen but $0 unlike any palmar lesion due to yaws that confusion should be cas avoided. Palmar and Plantar Lesions of Knom Cause Coms and callosities are local thickenings of the horny layers of skin where it is subjected to pressure and friction. Corns are relative small and penetrate deeply, callosities are diffuse and are frequently se on pressure areas of the soles and on the palms (caused by work) (Fig 1 Corns occur in persons wearing shoes or sandals and are most frequent the knuckles of the fourth and filth toes. Callosities occur on the sol whether shoes are worn or not. Both are uncommon in children. T surface of callosities is flat, hard and often polished, and of a light yellow ·20 DIFFERENTIAL DIAGNOSIS OF YAWS colour (see Fig. 41). They do not closely resemble any yaws lesion, but their tenderness may lead to confusion with carly plantar papillomata. Papillomata are more tender and less hard than callosities. In some yaws campaigns auxiliary workers spend much time palpating the soles, apparently in the erroneous belief that plantar tenderness is synonymous with plantar yaws. Plantar warts (verrucae plantares) may be single or multiple, and occur most frequently on pressure points (Fig. 38). They may be confused with plantar papillomata (Yaws nomenclature, Fig. 13 B). They are essentially a localized hypertrophy of the epithelium and are in fact infective benign tumours. On other parts of the body they project above the surface, but on the weight-bearing areas of the solc this projection cannot occur and the wart is forced below the surface, where it continues to grow up to 1 cm in diameter and to a depth of 0.5 cm. below the normal skin level. A callous ring and covering invariably form and contribute to the pain and tenderness. At this stage it closely resembles a plantar callosity. Frequently the central point of the callus crumbles away, giving the appearance scen in Fig. 39 and 40. On the heels in these two illustrations are mosaic warts caused by coalescence of many warts. The annular depressions surrounding the warts in Fig. 38 and 39 do not occur round corns. Adjacent to established plantar warts, tiny pits are frequently observed (Fig. 39-41). When the horny layer is pared away from these pits, tiny warts can be seen in their depths; strong magnification and a good light are necessary. Fig. 41 shows, on the right sole, plantar warts proximal to the right little toc and on the heel with several tiny pits; with these warts is much callosity. On the heel shown in Fig. 40 is probably a large mosaic wart with the same pits adjacent to it. Warts are due to a virus infection and their high prevalence at times in villages where there are a limited number of washing places may suggest an epidemic. Ras bytes often occur at night, when the thick plantar epidermis may be nibbled by rats without the victim being awakened. This is more likely to occur when hyperkeratosis is present and where fissures provide an entry for the rats' incisors. The smooth grooves made by the upper incisors are characteristic, so that the origin of the lesions should be recognized at once (Fig. 42). Furnell (1943) describes these lesions. Other lesions of the palms and soles that might be confused with yaws hyperkeratoses include the cuts and abrasions in various stages of healing, with or without secondary infection etc. Such changes are more extensive on the Jellt hand (Fig. 43), if acquired during bush clearing. These should not cause senous difficulties.

·DIFFERENTIAL DIAGNOSIS OF YAWS 21 LESIONS LIKELY TO BE CONFUSED WITH LATE YAWS LESIONS Tropical (pbagedenic) ulcers anse from a rapid necrosis and sloughing of the whole thickness of the skin and subcutaneous tissues. They often commence as a vesicle, wbich is soon followed by inflammation and necrosis (Fig. 44). At this stage there is the characteristically disagreeable and penetrating odour and often a blood-stained discharge, which are never met in yaws. After the slough bas been shed (Fig 45 and 46), the underlying muscle, tendon or bone may be exposed, but later this base is covered with granulation tissue (cf. Yaws nomenclature, Fig. 25 A and 26 A). In the early stages of tropical ulcer the base is more depressed and the edge more thickened than in late yaws ulcers Tropical ulcers are painful and occur most frequently on the lower third of the leg Yaws ulcers commence by a slower breaking down and ulceration of necrotic foci and are more frequent than tropical ulcers on the upper limbs and other parts of the body. When a tropical ulcer has reached the granulation stage differentiation from the later stages of a yaws ulcer may be difficult. It is frequently single, as is the late yaws ulcer, and in both conditions the response to penicillin is favourable. Yaws lesions are, however, less decply destructive, and are often little more than a skin deep" Although superficial fate yaws lesions may extend over considerable areas they do not extend deeply to expose muscles and botes, and their development is slower and more gradual than that of tropical ulcers, though in both spontaneous healing is slow. Granuloma veneream may occasionally be clinically indistinguishable from extensive superficial late yaws ulceration in the genito-crural region The diagnosis can be established by the demonstration of Donovan bodies in scrapings from the lesion. Cutaneous tuberculosis (Fig 47) and other granulomatous conditions may resemble late yaws ulcers but are unusual at present in areas where yaws occurs Lupus vulgaris . 48) is infrequent in most tropical countries but may resemble ulcerated nodular late yaws (Yaws nomenclature, Fig 26 B) Perforating ulcers of the sole (Fig 49) mostly follow neural damage from leprosy and usually other indications of this discase are apparent (see page 12). These ulcers occur on the sole on points of pressure and are usually single. Cutaneous leishmaniasis involving the mucous membranes may resemble gangosa but is unusual except in South America Slow progressive ulceration of the nose and mouth occurs, leading to destruction of the palate and much of the nose, naso-pharynx and lower pharynr.

