The newer corticosteroids for local application, betamethasone valerate and fluocinolone acetonide, are so much better than their predecessors that the need to use other routes of administration is diminishing. Lichen planus, lichen simplex and chronic discoid lupus erythematosus respond, particularly if penetration of the drug is assisted by the technique of occluding the anointed area with an impervious layer of material such as polythene sheeting. This improvement in therapeutic effect, however, has been achieved only by reducing the margin of safety; with the occlusive technique systemic absorption is increased to such a degree that adrenocortical suppression is possible. It is therefore advisable to limit the duration of occlusion to periods of 12 hours; and the area treated at one time must not exceed one-third of the total body surface.
Intra-cutaneous Injection.—Resistant patches of lichenification, lichen planus, discoid lupus erythematosus and psoriasis can be treated by the injection of triamcinolone around the lesions, the total volume used being not more than 0-5 ml. The injections are repeated at weekly intervals until a satisfactory response has been obtained. Small patches of alopecia areata are also suitable for such treatment, but widespread loss of hair cannot be treated by this method.
Systemic Treatment.—Corticosteroids are needed as a life-saving measure in fulminating illness associated with drug eruptions, urticaria and erythema multiforme of the Stevens-Johnson type. The treatment should be started by giving 0.1 g. of hydrocortisone hemisuccinate intravenously and 40 mg. of prednisolone in divided doses by mouth, during the first 24 hours. The dose is adjusted thereafter according to the patient's response; the daily dose should be tailed off and eventually stopped as soon as the activity of the disease has abated—which will probably be within three weeks.
Long-term corticosteroid treatment is required in exfoliative dermatitis, the pemphigus group of diseases, mycosis fungoides, the cutaneous reticuloses and disseminated lupus erythematosus. Since these are mortal diseases or at least endanger life, such treatment is manifestly justifiable. After initial high dosage of the order of 60 mg. of prednisolone daily to achieve control, a maintenance dose as low as 10 to 15 mg. of prednisolone daily is often possible.
Difficulty arises in deciding whether to use systemic corticosteroid treatment in chronic non-fatal dermatoses, for if such treatment is begun it may have to be continued indefinitely. It is established practice to use oral treatment to tide a patient over a severe attack of urticaria, erythema multiforme or a drug eruption since these are likely to be self-limiting. A severe attack of eczema which is attributable to some remediable stimulus such as contact with a known irritant can reasonably be suppressed during the period of its activity with the prospect of being able to stop the treatment within a few weeks. The management of lichen planus is more debatable since local application of the newer corti-costeroids under occlusion is so effective. Most debatable of all are cases of obstinate and disabling dermatosis when there is some prospect of being able to effect material improvement but at the risk of keeping the patient permanently on corticosteroid treatment. Many dermatologists regard the risk as too great to contemplate in any circumstances; but this is perhaps a somewhat extreme view, and it is not borne out by the experience of those who have used long-term treatment over a period of several years with strict supervision of the patients. It seems probable that if the maintenance dose can be kept at or below 10 mg. of prednisolone daily, and never exceeding 15 mg. daily (except under conditions of stress as mentioned below), the risks are very much reduced and may be acceptable for the few patients who would fall within the terms of the following conditions :
The dermatosis is so severe as to interfere seriously with the patient's life and ability to work, either by reason of physical incapacity or psychological handicap such as an overpowering feeling of inferiority.
A carefully supervised and adequately prolonged period of treatment (say one year) by other means has failed to bring substantial relief.
There is no history suggesting peptic ulceration, psychosis, diabetes mellitus, significant hypertension or severe osteoporosis.
There is no active focus of tuberculosis. A past history of this disease points to the need for a careful clinical and radiological survey and, even if no activity is detectable, anti tuberculous drugs should be given concurrently with corticosteroids. A close watch should be kept during treatment in all cases, irrespective of a known history of tuberculosis, for signs of this disease.
The patient is intelligent and co-operative. He should understand the nature of the risk involved in the treatment and accept it. He should be prepared to attend regularly for follow-up, and should carry a corticosteroid treatment card which should be kept up to date.
In the case of alopecia treatment should be restricted to those in whom the loss of hair is total, or nearly so; the alopecia should have occurred after puberty, and a wig should have proved unsatisfactory.
It is recommended that the initial daily dose of prednisone should be 15 mg., that, except as mentioned below, this dose should never be exceeded, and that the maintenance dose should be kept at or below 10 mg. daily at a level at which the disease is just active. If worthwhile improvement has not occurred within 12 weeks, the treatment should be abandoned by gradually tailing off the dose. The follow-up needs to be at weekly intervals initially until the disease has been controlled and the dosage stabilized, and thereafter at increasing intervals but never longer than eight weeks. At each visit the patient is assessed clinically, has his blood pressure taken, is weighed and has his urine examined for sugar and albumin. The most serious risk of the treatment is suppression of adrenocortical function which could lead to sudden adrenal failure in face of the stress of an infection, an anesthetic (even a dental gas) or an injury. The. remedy is to cover periods of stress with an increased dose of steroid, say three to four times the normal. The corticosteroid record card is the patient's only safeguard if he is involved in an accident and taken unconscious to hospital.
The method will be found applicable to selected cases of severe atopic eczema (Besnier's prurigo), generalized neurodermatitis and alopecia totalis. Psoriasis is unsuitable (even if triamcinolone, which has been specially recommended for this condition, is used) because the maintenance dose is usually above the recommended maximum, and there is also a tendency for the disease to relapse violently when the treatment is stopped.
It is possible that as far as their effect upon diseases of the skin is concerned, some corticosteroids are more effective than others. In pemphigus cortico-trophin injections can be much more effective than oral corticosteroids but this might be due to defective absorption from the gut. In alopecia there is an impression that methyl prednisolone and triamcinolone are more effective than prednisolone in equivalent dosage. On the other hand prednisolone is regarded as safer than triamcinolone.
Tuesday, July 29, 2008
URTICARIA Treatment
Urticaria is the result of localized ædema in the skin produced by leakage of fluid without red cells from the blood. The transient increased permeability of the vessels is usually brought about through the release of histamine (or histamine-like substances), by a variety of stimuli including injury, and the occurrence of antigen-antibody reactions. Some skins weal abnormally with injury (dermo-graphism). Others weal through the action of heat, cold or light; and among the less common precipitating factors are emotional stress and hypnotic suggestion. Urticaria is a common disability, but it is often of limited duration and the eruption can usually be controlled with oral antihistamines. Further the search for the provocative stimulus is difficult and time-consuming, and not surprisingly the cause is seldom found. Some cases become chronic, and then it is imperative to identify the cause if rational treatment is to be given.
Provocative Stimuli.—The search for possible antigens should be directed to the diet, to drugs, to inhalants, to the contents of the hollow viscera and to the patient's own tissues.
The diet should be recorded day by day, with a note on the condition of the skin written on the adjacent page. Things that have been eaten in the 24 hours preceding each fresh outbreak should be reviewed and any foodstuff common to each incident noted. All suspicious foods should be banned. If the urticaria disappears, the foods can be added one by one at intervals of a week and the results observed. If the true cause has been found it should be possible to make the urticaria appear and disappear at will by introducing and withholding it from the diet. Failing this the patient can be starved for two days, except for water ; persistence of the urticaria would make a dietary cause most unlikely. If the diet is suspected but observation has failed to identify the cause, skin tests may be successful provided that the test solutions used are potent.
Of drugs, penicillin and aspirin are said to be the commonest causes of chronic urticaria. The eruption can outlast the giving of penicillin by many months—possibly due in part to the ingestion of traces of penicillin in milk and partly by inhalation, for example in hospitals. Aspirin often acts as a nonspecific stimulus by aggravating urticaria due to other causes. A diary is necessary as in the case of the diet. One should remember that drugs can be taken unwittingly—for example quinine in drink and phenolphthalein in toothpaste ; and also that drugs can be ingested, injected, inhaled, anointed or placed in any of the natural orifices.
Inhalants, such as mould spores, dusts and pollens, which do not necessarily cause sneezing or ocular discomfort, produce a seasonal or intermittent pattern of attack according to the climatic conditions under which they are produced, or their location. Skin testing facilitates precise identification, but specific desensitization may not be practicable.
The hollow viscera, such as the gut and gall bladder can contain organisms or products of their activity which are absorbed and act as antigens. Yeast infection of the bowel or of diverticulae of the bowel (including blind loops left by surgery) often causes urticaria.
The patient's tissues may harbour infections such as dental infection or a tumour which is breaking down rapidly, and these can act as antigens. The auto-antibody disease, lupus erythematosus in its disseminate form, can present as urticaria, and so can the vascular disease, polyarteritis nodosa
Emotional stimuli can be entertained as factors only when, in addition to a lack of physical causes, there are positive psychological ones. Suppressed anger at some intolerable but apparently irremediable situation is a potent stimulus.
Symptomatic Treatment.—In many cases none of the above causes can be found and then the only available treatment is symptomatic. The antihistamine drugs, taken by mouth, are usually effective but it may be necessary to find by trial and error which drug suits the individual patient. The intramuscular injection of an antihistamine is worthy of trial if the response to oral treatment is poor. One of the chief anxieties about antihistamine treatment in the ambulant patient is its possible effect on the ability to handle machinery, particularly motor cars and aeroplanes, for even if antihistamines do not have an hypnotic effect they may impair judgment. The object is first to suppress the eruption with, for example, between 0-15 g. and 0.3 g. of diphenhydramine hydrochloride in divided doses daily, and then to find the minimal dose that will just control the eruption. Children tolerate these drugs well and for them elixirs are very acceptable. An alternative to the antihistamine drugs is to use chloroquine by mouth, for example from 0.25 g. to 0.5 g. of the phosphate daily; but chloro- quine given for long periods has important side- and toxic effects. Corticosteroids usually control urticaria but their use is justifiable only to tide the patient over an acute attack, particularly when the precipitating stimulus is known and can subsequently be avoided—as in urticaria caused by penicillin, In fulminating attacks or when the airway is threatened by ædema, adrenaline hvdrochloride solution, i ml. (i in 1000), is given subcutaneously. These circumstances also warrant giving hydrocortisone hemisuccinate parenterally.
Provocative Stimuli.—The search for possible antigens should be directed to the diet, to drugs, to inhalants, to the contents of the hollow viscera and to the patient's own tissues.
The diet should be recorded day by day, with a note on the condition of the skin written on the adjacent page. Things that have been eaten in the 24 hours preceding each fresh outbreak should be reviewed and any foodstuff common to each incident noted. All suspicious foods should be banned. If the urticaria disappears, the foods can be added one by one at intervals of a week and the results observed. If the true cause has been found it should be possible to make the urticaria appear and disappear at will by introducing and withholding it from the diet. Failing this the patient can be starved for two days, except for water ; persistence of the urticaria would make a dietary cause most unlikely. If the diet is suspected but observation has failed to identify the cause, skin tests may be successful provided that the test solutions used are potent.
Of drugs, penicillin and aspirin are said to be the commonest causes of chronic urticaria. The eruption can outlast the giving of penicillin by many months—possibly due in part to the ingestion of traces of penicillin in milk and partly by inhalation, for example in hospitals. Aspirin often acts as a nonspecific stimulus by aggravating urticaria due to other causes. A diary is necessary as in the case of the diet. One should remember that drugs can be taken unwittingly—for example quinine in drink and phenolphthalein in toothpaste ; and also that drugs can be ingested, injected, inhaled, anointed or placed in any of the natural orifices.
Inhalants, such as mould spores, dusts and pollens, which do not necessarily cause sneezing or ocular discomfort, produce a seasonal or intermittent pattern of attack according to the climatic conditions under which they are produced, or their location. Skin testing facilitates precise identification, but specific desensitization may not be practicable.
The hollow viscera, such as the gut and gall bladder can contain organisms or products of their activity which are absorbed and act as antigens. Yeast infection of the bowel or of diverticulae of the bowel (including blind loops left by surgery) often causes urticaria.
The patient's tissues may harbour infections such as dental infection or a tumour which is breaking down rapidly, and these can act as antigens. The auto-antibody disease, lupus erythematosus in its disseminate form, can present as urticaria, and so can the vascular disease, polyarteritis nodosa
Emotional stimuli can be entertained as factors only when, in addition to a lack of physical causes, there are positive psychological ones. Suppressed anger at some intolerable but apparently irremediable situation is a potent stimulus.
Symptomatic Treatment.—In many cases none of the above causes can be found and then the only available treatment is symptomatic. The antihistamine drugs, taken by mouth, are usually effective but it may be necessary to find by trial and error which drug suits the individual patient. The intramuscular injection of an antihistamine is worthy of trial if the response to oral treatment is poor. One of the chief anxieties about antihistamine treatment in the ambulant patient is its possible effect on the ability to handle machinery, particularly motor cars and aeroplanes, for even if antihistamines do not have an hypnotic effect they may impair judgment. The object is first to suppress the eruption with, for example, between 0-15 g. and 0.3 g. of diphenhydramine hydrochloride in divided doses daily, and then to find the minimal dose that will just control the eruption. Children tolerate these drugs well and for them elixirs are very acceptable. An alternative to the antihistamine drugs is to use chloroquine by mouth, for example from 0.25 g. to 0.5 g. of the phosphate daily; but chloro- quine given for long periods has important side- and toxic effects. Corticosteroids usually control urticaria but their use is justifiable only to tide the patient over an acute attack, particularly when the precipitating stimulus is known and can subsequently be avoided—as in urticaria caused by penicillin, In fulminating attacks or when the airway is threatened by ædema, adrenaline hvdrochloride solution, i ml. (i in 1000), is given subcutaneously. These circumstances also warrant giving hydrocortisone hemisuccinate parenterally.
SYCOSIS BARBAE Treatment
This form of chronic folliculitis of the beard region has become much less common since the days of antibiotics. The causative organism, usually staphylo-coccus aureus, lurks in the depths of the follicles and is not readily accessible to local applications. Local preparations should therefore be massaged well into the skin, night and morning. Experience has shown that it is best to prescribe a succession of different antibacterial applications rather than to continue with the same one : thus, chlortetracycline ointment could be followed by quinolor compound ointment, neomycin ointment, iodochlorhydroxyquinoline ointment, etc. A small amount should also be applied inside the nostrils. If such treatment gives rise to discomfort it can be combined with local corticosteroid therapy. The shaving tackle should be cleaned carefully and if possible sterilized after every use ; and when shaving the strokes should be made only with the grain of the hair.
SUNBURN Treatment
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Burning of the skin as a result of excessive exposure to the sun is best treated with calamine lotion, lead and zinc lotion or a local corticosteroid preparation. Local use of antihistamines is not recommended because of the risk of sensitization. It should be noted that cosmetic lotions, designed to imitate the colour of sunburn, offer little or no protection.
