Chapter 6

It is a rare vesicular disease usually seen in boys (only two or three exceptions), occurring upon uncovered parts, especially the nose, cheeks, and ears. The lesions begin as red spots, discrete or in groups, rapidly exhibit vesiculation, and later umbilication; the contents become milky, dry to crusts, which fall off and leave small pit-like scars. Fresh outbreaks may take place almost continuously, and the process go on indefinitely, at least up to youth or manhood, when the tendency subsides. Its activity is usually limited to the warm season. Arthritic symptoms and general disturbance are sometimes noted in severe cases.

It is doubtless a vasomotor neurosis. Exposure to sun and wind is an important, if not essential, etiological factor. Primarily the lesion begins in the rete middle layers, and is purely vesicular in character; later, necrosis of the rete and extending deep in the corium is observed.

Treatment so far has only been palliative, consisting of the applications employed in similar conditions. Constitutional medication is based upon general principles. The patient should avoid exposure to the sun, strong wind and excessive artificial heat.

#Epidermolysis Bullosa.#

#Describe epidermolysis bullosa.#

This is a rare, usually hereditary, disease or condition, characterized by the formation of vesicles and blebs on any part subjected to slight rubbing or irritation. No scarring is left, and no pigmentation noted. The predisposition to these lesions persists indefinitely. The general health is not involved. The nature of the disease is obscure.

Treatment has no influence in modifying or lessening this tendency. The vulnerable parts should so far as possible be protected from knocks and undue friction.

#Dermatitis Repens.#

#What do you understand by dermatitis repens?#

It is a rare spreading dermatitis starting from an injury, extending by a serous undermining of the epidermis, and usually occurring upon the upper extremities.

It usually begins shortly after an injury, and, as a rule, presents itself by redness and serous exudation. The overlying epidermis breaks, and the area of disease gradually progresses by an extension of the serous undermining process, the denuded part looking red and raw, with usually an oozing surface. As the disease spreads the oldest part becomes dry and heals, the new epidermal covering being thin and atrophic in appearance. Its most usual beginning is on some part of the hand, and from here it may spread up the arm and involve considerable area.

The injury from which it starts may be extremely insignificant, apparently affording an opening for the introduction of the causative factor, doubtless parasitic. Beyond a feeling of soreness there seem to be no special subjective symptoms.

#Give the prognosis and treatment.#

The malady shows but little tendency to spontaneous cure. The frequent or constant application of a mild antiseptic lotion, such as boric acid and resorcin, or of a mild parasiticide ointment will generally bring the disease gradually to an end.

#Herpes Zoster.# (_Synonyms:_ Zoster; Zona; Shingles.)

#Give a definition of herpes zoster.#

Herpes zoster is an acute, self-limited, inflammatory disease, characterized by groups of vesicles upon inflammatory bases, situated over or along a nerve tract.

#Upon what parts of the body may the eruption appear?#

It may appear upon any part, following the course of a nerve; it is therefore always limited in extent, and confined to one side of the body. It is probably most common about the intercostal, lumbar and supra-orbital regions. In rare instances the eruption has been observed to be bilateral.

#Are there any subjective or constitutional symptoms?#

Yes; there is, as a rule, neuralgic pain preceding, during and following the eruption; and in some cases, also, there may be in the beginning mild febrile disturbance. There is also a variable degree of tenderness and pain.

#What are the characters of the eruption?#

Several or more hyperæmic or inflammatory patches over a nerve course appear, upon which are seated vesico-papules irregularly grouped; these vesico-papules become distinct vesicles, of size from a pin-head to a pea, and soon dry and give rise to thin, yellowish or brownish crusts, which drop off, leaving in most instances no permanent trace, in others more or less scarring. In some cases the lesions may become pustular and, on the other hand, the eruption may be abortive, stopping short of full vesiculation.

#What is known in regard to the nature of the disease?#

An inflamed and irritable state of the spinal ganglia, nerve tract, or peripheral branches is directly responsible for the eruption, and this state may be due to atmospheric changes, cold, nerve-injuries and similar influences. The view has also been advanced that the disease is of specific and infectious character.