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·FIG
1 IMPETIGO CONTAGIOSA
Johannesburg
By courtesy of Dr M Ross

·FIG. 2 ECTHYMA
MONO
Right side of body at about the level of the umbilicus Cute holte

·ECTHYMA Ilealing and

·FIG 4 SCABIES
---
1
Ao Durrons can be seen hur the result of secondary infection, which is nurly always prese
is orgurent Ugandu.

·FIG S SCABIES
NO
By courtesy of Dr OH Clarke
Av hurrina) con be seen but the smarten ut the infarved bruns is characımc Lagus

·FIG. 6 TUNGIASIS The inundual lesions are clearly sthir. Ugunis

·FIG 7 TUNGIASIS
Healing lessons leave on! slight scurring
Right sole Uganda
31 -

·* LEPROSY
Lapora ne shit
Iniettemme hypochromie macular lesions Coll d'huire.

·FIG 9 LEPR Vinor takmai taw ka me sfitwer Grade

·FIG 10 PITYRIASIS ROSEA
By courtesy of the lare De Howard for New York
- 34 -

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·FIG 14 MYCOSIS OF THE HEEL - 8E — ·FIG 15 PHRYNODERMA Outer surface of teft knee Johannesburg

·FIG 16 SICKLE-CELL ANAEMIA DACTYLITIS
Uganda
By courtesy of Dr DB Je
40

·FIG
17 TUBERCULOUS DACTYLITIS
By courtesy of Dr ) and Dr C Lambolte-Legrand
Skelteng of the second and third fingers in carh suberculosis in a child aged 51, curs
Belgian Congo

·FIG 18 " TROPICAL PLANTAR PITTING"
Keratoma planture sulotum of Castellani (1910) Small drep pils mith some
variation in ; Early lesions on anterior part of sole Northern Ifaure l'olio
– 42 -

·FIG 19 "TROPICAL PLANTAR PITTING"
--
Lurger, fatiet pits more unfurm in die than in Fig 18 Northern Haute Sotra

·FIG 20 "TROPICAL PLANTAR PITT" Uneor coalescence Cote d'hoire

·FIG 31 "TROPICAL PLANTAR PITTING"
Lesions on anterior part of sole Central Jara
- 15

·FIG 22
* TROPICAL PLANTAR PITTING*
urhed lesions
Note relative freedom of undersurface of tors Central Jara

·FIG 23
PUNCTATE PLANTAR PITTING
Slight desquamation
Hanilanna
47 -

·FIG 24 KERATOMA DISSIPATUM HEREDITARIUM PALMARE
(BRAUER, 1912)
E
By courtesy of Dr NM van der Hoff
Keratodermia punctata of Chalmers & Kamar (1917) Characteristic paliar changes
Mfany plugs present Brunish Comervons
— 48 -

·FIG 25 PLANTAR FOLDING ALONG SKIN CREASES
Iery few hssures
Same fit es in Foz 33 Uganda
49 -

·FIG 26. PLANTAR FISSURES
Ugandu
- 50 -

·FIG 37 PLANTAR FISSURES WITH DRYNESS AND DESQUAMATION Sume for us to his and 4 guna

·FIG 28 PLANTAR FOLDING AND FISSURES
Uganda
- 52 -

·FIG 29
EXTENSIVE SUPERFICIAL PLANTAR FISSURES WITH SLIGHT
DESQUAMATION
Mauritania

·FIG 30 EXTENSIVE SUPERFICIAL PLANTAR FISSURES Mauritania ·FIG 31 EXTENSIVE SUPERFICIAL PLANTAR FISSURES fushe shaper Ifuwlamid

·FIG 32 FISSURES OF THE HEEL
- 56 -
.
These start in childhood as superficial arhorescent fissures
Ugunda