Adverse reactions to an apparently small dose of sunlight suggest that the skin has become photosensitive. This may be a drug reaction (antibiotics, pheno-thiazines, sulphonamides), contact with certain plants (such as hogweed), with a cosmetic (such as lipstick), with a local application (such as tar or oil of bergamot) or with soap. Alternatively there may be an inherent state of photosensitivity; this is often idiopathic but is sometimes associated with abnormalities of por-phyrin metabolism. Apart from the removal of any causative stimulus and avoidance of the sun, the application ofa" light screen " such as Uvistat, corticosteroids locally and chloroquine by mouth may be helpful.
SCABIES Treatment
Scabies is due to a mite, Acorns scabies. The female burrows superficially in the skin to lay her eggs. The infestation is derived from close contact with another person suffering from the disease, and in families it spreads readily. Animal scabies causes only a transient eruption in humans. The prominent part of the eruption, which is very itchy, is an ide resulting from the development of hypersensitivity to the products of infestation but it is necessary to treat the whole body surface—excluding the head—to be certain of a cure. All affected members of the family must be treated simultaneously. Benzyl benzoate application B.P. is applied to the whole surface of the body below the chin on three occasions at 12-hour intervals. Twelve hours after the last application the patients should have a bath, put on clean underclothes and change their sheets.
They should now be cured of the infestation but will probably continue to itch for some weeks. They should be treated with calamine liniment or some similar bland application, and mild silver proteinate B.P.C. can be added in ¼ per cent. strength if secondary infection is present. Children should be treated with the half-strength application, that is I 2½ per cent. benzyl benzoate, and babies (whose heads must also be treated) with quarter-strength sulphur ointment B.P. (2½ per cent. of sulphur). Any accompanying sepsis of the skin must wait until the anti-scabetic treatment has been applied. Crotamiton N.F. will also cure scabies, although the drug is designed for the relief of irritation.
They should now be cured of the infestation but will probably continue to itch for some weeks. They should be treated with calamine liniment or some similar bland application, and mild silver proteinate B.P.C. can be added in ¼ per cent. strength if secondary infection is present. Children should be treated with the half-strength application, that is I 2½ per cent. benzyl benzoate, and babies (whose heads must also be treated) with quarter-strength sulphur ointment B.P. (2½ per cent. of sulphur). Any accompanying sepsis of the skin must wait until the anti-scabetic treatment has been applied. Crotamiton N.F. will also cure scabies, although the drug is designed for the relief of irritation.
PSORIASIS Treatment
Dry Itchy Scalp & Dandruff Causes & Remedies.!
The fundamental lesion in psoriasis is probably biochemical since the disease is often present in forebears, siblings or collaterals, but its exact pathogenesis is not understood. It is a reversible change; and, if the lesions disappear, the skin is unblemished. People who are subject to the disease often develop it for no obvious reason but at other times attacks clearly follow infections (tonsillitis provokes guttate psoriasis), physical trauma to the skin (operation scars, etc.), climatic changes, endocrine disturbances (pregnancy and the menopause) and emotional upsets. It is associated with an arthritis more commonly than can be accounted for by chance ; the disorder affecting the joints is often rheumatoid in type, but some patients develop a specific psoriatic arthropathy which can be distinguished by clinical and serological methods.
Corticosteroid drugs taken systemically suppress psoriasis as a rule but the dose required to maintain the improvement is too great to make this a practicable form of treatment; and there is an impression that systemic corticosteroids may precipitate the serious pustular form of the disease. The newer corticosteroid local applications, betamethasone valerate and fluocinolone acetonide, are effective particularly when their penetration is assisted by occlusion of the area with polythene film. This method, however, carries the risk of significant systemic absorption and it is advisable to limit the periods of occlusion to not more than 12 out of the 24 hours applied to no more than one-third of the total body surface at one time. Corticosteroid applications seldom produce a permanent effect on their own and the best results are obtained by alternating them with tar or dithranol.
Psoriasis which is extensive and waxing should always be treated with respect —for fear of aggravating it or even converting it into an exfoliative dermatitis. In such cases the patient should be put to bed and given salicylates as though he had rheumatic fever, and soft yellow paraffin should be used locally.
The usual problem is to deal with localized scaly patches involving the scalp, limbs and trunk. It is unfortunate that the most effective remedies are the most messy, for example crude coal tar and dithranol. These active agents should be applied after the worst of the scales have been removed with an ointment containing from 2 to 4 per cent. salicylic acid in emulsifying ointment, combined with soaking in a bath and washing off the scales gently where this is tolerated. Tar is started as 2 per cent. crude coal tar in zinc paste and worked up to 10 per cent. Its effect is improved by giving ultra-violet light treatment concurrently. Dithranol is a more powerful substance and should be started at a strength of o-i per cent. in zinc paste and worked up to 2 per cent., although some patients need—and wall tolerate—greater strengths. Dithranol is unsuitable for application to the face and scalp because it irritates the eyes. For the. scalp 12 per cent. oil of cade is useful, combined with 4 per cent. of camphor and 4 per cent. of yellow oxide of mercury in emulsifying ointment. The oil of cade has a strong smell which many patients dislike ; but purified tars—which are cosmetically more acceptable—are less effective. The hair needs washing twice a week during this regimen, and soap spirit B.P.C. or any ordinary shampoo can be used. The obsessive patient will overtreat his psoriasis, and for him sedatives are indicated : externally Lassar's paste should be applied; and phenobar-bitone, 30 mg. twice daily, is often useful. The efficacy of inorganic arsenic taken bv mouth is bevond doubt. Arsenic, however, is a cumulative poison with unpleasant delayed effects, and it is doubtful whether its use is ever justified even in short courses. Recently antimitotic drugs have been used with some success but the treatment needs very careful supervision and it is too early to define its indications and limitations. It is regrettable that in many cases the psoriatic spots remain obstinately present. The physician must train himself and his patient to the view that perfectionism is not without its dangers, and that the virtues of the immaculate state can be exaggerated.
Dry Itchy Scalp & Dandruff Causes & Remedies.!
PRURITUS Treatment
Eczema, scabies, lichen planus and dermatitis herpetiformis are all associated with intense itch; and lichenification manifests itself chiefly as irritation. The treatment of these conditions is that which is needed to relieve the irritation ; but it sometimes happens that the irritation is overwhelming, dominating the patient and his household, and something more is required. On these occasions it is tempting to apply local anaesthetic and antihistamine preparations to the skin, but this is a temptation that should be resisted because these preparations are sensitizing agents. Sedatives are useful when given orally, and this applies also to antihistamines—which are valuable for their sedative and tranquillizing properties. A combination of promethazine hydrochloride 12-5 mg. and amylobarbitone 50 mg. is useful; but if promethazine causes undue drowsiness it can be replaced by triprolidine hydrochloride. In the elderly, however, barbiturates are often poorly tolerated ; they may produce a state of confusion and then the itch plays a disturbing and demoralizing role. In these circumstances chloral hydrate is the best drug to use—after allowing a few days to, elapse without the use of any cerebral depressant drugs. For local treatment one should be content with simple applications of low sensitizing potential such as the lead compound lotion B.N.F., equal parts of linseed oil and lime water, or liquefied phenol 1 ml., zinc oxide 2 g., calamine 1 g, glycerin 2 ml., magnesium hydroxide mixture, B.P., to 30 ml. These preparations may be either painted on frequently or used as wet compresses. There is a place for corticosteroids either as a spray (which is convenient for covering large areas quickly, but often making the skin feel uncomfortably dry), a lotion (if the surface is moist) or a cream or ointment if it is dry. It is justifiable in extreme cases to give a short course of oral corticosteroid treatment.
A separate problem arises when, in spite of the patient's complaint of intense irritation, nothing abnormal is visible except the marks that he has made by scratching himself. It is then necessary to identify the precipitating cause. There are many possible explanations : scabies, in a person who is so clean that few lesions develop ; pediculosis corporis which can be recognized by examining the seams of the underclothing ; senile change in the skin (for which testosterone or chlorpromazine are indicated) ; a side-effect of certain drugs such as morphine or carbromal (neither of which should be used by patients liable to pruritus or actually suffering from the condition) ; psychoses—when the patient usually presents the doctor with a folded piece of paper stated to contain "the insects" ; a manifestation of renal or hepatic disease with toxaemia ; a symptom heralding a metabolic disorder such as diabetes mellitus ; an accompaniment of blood dyscrasias including the leukaemias and polycythaemia vera ; and—fairly commonly—in lymphadenoma. This differential diagnosis, by no means exhaustive, may serve to emphasize the need for taking a detailed history and making a thorough physical examination.
A separate problem arises when, in spite of the patient's complaint of intense irritation, nothing abnormal is visible except the marks that he has made by scratching himself. It is then necessary to identify the precipitating cause. There are many possible explanations : scabies, in a person who is so clean that few lesions develop ; pediculosis corporis which can be recognized by examining the seams of the underclothing ; senile change in the skin (for which testosterone or chlorpromazine are indicated) ; a side-effect of certain drugs such as morphine or carbromal (neither of which should be used by patients liable to pruritus or actually suffering from the condition) ; psychoses—when the patient usually presents the doctor with a folded piece of paper stated to contain "the insects" ; a manifestation of renal or hepatic disease with toxaemia ; a symptom heralding a metabolic disorder such as diabetes mellitus ; an accompaniment of blood dyscrasias including the leukaemias and polycythaemia vera ; and—fairly commonly—in lymphadenoma. This differential diagnosis, by no means exhaustive, may serve to emphasize the need for taking a detailed history and making a thorough physical examination.
Friday, July 25, 2008
PITYRIASIS ROSEA Treatment
This common condition is sometimes confused with secondary syphilis—but this, by comparison, is a rarity. If the diagnosis is in doubt a full clinical survey and serological tests for syphilis must be carried out. Pityriasis rosea is not obviously infective but in other respects it behaves like an infection with its primary lesion at onset and the ide eruption following this, with its resolution after a course of six to eight weeks and an immunity to further attacks. Emulsifying ointment B.P. is all that need be applied in the average episode, and in mild cases nothing is needed. When the disease is severe and the lesions become confluent in the flexures the patient should be advised to stay in bed for a few days, and a corticosteroid ointment should be applied in the areas most severely affected.
PEMPHIGUS Treatment
Pemphigus vulgar-is was formerly fatal, but corticosteroids given by mouth will usually suppress the eruption and permit a normal life. A few patients have apparently recovered and have been able to dispense with the treatment, but the majority need treatment for life—an attempt being made to find the smallest dose which will effectually keep the condition under control. Pemphigus neonatorum is a form of impetigo (q.v.) and requires antibiotic therapy as for an acute infection.
PEDICULOSIS Treatment
Infestation with head lice is best treated by wetting the hair with paraffin (kerosene) and swathing the head in a towel for an hour. The paraffin must disperse widely in the hair down to the scalp but must not run into the eyes or down the neck. An alternative is dicophane application, B.P.C., but this does not destroy the fertile eggs and therefore the treatment should be repeated on three occasions at weekly intervals. After either application the hair is washed thoroughly. It is then combed with a fine-toothed comb moistened in vinegar to loosen the cement holding the eggs (nits) on to the hairs. Subsequently any impetiginous lesions should be treated.
Body lice live in the seams of the clothing and are dealt with by steam dis-infestation of the clothes. When this is not available, laundering and careful ironing of the seams, combined with a sprinkling of dicophane dusting powder will suffice. Crotamiton cream which will help to relieve the intense itch produced by the disease will also- kill any parasites on the body.
Pubic lice (crab lice) live among stiff hairs holding on with either claw, and are found in the eyebrows, eyelashes, axillary and pubic hair. In the pubic region they are easily dealt with by shaving, but around the eyes they should be treated with mercuric oxide eye ointment and removed by gentle washing with liquid paraffin. The shaved areas can be treated with dilute ammoniated mercury ointment.
Body lice live in the seams of the clothing and are dealt with by steam dis-infestation of the clothes. When this is not available, laundering and careful ironing of the seams, combined with a sprinkling of dicophane dusting powder will suffice. Crotamiton cream which will help to relieve the intense itch produced by the disease will also- kill any parasites on the body.
Pubic lice (crab lice) live among stiff hairs holding on with either claw, and are found in the eyebrows, eyelashes, axillary and pubic hair. In the pubic region they are easily dealt with by shaving, but around the eyes they should be treated with mercuric oxide eye ointment and removed by gentle washing with liquid paraffin. The shaved areas can be treated with dilute ammoniated mercury ointment.
PARONYCHA Treatment
Chronic paronychia due to yeast or staphylococcal infection is a troublesome disease in housewives and others whose occupations necessitate repeated immersion of the hands in water. The first essential is to enforce dryness, and unless this can be done the chance of cure is small. Nystatin ointment can be applied at night and worked into the nail fold. During the day the patient should use a preparation which will readily seep into the nail fold such as • Castellani's paint or hydrargphen. The usual sources of infection are the garden, the kitchen sink and the bowel. When the condition has healed, special care should be taken to avoid trauma to the hands through working in the garden or in the kitchen .since these forms of injury open the way for further infection.
LUPUS VULGARIS Treatment
Lupus vulgaris is due to tuberculous infection of the skin. The diagnosis makes it essential to examine the patient for evidence of other active foci of the disease. Lupus vulgaris was formerly one of the dermatological horrors ; it caused appalling scarring because of the relentless spread of the disease. Nowadays, however, it is justifiable to regard the disease as " benign " because of the brilliant results which are readily obtained from anti-tuberculous drugs. Dermatologists have not been troubled by resistant organisms in the skin, but it is well to remember that this problem does face the chest physician and that, if a pulmonary focus is present, full combined treatment should be given to minimize the chance of resistance developing. A suitable regimen is to give streptomycin by injection, 1 g. twice weekly, and 0.3 g. of isoniazid daily by mouth in divided doses. Ulceration of old lesions of lupus vulgaris always arouses the suspicion of malignancy. The best means of settling this question is to carry out a biopsy and to seek the help of an experienced pathologist.
LUPUS ERYTHEMATOSUS Treatment
Chronic discoid lupus erythematosus is believed to be due to a localized auto-antibody phenomenon. It responds to anti-malarial drugs given by mouth and to inunction with betamethasone valerate and fluocinolone acetonide. Local injection of triamcinolone is used for stubborn lesions. Mepacrine, which was the first anti-malarial to be used, stains the skin yellow and chloroquine is now preferred. Chloroquine phosphate, 0.5 g. daily, is given initially and when the eruption has been brought under control, the smallest effective dose is given for maintenance—usually between 1 and 2 g. per week. It is convenient to reduce the dose by omitting certain days from treatment since this will give some relief from gastric irritation which is a common side-effect to chloroquine. The most serious toxic effects concern the eye. The patient complains of blurred vision which is caused by interference with accommodation. This disorder may cause inconvenience (reading, driving a car, etc.) but it is not in itself of grave significance. Serious ocular complications, however, include damage to the cornea, the retina and the optic nerve. Symptoms develop insidiously : complaints of coloured halos around lights are significant, and may herald serious impairment of vision. It is, therefore, most desirable that patients receiving prolonged courses of chloroquine should be seen regularly by an ophthalmologist. The affected skin should be protected from direct sunlight (these patients should never sunbathe) and from cold wind. Cosmetic preparations that hide the scars should be used.
