Chapter 18

#How would you distinguish favus from eczema and ringworm?#

From eczema by the condition of the affected hair, the atrophic and scar-like areas, the odor, and the history. From ringworm by the crusting and the atrophy. In this latter disease there is usually but slight scaliness, and rarely any scarring.

Finally, if necessary, a microscopic examination of the crusts may be made.

#State the method of examination for fungus.#

A portion of the crust is moistened with liquor potassæ and examined with a power of three to five hundred diameters. The fungus, (achorion Schönleinii), consisting of mycelium and spores, is luxuriant and is readily detected.

#State the prognosis of favus.#

Upon the scalp, favus is extremely chronic and rebellious to treatment, and a cure in six to twelve months may be considered satisfactory; in neglected cases permanent baldness, atrophy, and scarring sooner or later result. Although favus of the scalp persists into adult life, it becomes less active and, finally, as a rule, gradually disappears, leaving behind scarred or atrophic bald areas.

Upon the general surface it usually responds readily to treatment, excepting favus of the nails, which is always obstinate.

#How is favus of the scalp treated?#

Treatment is entirely local and consists in keeping the parts free from crusts, in epilation and applications of a parasiticide.

The crusts are removed by oily applications and soap-and-water washings. The hair on and around the diseased parts is to be kept closely cut, and, when practicable, depilation, or extraction of the affected hairs, is advised; this latter is, in most cases, essential to a cure. Remedial applications--the so-called parasiticides--are, as a rule, to be made twice daily. If an ointment is used, it is to be thoroughly rubbed in; if a lotion, it is to be dabbed on for several minutes and allowed to soak in.

#Name the most important parasiticides.#

Corrosive sublimate, one to four grains to an ounce of alcohol and water; carbolic acid, one part to three or more parts of glycerine; a ten per cent. oleate of mercury; ointments of ammoniated mercury, sulphur and tar; and sulphurous acid, pure or diluted. The following is valuable:--

[Rx] Sulphur, præcip., .................... [dram]ij Saponis viridis, Ol. cadini, ....... [=a][=a] ......... [dram]j Adipis, .............................. [Oz]ss. M.

Chrysarobin is a valuable remedy, but must be used with caution; it may be employed as an ointment, five to ten per cent. strength, as a rubber plaster, or as a paint, a drachm to an ounce of gutta-percha solution. Formalin, weakened or full strength, has been extolled. Some observers have experimentally tried the effect of _x_-ray exposure with alleged good results, pushing the treatment to the point of producing depilation; if used great caution should be exercised.

#How is favus upon the general surface to be treated?#

In the same general manner as favus of the scalp, but the remedies employed should be somewhat weaker. In favus of the nail frequent and close paring of the affected part and the application, twice daily, of one of the milder parasiticides, will eventually lead to a good result.

#Is constitutional treatment of any value in favus?#

It is questionable, but in debilitated subjects tonics, especially cod-liver oil, may be prescribed with the hope of aiding the external applications.

#Tinea Trichophytina.# (_Synonym:_ Ringworm.)

#What is tinea trichophytina?#

Tinea trichophytina, or ringworm, is a contagious, vegetable-parasitic disease due to the invasion of the cutaneous structures by the vegetable parasite, the trichophyton, or the microsporon Audouinii.

#Do the clinical characters of ringworm vary according to the part affected?#

Yes, often considerably; thus upon the scalp, upon the general surface, and upon the bearded region, the disease usually presents totally different appearances.

#Describe the symptoms of ringworm as it occurs upon non-hairy portions of the body.#

Ringworm of the general surface (_tinea trichophytina corporis_, _tinea circinata_) appears as one or more small, slightly-elevated, sharply-limited, somewhat scaly, hyperæmic spots, with, rarely, minute papules, vesico-papules, or vesicles, especially at the circumference. The patch spreads in a uniform manner peripherally, is slightly scaly, and tends to clear in the centre, assuming a ring-like appearance. When coming under observation, the patches are usually from one-half to one inch in diameter, the central portion pale or pale red, and the outer portion more or less elevated, hyperæmic and somewhat scaly. As commonly noted one, several or more patches are present. After reaching a certain size they may remain stationary, or in exceptional cases may tend to spontaneous disappearance. At times when close together, several may merge and form a large, irregular, gyrate patch.

