SKIN DISEASES

TREATMENT for disease of the skin does not differ in principle from the treatment of other forms of disease; but certain aspects which simplify or complicate the issue must be considered. The accessibility of the skin is both an advantage and a disadvantage: it is an advantage to be able to see exactly what is happening, and to be able to apply medicaments directly to the diseased part; it is a disadvantage to have the lesions prominently displayed, open to the patient's interference, and a badge of alarm to himself and to his associates. It is a disadvantage, also, that the attention of both the patient and of his physician can become rooted to the skin, which is after all only the rind of the body, to the exclusion of the contained organism in both its physical and its emotional being. Physicians tend to approach the skin with an un­necessary feeling of inferiority—bred perhaps by a fear of those dimly remem­bered and complicated names that were commonly taken to comprise the esoteric art of dermatology. They should in fact approach it full of interest at having to deal with such a large and accessible organ which, apart from adding clothing and adornment to the human frame, is the limiting membrane between man and his environment. The physician's attention must be directed, therefore, both inwards—to the body and mind—as well as outwards—to that physical and emotional climate in which the patient lives and moves and has his being.
Study of the skin without regard to its internal and external environment may suffice to provide a diagnosis which is morphological. Such a diagnosis seldom indicates precisely the astrological stimulus; and still less often does this approach reveal those changing circumstances which, though trivial in themselves, may be highly significant in the context of the individual patient and his coetaneous lesions. For example, a patient develops attacks of itchy blisters on the fingers and is then said to have cheiropompholyx; but this could be due to his handling an irritant (such as turpentine), to his having a fungus infection elsewhere (perhaps between the toes), or to anxiety—perhaps because of imminent examinations. Minute inspection of the blisters themselves cannot distinguish between these possibilities, and it is only by considering the patient as a whole that the problem can be interpreted in its true perspective. Very often there are many etiological factors which interact, and the disease represents their combined effect. For example, emotional tension will promote sweating; this predisposes to an exacerbation of a latent fungus infection; and this in turn contributes to hypersensitivity, developed against the absorbed products of the infection. Sweating from any cause will also dissolve irritants from the clothing and will ensure closer contact between it and the skin; both actions foster 'contact dermatitis. Hypersensitivity to one irritant is very liable to be followed by hypersensitivity to another; thus it may develop first to the fungus infection, then to footwear and later, perhaps, to some local application. There are many possible combinations of such circumstances and the prospect of curing the patient, as opposed to giving him temporary relief, depends to a large extent upon understanding them.
The general practitioner is well placed to perform this task of comprehensive diagnosis, for he is able to view the patient as a person much more easily than the hospital physician who sees him briefly and away from his environment, like a fish out of water. It is a commonplace that a visit to the patient's home can provide the solution to a puzzling problem; whether it be the primula standing on the hall table, the forgotten packet of sedative powders beside the bed, or the cantankerous and bed-ridden elderly relative. The physician needs a keen eye for all such circumstances as well as a clear understanding of the reaction patterns in the skin. He must also use the diagnostic techniques of the general physician and maintain an interest in psychology—with special regard to the patient's domestic setting. Not least important he must constantly strive to integrate the different kinds of information he collects and then devise a logical and com­prehensive plan of treatment. The dermatologist shares with other practitioners the obligation to observe the patient until he is better, or—when the treatment fails—to review the diagnosis and every aspect of management.
Few special prescriptions are needed, and no special apparatus other than a magnifying glass and an elementary dermatological text. In fact, the treatment of disease of the skin is a task eminently suitable for the general practitioner. The supposed difficulties are largely due to the traditional, but erroneous, belief that "skins" are difficult, that nothing does any good, and that "they" never get better: the result is that the trade samples and the blotter advertisements become the practitioner's signposts as he threads his way through the labyrinth of dermatological practice. The doctor can reinstate himself by treating the patient as a general medical problem : this is a theme that will be elaborated in the ensuing pages.
As in every other branch of medical practice, the first step in treatment is diagnosis. In dermatology, the diagnosis is inevitably morphological, but as often as possible a purely descriptive commentary must be amplified to take into account all possible astiological factors. For example, the morphological diagnosis may be erythema nodosum, but the setiological differential diagnosis will include tuberculosis, streptococcal infection, drug eruption, sarcoidosis, leprosy, coccidioidomycosis, etc., the distinction between these causes being made after weighing all the facts gleaned from the history, examination and special diagnostic tests. The principle remains the same in less exotic diseases such as eczema, where the traditional method of history and examination should still be followed, although greater stress than usual 'should be placed on environmental factors which are often more important in skin diseases than in constitutional disorders. The doctor who is fair to his patient and to himself will insist on making a full and unhurried examination of the skin in bright daylight. It is reprehensible to base an opinion on a hasty glance directed down the cavern formed by the patient's raised, crumpled shirt and the sagging trousers while he crouches in the half light of a curtained cubicle. The patient's previous health, and that of his progenitors and sibs, is as important as it is in any other form of disease. Time and trouble are in fact the prime ingredients of success, and if special knowledge and experience are lacking at first there are dermatological texts and dermato­logists available to remedy any deficiencies and point the way to the development of future skill.
