XANTHOMA DIABETICORUM⁶

Definition.—A rare eruption observed in diabetic individuals,
consisting of scattered, sometimes grouped and aggregated, somewhat

¹ McGuire, Jour. Cutan. Dis., 1898, p. 328.

² Stern, Berlin, klin. Wochenschr., 1888, p. 393.

³ Morrow, loc. cit.

⁴ Roberts, Brit. Jour. Derm., 1894, p. 148.

⁵ Besnier, Jour, de méd. et de chirurg., April, 1886—quoted by Jackson.

⁶ Literature: Malcolm Morris, London Patholog. Soc’y Trans., 1883, vol. xxxvi,
p. 278, with histologic plate (committee report on the subject, p. 284); a second case,
with histologic examination, by J. C. Clarke (with histologic cuts), Brit. Jour. Derm.,
1892, p. 237. In this case Morris gives an abstract and literature references of the cases
reported by Addison and Gull, Bristowe, Hillairet, Chambard, Hardaway, Barlow,
Cavafy, Colcott Fox, Besnier, and Robinson. Johnston (“Xanthoma Diabeticorum;
Its Place among the Dermatoses“), Jour. Cutan. Dis., 1895, p. 401, reviews the subject
and gives full bibliography (both as to cases and other pertinent literature) to date—
including, in addition to the above cases, those since reported by Crocker, Payne, Tims,
Pollitzer, Jamieson, Hallopeau, and Schamberg. I am indebted to this exhaustive

XANTHOMA DIABETICORUM                           675

inflammatory papular or nodular elevations, with usually, in most lesions,
the basal portion reddish and the apex of a yellowish or yellowish-white
color, and generally accompanied by slight subjective symptoms of itch­
ing and pricking.

Until recent years this malady had scarcely been known, but since
the clear exposition by Malcolm Morris its clinical individuality has
been generally recognized, and, in addition to Morris’s case, and the few
previously reported, numerous new examples have been recorded by other
observers, among whom Colcott Fox, Hutchinson, Cavafy, and others
in England, Besnier and Vidal in France, and Hardaway, Robinson,
Pollitzer, Schamberg, Johnston, and others in America.

Symptoms.—The eruption may present itself gradually, or it
may be more or less abundant from the start. In their earliest devel­
opment the lesions are usually dull reddish or of inflammatory hue, some­
times a raw-beef color, with very soon, in most or many of them, a yellow­
ish or .yellowish­white apex, somewhat suggestive of a minute pustule,
and later a fading of the peripheral and basal portion to a pinkish color,
and usually a widening-out of the yellow tint. The lesions are somewhat
firm or hard, pin-head­ to small split-pea-sized, rounded or conic, rather
sharply defined, papules; discrete for the most part, although often
aggregated, and sometimes crowded close together into patches. Some
papules may be pierced by a hair, and there may be also some showing
red points or lines due to capillary dilatation. Some of the lesions may
undergo involution and disappear without trace, and new papules may
continue to appear from time to time. Exceptionally the yellowish
xanthoma color is quite conspicuous or predominant. The lesions
sometimes occur in ill-defined streaks or seem to follow, in some regions,
the cutaneous nerve distribution. Some of the lesions may be more
or less flattened, as in Hardaway’s^l case, and the whole aspect be some­
what similar to ordinary xanthoma. While scarcely any portion of the
body is free from the possibility of being the seat of lesions, the buttocks,
the extensor surfaces of the forearms, the elbows, knees, and the back
are favorite situations; in some of the less extensive cases they may be
more or less limited to these regions, with other parts sometimes showing
a slight sprinkling only. The feet, legs, hands, and face also frequently