·FIG 33 HSSURES OF THE HEEL
3
(buter surface of left andre
Some fepe J is 1$ ? unul 34 Uguns

·FIG 34 FISSURES OF THE HEEL
Lefi sul
Under surfure of heel shown in Fig 33 L'gundir.
SS

·Diri 1}

·FIG 36 VERTICAL LINEAR FISSURES OF THE HEEL
Plantar surfaces have remained normal
Outer murgin of left foot Ugandu
EINAR
INNE:44. N
VIHJE A
F
III ANE
. INKIN
INNR.1

·VERTICAL LINE AR FISSURES OF THE HEEL AND FISSURES IN INSTEP 17

·FIG 38 SMALL PLANTAR WARTS OVER HEADS OF METATARSALS
Core dhoire.
- 62 -

·FIG 19. PLANTAR WART OVER HEAD OF FIFTH METATARSAL
AND MOSAIC WART ON HEEL
Tore small puls near these testen
Cote d'hort
63 -

·FIG 40 PLANTAR WARTS AND MOSAIC WART ON HEEL
Note small pits and some degeneration and desquamawon of thichenrd epithelium
Cote d"Broire.

·FIG 41 PLANTAR WARTS WITH WELL-DEVELOPED CALLOSITIES hote smull pits un nghi sole The straight sides of the lesions surgest some preuws wreatment Johannesburg - 63 - ·FIG 42 RAT BITES L'ganu

·FIG 43 MULTIPLE INJURIES TO LEFT HAD FROY HOLDING
VEGETATION TO BE CUT WITH IMPLEVEL HELD IS RIGHT HAND
UTIN
07
3

·FIG 44 TROPICAL ULCER -- 68 - The slough has recently separated. This ulcer commenced as a vesicle on on vedentelous area, which was attributed by the panent to a slight burnt. a few days luitt the slough appeared. Uganda

·FIG 45 TROPICAL ULCER
The base de course grunututun hisse hus the ruler is enll tassen
naftne ducharge
15 frequent AniMat wife of kefile LT
69

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·FIG 48 LUPUS VULGARIS
By courtesy of the late Dr Howard For. c* York
72

·FIG. 49. PERFORATING ULCERS I LEPROSY
Sh
...
B) Louriey of D V Alartner Dominus
SPURSA Game
. 73