The physician's advice will consist of details relating to general management and also to the use of drugs—prescribed for internal administration or for topical application. The application of drugs to the skin is traditional in dermatology, but general management is becoming increasingly important as we learn more about the ætiology of disease of the skin. All local treatment is subject to the general caution that what suits one person's skin will not necessarily suit another's ; and the general principle that one should avoid doing harm—a principle much easier to enunciate than to observe in practice, owing to the unexpected sensitiveness of some skins. The familiar preparations, calamine lotion and Lassar's paste, for example, succeed by their harmlessness and their protective power which allow the natural healing process to work unhindered. Even preparations widely regarded as harmless will irritate some skins—for example, people who are sensitive to grease will be irritated by any ointment, however mild, and it is therefore prudent when prescribing for a diffuse eruption or one which is spreading to advise that the treatment should be applied first of all in small quantity to a limited area, until the patient's response can be gauged. It is most desirable to do so when ordering a strong application such as dithranol, and to prescribe the substance for initial use in a concentration weak enough (in this case 0.1 per cent.) to avoid doing harm—except perhaps to the hyper­sensitive. Patients who are known to be hypersensitive should have the fact clearly recorded on their medical documents.
If there has been no response after an active treatment has been applied for an adequate period of time, the strength of the application can be increased safely by stages until an effect has been obtained or the limit of tolerance of the patient's skin has been reached. The blonde, the freckled, and those with dry skins should be treated more cautiously than those with dark hair and greasy skins. The risk of producing sensitization by local applications is greater with some preparations than others and, in the case of the following drugs, it is too great to accept: sulphonamides, antihistamines, local anesthetics, acriflavine, chloramphenicol, penicillin and streptomycin. None of these should be pre­scribed for topical application to the skin, either alone or in combination. An increasing number of patients coming to the dermatologist has developed one or more sensitivities to local applications, and the result may completely dominate the original eruption which may indeed have been quite trivial.
A record of the drugs he has used and the date of their prescription is as essential to the practitioner looking after his own patient as it is to the dermato­logist whose advice he seeks; and when a preparation has done harm a note should be made for future guidance. The prescription of local applications for any patient is an individual problem, and fallibility of memory makes an accurate documentary record essential for rational management.
Acute and sub-acute dermatoses, in general, should be treated with bland local medicaments. In contrast, chronic dermatoses often need stronger applications which, if used in the acute or waxing stage of the disease, would be likely to do harm. Eczema, erupting psoriasis and pityriasis rosea are often made worse unintentionally in this manner. When using strong applications such as peeling pastes for acne, tar for eczema, and dithranol for psoriasis, it is necessary to find by trial and error a concentration of the active ingredient that will produce benefit with the minimal irritation of the patient's skin. The commonest cause of failure to influence chronic diseases of the skin is to use preparations that are too weak for the individual's skin. For example, 1 percent. or 2 percent. of sulphur helps in some cases of acne vulgaris but many need between 4 per cent. and 12 per cent. while a few, with very tough skins, need up to 30 per cent. as well as other active ingredients. On the other hand some skins are hypersensitive to sulphur which, if present in even 1 per cent. strength, will provoke a dermatitis so that for them sulphur cannot be used at all and some alternative treatment must be found. This example illustrates both the difficulty of prescribing local applications and the need for careful clinical records, if hard-won experience is to be turned to good account.
A skin that is healthy, clear and unspotted is a possession that is properly appreciated only by those who have lost it. The occurrence of spots on a pre­viously unblemished skin creates an emotional shock though knowledge of the disturbance is usually relegated swiftly to subconscious levels. It is difficult to explain why the maculous state should generate a sense of shame, but perhaps there are elements derived from the fear of physical contagion—smallpox, syphilis, leprosy and even of moral impurity. In the Oxford English Dictionary the meaning of spot is extended to apply to "a moral stain, blot, or blemish; a stigma or disgrace"; such words are powerful and evocative. Those extreme manifestations of public fear—the practice of segregating lepers, and searching the skin for witches' marks—have gone. Nevertheless, in relation to diseases of the skin there is abundant evidence of a lingering public anxiety; it may result in the ostracizing of patients with such simple disorders as psoriasis. This widespread fear which is rooted in primitive emotions merits careful study by any physician who is striving for perspective in his analysis of the behavior of patients and the communities in which they live. At its worst it can completely dominate the patient who will then need psychiatric help. As a rule it is un­expressed except by conversion into other symptoms, including the aggravation of itch. It is one of the factors which interfere with the natural healing process. Simply to recognize it is to rob this complication of much of its importance, but it will never be possible to ignore it until public opinion can accept skin diseases as being of the same general kind as high blood pressure, appendicitis, asthma, or the common cold. The physician can help his patient best by assuring him whenever it is justifiable that his particular skin disease is not infectious; the look of relief that often follows this information is proof of the fear that is present and which often aggravates a disability of this kind.
The general advice given above may now be summarized. No matter which system of the body is involved, due regard must be paid to the patient as an individual. If illness is declared by symptoms and signs affecting the skin, it will be amenable to the same principles of investigation and treatment as those that apply to abnormal conditions in other parts of the body. There is a limited number of ways in which the skin can react; and to discover the stimuli that have provoked the reaction will eventually prove more helpful than merely prescribing medicaments to calm it down. In the following pages the treatment of some common diseases of the skin is described as well as a few specialized. problems of management. Particular attention, however, is paid to etiological factors so that the general physician may turn to his own experience to supple­ment the specific dermatological treatment.