#Give the chief diagnostic features of herpes zoster.#

The prodromic neuralgic pain, the appearance of grouped vesicles upon inflammatory bases following the course of a nerve tract, and the limitation of the eruption to one side of the body.

#What is the prognosis?#

Favorable; the symptoms usually disappearing in two to four weeks. In some instances, however, the neuralgic pains may be persistent, and in zoster of the supra-orbital region the eye may suffer permanent damage.

#How would you treat herpes zoster?#

_Constitutional treatment_, usually tonic in character, is to be based upon general principles; moderate doses of quinia, with one-sixth grain of zinc phosphide, four or five times daily, appear in some cases to have a special value. The accompanying neuralgic pain may be so intense as to require anodynes. _Local treatment_ should be of a soothing and protective character. A dusting-powder of oxide of zinc and starch (to the ounce of which twenty to thirty grains of camphor may be added) proves useful; and over this, in order that the parts be further protected, a bandage or a layer of cotton batting. Oxide-of-zinc ointment, and in those cases in which there is much pain, ointments containing powdered opium or belladonna, or orthoform, may be used. A mild galvanic current applied daily to the parts is often of great advantage, both in its influence upon the course of the eruption and upon the neuralgic pain. The plan, so often advised, of painting the parts with flexible collodion is not to be commended.

#Dermatitis Herpetiformis.# (_Synonyms:_ Hydroa Herpetiforme (Tilbury Fox); Herpes Gestationis (Bulkley); Pemphigus Prurigiuosus; Duhring's Disease.)

#Give a definition of dermatitis herpetiformis.#

Dermatitis herpetiformis is a somewhat rare inflammatory disease, characterized by an eruption of an erythematous, papular, vesicular, pustular, bullous or mixed type, with a decided disposition toward grouping, accompanied by itching and burning sensations, with, as a rule, more or less consequent pigmentation, and pursuing usually a chronic course with remissions.

#Describe the erythematous type of dermatitis herpetiformis.#

The character of the eruption in the erythematous type resembles closely that of erythema multiforme and of urticaria, especially the former. The efflorescences usually make their appearance in crops, and are more or less persistent; fading sooner or later, however, and giving place to new outbreaks. Vesicles are often intermingled, developing from erythematous and erythemato-papular lesions or arising from apparently normal skin.

It may continue in the same type, or change to the vesicular, bullous or other variety.

#Describe the papular type of dermatitis herpetiformis.#

This is rarely seen as consisting purely of papular lesions, but is commonly associated with the erythematous and vesicular varieties. In a measure it resembles the papular manifestations of erythema multiforme, with a distinct disposition toward group formation. The papules tend, sooner or later, to develop into vesicles, new papular outbreaks occurring from time to time; or the whole eruption changes to the vesicular or other type of the disease. It is not a common type.

#Describe the vesicular type of dermatitis herpetiformis.#

This is the common clinical type of the disease, and is characterized by pin-head to pea-sized, rounded or irregularly-shaped, distended or flattened and stellate vesicles, occurring, for the most part, in irregular and segmental groups of three or more lesions, seated either upon apparently normal integument or upon hyperæmic or inflammatory skin. They exhibit no tendency to spontaneous rupture, but after remaining a shorter or longer time, are broken or disappear by absorption. The lesions tend to appear in crops. It may, as it not infrequently does, continue in the same type, or it may become more or less erythematous or bullous in character. In not a few instances pustules, few or in numbers, are at times intermingled.

#Describe the pustular type of dermatitis herpetiformis.#

This is rare. It is similar in its clinical characters to the vesicular type, except that the lesions are pustular. It is met with, as a rule, in association with the vesicular and bullous varieties of the disease.

#Describe the bullous type of dermatitis herpetiformis.#

The bullous expression of the disease is usually of a markedly inflammatory nature, often innumerable blebs, small and large, appearing almost continuously, and in some instances involving the greater part of the surface. The lesions arise from erythematous skin, from preëxisting vesicles or vesicular groups, or from apparently normal integument. There is a marked disposition to appear in clusters. A change of type to the erythematous or vesicular varieties is not unusual.

