Through visual media, we are nowadays accustomed to “exotic-looking” things. However, if these are hyper-realistic reproductions in wax and can be admired directly, it’s definitely something else.
During the annual Long Night of the Museums in Zurich 2018, the Museum of Wax Moulages focused on “the exotic”, i.e. the strange, the unusual and the foreign in skin disease.
This includes not only skin changes such as the Mongolian Spot, but also diseases such as Leprosy, which occurred in Switzerland in the past, and is now considered “exotic”. In our globalized world, skin diseases sometimes get picked up as “souvenirs” during an exotic beach holiday, such as the worm larva in Larva migrans.
«What the mask can hide …»
Wearing a protective hygiene mask is harmless and, contrary to many fears, does not lead to skin diseases. As a positive side effect, however, it can hide disturbing or even disfiguring skin symptoms. The moulages compiled here show findings on the face which are rare today and usually harmless, but which used to be a great social handicap for the people affected and could even be fatal.
Bacteria, viruses, and fungi colonize our skin as a microbiome and help us to defend ourselves against pathogenic (disease-causing) influences. Nevertheless, aggressive bacteria can invade hair roots, sebaceous glands or enter tissues through small injuries and lead to inflammation with pustules or ulcers. In extreme cases, these bacteria can lead to sepsis (blood poisoning).
Thanks mainly to the discovery and targeted use of antibiotics, these infections are now much rarer and seldom dangerous.
Examples: Moulages 707, 744 and 767.
Moulage 285: 10-year-old Gottfried B. had been suffering from a swelling under his nose for 8 days. The abscess was cut open and the bacterium Staphylococcus pyogenes was detected.
Further moulages on bacterial inflammations can be found in showcase 26.
This clinical picture is an infection caused by actinomycetes and other bacteria that normally occur in the oral cavity. If the mucosa is injured, these can penetrate into the tissue and bone and cause a purulent deep inflammation with tissue destruction that leaves scars. To stop the spread of the infection, the affected tissue used to have to be generously removed surgically.
Moulages 17, 39, 177 (above, display case) show the findings of 26-year-old Emilie B. before and after the operation and the health status after two months. She was operated on 13 November 1919.
Tuberculosis (Lupus vulgaris)
Until 1950, tuberculosis (consumption) was very common. It primarily affects the lungs, but the infection can spread to all tissues and organs and be fatal.
The spread of mycobaterium tuberculosis in the facial skin leads to lupus vulgaris (the "devouring wolf") with severe inflammation and disfiguring scars. In 1903, Niels Ryberg Finsen received the Nobel Prize for discovering the UV light therapy of lupus vulgaris.
Moulages 566, 552, 459 and 458: The moulages shown here document the success of the "superposed intensive irradiation" developed further in Zurich. This was combined with the "Gerson diet", which later proved to be ineffective.
Superposed intensive irradiation
Intensive irradiation meant treatment with extremely high doses and long irradiation times of more than half an hour, resulting in severe sunburns with heavy blister formation. The irradiations were repeated as soon as the blisters and crusts - treated with ointments and compresses - could be removed with tweezers and scissors, usually after 2-3 days. Thus, the treatment did not wait until the sunburn had healed, hence the name "superponated".
The therapy was extremely painful and had to be continued for several months. The period of irradiation is noted on some moulages. However, the patients' suffering from tuberculosis justified this. The patients were socially excluded and could no longer find work because - due to their appearance - no one hired them. One 50-year-old patient stopped treatment early "because it looked nice enough" and reported after six months that she did not come for check-ups because she was doing well and the factory that employed her provided enough work.
The local skin therapy was combined with a complicated fat- and salt-free vegetarian diet invented by the German doctor Max Gerson. He had originally developed this for migraine therapy and later promoted it as a "metabolic therapy" for tuberculosis to "eliminate toxins". It was used in many clinics around 1930 until its ineffectiveness was finally proven. Nevertheless, Gerson later promoted the diet as a therapy for cancer and diabetes. After emigrating to New York, his membership of the local medical society was withdrawn because he continued to propagate his diet despite clearly disproving data. Even today, the therapy is sold to cancer patients seeking help and is even offered in specialized clinics, usually advertised with unverifiable stories of miraculous cures of terminally ill patients.
Moulages 962 and 383 show chronic inflammatory tuberculosis of the lips.
Moulage 962: The suppuration on the upper lip of A.G., a 16-year-old girl, had started five months ago and had spread to the gums.