Transition of the discoid form of the disease to the acute disseminated form occurs occasionally. This serious complication should be suspected when the eruption suddenly becomes more extensive or more livid ; and also if there is unexplained fever, toxasmia or lymphadenopathy. The onset of pulmonary, pericardial, renal or arthritic complications is also of sinister significance. These signs of dissemination call for treatment by corticosteroids given systemically with the patient at rest in bed.
Transition of the discoid form of the disease to the acute disseminated form occurs occasionally. This serious complication should be suspected when the eruption suddenly becomes more extensive or more livid ; and also if there is unexplained fever, toxasmia or lymphadenopathy. The onset of pulmonary, pericardial, renal or arthritic complications is also of sinister significance. These signs of dissemination call for treatment by corticosteroids given systemically with the patient at rest in bed.
LUPUS VULGARIS Treatment
Lupus vulgaris is due to tuberculous infection of the skin. The diagnosis makes it essential to examine the patient for evidence of other active foci of the disease. Lupus vulgaris was formerly one of the dermatological horrors ; it caused appalling scarring because of the relentless spread of the disease. Nowadays, however, it is justifiable to regard the disease as " benign " because of the brilliant results which are readily obtained from anti-tuberculous drugs. Dermatologists have not been troubled by resistant organisms in the skin, but it is well to remember that this problem does face the chest physician and that, if a pulmonary focus is present, full combined treatment should be given to minimize the chance of resistance developing. A suitable regimen is to give streptomycin by injection, 1 g. twice weekly, and 0.3 g. of isoniazid daily by mouth in divided doses. Ulceration of old lesions of lupus vulgaris always arouses the suspicion of malignancy. The best means of settling this question is to carry out a biopsy and to seek the help of an experienced pathologist.
LUPUS ERYTHEMATOSUS Treatment
Chronic discoid lupus erythematosus is believed to be due to a localized auto-antibody phenomenon. It responds to anti-malarial drugs given by mouth and to inunction with betamethasone valerate and fluocinolone acetonide. Local injection of triamcinolone is used for stubborn lesions. Mepacrine, which was the first anti-malarial to be used, stains the skin yellow and chloroquine is now preferred. Chloroquine phosphate, 0.5 g. daily, is given initially and when the eruption has been brought under control, the smallest effective dose is given for maintenance—usually between 1 and 2 g. per week. It is convenient to reduce the dose by omitting certain days from treatment since this will give some relief from gastric irritation which is a common side-effect to chloroquine. The most serious toxic effects concern the eye. The patient complains of blurred vision which is caused by interference with accommodation. This disorder may cause inconvenience (reading, driving a car, etc.) but it is not in itself of grave significance. Serious ocular complications, however, include damage to the cornea, the retina and the optic nerve. Symptoms develop insidiously : complaints of coloured halos around lights are significant, and may herald serious impairment of vision. It is, therefore, most desirable that patients receiving prolonged courses of chloroquine should be seen regularly by an ophthalmologist. The affected skin should be protected from direct sunlight (these patients should never sunbathe) and from cold wind. Cosmetic preparations that hide the scars should be used.
Transition of the discoid form of the disease to the acute disseminated form occurs occasionally. This serious complication should be suspected when the eruption suddenly becomes more extensive or more livid ; and also if there is unexplained fever, toxasmia or lymphadenopathy. The onset of pulmonary, pericardial, renal or arthritic complications is also of sinister significance. These signs of dissemination call for treatment by corticosteroids given systemically with the patient at rest in bed.
Transition of the discoid form of the disease to the acute disseminated form occurs occasionally. This serious complication should be suspected when the eruption suddenly becomes more extensive or more livid ; and also if there is unexplained fever, toxasmia or lymphadenopathy. The onset of pulmonary, pericardial, renal or arthritic complications is also of sinister significance. These signs of dissemination call for treatment by corticosteroids given systemically with the patient at rest in bed.
LICHEN PLANUS Treatment
Lichen planus causes unbearable irritation. It should probably be regarded as a special form of neurodermatitis since most patients have a background of emotional difficulty. There are some cases, however, which result from ;physical cause such as a reaction to anti-malarial drugs or to gold therapy When the eruption is a sequel to psychological upset it is self-limiting ; it last for a period of months or years ; the more acute the onset the more rapid is the course, and disappearance of the lesions is heralded by their intense pigmentation It is traditional to give mercury by mouth, for example 4 ml. of a solution of mercuric chloride in chloroform water thrice daily; and latterly isoniazic aminosalicylate tablets, one tablet (0.1 g.) per 20 lb. body weight, have beer recommended but the natural tendency for the disease to regress makes the true worth difficult to assess. An investigation of the circumstances of the patient's emotional life may suggest practical means of alleviating difficulties at home or at work, and there may be an indication for a radical change in the ( patient's way of life since some patients are shouldering an unmanageable burden of responsibility or are burning the candle at both ends for financial or other reasons. Betamethasone valerate and fluocinolone acetonide under polythene film occlusion are very effective and usually avoid the need to give corticosteroids orally, but it should be emphasized that considerable corticosteroid absorption can result from this method. Chronic localized patches—especially of the warty variety—are best treated by injecting corticosteroids into the lesions.
LICHENIFICATION Treatment
Lichenification (neurodermatitis) has already been mentioned as a sequel to any kind of eczema when it is produced by the patient rubbing and scratching the irritable skin. It can start in any skin lesion which the patient feels compelled to rub such as a cut, scratch, graze, burn, pimple, patch of herpes simplex and so on. It thus results from obsessive interference with the skin, hence the name neurodermatitis. It is possible that primary patches can appear in response to itch produced under emotional stress. It is a self-perpetuating phenomenon because the rubbing eventually gives rise to further itch and further rubbing is evoked. This vicious circle may be attacked at several points: the pruritic threshold can be raised by giving sedatives by mouth, such as a combination of amylobarbitone 50 mg. and promethazine hydrochloride 12-5 mg. ; if practicable, the itchy part can be occluded with a bandage which is kept in place for a week or more at a time; treatment by tar can be combined with the occlusion or used alone ; corticosteroids can be used by inunction or, if the patch is chronic and localized, by injection into the lesion, or betamethasone valerate or fluocinolone acetonide can be used locally under polythene occlusion. Another measure to be considered is diverting the patient's attention to a hobby, and psychotherapy may be justified. Radiotherapy has hitherto been a routine method but it is now avoided if possible, particularly in those of childbearing age.
INSECT BITES Treatment
People who say that insects like biting them base their belief on the fact that their skins are severely affected, whereas their more fortunate neighbours appear to escape. It is more true to say that all are bitten but only the hypersensitive ones react badly to the bites. Those who are susceptible should certainly use insect repellents (dibutylphthallate cream), and experience may justify the taking of antihistamines in anticipation of exposure to attack by insects. Established bites should be treated with calamine lotion or corticosteroid applications as well as by any measures required to deal with secondary infection. Papular urticaria of children is usually due to insect bites; but the mother will seldom countenance this explanation because it is regarded as an implied criticism of the standard of hygiene in her household. The local use of Crotamiton cream and an anti-histamine elixir by mouth is usually effective. If this fails, the child should be admitted to hospital; here cure takes place spontaneously though when the child goes home a relapse is only too likely to occur.
IMPETIGO CONTAGIOSA Treatment
Impetigo contagiosa and its more serious variant pemphigus neonatorum are due to superficial infection of the epidermis with pathogenic staphylococci or streptococci. It is a common sequel to chicken-pox. Not infrequently pediculosis capitis or scabies are the underlying diseases ; if present these conditions should be treated first. For localized outbreaks the application of chlortetra-cycline ointment is suitable, after having removed the crusts by bathing or with starch poultices. A swab should be taken before starting treatment so that, in the event of the disease failing to respond, no time will be lost in prescribing an appropriate alternative. When the lesions are extensive it is more satisfactory to give oxytetracycline by mouth in full doses, as for an acute infection. The cure of the impetigo often reveals an unsuspected eczema requiring appropriate treatment. Failure of the impetigo to respond calls for a review of the diagnosis; in particular the possibility of underlying ringworm should be considered. The occurrence of a case of pemphigus neonatorum in a maternity unit calls for an urgent bacteriological survey of the patients and staff.
HERPES ZOSTER Treatment
Zoster (shingles) is due to a virus indistinguishable from that causing chicken-pox which results in an inflammation of one or more posterior root ganglia. It usually occurs spontaneously but sometimes it seems to be precipitated by injury to the spine, by the reticuloses or chronic arsenical poisoning. The disease produced is variable in severity and can range from pain without cutaneous involvement to severe cutaneous gangrene—with intermediate grades of erythema only, or erythema with groups of tense vesicles which pass through stages of pustulation, crusting and scarring. This natural variability makes it impossible to assess the results of early treatment in individual cases and it is unlikely that any of the recommended means of aborting attacks—such as injections of pitressin or of thiamine—have any significant effect. The objects of treatment are to relieve pain (which can be extremely severe), to protect the affected skin from friction, to prevent secondary infection and—if the eye is involved—to prescribe mydriatics and seek the help of an ophthalmologist as soon as possible. The pain is best treated by keeping the patient warm in bed, by painting the skin with flexible collodion B.P., and thereafter powdering it with zinc, starch and talc dusting powder B.P.C., by protecting it from friction by a thick layer of cotton-wool and by giving oral analgesics. The local or systemic use of antibiotics is indicated only in severe attacks or if the eye is involved.
Post-tier fetic pain can be a grievous problem and is liable to occur in elderly patients. Analgesics (aspirin or paracetamol) are used and their effect can be enhanced by giving promazine hydrochloride. Vibration therapy (the Pifco vibrator is commonly used) is worthy of trial. There is a tendency for improvement to occur up to six months after the attack. In the intractable case the problems are similar to those found in the management of trigeminal neuralgia and may require to be reviewed by a neurosurgeon.
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Post-tier fetic pain can be a grievous problem and is liable to occur in elderly patients. Analgesics (aspirin or paracetamol) are used and their effect can be enhanced by giving promazine hydrochloride. Vibration therapy (the Pifco vibrator is commonly used) is worthy of trial. There is a tendency for improvement to occur up to six months after the attack. In the intractable case the problems are similar to those found in the management of trigeminal neuralgia and may require to be reviewed by a neurosurgeon.
HERPES SIMPLEX Treatment
Herpes simplex usually presents as a patch of blisters that recur repeatedly on the same piece of skin, often near the mouth but sometimes on the genital region or on a finger. It results from a latent cellular virus infection subject to repeated reactivation and beyond the reach of the circulating antibodies that can be demonstrated in the blood. The recurrences are determined by a variety of stimuli such as exposure to the sun, the common cold, menstruation and emotional stress ; and particularly severe attacks can be precipitated by severe infections. The treatment is to apply an antibiotic (bacitracin, 500 units per g. base) with a corticosteroid ointment. This helps to abort the attack and diminishes the chance of scarring from secondary infection. No certain methods of treatment exist for preventing recurrences and the reputedly successful ones are so diverse—such as oral sedation, repeated vaccination against smallpox and high frequency sparking—that one is tempted to think that the power of suggestion is the common factor. It is important that patients with active lesions should not come into close contact with those suffering from eczema, since the virus of herpes simplex finds eczematous skin a congenial habitat and the resulting illness can be very severe or even fatal.
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FURUNCULOSIS Treatment
Recurrent boils can be a symptom of deranged metabolism such as diabetes mellitus, and they call for thorough medical examination. They may also complicate scabies. The staphylococci which cause the lesions are harboured in the nose, throat, peri-anal skin or other focus, from which they are disseminated over the general surface of the skin. The skin should be washed daily in a bath using hexachlorophene, special attention being paid to the possible primary foci. An appropriate antibiotic cream (determined by sensitivity tests) should be applied to the boils and to the skin immediately surrounding them, and also to the nostrils. In a severe case the patient should take sulphafurazole tablets by mouth, 0-5 g. three times daily for the first month, twice daily for the second and once daily for the third month.
FUNGUS INFECTIONS
The introduction of griseofulvin has provided an effective means of treating ringworm of the scalp, including favus, and is an improvement in the treatment of ringworm of the nails. Nevertheless, it is not very effective in ringworm of the feet (athlete's foot) nor is it effective against yeasts; thus monilial paronychia and systemic monilial infections are not helped by it. Griseofulvin is taken by mouth and it becomes loosely incorporated in skin, hair and nails during their growth, making them unacceptable to the fungi which thus find themselves deprived of their usual food—freshly formed keratin—and they are cast off as the keratin containing tissues undergo normal wastage by; desquamation, etc. The recommended dose is i g. daily in divided doses but, a if the finely divided form of griseofulvin is used, half this amount is stated to be effective. Reduction of the dose below the recommended level is likely to prove ] unsatisfactory. In treating ringworm of the scalp a course lasting six weeks is usually required, and it should be combined with the local use of Whitfield's ointment and clipping the hair short. The proper duration of treatment is very difficult to assess even with full mycological control, and it is possible that further experience will modify current views on this dosage. In ringworm of the nails; the treatment will have to be continued for nine months or more until the last ^ traces of the diseased nail have disappeared. The local use of fungicides is recommended, for example magenta paint B.P.C., and removal of the diseased, I friable nail is desirable. This can be done by using a piece of broken glass or; sandpaper as a scraper; all the scrapings should be burnt. Very few toxic effects have resulted from treatment with griseofulvin apart from mild gastro-intestinal upset; disturbance of porphyrin metabolism has also been reported.