#Describe the mixed type of dermatitis herpetiformis.#

In this type the eruption is made up of erythematous patches, vesicles, bullæ, and often with pustules intermingled, appearing irregularly or in crops, and with a tendency to patch or group formation.

#Describe the characters of the vesicles, pustules and blebs.#

As a rule, these several lesions, especially the vesicles and blebs, are somewhat peculiar: they are usually of a strikingly irregular outline, oblong, stellate, quadrate, and when drying are apt to have a puckered appearance. They are herpetic in that they show little disposition to spontaneous rupture, occur in groups, and are usually seated upon erythematous or inflammatory skin--in some respects similar to the groups of simple herpes and herpes zoster.

#What is to be said in regard to the subjective symptoms?#

The subjective symptoms are usually the most troublesome feature of the disease, consisting of intense and persistent itching and a feeling of heat and burning.

#Are there any constitutional symptoms in dermatitis herpetiformis?#

As a rule, not, excepting the distress and depression necessarily consequent upon the intense itchiness and loss of sleep. In the pustular and bullous varieties there may be mild or grave systemic symptoms, but even in these types the constitutional involvement is, in most instances, slight in comparison to the intensity of the cutaneous disturbance.

#What is the course of dermatitis herpetiformis?#

Extremely chronic, in most instances lasting, with remissions, indefinitely. The skin is rarely entirely free. From time to time the type of the disease may undergo change. From the continued irritation and scratching more or less pigmentation results.

#What is to be said in regard to the etiology?#

The disease is in many instances essentially neurotic, and in exceptional instances septicæmic. Pregnancy and the parturient state are factors in some instances (so-called herpes gestationis). It is possible in some instances that the eruption may be an expression of a mild toxemia of gastro-intestinal origin. In some cases no cause can be assigned. In the majority of patients the general health, considering the violence of the eruptive phenomena, remains comparatively undisturbed.

Nervous shock and mental worry are factors in some cases. Polyuria, with sugar in the urine, has occasionally been noted. Eosinophile cells have been found both in the vesicles and the blood. In some instances--exceptionally, it is true--the disease has appeared shortly after vaccination.

#Mention the diagnostic features of dermatitis herpetiformis.#

The multiformity of the eruption, the characters of the lesions, the disposition to grouping, the absence of tendency to form solid sheets of eruption (as in eczema), the intense itching, history, chronicity and course. In doubtful cases, an observation of several weeks will always suffice to distinguish it from eczema, erythema multiforme, herpes iris and pemphigus, diseases to which it at times bears strong resemblance.

#Give the prognosis of dermatitis herpetiformis.#

An opinion as to the outcome of the disease should be guarded. It is exceedingly rebellious to treatment, and relapses are the rule. Exceptionally the bullous and pustular varieties prove eventually fatal. The erythematous and vesicular varieties are the most favorable.

#State the treatment to be advised.#

There are no special remedies. Constitutional treatment must be conducted upon general principles. A free action of the bowels is to be maintained. In occasional instances arsenic in progressive doses seems of value. Externally protective and antipruritic applications, such as are employed in the treatment of eczema and pemphigus, are to be employed:--

[Rx] Ac. carbolici, ....................... [dram]j-[dram]ij Thymol, .............................. gr. xvj. Glycerinæ, ........................... [Oz]ss-[Oz]j Alcoholis, ........................... f[Oz]ij Aquæ, q.s., ......... ad ............. Oj. M.

Other valuable applications are: lotions of carbolic acid, of liquor carbonis detergens, of boric acid; alkaline baths, mild sulphur ointment and carbolized oxide-of-zinc ointment, and dusting-powders of starch, zinc oxide, talc and boric acid. A two- to ten-per-cent. ichthyol lotion or ointment is sometimes of advantage; thiol employed in the same manner has also been commended.