·FIG 50 BLASTOMYCOSIS
Sfuco-cutaneous lesiont Braut
74 -

·DFPIGMENTATION WITH NO APPARENT SCARRING Ugundul

·FIG 5?
DEPIGMENTATION OF LEFT WRIST WITH NO APPARENT SCA
L'ganda,
-76-

·DIFFERENTIAL DIAGNOSIS OF YAWS 77 A SUMMARY OF SOME REFERENCES TO TWO TYTES OF PLANTAR LESIONS Axaex "Tropical plantar pitting" and " keratoma dissipatum hereditanum palmare et plantare " (Brauer, 1912, Kuess, 1930) have been referred to frequently in the literature of tropical medicine, the former as “keratoma plantate sulcatum " originally by Castellani in 1910 and the latter as keratodermia punctata originally by Chalmers & Kamar in 1917. Considerable confusion has aftsen about the cause of these conditions, Keratona Plaptare Sulcatam (Castellapl, 1910) (sre page 16) Castellani (1910) and Castellani & Chalmers (1910b) say that keratoma plantare sulcatum is prevalent in barefooted Indian and Chinese labourers. The epidermis of the anterior part of tbe soles and of the beels is thickened and yellowish with numerous deep furrows, which may be straight, semicircular or elliptical, and wluch appear dark owing to the debris collected in them. If this debris is removed the furrows are punish or wbutish There is no local inflammation but the feet may be tender and painful after much walking. The condition is most frequent during the rainy season and improves or disappears during the dry season. Rest and the application of salicylates may produce marked improvement. Fig. 336 sa Castellani & Chalmers (19106) closely resembles Fig. 22 of this monograph. Daermann (1911) illustrates the sole of a patient wib carly yaws la which there is plantar hyperkeratosis of yaws and also keratoma plantare sulcatum (his Fig, 72 on Plate 6) which resembles our Fig. 22. In hus description he makes no meation of the keratoma Castellani & Chalmers (1913, 1919) add to their earlier description (Cas- {ellani & Chalmers, 19106) that the condition oscurs in Ceylon, India and tropical Africa and that it consists of decp sulci and punched-out holes in thickened epidermis. Alercury and iodides have no effect Castellani (1949) includes keratoma plaatare sulcatum among the little known tropical diseases". He says that the cause is unknown, that the Wassermann reaction is usually negative and that antisyphilitc trcalment has no effect on it. The diagnosis is based on the presence of the chas. acteristic deep sulci and punched-out holes in the ihickened epidermis, wuch are absent ia the lesions of the soles of the feet of syphilitic origin" ·78 DIFFERENTIAL DIAGNOSIS OF YAWS He also states that the pitted plantar lesions due to yaws do not have seasonal variation which is a feature of the condition discussed here. Gutierrez (1922; p. 281) says that keratosis is the most frequent 1 yaws lesion. He says that it is sometimes called clavus and was cal by Castellani & Chalmers (1919) “ peculiar pitted condition of the hands He has no doubt that it is a tertiary lesion which may appear " during latter phase of the secondary eruptions, as observed by Castellani. the other hand, it may appear years after all signs of the disease ha disappeared " Gutierrez (1923) writes of " keratosis palmaris et plantaris" due yaws. His evidence that yaws is the cause is rather uncertain. He su that there are two types: (1) Thickened palms or soles (hyperkeratosis) from which sago-gra whorls of hardened corneum fall out. There is tenderness on walkin He calls the condition claviform keratosis. Several months after a fe injections of arsphenamine the lesions appeared to have improved in few cases. His illustrations of plantar lesions (Fig. 1 and 9 of his pape do not very closely resemble keratoma plantare sulcatum and his descri tion is more that of keratodermia punctata (Chalmers & Kamar, 1917 He refers to the description by Castellani & Chalmers (1919). (2) Thickening of the corneal layers (keratosis) without the formatic of grain-like whorls. It is associated with hyperigmentation, may sprea to the dorsa of the hands and feet, and results in depigmentation, While the second type might well be duc to yaws, the first is probab not. He appears to regard both lesions as late or tertiary yaws fesion Gutierrez (1925), in a paper on the late manifestations of yaws, say tbat" secondary and tertiary "and even "primary, secondary and tertiary lesions can occur at the same time in the same patient. He says tha Castellani & Chalmers (1919) were the first to use the name "Keratom plantare sulcatum" but that it was known under several other names Gutierrez proposed to change the name to “keratoderma palmarise plantaris (sic) sulcatum " in accordance with Chalmers & Kamar (1917 and because the palms were also involved. It is, he says, the most frequen Jate lesion of yaws. He refers to his previous paper (1923), in which h says there are two types of this lesion. His description is rather confusing for it appears that he includes, under the name he proposes, all non Papillomatous yaw's lesions of the hands and feet, as well as keratoma plantare sulcatum and keratodermia punctata (Chalmers & Kamar, 1917) His Fig. 8, which has the caption" Keratoderma plantare sulcatum showing pits of cornlike bodies", resembles neither Fig. 22 nor Fig. 24 of this monograph. He says that the lesions to which he refers may appear directly after the secondary manifestations have healed or twenty years after they ·DIFFEREYTIAL DIAGNOSIS OF YAW 79 have disappeared and all manifestations of the disease bale gone. When once they have appeared they last for life. As the lesion progresses st may involve the dorss of the hands and feet and cien the skin of the knees and elbows Bittner (1926) says that keratoma plantare sulcatum is known in India, Africa, Java and Sumatra The cause is unknown but he thinks that it is a late yaws lesion. There are " deep sulct with punched-out areas un tremendously thickened epidermis of the plantar surface" and also great pain and tenderness on walking Hands as well as feet may be affected. It may appear after yaws papules have disappeared, and therefore, if it is due to yaws, it is a lste lesion. A single injection of ncoarsphenamine completely healed the painful plantar fissures in three cases whose sera nere reactose to the Wassermann test. He does not, horever, record the effect on the *punched-out areas". His Fig 3 us of yaws hyperkeratosis over the heads of the metatarsals and the heel with the lesions of keraloma in thickened epidermis aloog the lateral part of the foot between these areas These changes resemble those in Fig 22 of this monograph The lesions of the hands are not distinct in the illustration, but may possibly be those of keratodermia punctata (Chalmers & Kamar, 1957) Acton & McGuire (1930) say keratolysis plantare sulcatum is the same as Castellani's “ peculiar pitting of the hands and feet and keratoma plantare sulcatum. They refer to Chalmers & Kamar (1917). Castellana (1920) and Gutierrez (1923, 1925). Acton & McGure say keratoma plantare sulcalum and keraloderma cribrata (sce below)" have been very much confused by many workers with late manifestations of yaws" and that keratoma plantare sulcatum is actinomycouc while keratodermia cribrata is a lale syphilitc manifestation, in fact, the latter is pathognomonic of syplulis Keratolysis plantare sulcatum is prevalent in Bengal duning the monsoon in barefooled people They have seen it in two Europeans. Yawe did not occur in Bengal It starts as pits with regular edges which coalesce, like a moderately course sponge, to form furrows. Their Plate 1, Fig. I resembles Fig 21 and 22 of this monograph, Acton & McGuire (1931) deal with lesions of the skin of the hands and fect due to Actinomyces keratolytica. They say that this organism which they describe as a new species-ds responsible for split and cracked heels with hyperkeratosis, keratolysis plantare sulcatum, tungo tocs (interdigital sodden cpithelium), paronych:3, onychomycosis and vesicular cruptions The condition has occurred in European ships' officers, They claim to have isolated the fungus from 42 consecutive patients and to have reproduced lessons in human volunteers. The application of formaln. slycerine and gentian violet sill cure the infection. It is most frequent on the heel and steeds of the foot. The palms are rarely attached There is no localized by peristatosis nor salammation ·80 DIFFERENTIAL DIAGNOSIS OF YAHS of the sole. In keratodermia cribrata there is hyperkeratosis and horny plugs can be lifted out. They isolated Actinomyces boris from the lesions and say that the pits or ſurrow's are due to lysis of the horny cells. Keratolysis plantare sulcatum can be prevented and cured by the application of 5% formalin and keeping the feet dry. Hermans (1931) refers to a condition seen in the Moluccas in which there are cracks or deep clefts which may be very painful. His Fig. 14 illustrates the condition, which he says responds to arsenic. It resembles Fig 37 of this monograph but with more erosion, which is suggestive of a yaws lesion. He continues that Castellani describes the same condition as keratoma plantare sulcatum, and his Fig. 15 is of this condition and resembles Fig. 20 of this monograph. He appears to be reſerring to two different lesions. Hermans (1939) sa that Castellani gave the name " keratoma plantare sulcatum " to plantar lesions of yaws characterized by hypertrophy of the margins of the feet in which painful fissures developed. This description does not appear to reſer to keratoma plantare sulcatum. Aars (1931) describes keratoma plantare sulcatum. It is a thickening of that part of the soles in contact with the ground. The horny layer of the cpidermis contains numerous holes of different sizes and depth and later many fissures, which never extend more decply than the inner limits of the stratum corneum. The lesion is worse in the rainy season ; pitting and fissuring disappear in the dry season but the thickening remains. The thickening is at first spongy but later becomes hard and horny. Aars never saw plugs in the lesions, not did he see the palms affected. The lesions were never wet, and he saw them only in men. His illustration closely resembles Fig. 21 of this monograph. He says the condition is not very painful. He summarizes the histopathological changes as follows: "The corium showed small perivascular infiltrations extending to the papillary layer and consisting mainly of lymphocytes. Moderate acanthosis and a slight degree of spongiosis were noted in the rete malpighii. In one case considerable ocdema was r... -- Apa11e riving risc . ibickened "11 ding with Aars (1934) says keratoma plantare sulcatum occurred in Africans in Dutch Guiana (Surinam), in Javanese and in Indians, particularly in the rainy season. There is thickening of the epidermis, where the sole touches the ground, in which the depressions develop. The fesion never evteads more deeply than the inner parts of the stratum corneum. The depressions are darkened by debris. The condition appears carly in life but only after the individual has started to walk. In the wet season the epidermis is spongy and in the dry season it becomes a dry hyperkeratosis. Symptoms ·DIFFERENTIAL DIAGNOSIS OP YAWS are not marked; only in the wet season may pain or * buming" of the feet be experienced after much