Itching, usually slight, may or may not be present.

Exceptionally ringworm appears as a markedly inflammatory pustular circumscribed patch, formerly thought to be a distinct affection and described under the name of _conglomerate pustular folliculitis_. It consists of a flat carbuncular or kerion-like inflammation, somewhat elevated, and usually a dime to silver dollar in area. The most common seats are the back of the hands and the buttocks. The surface is cribriform, and a purulent secretion may be pressed out from follicular openings.

#Describe the symptoms of ringworm when occurring about the thighs and scrotum.#

In adults, more especially males, the inner portion of the upper part of the thighs and scrotum (_tinea trichophytina cruris_, so-called _eczema marginatum_) may be attacked, and here the affection, favored by heat and moisture, develops rapidly and may soon lose its ordinary clinical appearances, the inflammatory symptoms becoming especially prominent. The whole of this region may become involved, presenting all the symptoms of a true eczema; the border, however, is sharply defined, and usually one or more outlying patches of the ordinary clinical type of the disease may be seen.

#Describe the symptoms of ringworm when involving the nails.#

In ringworm of the nails (_tinea trichophytina unguium_) these structures become soft or brittle, yellowish, opaque and thickened the changes taking place mainly about the free borders. Ringworm on other parts usually coexists.

#Describe the symptoms of ringworm as it occurs upon the scalp.#

Ringworm of the scalp (_tinea trichophytina capitis_, _tinea tonsurans_) begins usually in the same manner as that upon the general surface, but, as a rule, much more insidiously. Sooner or later, however, the hair and follicles are invaded by the fungus, and in consequence the hair falls out or becomes brittle and breaks off. The follicles, except in long-standing cases, are slightly elevated and prominent, and the patch may have a puffed or goose-flesh appearance. In addition, there is slight scaliness.

#Describe the appearances of a typical patch of ringworm of the scalp.#

The patch is rounded, grayish, somewhat scaly, and slightly elevated; the follicles are somewhat prominent; there is more or less alopecia, with here and there broken, gnawed-off-looking hairs, some of which may be broken off just at the outlet of the follicles and more or less surrounded by a whitish or grayish-white dust. This type is produced by the small-spore fungus--microsporon.

#Does ringworm of the scalp always present typical appearances?#

Not invariably. In some cases the patch or patches may become almost completely bald, and in others a tendency to the formation of pustules, with more or less crust-formation, may be seen. The affection may also appear as small scattered spots or points.

The markedly inflammatory and pustular types are produced by the large-spore fungus--trichophyton.

#What is tinea kerion?#

Tinea kerion (_kerion_) is a markedly inflammatory type of ringworm of the scalp involving the deeper tissues, appearing as a more or less bald, rounded, inflammatory, [oe]dematous, boggy, honeycombed tumor, discharging from the follicular openings a mucoid secretion.

#Does ringworm of the scalp ever occur in adults?#

No. (Extremely rare exceptions.)

#Describe the symptoms of ringworm of the bearded region.#

Ringworm of the bearded region (_tinea trichophytina barbæ_, _tinea sycosis_, _parasitic sycosis_, _barber's itch_) begins usually in the same manner as ringworm on other parts, as one or more rounded, slightly scaly, hyperæmic patches. In rare instances the disease may persist as such, with very little tendency to involve the hairs and follicles; but, as a rule, the hairy structures are soon invaded, many of the hairs breaking off, and many falling out. From involvement of the follicles, more or less subcutaneous swelling ensues, the parts assuming a distinctly _lumpy and nodular_ condition. The skin is usually considerably reddened, often having a glossy appearance, and studded with few or numerous pustules. The nodules tend, ordinarily, to break down and discharge, at one or more of the follicular openings, a glairy, glutinous, purulent material, which may dry to thick, adherent crusts.