Tinea Pedis.—This extremely chronic infection usually takes the form of macerated skin between the toes which causes little trouble until the feet get I very hot when there is liable to be an explosive outbreak of an acute eczema with i vesiculation due to the fungus growing vigorously in the skin under the warm, i moist conditions. Should this exacerbation provoke an ide eruption, it is important to realize that the ide does not contain active fungus elements and it is, therefore, appropriate to treat it as an eczema without using fungicides. The active fungus infection should be treated as an acute eczema initially, using soaks or wet dressings and confining the patient to bed if there is lymphangitis. It is usual to give an anti-infective agent orally for its systemic effect; this should preferably be a sulphonamide because an antibiotic might produce an unpleasant reaction if, as an antigen, it has something in common with the fungus present in the patient's eczematous skin. Fungicides such as Whitfield's ointment (benzoic acid compound ointment, B.P.C.) and Castellani's paint (magenta paint, B.P.C.) are used when the eruption is less angry in appearance. In the resting phase the disease is sometimes intractable. If an attempt is made to eradicate the disease, it is essential to keep the skin as clean, dry and cool as possible, to destroy fungus present on the footwear, to prevent re-infection and to continue using fungicides. In order to comply with this advice, the patient needs to adhere to a very exacting programme of personal hygiene. He should wash his feet twice daily in soap and water and dry the skin very carefully afterwards, using a towel kept exclusively for his use. Dead skin should be removed with forceps, not the finger nails ; and Whitfield's ointment should be rubbed thoroughly into the webs between the toes, after which the feet and the socks should be dusted with zinc undecenoate dusting power, B.P.C. He should wear a thin pair of white cotton socks next to the skin, putting on a clean pair after every washing and having the dirty pair boiled. His oversocks should be thin and—in order to minimize sweating—not made of synthetic fibre. He should wear thin, leather-soled shoes or sandals. The inside of his shoes should be treated with formalin vapour, but great care should be taken to leave as little as possible in the shoe or he will develop a contact eczema. If he perseveres with these instructions for some months he may be cured but, if he is, he will have to continue taking precautions against re-infection for the rest of his life by refusing to walk anywhere in bare feet (except on his own bath mat) and by continuing to take particular care of his feet, using zinc undecenoate ointment, B.P. prophylactically.
Cattle Ringworm.—In farming areas ringworm derived from farm animals causes severely inflamed lesions (kerion). They are self limited because the severity of the reaction casts the fungus off the skin. The pustulation that occurs is not due to secondary infection so much as to hypersensitivity developed against the causative fungus, so that oral corticosteroid therapy has a place in very severe infections. To allow the disease to take its course may involve an illness of 8 to 16 weeks but its duration can be reduced by giving griseofulvin by mouth for two or three weeks early in the course of the infection. After having removed the debris by gentle washing or with starch poultices and having clipped the surrounding hair short, local dressings are applied : they consist of 5 per cent. ichthammol in water used as wet dressings under oiled silk. Later an ointment, containing equal parts of a corticosteroid ointment and Whitfield's ointment, should be rubbed in thoroughly twice daily until all pustulation has ceased. The remaining lumpiness can then be left to settle spontaneously. It should be noted that although large lesions are tumid and studded with pustules, no benefit is obtained by incision because the pus is contained within the individual hair follicles and is not amenable to the knife.
Tinea Circinata.—Ringed lesions of the open skin usually respond quickly to. Castellani's paint or to Whitfield's ointment. Infections due to Trichophyton rubrum may prove resistant (onvchia is almost certain to co-exist) and then griseofulvin by mouth would be indicated. The diagnosis of tinea circinata calls for consideration of the origin of the infection ; the scalp should be examined for the scalv, bald patches of ringworm, and inquiry should be made about possible animal sources—particularly proximity to kittens and puppies.
Scalp Ringworm.—Griseofulvin is the treatment of choice. Epilation by X-rays or by thallium acetate is now unnecessary. It is very desirable that the public health and school medical authorities should be informed of cases that occur so that they can take steps to trace the source of infection and to find all the cases in order to prevent epidemic spread of the disease.
Groin Infections.—The infection often stems from the feet which should be treated simultaneously. If the skin is acutely inflamed treatment should first be that used in acute eczema; and when the angry phase has subsided fungicides may be applied, for example Whitfield's ointment or Castellani's paint. When the infection appears to have been cured the patient should still take the precaution of drying himself thoroughly after his bath, and should dust the skin with zinc undecenoate powder B.P.C.
Nail Infections.—Formerly, infection of the nails with fungus was often incurable even though the affected nails were avulsed and fungicides applied during their subsequent growth. With griseofulvin the results are sometimes good and permanent cure can occur.
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Tinea Pedis.—This extremely chronic infection usually takes the form of macerated skin between the toes which causes little trouble until the feet get I very hot when there is liable to be an explosive outbreak of an acute eczema with i vesiculation due to the fungus growing vigorously in the skin under the warm, i moist conditions. Should this exacerbation provoke an ide eruption, it is important to realize that the ide does not contain active fungus elements and it is, therefore, appropriate to treat it as an eczema without using fungicides. The active fungus infection should be treated as an acute eczema initially, using soaks or wet dressings and confining the patient to bed if there is lymphangitis. It is usual to give an anti-infective agent orally for its systemic effect; this should preferably be a sulphonamide because an antibiotic might produce an unpleasant reaction if, as an antigen, it has something in common with the fungus present in the patient's eczematous skin. Fungicides such as Whitfield's ointment (benzoic acid compound ointment, B.P.C.) and Castellani's paint (magenta paint, B.P.C.) are used when the eruption is less angry in appearance. In the resting phase the disease is sometimes intractable. If an attempt is made to eradicate the disease, it is essential to keep the skin as clean, dry and cool as possible, to destroy fungus present on the footwear, to prevent re-infection and to continue using fungicides. In order to comply with this advice, the patient needs to adhere to a very exacting programme of personal hygiene. He should wash his feet twice daily in soap and water and dry the skin very carefully afterwards, using a towel kept exclusively for his use. Dead skin should be removed with forceps, not the finger nails ; and Whitfield's ointment should be rubbed thoroughly into the webs between the toes, after which the feet and the socks should be dusted with zinc undecenoate dusting power, B.P.C. He should wear a thin pair of white cotton socks next to the skin, putting on a clean pair after every washing and having the dirty pair boiled. His oversocks should be thin and—in order to minimize sweating—not made of synthetic fibre. He should wear thin, leather-soled shoes or sandals. The inside of his shoes should be treated with formalin vapour, but great care should be taken to leave as little as possible in the shoe or he will develop a contact eczema. If he perseveres with these instructions for some months he may be cured but, if he is, he will have to continue taking precautions against re-infection for the rest of his life by refusing to walk anywhere in bare feet (except on his own bath mat) and by continuing to take particular care of his feet, using zinc undecenoate ointment, B.P. prophylactically.
Cattle Ringworm.—In farming areas ringworm derived from farm animals causes severely inflamed lesions (kerion). They are self limited because the severity of the reaction casts the fungus off the skin. The pustulation that occurs is not due to secondary infection so much as to hypersensitivity developed against the causative fungus, so that oral corticosteroid therapy has a place in very severe infections. To allow the disease to take its course may involve an illness of 8 to 16 weeks but its duration can be reduced by giving griseofulvin by mouth for two or three weeks early in the course of the infection. After having removed the debris by gentle washing or with starch poultices and having clipped the surrounding hair short, local dressings are applied : they consist of 5 per cent. ichthammol in water used as wet dressings under oiled silk. Later an ointment, containing equal parts of a corticosteroid ointment and Whitfield's ointment, should be rubbed in thoroughly twice daily until all pustulation has ceased. The remaining lumpiness can then be left to settle spontaneously. It should be noted that although large lesions are tumid and studded with pustules, no benefit is obtained by incision because the pus is contained within the individual hair follicles and is not amenable to the knife.
Tinea Circinata.—Ringed lesions of the open skin usually respond quickly to. Castellani's paint or to Whitfield's ointment. Infections due to Trichophyton rubrum may prove resistant (onvchia is almost certain to co-exist) and then griseofulvin by mouth would be indicated. The diagnosis of tinea circinata calls for consideration of the origin of the infection ; the scalp should be examined for the scalv, bald patches of ringworm, and inquiry should be made about possible animal sources—particularly proximity to kittens and puppies.
Scalp Ringworm.—Griseofulvin is the treatment of choice. Epilation by X-rays or by thallium acetate is now unnecessary. It is very desirable that the public health and school medical authorities should be informed of cases that occur so that they can take steps to trace the source of infection and to find all the cases in order to prevent epidemic spread of the disease.
Groin Infections.—The infection often stems from the feet which should be treated simultaneously. If the skin is acutely inflamed treatment should first be that used in acute eczema; and when the angry phase has subsided fungicides may be applied, for example Whitfield's ointment or Castellani's paint. When the infection appears to have been cured the patient should still take the precaution of drying himself thoroughly after his bath, and should dust the skin with zinc undecenoate powder B.P.C.
Nail Infections.—Formerly, infection of the nails with fungus was often incurable even though the affected nails were avulsed and fungicides applied during their subsequent growth. With griseofulvin the results are sometimes good and permanent cure can occur.
ERYSIPELAS Treatment
Erysipelas, called "la rose" in France and still called rose in Scotland, is due to an infection of the skin with hasmolytic streptococci. It will respond to systemic penicillin and sulphonamides given in full doses as for an acute infection. Search should be made for any crack in the skin through which infection could have entered, for example at the angle of the nostril, the junction of the ear with the skin of the scalp or at the outer canthus of the eye. Any such . lesion should be treated with an antibiotic ointment such as neomycin, not only until the crack has healed but for several months afterwards to try to prevent a. recurrence. Repeated attacks of erysipelas are likely to lead to lymphatic; damage with consequent chronic edema of the tissues and, since it is impossible to restore the normal lymphatic drainage, it is important to treat recurrences of erysipelas promptly and vigorously.
ECZEMA Treatment
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Eczema is derived from a Greek word meaning "to boil". The term is descriptive of the acute stage of the process when the skin is covered with small blisters, like bubbles on boiling water. The blisters which are formed within the epidermis break readily (except on the hands and feet where they are preserved by the thick horny layer, and the names cheiropompholyx and podopompholyx have been given to this type of eczema) resulting in copious weeping from a denuded, raw surface followed by crusting as the exudate dries, and often complicated by secondary infection of bacterial, fungal or viral origin. In the later stages the eruption is dry and is characterized by redness, scaling and cracking consequent upon the disordered growth of the epidermis.; and these changes persist until a healthy horny layer has reformed. Thickening of the skin occurs as a result of cellular infiltration and oedema in the dermis, and it is much increased by compulsive scratching and by rubbing of the itchy skin until a leathery texture is produced known as lichenification. At all stages of eczema patients complain that the lesions itch.
Eczema is not a disease but a reaction pattern in the epidermis1 which can be precipitated by many stimuli. It follows that the causative agents must be identified and neutralized if the eczema reaction is to subside. The pattern is not necessarily fully developed in every case. Thus one may speak of a " wet " eczema, where the early stages of the process predominate, and of a " dry " eczema at a later stage. A single, unrepeated eczema-producing stimulus—for example contact of a sensitized skin with a leaf of primula obconica—will result in an inevitable and relentless chain of events consisting of itch and erythema for a few hours, blisters and weeping for a few days, and scaling for about three or four weeks, by which time—barring the occurrence of lichenification as a result of the patient's own interference—the skin will have healed except, perhaps, for some residual staining. This erstwhile inexorable result of a single unrepeated stimulus can nowadays be suppressed by the use of corticosteroid preparations which can be used during the normal three or four weeks required for healing, without interfering with the healing process. Consequently, provided that the stimulus is not repeated, this treatment will appear to have " cured " the patient; but if, as is usual, the stimulus continues, a relapse will follow when it is stopped.
The treatment of eczema consists first in identifying and eliminating the provocative stimuli, and second in calming down the inflamed skin until the natural healing process has had time to occur. Since unfortunately the former aim. is sometimes unattainable, the latter must perforce on these occasions suffice. The provocative stimuli are now considered. From their diversity it will be apparent that a thorough investigation of eczema is bound to involve a full history and examination, such as are required in any medical case, but with particular attention directed towards the external environment.
PROVOCATIVE STIMULI
External Irritants.—Primary irritants such as strong acids and alkalis many oils, paraffin, turpentine, petrol, soap, and many antiseptics, will irritate any skin if allowed to come into contact with it in high enough concentration for a sufficient time. The effect is enhanced by removal of the natural greasy protective covering of the skin such as occurs in housewives, nurses, charwomen and metal turners who are habitually using detergents. Allergenic irritants such as primula obconica, chrome, nickel, penicillin, paraphenylenediamine, etc., will in time produce a state of allergic hypersensitivity in certain skins which will then react to the irritant in high or in low concentration. Their identification is often exceedingly difficult since, as far as the patient is concerned, they are harmless (for example cosmetics, flowers, clothing, footwear, ointments, etc.) and it seldom occurs to the patient to suspect such commonplace things. Their recognition depends upon raising the possibility, combined with. Considering
1 For practical purposes eczema is synonymous with dermatitis though dermatitis is used in a general way to describe dermal as well as epidermal inflammation, as in dermatitis herpetiformis. Eczema is to be preferred when a specifically epidermal reaction is implied.
The pattern of the eruption: 'footwear, for example, causes air eczema which primarily involves the feet although the eruption may spread later to other skin which has never been in direct contact with the irritant by a process of auto-sensitivity. These secondary lesions are called by dermatologists the " ide " eruptions and are regarded as allergic complications effected by a humoral mechanism. The ide eruptions are extremely important as they sometimes dominate the clinical picture. Thus it is possible for a patient to present with oedema of the eyelids, or with eczema of the ante-cubital fossae which is an ide reaction resulting from nickel sensitivity induced by metal suspender clips ; it is even possible for only one out of the four clips to produce a mild eczema at the site of primary contact with nickel—so mild that the patient, having merely noticed the mark, has dismissed it as of no account. There are so many potential irritants, that one can only describe the common patterns of eruption produced.
In the face the skin of the eyelids is especially sensitive, and oedema and itching is usual. Things that obviously touch the face should be considered first such as cosmetics, washing materials, handkerchiefs, spectacles, and local applications, whether for the skin or the eye. Secondly there are things that are brought into contact with the face indirectly, being carried thence on the hands and fingers by the unconscious habit of rubbing the face. These include plant juices such as primula and chrysanthemum, nail varnish, hair dye, antibiotics, antiseptics, red or green ink from ball-point pens, etc. The seasonal incidence of many horticultural allergens helps to identify them. Thirdly, as already mentioned, the possibility of an ide eruption from some other primary focus such as nickel sensitivity or a " varicose " eczema must be considered.
On the hands the skin is much less reactive than it is on the face because of the thicker horny layer. Many of the irritants affecting the hands are of the primary irritant variety, and are associated with the degreasing effects of detergents and the macerating effects of water. Housewives and charwomen are particularly liable to this kind of trouble. A state of allergic hypersensitivity is often added ; this applies for example to an antiseptic, rubber, turpentine, or to a pharmaceutical preparation applied locally—especially local anaesthetics and antihistamines. Other occupations hazardous in this respect include baking (flour, sugar, fats, flavourings), engineering (oils, greases, paraffin, diesel, petrol), building (cement, diesel), and working on railways (diesel, chromate). So much detail about the occupational causes of eczema has been collected that special works which deal entirely with occupational skin diseases are available for reference. The mere distribution of the eruption will sometimes reveal the causative irritant, as between the fingers from holding a pen ; in the palm of one hand where an orange has been held, between the fingers where the juice has trickled, and on the thumb and forefinger of the opposite hand which did the peeling ; on one finger from a rubber finger protector ; on the backs of the fingers of one hand from going into a handbag.