#Psoriasis.#

#Give a definition of psoriasis.#

Psoriasis is a chronic, inflammatory disease, characterized by dry, reddish, variously-sized, rounded, sharply-defined, more or less infiltrated, scaly patches.

#At what age does psoriasis usually first make its appearance?#

Most commonly between the ages of fifteen and thirty. It is rarely seen before the tenth year, and a first attack is uncommon after the age of forty.

#Has psoriasis any special parts of predilection?#

The extensor surfaces of the limbs, especially the elbows and knees, are favorite localities, and even when the eruption is more or less general, these regions are usually most conspicuously involved. The face often escapes, and the palms and soles, likewise the nails, are rarely involved. In exceptional instances, the eruption is limited almost exclusively to the scalp.

#Are there any constitutional or subjective symptoms in psoriasis?#

There is no systemic disturbance; but a variable amount of itching may be present, although, as a rule, it is not a troublesome symptom.

#Describe the clinical appearances of a typical, well developed case.#

Twenty or a hundred or more lesions, varying in size from a pin-head to a silver dollar, are usually present. They are sharply defined against the sound skin, are reddish, slightly elevated and infiltrated, and more or less abundantly covered with whitish, grayish or mother-of-pearl colored scales. The patches are usually scattered over the general surface, but are frequently more numerous on the extensor surfaces of the arms and legs, especially about the elbows and knees. Several closely-lying lesions may coalesce and a large, irregular patch be formed; some of the patches, also, may be more or less circinate, the central portion having, in a measure or completely, disappeared.

#Give the development and history of a single lesion.#

Every single patch of psoriasis begins as a pin-point or pin-head-sized, hyperæmic, scaly, slightly-elevated lesion; it increases gradually, and in the course of several days or weeks usually reaches the size of a dime or larger, and then may remain stationary; or involution begins to take place, usually by a disappearance, partially or completely, of the central portion, and finally of the whole patch.

#Describe the so-called clinical varieties of psoriasis.#

As clinically met with, the patches present are, as a rule, in all stages of development. In some instances, however, the lesions, or the most of them, progress no further than pin-head in size, and then remain stationary, constituting _psoriasis punctata_; in other cases, they may stop short after having reached the size of drops--_psoriasis guttata_; in others (and this is the usual clinical type) the patches develop to the size of coins--_psoriasis nummularis_. In some cases there is a strong tendency for the central part of the lesions to disappear, and the process then remain stationary, the patches being ring-shaped--_psoriasis circinata_; and occasionally several such rings coalesce, the coalescing portions disappearing and the eruption be more or less serpentine--_psoriasis gyrata_. Or, in other instances, several large contiguous lesions may coalesce and a diffused, infiltrated patch covering considerable surface results--_psoriasis diffusa, psoriasis inveterata_.

#Is the eruption of psoriasis always dry?#

Yes.

#What course does psoriasis pursue?#

As a rule, eminently chronic. Patches may remain almost indefinitely, or may gradually disappear and new lesions appear elsewhere, and so the disease may continue for months and, sometimes, for years; or, after continuing for a longer or shorter period, may subside and the skin remain free for several months or one or two years, and, in rare instances, may never return.

#Is the course of psoriasis influenced by the seasons?#

As a rule, yes; there is a natural tendency for the disease to become less active or to disappear altogether during the warm months.

#What is known in regard to the etiology of psoriasis?#

The causes of the disease are always more or less obscure. There is often a hereditary tendency, and the gouty and rheumatic diathesis must occasionally be considered potential. In some instances it is apparently influenced by the state of the general health. It is a rather common disease and is met with in all walks of life.

#Is psoriasis contagious?#

No. In recent years the fact of its exhibiting a family tendency has been thought as much suggestive of contagiousness as of heredity.

#What is the pathology?#

According to modern investigations, it is an inflammation induced by hyperplasia of the rete mucosum; and it is beginning to be believed that this hyperplasia may have a parasitic factor as the starting-cause.