The disease may be limited to one patch, or a large area, even to the extent of the whole bearded region, becomes involved. The upper lip is rarely invaded. Ringworm of the bearded region is due to the trichophyton.

#To what is ringworm due?#

To the presence and growth in the cutaneous structures of a vegetable parasite. Although the disease is contagious, individuals differ considerably as to susceptibility. It is much more common in children than in those past the age of puberty, ringworm of the scalp being limited to the former (rare exceptions), and tinea sycosis being a disease of the male adult.

Until recently the ringworm was thought to be due to but one fungus--the trichophyton; it is now known that there are several forms of fungi, the main forms being the small-spored (microsporon Audouini) and the large-spored (trichophyton). Of this latter there are two main subvarieties--endothrix and ectothrix. The small-spored fungus is found as the cause in the majority of scalp cases; the endothrix also commonly invades the scalp integument. The ectothrix variety is usually derived directly or indirectly from domestic animals, and is chiefly responsible for body-ringworm, and for suppurative ringworm, whether upon the bearded region or elsewhere.

#What is the pathology of ringworm?#

On the general surface the fungus has its seat in the epidermis, especially in the corneous layer; upon the scalp and bearded region the epidermis, hair-shaft, root and follicle are invaded. The inflammatory action may vary considerably in different cases, and at different times in the same case.

The fungus consists of mycelium and spores. In the epidermic scrapings it is never to be found in abundance, and the mycelium predominates, while in affected hairs the spores and chains of spores are almost exclusively seen, and are usually present in great profusion.

#How do you examine for the fungus?#

The scrapings or hair should be moistened with liquor potassæ, and examined with a power from three hundred diameters upward.

#How is ringworm of the general surface to be distinguished from eczema, psoriasis and seborrh[oe]a?#

By the growth and characters of the patch, the slight scaliness, the tendency to disappear in the centre, by the history, and, if necessary, by a microscopic examination of the scales.

#How is ringworm of the scalp to be distinguished from alopecia areata, favus, eczema, seborrh[oe]a, and psoriasis?#

By the peculiar clinical features of ringworm on this region--the slight scaliness, broken hair and hair stumps, with a certain amount of baldness--and in doubtful cases by a microscopical examination of the hairs.

In favus, although the same condition of the hair is noted, the yellow, cup-shaped crusts, and the presence of the atrophic areas in that disease are pathognomonic.

#How is ringworm of the bearded region to be distinguished from eczema and sycosis?#

By the peculiar lumpiness of the parts, the brittleness of the hair, more or less hair loss, and the history.

The superficial type of ringworm sycosis--those cases in which the disease remains a surface disease--is readily distinguished, as the symptoms are essentially the same as ringworm of non-hairy parts, except that some of the hairs in the areas may become invaded and break off or fall out.

In doubtful cases recourse may be had to microscopical examination.

#What is the prognosis of ringworm of these several parts?#

When upon the general surface, the disease usually responds rapidly to therapeutical applications; upon the scalp it is always a stubborn affection, and, as a rule, requires several months to a year of energetic treatment to effect a cure. In this latter region the disease will disappear spontaneously as the age of fifteen or sixteen is reached. Tinea sycosis yields in most instances in the course of several weeks or a few months.

#Is ringworm of these several parts treated with the same remedies?#

As a rule, yes; but the strength must be modified. The scalp will stand strong applications, as will likewise the bearded region; upon non-hairy portions the remedies should be used somewhat weaker. They should be applied twice daily; ointments, if used, being well rubbed in, and lotions thoroughly dabbed on.

#How would you treat ringworm of the general surface?#

By applications of the milder parasiticides, such as a ten to fifteen per cent. solution of sodium hyposulphite; carbolic acid, five to thirty grains to the ounce of water, or lard; a saturated solution of boric acid; ointments of tar, sulphur and mercury, official strength or weakened with lard; and tincture of iodine, pure or diluted.