On the feet, as on the hands, the skin is tough. Irritants will affect the thinner skin on the dorsum and on the instep, before the horny areas of the sole. The chief hazard is footwear which contains many potential irritants including formalin, dyes, adhesives, rubber and chrome. Potentially irritant footwear or clothing can sometimes be worn for months with impunity until either a soaking or sweating can precipitate an acute contact eczema.
On the trunk and limbs, nickel sensitivity is confined initially to the areas of contact of nickel containing metals with the skin, such as suspender clips, brassiere buckles, watch strap buckles, zip fasteners and ear-rings. An ide eruption on the face and forearms commonly accompanies nickel sensitivity. Clothing sensitivity often due to dye or formalin produces patterns depending on the nature of the offending garment, and the degree to which the skin is protected by the remainder of the clothing. For example, the underclothes protect the parts that they cover from an irritant shirt; and a short-sleeved blouse will protect all but the forearms from an irritant jersey. Irritant clothing in direct contact with the trunk tends to affect the friction areas—the axillary folds, the belt line and the buttocks—initially. Clothing which is not irritant in itself can become irritant by being washed in a detergent to which the patient's skin is sensitive.
On the neck there may be a localized irritation from the collar, from a necklace or its clasp, from a hairnet (involving the ears and brow as well), from a clothing tab, and so on.
All patterns of contact eczema should conform to the following criteria : the eruption should begin on a piece of skin that has been in close contact with the supposed irritant; its removal should result in clearance of the eczema; its re-introduction should provoke a relapse; a patch test using it, suitably diluted, should be positive. This last condition is hedged about with qualifications connected with the practical difficulties of doing and interpreting patch tests, and the advice of a dermatologist is desirable.
The bizarre histories sometimes associated with contact eczema are due to intermittent contact with the irritant. A suit, a scent, a handkerchief or a soap may be used only occasionally resulting in a series of remissions and relapses of the original eczema, and here a diary is important to record the dates of the recurrences. The amount of an irritant required to provoke a relapse may be very small; for example in a case of hypersensitivity to an antihistamine cream, the patient's convalescence was interrupted by a severe exacerbation of the eruption at one wrist due to wearing for one hour a raincoat which she had worn at the beginning of her illness. Although there was no visible stain at the wrist there must have been enough of the cream present to provoke an exacerbation. This garment had been overlooked when carrying out the injunction to have everything cleaned that could possibly contain a trace of the cream.
The management of a case of contact eczema consists in preventing contact between the offending substance and the patient's skin by removing it from the patient's environment, or by removing the patient from its vicinity. This advice sometimes implies a change of work. For those who cannot change their work, such as housewives, protection combined with the suppressive effect of corti-costeroid applications is a second best choice. Barrier creams are not very satisfactory, and protection of the hands with rubber gloves which must be worn over very thin cotton ones (clumsy as this may be) is the best choice, together with measures designed to reduce contact with water and detergents to a minimum.
Infections.—There are several ways in which infection can occur as a complication of eczema. Most commonly the eczematous area becomes secondarily infected ; the original lesion is thus perpetuated or there may be an exacerbation of the eruption. The most dramatic occurrence of this sort is seen when eczema, usually infantile eczema, becomes secondarily infected with the virus of vaccinia or of herpes simplex—a condition known as Kaposi's varicelli-form eruption. The risk of this complication explains why babies suffering from eczema should not be vaccinated. Much more usual, and more insidious, is the growth of bacteria or yeasts which takes place on any area of eczematous skin. In addition to causing persistence of the eruption, this supra-infection can change its appearance as a result of hypersensitivity to the products of infection. An example of this is the eczema of coal miners. This begins locally with a traumatic eruption arising from the friction of coal dust but with the development of an ide eruption—the consequence of secondary infection—the lesion changes into a widespread post-traumatic infective eczema. Primary infection of the skirt, especially tinea of the feet, can give rise to eczematous ide eruptions such as eheiropompholyx. The part played by infection in seborrhoeic eczema is important, but it is not clear whether the infection or some constitutional abnormality is the primary factor. It is certain that anti-infective local measures are required in its treatment. A focus of extra-cutaneous infection such as septic teeth, tonsils, gall bladder, etc., is rarely responsible for producing or maintaining eczema.
The treatment of an infection residing on the skin is to apply anti-infective agents either topically or systemically or both, but always in conjunction with the routine treatment for eczema. When the severity or the extent of the infection makes oral antibiotics advisable a bacteriological diagnosis should be made. While the report on the bacterial flora is awaited it may be justifiable to give oxytetracycline, 0.5 g. twice daily, modifying the antibiotic treatment in the light of advice received from the bacteriologist. Sulphonamides have a place in . oral treatment but none for local use, since sensitization to these drugs can cause a chronic and disabling dermatosis precipitated by exposure to sunlight and tending to recur every summer. For local use the brightly coloured dyes work very well against a wide variety of organisms, but they have assthetic disadvantages : thev are crystal violet paint B.N.F., and a solution of eosin in water, ½ per cent. Magenta paint B.P.C. should be diluted with one to four volumes of water before being applied to an acutely inflamed skin. All are useful when large areas of skin have to be treated, especially with flexural eruptions. A thin layer of these dyes carefully applied is fully effective, and when used in this way the treatment is much less messy and inconvenient. Mild silver proteinate, B.P.C. is a non-sensitizing mild antiseptic useful for adding to calamine liniment in ¼ per cent. strength. Cleaner alternatives are the detergent hexachlorophene which is useful for washing the skin in the presence of infection, and the chemical or antibiotic agents chlorhydroxyquinoline (in the form of quinolor compound ointment), iodochlorhydroxyquinoline ointment, polynoxylin ointment or paste, and chlortetracycline, neomycin, bacitracin, framycetin and gramicidin. These should be prescribed, singly or in combination, together with corticosteroids. At the time of writing, preparations of this kind are not listed in the National Formulary but there are many proprietary preparations to choose from. No anti-infective agents are free from the possibility of causing sensitization, and neomycin does so in a rather insidious manner which may escape notice ; the patient does not complain of an acute exacerbation of dermatitis but merely that the ointment has lost its effect. Patch tests to neomycin carried out on normal skin are likely to be negative unless the skin has been " stripped " with cellophane tape first. Lesions caused by yeasts are amenable to treatment with dyes, nystatin ointment, or the organic mercurial, penotrane. Viral infection can be treated only by measures directed against the secondary invaders. Until a reliable anti-viral agent is available for general use, very severe cases of Kaposi's eruption should be given an injection of immune globulin. Such treatment carries a risk of transmitting serum hepatitis, but if the patient's life is in danger it is clearly justifiable to accept this risk. Tar has a place in the treatment of seborrhceic eczema and post-traumatic infective eczema.
Ingesta.—Ingestion of a drug to which the patient's skin has been sensitized —such as penicillin or the sulphonamides—may result in a recurrence of the original eruption. More difficult to trace is the drug that is taken in non-medical form, such as quinine in tonic water. Food allergies that affect the skin usually produce urticaria but can provoke eczema, especially in hypersensitive (" atopic ") subjects. The intelligent co-operation of the patient or his parents is essential in order to identify the allergen.; A diary must be kept as an essential preliminary to skin testing. Careful records relating to diet, drugs and other possible sources of allergens must be kept. Further it must be remembered that unless the test solutions are of suitable concentration for the purpose the results may be misleading. Once the offending allergen has been identified, the patient must be advised to stop ingesting it.
Inhalants.—Inhalation of allergens, particularly house dust and pollens, will exacerbate some cases of atopic eczema. The patient does not necessarily complain of sneezing or a running nose. The most obvious preventive measure consists in minimizing exposure to household dust. Old-fashioned methods of sweeping which create dust should be abandoned in favour of vacuum cleaners. In some patients desensitization may be effective.
Physical Factors.—Eczema that is provoked by light can be due to previous contact with photosensitizing substances such as tar, the sulphonamides and many plant juices, but more often it is idiopathic. Occasionally the condition is associated with an abnormal porphyrin metabolism. Complete avoidance of sunlight is burdensome. It necessitates changing to night work ; but partial avoidance of sunlight combined jwith local application of corticosteroids to suppress the eczema, a light " screen " (such as 10 per cent. phenyl salicylate in soft yellow paraffin, or Uvistat) to protect the skin and the empirical use of chloroquine phosphate by mouth (0-35 to 0-5 g. daily) usually suffices. Chloroquine should be reserved for occasional use only, as prolonged courses of treatment may cause blurred vision (interference with accommodation), giddiness or rarely permanent damage to the sight.
Heat provokes recurrences of eczema. It probably acts by causing retention of sweat in glands whose ducts have not fully recovered from eczema, although there may be no visible abnormality of the skin. Sweating predisposes to exacerbations of latent fungus infection and can precipitate an ide eruption. It also makes for more intimate and prolonged contact of the clothes with the skin, and this aids the transfer of irritants from the clothing to the skin. Patients convalescing from eczema should be given ample time to recover before returning to hot jobs or hot climates ; and patients subject to eczema should be encouraged to keep their skins dry and cool.
Moisture, particularly when combined with heat, encourages organisms to flourish on the skin. Prolonged maceration of the skin is tantamount to non-specific trauma ; it also makes the skin much more penetrable by chemical substances. The damage opens the way for an infective eczema. Wet work usually upsets the skins of those prone to eczema, but on the other hand soap and water used in moderation should not be prohibited in eczema unless it manifestly does harm, which seldom happens. A plain, unscented toilet soap is usually satisfactory but for those who cannot tolerate soap there are substitute available.
Cold weather causes chapping of the skin, particularly in ichthyotit and atopic subjects, which can start an infective eczema. Protection from the weather is important, but the atopic skin is usually intolerant to contact witt wool. The use of an ointment containing equal parts of glycerin of starch and ol salicylic acid ointment B.P. is a valuable prophylactic. A useful hand lotion is made up thus : glycerin 60 ml., compound tincture of benzoin 8 ml., a sufficiency of oil of rose and gum acacia, water to 170 ml.
Emotions.—It is debatable whether emotional upsets by themselves can cause eczema, but it is certain that they can potentiate many of the stimuli already mentioned. Under emotional stress the threshold of reaction to allergens can be lowered. Cosmetics, handkerchiefs and sedative drugs are in demand ; sweating is increased ; and, any itchy spot will be rubbed vigorously. Such conditions favour the aggravation and persistence of any form of eczema, and the lesion tends to become lichenified from rubbing. Patients with atopic eczema in particular are liable to exacerbations when under emotional stress. The management of the emotional situation demands measures appropriate to the individual patient; and the routine symptomatic treatment of the eczema is also required.
Metabolic Deficiency.—Deficiency of food rarely affects the skin unless there is a frank vitamin deficiency. Malabsorption from the gut is sometimes associated with eczema. The common form of metabolic disturbance of the skin is secondary to venous stasis in the legs, the result of damage to the deep veins. The chronically raised venous pressure causes oedema and interferes with the nutrition of the skin which then becomes liable to ulceration and eczema. Treatment consists in facilitating venous return by applying external pressure with a web bandage or by using elastoplast applied over zinc paste bandage. When recumbent, the patient should be encouraged to lie with the legs raised. If palliative measures fail, a surgical opinion should be obtained. If these methods are employed the eczema will look after itself, provided there are no other provocative stimuli such as infection. Eczema, the result of stasis, is particularly liable to be complicated by an ide eruption, either as a result of auto-sensitivity or sensitivity to a local application. In either case attention should be directed primarily to the leg—even though this may not be the site of the main part of the eruption.
Heredity.—The atopic constitution which is manifested by the occurrence of infantile eczema, Besnier's prurigo, asthma, hay fever, migraine and urticaria in succeeding generations of certain families, and sometimes by several of these diseases occurring successively or consecutively in one individual, is the basis of much chronic disability from skin trouble. Apart from the classical presentation with lichenified eczema of the antecubital fossae and the popliteal fossae there are many clinical variations, the worst of which involve almost the whole skin in what can only be described as chronic pruritic misery. Rigours of both the physical and emotional climate in which these patients live have a bad effect on their skins. Their treatment follows the same principles as those which apply to other cases of eczema ; but special care should be taken in tracing allergic, climatic and emotional stimuli, and in viewing the patient as a whole person. In the worst cases there is a place for oral corticosteroid treatment. The rare hereditary disease phenylketonuria is sometimes accompanied by infantile eczema. If the urine of all infants suffering from eczema were routinely tested with ferric chloride, the correct diagnosis would be obvious ; and this would be the preliminary to giving these infants the appropriate diet.
SYMPTOMATIC TREATMENT
Corticosteroids.—The introduction of the corticosteroid drugs has revolutionized the treatment of eczema, and it has also thrown into relief the part played by secondary infection. Eczema of all kinds will be suppressed by corticosteroid drugs locally applied. If a favourable response is not obtained the following possible explanations should be considered :
The skin may be too horny for the drug to penetrate the epidermis. The best response is seen where the skin is thin, for example on the face. Penetration can be aided by using an occlusive dressing such as plastic film but, if used on extensive areas and over long periods, this method carries some risk of systemic absorption.
Secondary infection may be interfering with the response. This would be an indication for using an anti-infective agent.
Contact factors may still be operating, for example an irritant cosmetic or a soap.
The corticosteroids for local application vary in their efficacy. Thus betamethasone valerate and fluocinolone acetonide are more effective than 2½ per cent. hydrocortisone which in turn is more effective than i per cent. hydro-cortisone.
The preparation being used may be potentially irritating. For example an incorporated anti-infective agent may cause irritation or the vehicle (such as an ointment base) may be responsible. Sensitivity to neomycin is often overlooked. The corticosteroid drugs used for local application do not cause irritation but by-products in their manufacture may, and traces of these have been known to give trouble. Unexplained irritation from a corticosteroid preparation should be reported to the manufacturer.
The patient may be fostering the eruption by neglecting the treatment, by deliberate interference or unwittingly by compulsive rubbing.
If none of these causes of failure apply, a different preparation should be tried. It is not practicable to list those available in order of potency, nor is it necessary since the question is largely theoretical; but there is general agreement that triamcinolone was more effective than its predecessors, and that fluocinolone and betamethasone are better still.
The various corticosteroids are available in several pharmaceutical preparations for dermatological treatment. These are made up as ointments (greasy), creams (non-greasy), lotions (suitable for moist areas) and sprays (easy to apply to large areas), and they are available with or without added anti-infective agents. It is desirable to have as standard one preparation and to prescribe that routinely, say betamethasone valerate or fluocinolone acetonide. They are normally prescribed as the ointment, but a cream and a lotion are available, the latter being indicated when treating any wet surface. When an added anti-infective agent is required, it is wise to depend on one preparation —say iodochlorhydroxyquinoline—and to change to some other preparation only if this is necessary.