#With what diseases are you likely to confound psoriasis?#

Chiefly with squamous eczema and the papulo-squamous syphiloderm; and on the scalp, also with seborrh[oe]a. It can scarcely be confounded with ringworm.

#How is psoriasis to be distinguished from squamous eczema?#

By the sharply-defined, circumscribed, scattered, scaly patches, and by the history and course of the individual lesions.

#In what respects does the papulo-squamous syphiloderm differ from psoriasis?#

The scales of the squamous syphilide are usually dirty gray in color and more or less scanty; the patches are coppery in hue, and usually several or more characteristic scaleless, infiltrated papules are to be found. The face, palms, and soles are often the seat of the syphilitic eruption; and, moreover, _concomitant symptoms of syphilis_, such as sore throat, mucous patches, glandular enlargement, rheumatic pains, falling out of the hair, together with the history of the initial lesion, are one, several, or all usually present.

#How does seborrh[oe]a differ from psoriasis?#

Seborrh[oe]a of the scalp is usually diffused, with but little redness and no infiltration; moreover, the scales of seborrh[oe]a are greasy, dirty gray or brownish, while those of psoriasis are dry and comonly whitish or mother-of-pearl colored. Psoriasis of the scalp rarely exists independently of other patches elsewhere on the general surface.

That variety of seborrh[oe]a, commonly known as eczema seborrhoicum, presents at times, both on scalp and general surface, a strong resemblance to psoriasis, but the character of the scales and distribution of psoriasis, as above stated, are distinguishing points; seborrh[oe]a, moreover, favors hairy surfaces and in extensive examples the scalp, eyebrows, sternal, and pubic regions rarely escape.

#How does psoriasis differ from ringworm?#

By its greater scaliness, by its higher degree of inflammatory action, and by its larger number of patches, as also by its history. In ringworm _all_ the patches tend to clear up in the centre; in psoriasis this is rarely, if ever, so. If there is still any doubt, microscopic examination of the scrapings will determine.

#Give the prognosis of psoriasis.#

The prognosis is usually favorable, so far as concerns the immediate eruption, but as to recurrences, nothing positive can be stated. In rare instances, however, the cure remains permanent.

#How is psoriasis treated?#

Both constitutional and local remedies are demanded in most cases.

#Do dietary measures exert any influence?#

As a rule, no; but the food should be plain, and an excess of meat avoided.

#Name the important constitutional remedies usually employed in psoriasis.#

_Arsenic_ is of first importance. It is not suitable in acute or markedly inflammatory types; but is most useful in the sluggish, chronic forms of the disease. The dose should never be pushed beyond slight physiological action. It may be given as arsenious acid in pill form, one-fiftieth to one-tenth of a grain three times daily, or as Fowler's solution, three to ten minims at a dose.

_Alkalies_, of which liquor potassæ is the most eligible. It is to be given in ten to twenty minim doses, largely diluted. It is valuable in robust, plethoric, rheumatic or gouty individuals with psoriasis of an acute or markedly inflammatory type; it is not to be given to debilitated or anæmic subjects.

_Salicin_, sodium salicylate, and salophen in moderately full doses act well in some cases. Occasionally thyroid preparations have a good effect.

_Potassium Iodide_, in doses of thirty to one hundred grains, t.d., acts favorably in some instances; there are no special indications pointing toward its selection, unless it be the existence of a gouty or rheumatic diathesis.

Oil of copaiba, potassium acetate, oil of turpentine, oil of juniper, and other diuretics are valuable in some instances, and, while often failing, sometimes exert a rapid influence, especially in those cases in which the disease is extensive and inflammatory. Wine of antimony, given cautiously, is also sometimes of service in the acute inflammatory type in robust subjects.

#Are such remedies as iron, quinine, nux vomica and cod-liver oil ever useful in psoriasis?#

Yes. In debilitated subjects the administration of such remedies is at times attended with improvement in the cutaneous eruption.

#What are the indications as regards the external measures?#

Removal of the scales, and the use of soothing or stimulating applications, according to the individual case.

#How are the scales removed?#