Moulage 383: The case of Heinrich B., who had been suffering from tuberculous inflammation of the lower lip for ten months, was published in a textbook with the remark that tuberculosis of the lip can easily be mistaken for skin cancer. The finding was treated with chemical irritants, surgical cleanings, and X-rays. The patient was simultaneously suffering from severe overt pulmonary tuberculosis with a poor prognosis.
Information and further moulages on tuberculosis can be found in showcase 12.
Lupus erythematosus of the skin
Lupus erythematosus is an inflammatory autoimmune disease that can affect various organs but can also affect exclusively the skin. The clinical picture is very similar to lupus vulgaris and a possible connection with tuberculosis was still discussed until the middle of the 20th century. However, lupus erythematosus is not an infectious disease.
Moulages 988, 412 and 411:
The inflammation, which worsened in UV light (daylight) could lead to severe disfigurement in the past because of scarred skin, as the mask hides in moulage 412. Thanks to cortisone and powerful modern anti-inflammatory therapies, such severe progressions can be avoided today. For more information on lupus erythematosus, see showcase 34.
Rosacea and perioral dermatitis
During the period of the pandemic when masks were mandatory, there was an increase in inflammatory diseases of the sebaceous glands on the face, both rosacea and perioral dermatitis. Even if the hygienic mask is not the cause of this inflammation, the warm and humid climate beneath it can worsen an existing problem. However, at least the mask at the same time hides the features which might be stressful for the individual.
Rosacea is a tendency to redness, swelling and inflamed sebaceous glands on the face, which is worsened by UV light, heat, and excessive rehydration.
Perioral dermatitis (POD) is closely related to rosacea. It causes inflammatory redness, papules and pustules with itching and a feeling of tightness and, over time, scaling. POD is triggered by "too much skin care" with regular moisturizing and re-lubricating or by using cortisone creams on the face. This leads to a vicious circle: because of the feeling of tension, the slightly flaky skin and the strong inflammation, people intuitively treat the skin even more intensively.
After discontinuation of all skin care products and consistent renunciation of cortisone, POD usually heals without further therapy - but only very slowly, and over several weeks. It is not necessary to take off the mask because the moist warmth under the mask contributes only minimally to the clinical picture. On the contrary: here, too, the ugly clinical picture can at least be well concealed behind a hygienic mask.
Information and moulages on rosacea and perioral dermatitis can be found in showcase 41.
Moulages no. 423, 1125 and 617 show, according to their labelling, an immune reaction of the skin in tuberculosis. It was disputed whether there really is a connection with tuberculosis. It may very well be that the cases documented here were so-called granulomatous rosacea. This corresponds to a mixed picture of POD and rosacea, often provoked by an incorrect local therapy of the pre-existing rosacea.
Rhinophyma is another distinct special form of rosacea, which used to be associated with alcoholism as "drunkard's nose". While alcohol can worsen rhinophyma, it is not the cause. The hypertrophic (excessively proliferating) sebaceous glands lead to a bulbous nose, which - fortunately only very rarely - can also take on grotesque forms, as can be seen in the moulage in the box at the bottom of the showcase. The therapy sounds brutal, but it is simple and effective: the excess sebaceous gland tissue can be surgically removed with a scalpel to the original shape of the nose and the skin usually heals quickly and without scarring.
Moulages and information on acne can be found in showcase 41.
The tendency to overactive, enlarged sebaceous glands and a cornification disorder leads to comedones and inflamed pimples, which in unfortunate cases heal with scars.
In moulage 501, the damage of the treatment of a severe acne can still be seen. Today, acne can be treated with retinoids (vitamin A acid) and other local therapies that act on the sebaceous glands. The private patient documented here was treated with X-rays around 1920 according to the textbook. This was a standard treatment for severe acne until the 1970s. This is astonishing from today's point of view, as it was already shown in 1930 with this and other moulages at dermatological conferences that repeated X-ray irradiation of the skin can lead to chronic damage (radioderma) and to skin cancer.
Moulages no. 1258, 91 and 408: The hygiene mask can hide red, rough patches, crusts or even ulcers, the cause of which is very often light skin cancer. The most important risk factor for developing light skin cancer is the cumulative amount of UV light collected over a lifetime. This is greatest on the face, where the skin is always exposed to daylight.
For more information on the different forms of skin cancer, see showcases 44, 45 and 46.
Catalogue p. 13
The typical rash appears three days after the initial fever and cold symptoms. Lung- and middle ear inflammation (pneumonia and otitis media) are common complications. A feared, but fortunately rare complication is the accompanying encephalitis. The measles virus only exists in humans and could be eradicated by consistent vaccination.