paper for much of the description of the disease here given. Other cases and literature
since recorded: Robinson (another case—woman), Trans. Amer. Derm. Assoc.for 1896;
Norman Walker, Brit. Jour. Derm., 1897, p. 461, with colored plate and a valuable
analytic table and literature references of all cases above (except Robinson’s second
case), and those since recorded by Darier, Colombini, Toepfer, Geger, making in all
30 cases; Abraham, ibid., p. 484 (case demonstration—male, aged forty-five); Sher-
well, with histologic report by Johnston (case, woman, aged forty), Jour. Cutan. Dis.,
1900, p. 387; Schwenter-Trachsler, Monatshefte, 1898, vol. xxyii, p. 209 (male—colored
plate and an abstract résumé and references of most of the reported cases); Krzysztalo-
wicz, ibid., 1899, vol. xxix, p. 201 (male—with 8 colored histologic cuts and bibliog­
raphy); Sequeira, Brit. Jour. Derm., 1901, p. 56 (case demonstration—male—free from
glycosuria); total, 36 cases. Abstracts of several interesting cases, reported in the past
three years by Abraham, Antonino, and Bossellini (3 cases), are given in Jour. Cutan.
Dis., 1905, pp. 186-190; Lancashire, Brit. Jour. Derm., 1907, p. 269 (with illustration
of palms; eruption consisted of streaks and nodules on palms and fingers, and nodules
on wrists and elbows); Pusey and Johnston, Jour. Cutan. Dis., 1908, p. 553 (patient
also had a lipoma multiplex; case and histologic illustrations).
¹ Hardaway, St. Louis Courier of Medicine, Oct., 1884.

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show the characteristic discrete and bunched papules. In Hutchinson’s^l
case, in which the eruption was extremely extensive, the scalp, face, and
lips were the seat of numerous and well-developed lesions, the scalp
especially being thickly covered.

In most patients the eruption is not abundant, but in that just named,
and in those of Hardaway, Morris (second case), Johnston, and a few
others, it was present in great profusion, and tended in places to coalesce
and form plaques, the latter being usually dotted over with the yellowish
points showing the individual component lesions. The eruption is rarely
on the eyelids,—the common site of ordinary xanthoma,—Besnier’s and
Hardaway’s cases being exceptional in this respect. Occasionally the
eruption has also been seen in the mouth. In some instances the itching
and burning, usually present to a variable degree, may be quite trouble­
some. The papules are, especially when appearing, often quite tender.
The course of the disease varies somewhat, but in most instances, after
lasting several months or a few years, during which time there is apt to
be irregular accession of new lesions and involution of some of the old ones
the eruption gradually disappears. No permanent traces are left.

Etiology.—There has been an associated diabetes mellitus in
most patients, and this has, therefore, been looked upon as etiologic; it
was, however, wanting in the cases of Cavafy, Hutchinson, Vidal, Geyer,
Sequeira, and a few others, and extremely slight in some instances.
The extent of eruption has, however, been usually noted to vary accord­
ing to the amount of sugar in the urine; this was especially noticeable in
Johnston’s patient. In one instance (Colombini)² there was pentosuria.
In some of those cases in which sugar was not found, as well as in a few
others, albumin was noted to be present—Cavafy’s case had suffered
from nephritis. Jaundice was present in Hardaway’s patient, and the
urine showed but a trace of sugar. The malady is seen chiefly in the
male sex—out of the total of 36 reported³ cases there were only 5 women
(Hillairet (2), Walker, Robinson (second case), and Sherwell). Its sub­
jects are commonly of the florid and obese type, and many in apparently
good health; almost all were between the ages of twenty-five and fifty,
Pollitzer’s case, a boy aged seventeen, being the youngest.

Pathology.—The proper position of this affection is not yet
determined, some holding that it is essentially a form of ordinary xan-
thoma, others that it is a distinct affection. Both the clinical and his-
tologic aspects furnish some support to either view. Besnier and Doyon⁴
are the most pronounced in their belief that the malady is not separable,
except as a variety, from ordinary xanthoma, and believe that the gly-
cosuria is merely the determining factor in the clinical differences.
Török,⁵ on the contrary, from his study of the various types, takes a
diametrically opposite view; most other investigators lean one way or

¹ Hutchinson, Arch, of Surgery, vol. i (1889-90), p. 381.

² Colombini, Monatshefte, 1897, vol. xxiv, p. 129.