The need for an anti-infective drug is by no means always obvious from the naked eye appearance of the eruption. Nevertheless the enhanced response that can often be obtained from such treatment supports the view that infection plays a much more important part in eczema than is commonly suspected. With a basic schedule of this kind the physician learns to recognize the expected response, and varies the treatment only when the results fall short of expectation. If the usual routine fails, he may choose a different anti-infective agent, a combination of agents or a more potent corticosteroid, according to the needs of the situation. Flexural eruptions—particularly those in the ano-genital region—are liable to possess a rich bacterial flora often including yeasts, and in this situation a combination of nystatin with another antibiotic or the use of one of the dyes may be conspicuously successful after a routine method has failed. There will be . occasions when the area to be treated is so extensive that giving the corti-costeroids bv mouth is more economical. Oral administration, however, especially over a long period of time carries the risk of undesirable side-effects.
Other Methods.—The impact made by the' corticosteroid drugs is too recent for their use to have been fully integrated with the older forms of treatment. It is dear though that many of the old prescriptions will be retained, not for sentimental reasons but because they are useful. The corticosteroids : produce their best results on thin skin such as that of the face and genital region, and they are least effective on the hands and feet although they can be made to | work in these places by plastic film occlusion. They are entirely suppressive ^ in their action and unless the eczema has had time and opportunity to heal s during the course of their application it will relapse at the end of treatment. The cost of corticosteroids must, of course, be considered but not without due regard to their unique action and great usefulness.
Acute weeping eczema is best treated by using wet dressings ; for example ½ per cent. of silver nitrate, 5 per cent. strong solution of lead subacetate or 1.5 per cent. aluminium acetate solution, in water. When secondary infection is present 5 per cent. to 10 per cent. of ichthammol in water should be used, corn- bined with oral antibiotics if there is lymphangitis, fever or toxaemia. An alternative procedure applicable to the hands and feet is to soak the affected skin; in a solution of potassium permanganate, i in 6,000, or in weak iodine solution B.P., I in 50 in water, every four to six hours and to keep the area wrapped in a j clean towel between the soakings.
Lassar's paste contains starch 24 parts, zinc oxide 24, salicylic acid 2, soft yellow paraffin 50. The salicylic acid is best omitted. Lassar's paste is a | particularly useful preparation which seldom irritates the skin, adheres to it gently but firmly and has a soothing effect. It is a satisfactory application for the | hands and feet which are often intolerant to more greasy preparations. It will: not deal with infections; these require anti-infective treatment—such as one of the dyes painted on the skin—before the paste is applied on top. It can be used as a vehicle for active medicaments such as tar. It is undesirable tc try to remove every trace of the old paste before applying it anew because clings so hard that its complete removal is difficult without damaging the skiri. .Once a day is usually quite often enough to change the dressings. The paste is very satisfactory to use after wet dressings have dried up a weeping eczema, and have left the skin dry and tending to crack.
Ichthammol paste is much thinner than Lassar's paste and, whereas Lassar's paste must be spread, ichthammol paste can be rubbed provided that the ares to be treated is not hairy. It contains i per cent. of ichthammol and 15 per cent of zinc oxide in soft yellow paraffin. To provide full protection it should be spread on to material such as calico and bandaged into position.
Calamine liniment is semi-liquid and can be spread easily over large areas, or used as wet dressings. It consists of 8 per cent of calamine and 6 per cent. of lanoline in a base consisting of equal parts of linseed oil and lime water. Ichthammol can be added, from i to 5 per cent. if desired, but since a few patients are sensitive to ichthammol it is safer to use the plain liniment unless the mild antiseptic action of ichthammol is required. Mild silver proteinate B.P.C. in ¼ per cent. strength is another suitable antiseptic agent to add.
Crude coal tar has a great healing action in eczema. Fortunately it is not appreciably carcinogenic in man when used therapeutically, although prolonged occupational contact with tar does lead to cancer of the skin. It can be applied in zinc paste from i to 10 per cent. in strength or painted on in its crude state as a varnish using a paint brush, allowed to dry and powdered with unscented talc. To avoid shaving hairy areas it can be diluted—12 g. of crude coal tar, 20 ml. of benzene and 90 ml. of acetone. It is not a particularly clean application; and purified tars, though cleaner, are less effective. Tar should be applied in the later stages of eczema as it may cause irritation in the early, acute stage; patients suffering from nummular eczema and seborrhceic eczema, however, usually tolerate tar well from a remarkably early stage. It is always advisable when using tar to make the first application to a limited area in case the skin proves to be sensitive to it. It should also be remembered that tar makes the skin photosensitive.
Occlnsive Bandaging is particularly suitable for the limbs. Its success depends upon the protection and rest that it affords and provided that the occlusion does not encourage any infection which may be present, and that there are no internal provocative stimuli, the eczema will heal. The most comfortable occlusive dressing is a zinc gelatine bandage. This is not easily prepared. Further its application calls for some skill: it must be painted on in successive layers and built up on a gauze bandage, the zinc gelatine being heated before use to ensure that it is of the correct consistence. The proprietary paste bandages which are ready for application are a serviceable substitute and the best are those that harden least during wear. All require careful application to avoid lumpiness and to achieve the correct tension or else friction sores will develop where the bandage rubs the skin. The bandage is kept in place for a period of from three days to six weeks according to the needs of the individual patient: it is best to change the dressing infrequently—so long as the patient remains comfortable. Medicaments such as ichthammol and tar can be incorporated in the bandage to produce a greater healing effect. In an apprehensive patient corticosteroids can be applied to the skin before the first application of the bandage to make the initial stage more comfortable. It should be remembered that many patients are often very alarmed at the thought of their limb being occluded, and their anxiety often becomes manifest as an increase of irritation. Hence this method of treatment, though useful, should never be regarded as a matter of routine.
X-rays have been used extensively in treating chronic eczema. There are many alternative applications, and it would seem wiser to avoid radiotherapy as much as possible but it is a valuable standby in very resistant cases.
Internal treatment, apart from corticosteroids, consists of the use of sedatives —either barbiturates (such as amylobarbitone) or antihistamines (such as promethazine hydrochloride) or both. In the treatment of eczema the anti- histamines are not used to block the actions of histamine but for their sedative and tranquillizing properties. No drug will relieve itch specifically and the treatment of itch in eczema is always the treatment of the eczema itself.
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Eczema is derived from a Greek word meaning "to boil". The term is descriptive of the acute stage of the process when the skin is covered with small blisters, like bubbles on boiling water. The blisters which are formed within the epidermis break readily (except on the hands and feet where they are preserved by the thick horny layer, and the names cheiropompholyx and podopompholyx have been given to this type of eczema) resulting in copious weeping from a denuded, raw surface followed by crusting as the exudate dries, and often complicated by secondary infection of bacterial, fungal or viral origin. In the later stages the eruption is dry and is characterized by redness, scaling and cracking consequent upon the disordered growth of the epidermis.; and these changes persist until a healthy horny layer has reformed. Thickening of the skin occurs as a result of cellular infiltration and oedema in the dermis, and it is much increased by compulsive scratching and by rubbing of the itchy skin until a leathery texture is produced known as lichenification. At all stages of eczema patients complain that the lesions itch.
Eczema is not a disease but a reaction pattern in the epidermis1 which can be precipitated by many stimuli. It follows that the causative agents must be identified and neutralized if the eczema reaction is to subside. The pattern is not necessarily fully developed in every case. Thus one may speak of a " wet " eczema, where the early stages of the process predominate, and of a " dry " eczema at a later stage. A single, unrepeated eczema-producing stimulus—for example contact of a sensitized skin with a leaf of primula obconica—will result in an inevitable and relentless chain of events consisting of itch and erythema for a few hours, blisters and weeping for a few days, and scaling for about three or four weeks, by which time—barring the occurrence of lichenification as a result of the patient's own interference—the skin will have healed except, perhaps, for some residual staining. This erstwhile inexorable result of a single unrepeated stimulus can nowadays be suppressed by the use of corticosteroid preparations which can be used during the normal three or four weeks required for healing, without interfering with the healing process. Consequently, provided that the stimulus is not repeated, this treatment will appear to have " cured " the patient; but if, as is usual, the stimulus continues, a relapse will follow when it is stopped.
The treatment of eczema consists first in identifying and eliminating the provocative stimuli, and second in calming down the inflamed skin until the natural healing process has had time to occur. Since unfortunately the former aim. is sometimes unattainable, the latter must perforce on these occasions suffice. The provocative stimuli are now considered. From their diversity it will be apparent that a thorough investigation of eczema is bound to involve a full history and examination, such as are required in any medical case, but with particular attention directed towards the external environment.
PROVOCATIVE STIMULI
External Irritants.—Primary irritants such as strong acids and alkalis many oils, paraffin, turpentine, petrol, soap, and many antiseptics, will irritate any skin if allowed to come into contact with it in high enough concentration for a sufficient time. The effect is enhanced by removal of the natural greasy protective covering of the skin such as occurs in housewives, nurses, charwomen and metal turners who are habitually using detergents. Allergenic irritants such as primula obconica, chrome, nickel, penicillin, paraphenylenediamine, etc., will in time produce a state of allergic hypersensitivity in certain skins which will then react to the irritant in high or in low concentration. Their identification is often exceedingly difficult since, as far as the patient is concerned, they are harmless (for example cosmetics, flowers, clothing, footwear, ointments, etc.) and it seldom occurs to the patient to suspect such commonplace things. Their recognition depends upon raising the possibility, combined with. Considering
1 For practical purposes eczema is synonymous with dermatitis though dermatitis is used in a general way to describe dermal as well as epidermal inflammation, as in dermatitis herpetiformis. Eczema is to be preferred when a specifically epidermal reaction is implied.
The pattern of the eruption: 'footwear, for example, causes air eczema which primarily involves the feet although the eruption may spread later to other skin which has never been in direct contact with the irritant by a process of auto-sensitivity. These secondary lesions are called by dermatologists the " ide " eruptions and are regarded as allergic complications effected by a humoral mechanism. The ide eruptions are extremely important as they sometimes dominate the clinical picture. Thus it is possible for a patient to present with oedema of the eyelids, or with eczema of the ante-cubital fossae which is an ide reaction resulting from nickel sensitivity induced by metal suspender clips ; it is even possible for only one out of the four clips to produce a mild eczema at the site of primary contact with nickel—so mild that the patient, having merely noticed the mark, has dismissed it as of no account. There are so many potential irritants, that one can only describe the common patterns of eruption produced.
In the face the skin of the eyelids is especially sensitive, and oedema and itching is usual. Things that obviously touch the face should be considered first such as cosmetics, washing materials, handkerchiefs, spectacles, and local applications, whether for the skin or the eye. Secondly there are things that are brought into contact with the face indirectly, being carried thence on the hands and fingers by the unconscious habit of rubbing the face. These include plant juices such as primula and chrysanthemum, nail varnish, hair dye, antibiotics, antiseptics, red or green ink from ball-point pens, etc. The seasonal incidence of many horticultural allergens helps to identify them. Thirdly, as already mentioned, the possibility of an ide eruption from some other primary focus such as nickel sensitivity or a " varicose " eczema must be considered.
On the hands the skin is much less reactive than it is on the face because of the thicker horny layer. Many of the irritants affecting the hands are of the primary irritant variety, and are associated with the degreasing effects of detergents and the macerating effects of water. Housewives and charwomen are particularly liable to this kind of trouble. A state of allergic hypersensitivity is often added ; this applies for example to an antiseptic, rubber, turpentine, or to a pharmaceutical preparation applied locally—especially local anaesthetics and antihistamines. Other occupations hazardous in this respect include baking (flour, sugar, fats, flavourings), engineering (oils, greases, paraffin, diesel, petrol), building (cement, diesel), and working on railways (diesel, chromate). So much detail about the occupational causes of eczema has been collected that special works which deal entirely with occupational skin diseases are available for reference. The mere distribution of the eruption will sometimes reveal the causative irritant, as between the fingers from holding a pen ; in the palm of one hand where an orange has been held, between the fingers where the juice has trickled, and on the thumb and forefinger of the opposite hand which did the peeling ; on one finger from a rubber finger protector ; on the backs of the fingers of one hand from going into a handbag.
On the feet, as on the hands, the skin is tough. Irritants will affect the thinner skin on the dorsum and on the instep, before the horny areas of the sole. The chief hazard is footwear which contains many potential irritants including formalin, dyes, adhesives, rubber and chrome. Potentially irritant footwear or clothing can sometimes be worn for months with impunity until either a soaking or sweating can precipitate an acute contact eczema.
On the trunk and limbs, nickel sensitivity is confined initially to the areas of contact of nickel containing metals with the skin, such as suspender clips, brassiere buckles, watch strap buckles, zip fasteners and ear-rings. An ide eruption on the face and forearms commonly accompanies nickel sensitivity. Clothing sensitivity often due to dye or formalin produces patterns depending on the nature of the offending garment, and the degree to which the skin is protected by the remainder of the clothing. For example, the underclothes protect the parts that they cover from an irritant shirt; and a short-sleeved blouse will protect all but the forearms from an irritant jersey. Irritant clothing in direct contact with the trunk tends to affect the friction areas—the axillary folds, the belt line and the buttocks—initially. Clothing which is not irritant in itself can become irritant by being washed in a detergent to which the patient's skin is sensitive.
On the neck there may be a localized irritation from the collar, from a necklace or its clasp, from a hairnet (involving the ears and brow as well), from a clothing tab, and so on.
All patterns of contact eczema should conform to the following criteria : the eruption should begin on a piece of skin that has been in close contact with the supposed irritant; its removal should result in clearance of the eczema; its re-introduction should provoke a relapse; a patch test using it, suitably diluted, should be positive. This last condition is hedged about with qualifications connected with the practical difficulties of doing and interpreting patch tests, and the advice of a dermatologist is desirable.
The bizarre histories sometimes associated with contact eczema are due to intermittent contact with the irritant. A suit, a scent, a handkerchief or a soap may be used only occasionally resulting in a series of remissions and relapses of the original eczema, and here a diary is important to record the dates of the recurrences. The amount of an irritant required to provoke a relapse may be very small; for example in a case of hypersensitivity to an antihistamine cream, the patient's convalescence was interrupted by a severe exacerbation of the eruption at one wrist due to wearing for one hour a raincoat which she had worn at the beginning of her illness. Although there was no visible stain at the wrist there must have been enough of the cream present to provoke an exacerbation. This garment had been overlooked when carrying out the injunction to have everything cleaned that could possibly contain a trace of the cream.
The management of a case of contact eczema consists in preventing contact between the offending substance and the patient's skin by removing it from the patient's environment, or by removing the patient from its vicinity. This advice sometimes implies a change of work. For those who cannot change their work, such as housewives, protection combined with the suppressive effect of corti-costeroid applications is a second best choice. Barrier creams are not very satisfactory, and protection of the hands with rubber gloves which must be worn over very thin cotton ones (clumsy as this may be) is the best choice, together with measures designed to reduce contact with water and detergents to a minimum.