When occurring upon the upper and inner part of the thighs (so-called eczema marginatum), the same remedies are to be employed, but usually stronger. Deserving of special mention is a lotion of corrosive sublimate, one to four grains to the ounce; or the same remedy, in the same proportion, may be used in tincture of myrrh or benzoin, and painted on the parts.

#How would you treat ringworm of the scalp?#

By occasional soap-and-hot-water washing; by extraction of the involved hairs, when practicable; by carbolic acid or boric acid lotions to the whole scalp, so as to limit, as much as possible, the spread of the disease; and by daily (or twice daily) applications to the patches and involved areas of a parasiticide. The following are the most valuable: the oleate of mercury, with lard or lanolin, in varying strength, from ten to twenty per cent.; carbolic acid, with one to three or more parts of glycerine or oil; corrosive sublimate, in solution in alcohol and water, one to four grains to the ounce; sulphur ointment; and citrine ointment, with one or two parts of lard. Chrysarobin is a valuable remedy, but is to be employed with care; it may be prescribed as a rubber plaster, or in a solution of gutta-percha, or as an ointment, ten to fifteen per cent. strength. [beta]-naphthol in ointment form, five to fifteen per cent. strength, is also useful. An excellent application for beginning areas on the scalp is a solution of the red iodide of mercury in iodine tincture, one to three grains to an ounce.

A compound ointment, containing several of the active remedies named, is convenient for dispensary practice, such as:--

[Rx] [beta]-naphthol, ................. [dram]ss-[dram]j Ol. cadini, ......................... [dram]j Ungt. sulphuris, ............ q.s. ad [Oz]j. M.

In that form known as tinea kerion mild applications are demanded at first; later the same treatment as in the ordinary type.

#How is ringworm of the bearded region to be treated?#

On the same general plan and with the same remedies (excepting chrysarobin) as in ringworm of the scalp. Depilation is to be practised as an essential part of the treatment. Special mention may be made of an ointment of oleate of mercury, sulphur ointment, a lotion of sodium hyposulphite ([dram]j-[Oz]j), and a lotion of corrosive sublimate (gr. j-iv to [Oz]j). The _x_-ray has been used in ringworm of this region with alleged success, pushing it to the production of a mild erythema and depilation. The above methods are, however, usually successful, and are without risk of damage.

#How is the certainty of an apparent cure in ringworm of the scalp or bearded region to be determined?#

By the continued absence of roughness and of broken hairs and stumps, and by microscopical examination of the new-growing hairs from time to time for several weeks after discontinuance of treatment.

Cure of ringworm of the general surface is usually self-evident.

#Is systemic treatment of aid in the cure of ringworm?#

It is doubtful, although in children in a depraved state of health the disease is often noted to be especially stubborn, and in such cod-liver oil and similar remedies may at times prove of benefit.

#Tinea Imbricata.# (_Synonym:_ Tokelau Ringworm.)

#What is tinea imbricata?#

A vegetable parasitic disease of moist tropical countries, characterized by the formation of patches composed of concentrically arranged, imbricated, scaly rings. It may begin at one or several points as a brownish, slightly raised spot, spreading peripherally; the renewed epidermis of the central part of the patch goes again through the same process; the result is a small or large area of concentrically arranged, imbricated, slightly scaly eruption. Several such areas fusing together may cover a large part of the surface, the ring-like arrangement being sometimes more or less completely lost. The malady is chronic. There may be a variable degree of itching. The cause of the disease, which is of a contagious nature, is a vegetable parasite closely similar to the trichophyton. The treatment is by the parasiticides, being essentially the same, in fact, as ringworm.

#Tinea Versicolor.# (_Synonyms:_ Pityriasis Versicolor; Chromophytosis.)