³ Hyde (discussion, Trans. Amer. Derm. Assoc. for 1897) also refers briefly to 2
cases, which would make the total 38; in 1 of his cases there was abundant glycosuria
associated with albuminuria. Since the above date new cases have been gradually
added.

⁴ Besnier and Doyon in French translation of Kaposi’s treatise, vol. ii, p. 335.

⁵ Török, loc. cit.

XANTHOMA DIABETICORUM

677

the other, but apparently their convictions are not as yet of a decided
character. The lack of involvement of the eyelids would seem to indi­
cate individuality, although Hardaway’s case presented many features
common to both. Its apparent relationship to diabetes mellitus, and
its disappearance under treatment for the latter, shows pretty strongly
that there is a common underlying cause, and this fact would, moreover,
seem to separate the malady from ordinary xanthoma, which is persistent
and unresponsive to any general treatment, and is rarely associated
with glycosuria. Preverted liver function, however, seems to be a factor
in both varieties of the multiform xanthomatous process. Török,
Kaposi, Johnston, and a few others (quoting from Johnston’s paper)
believe the cutaneous phenomena are due to an irritative process, the
irritation being supplied by the excess of glucose or some faulty product
of metabolism circulating in the blood; Johnston believes that this has
some support in the fact that the nodules begin in the corium in the
neighborhood of the sweat-glands and the hair-follicles, with their at­
tached sebaceous structures, all of which are supplied by the same set
of vessels, part of the excretory apparatus of the skin.

The pathologic histology has been studied by Robinson, Crocker,
Clarke, Payne, Schamberg, Pollitzer, Walker, and others, and with
few exceptions the conclusions are that microscopically the process
closely resembles that of ordinary xanthoma, except that the inflam­
matory element is clearly evident and the connective-tissue growth less
pronounced—according to Crocker there is no actual connective-tissue
growth. This latter, however, is not in accord with the investigations
of Robinson and others. The changes are especially conspicuous about
the hair-follicles. The “xanthoma cells” are also found. The process
is practically confined to the corium, and apparently the first step is
vascular dilatation, followed by other evidences of inflammatory action.
Central degenerative changes of a fatty nature take place, and to this
mass of fatty granules is due the central yellowish color. Pollitzer,¹
who has made extensive histologic studies of the various xanthomata,
considers the two varieties of generalized xanthoma as histologically
identical, the process in the diabetic form being a little more diffuse and
the tendency toward fatty degeneration more marked than in the non-
diabetic variety; in the Cohnheim sense he scarcely thought the process
could be considered an inflammatory one, but an irritative hyperplastic
development of connective tissue, with a tendency to fatty degeneration.
Walker agrees with Pollitzer in not viewing the process as inflammatory;
he considers it approaches nearest to the chronic granulomata, and sug­
gests the possibility of some organismal cause.

Diagnosis.—The color of the growths,—the reddish or pinkish
peripheral and basal portion, and the yellowish central apex—their
sudden evolution, absence from the eyelids, the firm, solid character of
the lesions, the occasional follicular origin, the involutionary changes,
often quite noticeable, and the accompanying glycosuria and the sub­
jective symptoms, together with the tendency, after months or a few
years, to spontaneous disappearance—are all different from the symp-

¹ Pollitzer, loc. cit.

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toms of ordinary xanthoma multiplex, and will serve to distinguish the
one from the other.

Prognosis and Treatment.—Probably sufficient has already
been said as to prognosis. The malady frequently disappears sponta­
neously in a few months or years, more quickly by treatment. Instances
of long duration—over seven or eight years in Cavafy’s case—and of
the tendency to extensive relapse in Johnston’s case, are of exceptional
occurrence.

The treatment consists in the adoption of measures for the cure or
palliation of the associated glycosuria, more especially by means of
regulation of the diet and the administration of such remedies as arsenic
and codein, or other drugs if indicated by other conditions. For relief
of the itching, often present, lotions of carbolic acid, of liquor carbonis
detergens, with or without saturated boric acid solution as a basis, or
any of the milder lotions or ointments employed in acute eczema or in
pruritus, would doubtless answer the purpose.

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