Typical spotty measles rash about two weeks after infection.
Catalogue p. 16
The herpes simplex virus (HSV) infests the skin and the nerve tissue. When transmitted via the mouth cavity, the virus causes the so-called “Fieberbläschen” (engl. fever blister). When sexually transmitted, however, the infection presents itself with redness and blisters in the genital region. The virus remains in the nerval ganglion and the disease can break out repeatedly.
“Fever blister” on the upper lip.
Catalogue p. 17
The verruca viruses cause a benign, tumor-like thickening of the epidermis.
Verrucae occur most frequently on body parts that are mechanically stressed or poorly supplied with blood (fingers, soles of the feet).
Water Warts (Molluscum contagiosum)
Catalogue p. 16
Water warts are highly contagious. Particularly affected are children between the age of 3 and 10.
Catalogue p. 14
Chickenpox, induced by the Varicella-Zoster-Virus (VZV), is one of the most common infectious diseases. 95% of humans have gone through this disease by the age of 15.
About two weeks after the droplet infection, small papulae appear on the skin and mucosae, evolving into blisters. In adults, an subsequent infection of the lungs and the meninges can be life-threatening.
Catalogue p. 15
After the healing of the chickenpox, the “sleeping” virus remains inactive in the nerve cells. When reactivated, it travels along the nerves and into the skin, producing shingles. The inflammation of the nerves can cause sharp or burning pain.
Herpes zoster in the area of the abdominal wall with a belt-like pattern. Beside it, so-called aberrant blisters on the entire body.
Additional moulages on viral skin diseases in showcase 47 on the left.
Catalogue p. 18
Not only can ticks transmit the Early Summer Meningoencephalitis (ESME) by their bite, but also the bacterium Borrelia burgdorferi. This infection (Borreliosis, Lyme disease) can be treated with antibiotics, however, there exists no vaccination as in the case of ESME.
Days or weeks after the infection, a rash will spread annularly: the Erythema migrans.
In early stages, swelling or lumps (pseudolymphocytoma) may appear on the skin, typically located on the earlobe or on the nipple.
On the skin the chronic infection leads to acrodermatitis chronica atrophicans, an inflammation with swelling, pain and eventual atrophy.
Sometimes fibrinoid nodes may occur in close proximity to joints.
Catalogue p. 19
Bacteria, usually streptococci or staphylococci, can enter the skin through injuries and will subsequently spread. The following extensive inflammation brings with it the danger of sepsis.
In the past, only an amputation of the affected limb well in advance could save the patient from a fatal sepsis. Nowadays, in addition to immobilisation, the use of antibiotics at an early stage is of prime importance.
Erysipelas on the thigh.
Erysipelas with participation of the eye with the danger of dissemination along the veins into the brain.
Catalogue p. 20
The bacterium Staphylococcus aureus can cause particularly purulent inflammations of the hair root (follicle).
Sycosis, also termed barber’s itch, resembles a sliced fig (gr. sykon = fig). Bacteria, fungi or, more infrequently, herpes viruses can be possible pathogens.
Catalogue p. 20
A folliculitis with heavy inflammation and necrosis may result in a painful abscess.
Furuncle on the upper lip.
Erysipelas in the face with formation of a furuncle.
Catalogue p. 21
If the skin gets injured by an eczema or by scratching, staphylococci or streptococci can enter and trigger a blistery and scabby inflammation – especially in children.
Impetiginized atopic eczema (neurodermatitis), superinfected with bacteria.
Catalogue p. 22
Certain groups of the bacterium Staphylococcus aureus produce a toxin, which disrupts the linkage between the horny cells (corneocytes) of the skin. Such an infection can lead to an extended flush, and superficial blisters with the destruction of the protecting epidermis in a very short time, especially in infants. Without treatment, this disease is fatal in up to half of the cases.
Staphylococcal Scalded Skin Syndrome, lethal outcome.
Catalogue p. 21
The chronic infection with the Mycobacterium Leprae can lead to heavy mutilation. The disease can be transmitted from human to human, but is only mildly contagious.
Depending on the patient’s immune response, an infection can evolve very diversely: from mere skin changes to severe damages of the nerves, skin and other organs. By taking antibiotics for several months, lepra can be cured.
Infectious type of lepra with a weak immune response and poor prognosis.
Additional moulages on bacterial skin diseases in showcase 47, left side.
Fungal infections can cause different inflammatory reactions on the skin. Therefore, the presence of the fungus inside the lesion is essential for the diagnosis. Skin scales, nail material or hair can be checked directly under the microscope for fungi, and the pathogens are cultivated for further classification.