walking. llc refers to the writings of Castellani, Hermans, Bacrmann and Acton & McGuire. Aars does not think the condition is due to a fungus nor to yaws. He says Castellani called attention to seasonal sanations, absence of palmar lesions, serotegative reactions, absence of response to antisyphilitic treatment, commencement in carly childhood and lack of previous history of yaws. His illustration closely resembles Fig. 22 of this monograph. Ale thinks the name for the condition should be " keratodermia (ne plantare sulcatum (Castellani)". Furnell (1943) reported observations arainly on Gold Coast (Ghanaan) soldiers, half from coastal areas and half from the northern territories. He described two main lesions (1) Cracked soles with or without hyperkeratoses and cracking of the heels. This is relatively painless and occurs in dry arcas , he thought it was due to excessive drying and injury from fine particles of sand Hlis Fig. I closely resembles Fig. 28 of this monograph, with more marked folding, (2) Pitting of thick skin of the sole whuch, he says, is identical with Castellani's keratoma plantare sulcatum. It may be present at the same time as cracks of the soles He thinks that injury and wetness are important causes of these lesions. He claims that these lesions developed in a European after spending four hours a day in a mangrove swamp for one week wearing only light canvas shoes He says it is not seen in habitual sandal wearers His Fig. 2 shons lesions closely resembling those in Fig 22 of thus monograph, Other lesions he saw were corns (clavus) and plantar warts (serrucac plantares), rat bites and "cut-onion effects on the heels wheck, he thinks, were due to wear during military fool-dnl). None of the lessons be describes were seen in Africans who habitually wort sandals. The reactions of the Kahn tests were no different in soldiers kith these plantar lesions and in others with none The response to arsenical preparatons was very disappointing", but the meaning of sandals hastened healing, Jedific & Humphreys (1952), in a suney of 464 Nigerian soldiers stationed at Ibadar, Western Nigeria, found marked plantar lesions in 31 individuals The lesions were as follows (1) Deep transverse and longitudinal fissures of the sole (17 cases) There were also superficial fissures resembling rig 27 of this monograph, but in their Fig. I "moderate scattered pitting was also apparen! (2) Plantar gutung. small (pen-point to a few millimetres), on the plantar surface, etcept for areas that did not have contact with the ground ·82 DIFFERENTIAL DIAGNOSIS OF YAWS (13 cases). These were sometimes limited to the heels. When they were extensive a "lace pattern" resulted. Their Fig. 2 resembles but is not identical with keratoma plantare sulcatum (Fig. 21 of this monograph) as the pits are smaller and relatively deeper. They say, however, that the pitting that they saw and keratoma plantare sulcatum" seem to be similar". (3) Fissuring of the rim of the heel in markedly thickened hyperkeratotic skin with multiple deep, usually painless fissures on the postero-lateral aspects of the heel ; frequently bilateral (10 cases). (4) Erosions of the plantar skin, which were superficial and multiple, and of varying sizes and irregular shape (6 cases). (5) Postero-lateral thickening of the heels (4 cases). Moderate, mostly painless, plantar changes were found in 196 soldiers (31%). The most frequent findings in these were lesions of type 5 above (100 cases) and superficial lesions of type 1 (54) and type 2 (24). Eleven of the 31 marked cases were seroreactors, but those with the most marked lesions were non-reactive. No serological studies of soldiers without plantar lesions were reported. Jelliffe & Humphreys think that most of these lesions were not due to yaws. In only two cases was infection with yaws possible; these were seroreactors and responded to treatment with neoarsphenamine. Most of the plantar changes occurred in soldiers from non-yaws areas who had sedentary duties. They think that the lesions are probably due to trauma of hot, dry, stony ground. Tengko Chen (1952) reports the high prevalence of this lesion in Taiwan especially in adolescents and adults who worked bare-footed in moist conditions. Clarke (1959) illustrates this condition as a plantar hyperkeratosis but says the cause is usually unknown. Turner (1959) also illustrates it among the plantar lesions not duc to yaws. Da Motta (1952), in an article on the palmo-plantar lesions of yaws, appears to include keratodermia plantare punctata (his Fig. 12) among the punctate keratodermias which he regards as due to yaws. Keratodermia Punctata (Chalmers & Kamar, 1917) Synonym : Keratodermia Cribrata (Castellani & Chalmers, 1919) (see page 17) Castellani & Chalmers (1910a) refer to a " peculiar pitted appearance of the palms". ** In several cases in the latter part of the scondary stage for yaws) hard, round, fastened papules or small nodules having a thick hard epidermic plug in their centre. may be observed on the palms and wrists. This plug falls off spontaneously or is easily ·DIFFERENTIAL DIAGNOSIS OF YAWS pulled out, when a depression remains The papules gradually disappear, but the depressions remain, and the palms acquire a peculiar preted appearance This condition of the palms may teraan unchanged for several years after all symptomatic yaw have disappeared Asomewhat similar appearance of the soles of the ſect is occasionally bet kih 83 Chalmers & Kamar (1917) describe as keratodermia punctata, pitting of the skin of the palmar surface of the hands from the distal skin folds of the wrist to the terminal phalanges--a