#What is tinea versicolor?#

Tinea versicolor is a vegetable-parasitic disease of the skin, characterized by variously-sized and shaped, slightly scaly, macular patches of a yellowish-fawn color, and occurring for the most part upon the upper portion of the trunk.

#Describe the symptoms of tinea versicolor.#

The disease begins as one or more yellowish macular points; these, in the course of weeks or months, gradually extend, and, together with other patches that arise, may form a more or less continuous sheet of eruption. There is slight scaliness, always insignificant and furfuraceous in character, and at times, except upon close inspection, scarcely perceptible. The color of the patches is pale or brownish-yellow; in rare instances, in those of delicate skin, there may be more or less hyperæmia, and in consequence the eruption is of a reddish tinge. The number of patches varies; there may be but a few, or, on the other hand, a profusion. Slight itching, especially when the parts are warm, is usually present.

#Does the eruption of tinea versicolor show predilection for any special region?#

Yes; the upper part of the trunk, especially anteriorly, is the usual seat of the eruption, but in exceptional instances the neck, axillæ, the arms, the whole trunk, the genitocrural region and poplitea, and in rare cases even the lower part of the face, may become invaded.

#What course does tinea versicolor pursue?#

Persistent, but somewhat variable; as a rule, however, slowly progressive and lasting for years.

#To what is tinea versicolor due?#

To a vegetable fungus--the _microsporon furfur_.

The affection is tolerably common, and occurs in all parts of the world. With rare exceptions, it is a disease of adults, and while looked upon as contagious, must be so to an extremely slight degree.

#What is the pathology?#

The fungus, consisting of mycelium and spores, the latter showing a marked tendency to aggregate, invades the superficial portion of the epidermis.

#Is tinea versicolor readily diagnosticated?#

Yes; if the color, peculiar characters and distribution of the eruption are kept in mind.

It is not to be confounded with vitiligo, chloasma, or the macular syphiloderm. If in doubt, have recourse to the microscope.

#State the method of examination for fungus.#

The scrapings are taken from a patch, moistened with liquor potassæ, and examined with a power of three to five hundred diameters.

#State the prognosis of tinea versicolor.#

With proper management the disease is readily curable. Relapses are not uncommon.

#What is the treatment of tinea versicolor?#

It consists in daily washing with soap and hot water (and in obstinate cases with sapo viridis instead of the ordinary soap) and application of a lotion of--sulphite or hyposulphite of sodium, a drachm to the ounce; sulphurous acid, pure or diluted; carbolic acid, or resorcin, ten to twenty grains to the ounce of water and alcohol; or corrosive sublimate, one to three grains to the ounce of water. Sulphur and ammoniated-mercury ointments are also serviceable. The following used alone, simply as a soap, or in conjunction with a lotion, is often of special value:--

[Rx] Sulphur, præcip., .................... [dram]iv Saponis viridis, ..................... [dram]xii. M.

After the disease is apparently cured, an occasional remedial application should be made for several months, in order to guard against the possibility of a relapse.

#Erythrasma.#

#Describe erythrasma.#

Erythrasma is an extremely rare disease, due to the presence and growth in the epidermic structures of the vegetable parasite--the _microsporon minutissimum_. It is characterized by small and large, slightly furfuraceous, reddish-yellow or reddish-brown patches, occurring usually on warm and moist parts, such as the axillary, inguinal, anal and genitocrural regions. It is slowly progressive and persistent, but is without disturbing symptoms other than occasional slight itching.

Treatment, which is rapidly effective, is the same as that employed in tinea versicolor.

#Dhobie Itch.#

Dhobie itch is a name used in certain tropical countries to designate a somewhat peculiar itching eruption of the genitocrural and axillary regions, and by some also a similar eruption about the feet. It consists of a dermatitis of variable degree, usually with a festooned, irregular border, with considerable itching. It is believed that such cases are variously due to the trichophyton of ringworm, to the microsporon furfur of tinea versicolor, to the microsporon minutissimus of erythrasma, and to other parasites.

#Actinomycosis.#

#Describe actinomycosis.#