Catalogue p. 24
Diseases caused by hyphomycetes (dermatophytes, trichophytes) nowadays are also termed tinea.
Tinea corporis: The fungus is often transmitted from the feet to the rest of the body.
Folliculitis: Fungi can also affect the hair and the hair root.
Fungal infection of the nails. However, inflammatory diseases like psoriasis can lead to exactly the same nail alterations. For diagnosis, the presence of the fungus has to be proven under a microscope or in a culture.
Catalogue p. 24
The yeast fungus Candida albicans can not only be found on the mucosa of a sick person, but also in healthy people. Treatment is only necessary in case of an inflammation or immune deficiency.
Candidoses can occur on humid, stressed skin parts, typically in skin folds and between the fingers.
Catalogue p. 23
The yeast fungus Malassezia furfur can be found on greasy skin areas in many people, especially on the scalp. If the fungus proliferates, as a result of heavy sweating, it can cause a slight inflammation.
On fair skin, brownish spots with a fine, branny poudery (pityriasiform) scaling may occur.
As the fungus produces the bleaching azelaic acid, the spots appear brighter on tanned skin.
Additional moulages on fungal infections in showcases 3, 10 and 11 and in showcase 47, left side.
Catalogue p. 24
Roughly a third of the people in Europe have an athlete’s foot. Humid feet as a result of contemporary footwear as well as bad blood circulation increase the risk.
The best-known form is the interdigital type with macerated skin and fissures between the fourth and fifth toe.
Hyperkeratotic foot fungus at the sole. Without proof of the fungus, the symptoms cannot be told apart from an eczema or psoriasis.
In rare cases, a foot fungus infection can cause blisters.
Catalogue p. 26
In tropical areas, the sand fly transmits Leishmania from rodents and dogs. Depending on the type of parasite and the immune state of the infected person, the infection remains limited to a spot on the skin or else spreads, sometimes affecting inner organs.
Local infection with a small, encrusted ulceration.
Other forms lead to various weeping skin changes, or to diffuse lumps.
Catalogue p. 26
Living on human beings are: the head louse, the clothes louse and the crab louse. Hereabouts, clothes lice are very rare. They can transmit pathogens of fever diseases. The head louse infests preferably children and people with long hair. At school, small epidemics occur at regular intervals.
After a few days, the stings evolve into red itchy papules and a scratched eczema as a reaction to the lice’s saliva.
The small crab louse is transmitted by close body contact, usually sexual contact. The lice stings evolve into small, bluish bleedings (Tâches bleues).
Catalogue p. 27
The itch mite lives only in the human horny skin. It is transmitted by close body contact or through clothes and bedding. The strongly itchy rush is caused by a hypersensitivity reaction to the mite or its faeces.
Typical locations are the folds between fingers and toes (Moulages 1450 and 728), the wrists, the penis shaft in men and the entire body (Moulage K42) as well as palms and soles in infants.
The bedbug lives in old wood and visits and bites human beings during the night.
Additional moulages on parasites on the skin in showcase 47, right side.
When the medical speciality of skin diseases was established in the 19th century, sexually transmitted syphilis was very common. In advanced stages, its skin symptoms can imitate almost every skin disease. Therefore, profound dermatological knowledge was necessary for the clinical assessment of syphilis, and STIs still demand a dermatologist’s expertise today.
The teaching of STIs is also termed venereology, derived from the name of Venus, the goddess of love.
Catalogue p. 39
The pathogen of syphilis is the bacterium Treponema pallidum, which is sensitive to penicillin. After the introduction of penicillin in Switzerland in 1946, both incidence and severity of syphilis decreased rapidly. Nowadays, with the spread of HIV and a less consistent safe-sex prophylaxis, the infection rates are again increasing significantly.
Roughly three weeks after direct transmission, painless ulcerations (hard chancre) occur accompanied by swelling of the lymph nodes.
The ulceration can remain undetected, e.g. if located at the cervix.
In rare cases, the infection appears only as a hard, inflammatory swelling of the genital skin.
After the healing of the primary stage, the infection slowly spreads throughout the entire body. Roughly three months later, a symptom-free, undulating rash occurs, which will eventually disappear, followed by a completely symptom-free phase.
A rash, which occurs symmetrically on both hands and feet, is typical for Lues II.
After the syphilitic inflammations have healed, pigment disorders may remain. The typical white, ring-like macules on the neck were formerly called “Necklace of Venus”.