condition which they observed on the hands of a Sudanese woman barber. The pits are sunk into the epidermis in patches of thickened epidermis There is no hyperaemia The lines of skin flexures may be fissured The following is their descrip tion: "When examined carefully by means of low-power lens it is nouced that the hordy layer of the epidermis as heaped up into a lotile circular ring at the orifice of sweat duct. This heaped-up mass of homy cells increases in size and joining with other milar small masses, forms a small translucent cupola or irregularly shaped swelling which may exude Nuid at les apex and forms a small central umbilicated sab This sad becomes surrounded by a arcular depression, which gradually deepens, and marks off a deep cone-shaped hotey plug sot unlike the core of a corn, while the surrounding epidermas becomes erythematous * The central corn-like mass comes away and leaves behind a deeglish cavity possess. ing a reddish base, stop walls, and undermined bomy edges This depression appears to be entirely situate in the horny layer "It is the formation of these depresyons which gives rise to the puted appearance of the hands, bile the cores before separation look like small coms The depression so produced gradually blls up from the bottom wish horny cells but in so doing is apt to give rise to crusts which, ben removed, show that the cavity is becoming shallower, while its edges become rolled in and not undermined "When completely filled in it forms a small thickened arca hach, when joined to 3mlar arcas, forms a borny patch "The swest pores on such a horny ridge or patch are quito petent, us can be dem onstrated by stimulating the horny tissue in the neighbourhood by means of a needle. when the sweat can be sen by means of a fons to exude from tbe pores, while a marked local erythema is also produced They also describe in detail the pathological changes seen in biopsy material, che possible causes of the condition, its differential diagnosis and its nomenclature. The paper is well illustrated. They summarize ** The characteristic features of Keratodermia punctata sgt the formation of corolike byperkeratotic punctations, preceded by small translucent, cupola-shaped swellings which may exude fund, and which are formed in association with the onfices of the Areal ducts "The corn-like punctations become loosnev and fall oui, kaving ta of depressons which all up and form homy patches on Auch the stat ports are patent Having cicluded syphilis and any as possible cIuses they conclude that the condition is of unknown onigin and worthy of consideration as a separate skin affection". They say that keratodermsa punctata may ·84 DIFFERENTIAL DIAGNOSIS OF YAWS affect palms and soles and that it is not the same as keratoma plantare sulcatum (Castellani), which is restricted to the soles and which, in addition to depressions in the skin, has furrows. It was almost certainly referred to by Castellani & Chalmers (19102). since it is illustrated by them later (Castellani & Chalmers, 1919). Castel- Jani & Chalmers (1919) illustrate punctate lesions in their Fig. 696 but these are not named, described or cross-referenced (p. 2257). Castellani & Chalmers (1919) describe as keratodermia cribrata a localized non-follicular hyperkeratosis of the hands and feet in which the changes are " little pits caused by the shedding of little corn-like projections". It is said that " in some remote way the condition is associated with framboesia or syphilis, congenital or acquired, and changes in the metabolism but not by the action of parasites ". There is a mild chronic inflammation of the dermis and a hyperkeratosis of the sweat orifices leading to the formation of corn-like projections which are freed peripherally and finally completely, and then fall out, leaving depressions. Palms and soles are affected, causing slight itching. The condition is bilateral and very chronic; its cause is unknown; and no treatment benefits it. Their Fig. 884 illustrates the condition. Castellani (1922) states that keratodermia cribrata must be regarded as a quaternary yaws lesion, often seen with secondary lesions and also with no such signs, and may occur in people with no history of yaws. Castellani (1923) gives keratodermia punctata as a synonym of keratodermia cribrata ; the description is identical with that of Castellani & Chalmers (1919). Acton & McGuire (1930) regard keratodermia cnbrata of Castellani and keratodermia punctata as synonymous. Localized hyperkeratosis is present and in India these conditions are always due to syphilis. Their Plate 2. Fig. 3 resembles Fig. 24 of this monograph. Hermans (1931) describes a condition in which " the thickened horny layer has a very characteristic aspect by reason of the numerous smaller and larger holes formed by the falling out of little balls of horny thickening". He refers to the description of Castellani & Chalmers (19j0a) of the same leston and says that Gutierrez (1923) gave the name keratoderma punctatum (sic) to it. Although the paper by Chalmers & Kamar (1917) is listed in his "Literature", he does not refer to it in relation to this lesion. He says that Spitt believed it to be due to yaws and that Powell saw it in Assam but did not think that it was due to yaws. Hermans often saw it in thc Moluccas, and thought that it was most probably due to Yaws. Hermans (1939) again refers to this condition in which small particles, from the size of a pin's head to 5 mm in diameter, of the corneal layer become detached. The margins are more or less raised. These lesions may become confluent and extend to cover a large part of the palm or sole.