Infections.—There are several ways in which infection can occur as a complication of eczema. Most commonly the eczematous area becomes secondarily infected ; the original lesion is thus perpetuated or there may be an exacerbation of the eruption. The most dramatic occurrence of this sort is seen when eczema, usually infantile eczema, becomes secondarily infected with the virus of vaccinia or of herpes simplex—a condition known as Kaposi's varicelli-form eruption. The risk of this complication explains why babies suffering from eczema should not be vaccinated. Much more usual, and more insidious, is the growth of bacteria or yeasts which takes place on any area of eczematous skin. In addition to causing persistence of the eruption, this supra-infection can change its appearance as a result of hypersensitivity to the products of infection. An example of this is the eczema of coal miners. This begins locally with a traumatic eruption arising from the friction of coal dust but with the development of an ide eruption—the consequence of secondary infection—the lesion changes into a widespread post-traumatic infective eczema. Primary infection of the skirt, especially tinea of the feet, can give rise to eczematous ide eruptions such as eheiropompholyx. The part played by infection in seborrhoeic eczema is important, but it is not clear whether the infection or some constitutional abnormality is the primary factor. It is certain that anti-infective local measures are required in its treatment. A focus of extra-cutaneous infection such as septic teeth, tonsils, gall bladder, etc., is rarely responsible for producing or maintaining eczema.
The treatment of an infection residing on the skin is to apply anti-infective agents either topically or systemically or both, but always in conjunction with the routine treatment for eczema. When the severity or the extent of the infection makes oral antibiotics advisable a bacteriological diagnosis should be made. While the report on the bacterial flora is awaited it may be justifiable to give oxytetracycline, 0.5 g. twice daily, modifying the antibiotic treatment in the light of advice received from the bacteriologist. Sulphonamides have a place in . oral treatment but none for local use, since sensitization to these drugs can cause a chronic and disabling dermatosis precipitated by exposure to sunlight and tending to recur every summer. For local use the brightly coloured dyes work very well against a wide variety of organisms, but they have assthetic disadvantages : thev are crystal violet paint B.N.F., and a solution of eosin in water, ½ per cent. Magenta paint B.P.C. should be diluted with one to four volumes of water before being applied to an acutely inflamed skin. All are useful when large areas of skin have to be treated, especially with flexural eruptions. A thin layer of these dyes carefully applied is fully effective, and when used in this way the treatment is much less messy and inconvenient. Mild silver proteinate, B.P.C. is a non-sensitizing mild antiseptic useful for adding to calamine liniment in ¼ per cent. strength. Cleaner alternatives are the detergent hexachlorophene which is useful for washing the skin in the presence of infection, and the chemical or antibiotic agents chlorhydroxyquinoline (in the form of quinolor compound ointment), iodochlorhydroxyquinoline ointment, polynoxylin ointment or paste, and chlortetracycline, neomycin, bacitracin, framycetin and gramicidin. These should be prescribed, singly or in combination, together with corticosteroids. At the time of writing, preparations of this kind are not listed in the National Formulary but there are many proprietary preparations to choose from. No anti-infective agents are free from the possibility of causing sensitization, and neomycin does so in a rather insidious manner which may escape notice ; the patient does not complain of an acute exacerbation of dermatitis but merely that the ointment has lost its effect. Patch tests to neomycin carried out on normal skin are likely to be negative unless the skin has been " stripped " with cellophane tape first. Lesions caused by yeasts are amenable to treatment with dyes, nystatin ointment, or the organic mercurial, penotrane. Viral infection can be treated only by measures directed against the secondary invaders. Until a reliable anti-viral agent is available for general use, very severe cases of Kaposi's eruption should be given an injection of immune globulin. Such treatment carries a risk of transmitting serum hepatitis, but if the patient's life is in danger it is clearly justifiable to accept this risk. Tar has a place in the treatment of seborrhceic eczema and post-traumatic infective eczema.
Ingesta.—Ingestion of a drug to which the patient's skin has been sensitized —such as penicillin or the sulphonamides—may result in a recurrence of the original eruption. More difficult to trace is the drug that is taken in non-medical form, such as quinine in tonic water. Food allergies that affect the skin usually produce urticaria but can provoke eczema, especially in hypersensitive (" atopic ") subjects. The intelligent co-operation of the patient or his parents is essential in order to identify the allergen.; A diary must be kept as an essential preliminary to skin testing. Careful records relating to diet, drugs and other possible sources of allergens must be kept. Further it must be remembered that unless the test solutions are of suitable concentration for the purpose the results may be misleading. Once the offending allergen has been identified, the patient must be advised to stop ingesting it.
Inhalants.—Inhalation of allergens, particularly house dust and pollens, will exacerbate some cases of atopic eczema. The patient does not necessarily complain of sneezing or a running nose. The most obvious preventive measure consists in minimizing exposure to household dust. Old-fashioned methods of sweeping which create dust should be abandoned in favour of vacuum cleaners. In some patients desensitization may be effective.
Physical Factors.—Eczema that is provoked by light can be due to previous contact with photosensitizing substances such as tar, the sulphonamides and many plant juices, but more often it is idiopathic. Occasionally the condition is associated with an abnormal porphyrin metabolism. Complete avoidance of sunlight is burdensome. It necessitates changing to night work ; but partial avoidance of sunlight combined jwith local application of corticosteroids to suppress the eczema, a light " screen " (such as 10 per cent. phenyl salicylate in soft yellow paraffin, or Uvistat) to protect the skin and the empirical use of chloroquine phosphate by mouth (0-35 to 0-5 g. daily) usually suffices. Chloroquine should be reserved for occasional use only, as prolonged courses of treatment may cause blurred vision (interference with accommodation), giddiness or rarely permanent damage to the sight.
Heat provokes recurrences of eczema. It probably acts by causing retention of sweat in glands whose ducts have not fully recovered from eczema, although there may be no visible abnormality of the skin. Sweating predisposes to exacerbations of latent fungus infection and can precipitate an ide eruption. It also makes for more intimate and prolonged contact of the clothes with the skin, and this aids the transfer of irritants from the clothing to the skin. Patients convalescing from eczema should be given ample time to recover before returning to hot jobs or hot climates ; and patients subject to eczema should be encouraged to keep their skins dry and cool.
Moisture, particularly when combined with heat, encourages organisms to flourish on the skin. Prolonged maceration of the skin is tantamount to non-specific trauma ; it also makes the skin much more penetrable by chemical substances. The damage opens the way for an infective eczema. Wet work usually upsets the skins of those prone to eczema, but on the other hand soap and water used in moderation should not be prohibited in eczema unless it manifestly does harm, which seldom happens. A plain, unscented toilet soap is usually satisfactory but for those who cannot tolerate soap there are substitute available.
Cold weather causes chapping of the skin, particularly in ichthyotit and atopic subjects, which can start an infective eczema. Protection from the weather is important, but the atopic skin is usually intolerant to contact witt wool. The use of an ointment containing equal parts of glycerin of starch and ol salicylic acid ointment B.P. is a valuable prophylactic. A useful hand lotion is made up thus : glycerin 60 ml., compound tincture of benzoin 8 ml., a sufficiency of oil of rose and gum acacia, water to 170 ml.
Emotions.—It is debatable whether emotional upsets by themselves can cause eczema, but it is certain that they can potentiate many of the stimuli already mentioned. Under emotional stress the threshold of reaction to allergens can be lowered. Cosmetics, handkerchiefs and sedative drugs are in demand ; sweating is increased ; and, any itchy spot will be rubbed vigorously. Such conditions favour the aggravation and persistence of any form of eczema, and the lesion tends to become lichenified from rubbing. Patients with atopic eczema in particular are liable to exacerbations when under emotional stress. The management of the emotional situation demands measures appropriate to the individual patient; and the routine symptomatic treatment of the eczema is also required.
Metabolic Deficiency.—Deficiency of food rarely affects the skin unless there is a frank vitamin deficiency. Malabsorption from the gut is sometimes associated with eczema. The common form of metabolic disturbance of the skin is secondary to venous stasis in the legs, the result of damage to the deep veins. The chronically raised venous pressure causes oedema and interferes with the nutrition of the skin which then becomes liable to ulceration and eczema. Treatment consists in facilitating venous return by applying external pressure with a web bandage or by using elastoplast applied over zinc paste bandage. When recumbent, the patient should be encouraged to lie with the legs raised. If palliative measures fail, a surgical opinion should be obtained. If these methods are employed the eczema will look after itself, provided there are no other provocative stimuli such as infection. Eczema, the result of stasis, is particularly liable to be complicated by an ide eruption, either as a result of auto-sensitivity or sensitivity to a local application. In either case attention should be directed primarily to the leg—even though this may not be the site of the main part of the eruption.
Heredity.—The atopic constitution which is manifested by the occurrence of infantile eczema, Besnier's prurigo, asthma, hay fever, migraine and urticaria in succeeding generations of certain families, and sometimes by several of these diseases occurring successively or consecutively in one individual, is the basis of much chronic disability from skin trouble. Apart from the classical presentation with lichenified eczema of the antecubital fossae and the popliteal fossae there are many clinical variations, the worst of which involve almost the whole skin in what can only be described as chronic pruritic misery. Rigours of both the physical and emotional climate in which these patients live have a bad effect on their skins. Their treatment follows the same principles as those which apply to other cases of eczema ; but special care should be taken in tracing allergic, climatic and emotional stimuli, and in viewing the patient as a whole person. In the worst cases there is a place for oral corticosteroid treatment. The rare hereditary disease phenylketonuria is sometimes accompanied by infantile eczema. If the urine of all infants suffering from eczema were routinely tested with ferric chloride, the correct diagnosis would be obvious ; and this would be the preliminary to giving these infants the appropriate diet.
SYMPTOMATIC TREATMENT
Corticosteroids.—The introduction of the corticosteroid drugs has revolutionized the treatment of eczema, and it has also thrown into relief the part played by secondary infection. Eczema of all kinds will be suppressed by corticosteroid drugs locally applied. If a favourable response is not obtained the following possible explanations should be considered :
The skin may be too horny for the drug to penetrate the epidermis. The best response is seen where the skin is thin, for example on the face. Penetration can be aided by using an occlusive dressing such as plastic film but, if used on extensive areas and over long periods, this method carries some risk of systemic absorption.
Secondary infection may be interfering with the response. This would be an indication for using an anti-infective agent.
Contact factors may still be operating, for example an irritant cosmetic or a soap.
The corticosteroids for local application vary in their efficacy. Thus betamethasone valerate and fluocinolone acetonide are more effective than 2½ per cent. hydrocortisone which in turn is more effective than i per cent. hydro-cortisone.
The preparation being used may be potentially irritating. For example an incorporated anti-infective agent may cause irritation or the vehicle (such as an ointment base) may be responsible. Sensitivity to neomycin is often overlooked. The corticosteroid drugs used for local application do not cause irritation but by-products in their manufacture may, and traces of these have been known to give trouble. Unexplained irritation from a corticosteroid preparation should be reported to the manufacturer.
The patient may be fostering the eruption by neglecting the treatment, by deliberate interference or unwittingly by compulsive rubbing.
If none of these causes of failure apply, a different preparation should be tried. It is not practicable to list those available in order of potency, nor is it necessary since the question is largely theoretical; but there is general agreement that triamcinolone was more effective than its predecessors, and that fluocinolone and betamethasone are better still.
The various corticosteroids are available in several pharmaceutical preparations for dermatological treatment. These are made up as ointments (greasy), creams (non-greasy), lotions (suitable for moist areas) and sprays (easy to apply to large areas), and they are available with or without added anti-infective agents. It is desirable to have as standard one preparation and to prescribe that routinely, say betamethasone valerate or fluocinolone acetonide. They are normally prescribed as the ointment, but a cream and a lotion are available, the latter being indicated when treating any wet surface. When an added anti-infective agent is required, it is wise to depend on one preparation —say iodochlorhydroxyquinoline—and to change to some other preparation only if this is necessary.
The need for an anti-infective drug is by no means always obvious from the naked eye appearance of the eruption. Nevertheless the enhanced response that can often be obtained from such treatment supports the view that infection plays a much more important part in eczema than is commonly suspected. With a basic schedule of this kind the physician learns to recognize the expected response, and varies the treatment only when the results fall short of expectation. If the usual routine fails, he may choose a different anti-infective agent, a combination of agents or a more potent corticosteroid, according to the needs of the situation. Flexural eruptions—particularly those in the ano-genital region—are liable to possess a rich bacterial flora often including yeasts, and in this situation a combination of nystatin with another antibiotic or the use of one of the dyes may be conspicuously successful after a routine method has failed. There will be . occasions when the area to be treated is so extensive that giving the corti-costeroids bv mouth is more economical. Oral administration, however, especially over a long period of time carries the risk of undesirable side-effects.
Other Methods.—The impact made by the' corticosteroid drugs is too recent for their use to have been fully integrated with the older forms of treatment. It is dear though that many of the old prescriptions will be retained, not for sentimental reasons but because they are useful. The corticosteroids : produce their best results on thin skin such as that of the face and genital region, and they are least effective on the hands and feet although they can be made to | work in these places by plastic film occlusion. They are entirely suppressive ^ in their action and unless the eczema has had time and opportunity to heal s during the course of their application it will relapse at the end of treatment. The cost of corticosteroids must, of course, be considered but not without due regard to their unique action and great usefulness.
Acute weeping eczema is best treated by using wet dressings ; for example ½ per cent. of silver nitrate, 5 per cent. strong solution of lead subacetate or 1.5 per cent. aluminium acetate solution, in water. When secondary infection is present 5 per cent. to 10 per cent. of ichthammol in water should be used, corn- bined with oral antibiotics if there is lymphangitis, fever or toxaemia. An alternative procedure applicable to the hands and feet is to soak the affected skin; in a solution of potassium permanganate, i in 6,000, or in weak iodine solution B.P., I in 50 in water, every four to six hours and to keep the area wrapped in a j clean towel between the soakings.
Lassar's paste contains starch 24 parts, zinc oxide 24, salicylic acid 2, soft yellow paraffin 50. The salicylic acid is best omitted. Lassar's paste is a | particularly useful preparation which seldom irritates the skin, adheres to it gently but firmly and has a soothing effect. It is a satisfactory application for the | hands and feet which are often intolerant to more greasy preparations. It will: not deal with infections; these require anti-infective treatment—such as one of the dyes painted on the skin—before the paste is applied on top. It can be used as a vehicle for active medicaments such as tar. It is undesirable tc try to remove every trace of the old paste before applying it anew because clings so hard that its complete removal is difficult without damaging the skiri. .Once a day is usually quite often enough to change the dressings. The paste is very satisfactory to use after wet dressings have dried up a weeping eczema, and have left the skin dry and tending to crack.
Ichthammol paste is much thinner than Lassar's paste and, whereas Lassar's paste must be spread, ichthammol paste can be rubbed provided that the ares to be treated is not hairy. It contains i per cent. of ichthammol and 15 per cent of zinc oxide in soft yellow paraffin. To provide full protection it should be spread on to material such as calico and bandaged into position.
Calamine liniment is semi-liquid and can be spread easily over large areas, or used as wet dressings. It consists of 8 per cent of calamine and 6 per cent. of lanoline in a base consisting of equal parts of linseed oil and lime water. Ichthammol can be added, from i to 5 per cent. if desired, but since a few patients are sensitive to ichthammol it is safer to use the plain liniment unless the mild antiseptic action of ichthammol is required. Mild silver proteinate B.P.C. in ¼ per cent. strength is another suitable antiseptic agent to add.
Crude coal tar has a great healing action in eczema. Fortunately it is not appreciably carcinogenic in man when used therapeutically, although prolonged occupational contact with tar does lead to cancer of the skin. It can be applied in zinc paste from i to 10 per cent. in strength or painted on in its crude state as a varnish using a paint brush, allowed to dry and powdered with unscented talc. To avoid shaving hairy areas it can be diluted—12 g. of crude coal tar, 20 ml. of benzene and 90 ml. of acetone. It is not a particularly clean application; and purified tars, though cleaner, are less effective. Tar should be applied in the later stages of eczema as it may cause irritation in the early, acute stage; patients suffering from nummular eczema and seborrhceic eczema, however, usually tolerate tar well from a remarkably early stage. It is always advisable when using tar to make the first application to a limited area in case the skin proves to be sensitive to it. It should also be remembered that tar makes the skin photosensitive.
Occlnsive Bandaging is particularly suitable for the limbs. Its success depends upon the protection and rest that it affords and provided that the occlusion does not encourage any infection which may be present, and that there are no internal provocative stimuli, the eczema will heal. The most comfortable occlusive dressing is a zinc gelatine bandage. This is not easily prepared. Further its application calls for some skill: it must be painted on in successive layers and built up on a gauze bandage, the zinc gelatine being heated before use to ensure that it is of the correct consistence. The proprietary paste bandages which are ready for application are a serviceable substitute and the best are those that harden least during wear. All require careful application to avoid lumpiness and to achieve the correct tension or else friction sores will develop where the bandage rubs the skin. The bandage is kept in place for a period of from three days to six weeks according to the needs of the individual patient: it is best to change the dressing infrequently—so long as the patient remains comfortable. Medicaments such as ichthammol and tar can be incorporated in the bandage to produce a greater healing effect. In an apprehensive patient corticosteroids can be applied to the skin before the first application of the bandage to make the initial stage more comfortable. It should be remembered that many patients are often very alarmed at the thought of their limb being occluded, and their anxiety often becomes manifest as an increase of irritation. Hence this method of treatment, though useful, should never be regarded as a matter of routine.
X-rays have been used extensively in treating chronic eczema. There are many alternative applications, and it would seem wiser to avoid radiotherapy as much as possible but it is a valuable standby in very resistant cases.
Internal treatment, apart from corticosteroids, consists of the use of sedatives —either barbiturates (such as amylobarbitone) or antihistamines (such as promethazine hydrochloride) or both. In the treatment of eczema the anti- histamines are not used to block the actions of histamine but for their sedative and tranquillizing properties. No drug will relieve itch specifically and the treatment of itch in eczema is always the treatment of the eczema itself.
DRUG ERUPTIONS Treatment
The treatment of drug eruptions is simply to stop the offending drug, and to treat the eruption symptomatically until it disappears. If the patient is very ill, intravenous or oral corticosteroid treatment may be required. The difficulty is in knowing which eruptions are due to drugs. Vivid widespread erythemas will be recognized easily, but there are many occasions when the eruption mimics or produces a commonplace dermatosis such as the urticaria caused by acetylsalicylic acid, erythema multiforme due to barbiturates, erythema nodosum due to sulphonamides and acneiform eruptions due to bromides or iodides. There are also patterns of eruption which are familiar to the dermatologist but not generally known. These are the bizarre purpura which shows a dependent distribution that is characteristic of carbromal sensitivity. Again there is the curious phenomenon of the fixed drug eruption. An erythematous or somewhat livid patch recurs intermittently in the same of skin over a period of many months. It is usually caused by taking phenol-phthalein—perhaps very infrequently—but sometimes other drugs such as quinine, barbiturates, analgesics and antibiotics are responsible. There are other occasions when an eruption is accompanied by a severe toxic illness perhaps with fever, lymphadenopathy and arthropathy. The constitutional upset may be so severe that comparatively little attention is paid to the skin eruption, and the correct diagnosis of drug sensitivity may thus be missed.
DERMATITIS HERPETIFORMIS Treatment
Dermatitis herpetiformis is not a very common disease but it is mentioned because its response to treatment is interesting. The lesions cause a great deal of irritation and this is a source of misery to the patient. It has been known for many years that inorganic arsenic given by mouth would suppress the eruption. As arsenic is potentially poisonous, it was gratifying to find that one of the earliest sulphonamides, sulphapyridine, is often effective. The dose required is small (0.5 to 1.0 g. daily). The drug is suppressive only; its administration has to be continued while the disease remains active and this is usually for some years. The sulphone, dapsone, also works well and is now regarded as the drug of choice; it is given in a dose of 50 to 150 mg. daily. This drug, however, is not free from toxic effects : it may cause anasmia with Heinz body formation in the red cells.
CHILBLAINS Treatment
Chilblains are due to an abnormal reaction of the skin vessels to cold involving a prolonged state of spasm whereby the nutrition of the skin suffers. The constitutional factors that produce this state are not understood. Those who are subject to chilblains must take an intelligent interest in the technique of preventing chilling of the extremities.
Use can be made of an effect of large doses of ultra-violet light which, by temporarily damaging the skin vessels, make them unable to shrink with cold for some months after treatment. Three to four times the erythema dose is given to the area of skin expected to be involved just before the time of the usual onset of chilblains, and this treatment is repeated twice more at weekly intervals. For established chilblains 5 per cent. compound tincture of benzoin in hydrous wool fat ointment is a soothing application. Some cases are so severe as to warrant sympathectomy.
Use can be made of an effect of large doses of ultra-violet light which, by temporarily damaging the skin vessels, make them unable to shrink with cold for some months after treatment. Three to four times the erythema dose is given to the area of skin expected to be involved just before the time of the usual onset of chilblains, and this treatment is repeated twice more at weekly intervals. For established chilblains 5 per cent. compound tincture of benzoin in hydrous wool fat ointment is a soothing application. Some cases are so severe as to warrant sympathectomy.
ANO - GENITAL PRURITUS Treatment
This condition results when any potentially pruritic eruption affects the ano-genital region. It is aggravated and prolonged by the process of lichenification. Pruritus has a pleasurable component—especially when it has this distribution. In sexual frigidity ano-genital pruritus may serve to rationalize the psychological disability. In some patients these attitudes towards pruritus greatly increase the difficulty in finding effective treatment.
Diabetes and threadworms must first be excluded. Local abnormalities causing vaginal discharge and secondary dermatitis are fairly easily diagnosed from the history and a careful physical examination.
For the symptomatic relief of the irritation the corticosteroid ointments have proved invaluable, and they should be combined with appropriate anti-infective agents to deal with the mixed flora of micro-organisms found in this region. Thus a combination of triamcinolone, neomycin, gramicidin and nystatin is often useful. Radiotherapy which was formerly in common use is now recommended only as a last resort, and should then be confined to women past the child-bearing age. Yeast infections of the bowel resulting from oral tetracycline therapy can precipitate anal pruritus. The bowel flora usually reverts to normal spontaneously when antibiotic therapy is stopped and the pruritus subsides. If, however, the yeast infection persists and causes ano-genital dermatitis, nystatin should be given by mouth in doses of ^ million units thrice daily. Recurring yeast infections in the ano-genital region should serve as a reminder to exclude a diagnosis of diabetes mellitus.
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Diabetes and threadworms must first be excluded. Local abnormalities causing vaginal discharge and secondary dermatitis are fairly easily diagnosed from the history and a careful physical examination.
For the symptomatic relief of the irritation the corticosteroid ointments have proved invaluable, and they should be combined with appropriate anti-infective agents to deal with the mixed flora of micro-organisms found in this region. Thus a combination of triamcinolone, neomycin, gramicidin and nystatin is often useful. Radiotherapy which was formerly in common use is now recommended only as a last resort, and should then be confined to women past the child-bearing age. Yeast infections of the bowel resulting from oral tetracycline therapy can precipitate anal pruritus. The bowel flora usually reverts to normal spontaneously when antibiotic therapy is stopped and the pruritus subsides. If, however, the yeast infection persists and causes ano-genital dermatitis, nystatin should be given by mouth in doses of ^ million units thrice daily. Recurring yeast infections in the ano-genital region should serve as a reminder to exclude a diagnosis of diabetes mellitus.
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ALOPECIA Treatment
The premature loss of hair, which affects the crown of the head and the temporo-frontal regions in men and in women only the crown, is not amenable to treatment.
Alopecia areata is often hereditary and is probably due to a biochemical abnormality connected with the activity of the hair follicles causing them to become dormant either temporarily or permanently. Since the nature of the disturbance is not understood there is no means of knowing how long it will last in any individual patient. Bad prognostic signs are onset of the condition before puberty, a family history of total alopecia, and dystrophy of the nails. The immediate prognosis can be determined by pulling the hair at the edge of the patches ; if it comes away easily and painles'sly the process is spreading. In those liable to the disease attacks can be precipitated by emotional stresses for example by bereavements and motor accidents, but some weeks may elapse before alopecia develops. No treatment has any regularly predictable effect, except the use of corticosteroids. Injections into the lesions are useful when the disease is localized. The application of betamethasone valerate or fluocinolone acetonide ointment with polythene occlusion can be helpful in very widespread cases. Oral treatment may have to be continued indefinitely, and the few occasions on which it might be justifiable are discussed elsewhere. It is probable that improvement, occurring during the various kinds of treatment commonly employed—such as ultra-violet light, scalp massage, painting with solutions of iodine or of lactic acid—is merely incidental; the natural history of the disease is usually towards resolution. When indicated by the emotional state of the patient a sedative such as phenobarbitone 30 mg. twice daily should be given. Painting with Thorium X is not recommended.
The hair may fall out—a defluvium of hair—following some toxic illnesses (especially pneumonia and influenza), in thyrotoxicosis, during the use of certain drugs such as heparin and cyclophosphamide and after parturition. This does not require treatment; the hair can be expected to grow again completely. In myxosdema the hair is dry and scanty but this does not justify the administration of thyroxin to everybody who complains of loss of hair.
The preceding forms of alopecia must be distinguished from the rarer ones in which there is scarring of the scalp. Here there is destruction of the hair follicles and there is no hope whatever of any regrowth of hair. Reference to a dermatologist is desirable, however, as it may be possible to arrest the disease. It is also important to remember that alopecia areata can be closely imitated by secondary syphilis, and that alopecia with scaling and pustulation may be due to ringworm.
In any form of loss of hair it is advisable to avoid unnecessary brushing and combing of the hair and to prohibit massage, since these measures in themselves can cause considerable loss if carried to excess. Hairbrushes with natural bristles are less traumatic than those with nylon bristles particularly the square-ended variety, the sharp angles of which tear the hair in brushing. If dandruff is present, the scalp should be shampooed once or twice weekly using cetrimide solution or soap spirit B.P.C. to which has been added 2 per cent. of oil of cade. For local application 2 per cent. of salicylic acid and 2 per cent. of precipitated sulphur in emulsifying ointment B.P. can be applied by rubbing in gently (making partings with a comb for the purpose if the hair is thick) or salicylic acid and mercuric chloride lotion B.P.C. can be sprinkled on- and worked in gently with the finger tips.
Alopecia areata is often hereditary and is probably due to a biochemical abnormality connected with the activity of the hair follicles causing them to become dormant either temporarily or permanently. Since the nature of the disturbance is not understood there is no means of knowing how long it will last in any individual patient. Bad prognostic signs are onset of the condition before puberty, a family history of total alopecia, and dystrophy of the nails. The immediate prognosis can be determined by pulling the hair at the edge of the patches ; if it comes away easily and painles'sly the process is spreading. In those liable to the disease attacks can be precipitated by emotional stresses for example by bereavements and motor accidents, but some weeks may elapse before alopecia develops. No treatment has any regularly predictable effect, except the use of corticosteroids. Injections into the lesions are useful when the disease is localized. The application of betamethasone valerate or fluocinolone acetonide ointment with polythene occlusion can be helpful in very widespread cases. Oral treatment may have to be continued indefinitely, and the few occasions on which it might be justifiable are discussed elsewhere. It is probable that improvement, occurring during the various kinds of treatment commonly employed—such as ultra-violet light, scalp massage, painting with solutions of iodine or of lactic acid—is merely incidental; the natural history of the disease is usually towards resolution. When indicated by the emotional state of the patient a sedative such as phenobarbitone 30 mg. twice daily should be given. Painting with Thorium X is not recommended.
The hair may fall out—a defluvium of hair—following some toxic illnesses (especially pneumonia and influenza), in thyrotoxicosis, during the use of certain drugs such as heparin and cyclophosphamide and after parturition. This does not require treatment; the hair can be expected to grow again completely. In myxosdema the hair is dry and scanty but this does not justify the administration of thyroxin to everybody who complains of loss of hair.
The preceding forms of alopecia must be distinguished from the rarer ones in which there is scarring of the scalp. Here there is destruction of the hair follicles and there is no hope whatever of any regrowth of hair. Reference to a dermatologist is desirable, however, as it may be possible to arrest the disease. It is also important to remember that alopecia areata can be closely imitated by secondary syphilis, and that alopecia with scaling and pustulation may be due to ringworm.
In any form of loss of hair it is advisable to avoid unnecessary brushing and combing of the hair and to prohibit massage, since these measures in themselves can cause considerable loss if carried to excess. Hairbrushes with natural bristles are less traumatic than those with nylon bristles particularly the square-ended variety, the sharp angles of which tear the hair in brushing. If dandruff is present, the scalp should be shampooed once or twice weekly using cetrimide solution or soap spirit B.P.C. to which has been added 2 per cent. of oil of cade. For local application 2 per cent. of salicylic acid and 2 per cent. of precipitated sulphur in emulsifying ointment B.P. can be applied by rubbing in gently (making partings with a comb for the purpose if the hair is thick) or salicylic acid and mercuric chloride lotion B.P.C. can be sprinkled on- and worked in gently with the finger tips.
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