·DIFFERENTIAL DIAGNOSIS OF YAW 85 The latter part of the description and his Fig. 4 do not resemble keratodermia punctata (Chalmers & Kamar, 1917). Da Motta (1952) says that one of the yaws lesions of the palms and soles is a punctate keratoderms and that it is very similar to the keratodermia disseminata plantatis et palmans of Buschke & Fischer or porokeratosis papillomatosa. The first of these, the Keratodermia of Buschke & Fischer, is synonymous with the keratoma of Brauer (1912) and 15 not due to yaws. Keratodermia punctata appears to be synonymous with Buschke- Fischer or Brauer disease It is ubiquitous and has no relationship to yaws or other treponematoses.

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·REFERENCES Als, C. (1931) Arch, Derm. Sypk (Chleogo), 24, 27) Airs, C. G. (1934) trop. Med. His . 37. 372 Acton, H W. & McGuite, C. (1930) Indian med. Goz, 65, 61 Acton, H W. & McGuire, C. (1931) Indian med. Gaz, 66, 65 Biermann, G. (1911) Arch. Schiffs- *. Tropenhyg, 15, Suppl. 6, 11 Baltser, L. H. (1920) Amer. 3. stop. Med , 6, 123 Brand, A. & Tass, J. (1952) Dermatologica (Basel), 105, 145 Brauer (1912) ZBI Plant-X, 25, 645 Castellani, A. (1910) J. Ceylox Br. Brit med Ass , 7, Castellani. A (1922) In: Byam, W & Archibald, R. G, ed. The practice of medicin in the tropics, London, Menry Frowdo & Ilodder & Stoughton, vol 2. p 1331 Castellani, A. (1923) In, Byam, W & Archibald. R O, ed. The proetice of medicine in the tropics, London, Henry Frowdo & Rodder & Stoughton, vol 3. p 2445 Castellari, A. (1949) An Inst Med. trop. (Lisboa), 6, 508 Castellani, A. & Chalmers, A. (1910a) Afanual of tropical medicine, London, Ballitre, Tindall & Cor, P 868 Castellani, A. & Chalmers, A. 3 (1910b) Afanual of tropical medicine, London, Railadre, Tindall & Cox, P {136 Castellani, A & Chalmeri, A, I (1913) Afanual of tropical medicine, 2nd ed, London, Bere. Tindall & Cox, P 1598 Castellani, A & Chalmers, A 3. (1919) Afanual of tropical medicine, 3rd ed. London, Baiere, Tindall & Cox, P 1549 Chalmers, A. 3. & Kamar, A. (1917) trop Med Hyr. 20, 121, 218 Clarke, G. AI, V (1959) Skin diseases by the African, London, lewys Davey, T. F. (1957) Bull WW Hith Org. 11, 435 Furne!?, M. J. G. (1943) Trans. roy. Soc. srop Med 1998, 37, 217 Gutierrez. P. D (1922) Arch Derm Syph (Chicago), 6, 265 Gutierrez, P. D. (1923) Arch. Derm Syph. (Chicago). 8, 382 Guturret, P, D. (1923) Arch. Derm Syph. (Chicago), 12, 465 Hackets, C. J. (1957) An international nomenclature of yaws lesions, Genesa (Horld Health Organization : Monogroph Series, No. 36 Hendrickx, R. O. (1950) Cent Ajf. Med, 6, 43 Flerman, E. 11. (1930) Framboesia tropice, Leider (Acta Iadensis, Hermans, E. II. (1939) Acta leidensia, 14. !!! Hudson, L. 11 (1936) AM trop Met Parasit, 30, 3 Sellise, D. B. & Humphreys, J (1952) J. Trop Med Hys. 55. ! Kkers, O (1930) Haxrhroniclex de llentieller and tuszoklen In Jadassohn, ffundeck der Haut- und Geschlechtskranktester, Berlin, Springer, vol 14, part 1, PP S$2, 631 ·22 DITAL DISC OF IAS Luz, C. & Lr23, J. (1353) La triedimoster indice à Les 19: Clips LTE-, los goles de l'eraz dok troploser le range, Pen, . 177 Lace- L254, C. & Labelere, J. (1989) L: Tro, H.C. & *** D. B., D.:casso diren leite des coudrais, London, A. p. 495 Mt:2, 1. ca (1952), Brabs, espeses findet!, BA-121 (Arzsda 17 Grual Las Derputar Florafos Prasileiros, Pecife, 1177) Acerzy. J. F., Merriwezhes, A. M. Fr, H.L. && Trier, D. 1 (* Bull. We Alth Org. 15, 975 Smith, E.C. (1932) An atlas of skin seases In the tropics, London, Pak & Dzx scene Tenzko Chen (1952) S. Formosan med. Ass. 51, 1932 ...rogorematoses with an extrated carpet of yoth of the Iosite for Medical Research of .

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