Chapter 7

In ordinary cases, either by warm, plain, or alkaline baths, or hot-water-and-soap washings; in those cases in which the scaling is abundant and adherent, washing with sapo viridis and hot water may be required. Baths of sal ammoniac, two to six ounces to the bath are also valuable in removing the scaliness. The tincture of green soap (tinctura saponis viridis) is especially valuable for cleansing purposes in psoriasis of the scalp. The hot vapor bath once or twice weekly is serviceable in keeping the scaliness in abeyance, and has, moreover, in some cases, a therapeutic value.

The frequency of the baths or washings will depend upon the rapidity with which the scales are reproduced.

#Are soothing applications often demanded in psoriasis?#

In exceptional cases; in those in which the disease is acute, markedly inflammatory and rapidly progressing, mild, soothing applications must be temporarily employed, such as plain or bran baths, with the use of some bland oil or ointment. As a rule, however, the conditions, when coming under observation, are such as to permit of stimulating applications from the start. The most efficient soothing applications are the mild lotions and ointments employed in eczema of acute type.

#How are the stimulating remedies employed in psoriasis applied?#

As ointments, oils, and paints (pigmenta).

An ointment, if employed, is to be thoroughly rubbed in the diseased areas once or twice daily. The same may be said of the oily applications. The paints (medicated collodion and gutta-percha solution) are applied with a brush, once daily, or every second or third day, depending mainly upon the length of time the film remains intact and adherent.

#Name the several important external remedies.#

Chrysarobin, pyrogallol, tar, ammoniated mercury, [beta]-naphthol, and resorcin.

#Are these several external remedies equally serviceable in all cases?#

No. Their action differs slightly or greatly according to the case and individual. A change from one to another is often necessary.

#In what forms and strength are these remedies to be applied?#

_Chrysarobin_ is applied in several ways: as an ointment, twenty to sixty grains to the ounce, rubbed in once or twice daily; this is the most rapid but least cleanly and eligible method. As a pigment, or paint, as in the following:--

[Rx] Chrysarobini, ........................ [dram]j Acidi salicylici, .................... gr. xx Etheris, ............................. f[dram]j Ol. ricini, .......................... [minim]x Collodii, ............................ f[dram]vij. M.

Or it may be used in liquor gutta-perchæ (traumaticin), a drachm to the ounce. It may also be employed in chloroform, a drachm to the ounce; this is painted on, the chloroform evaporating, leaving a thin film of chrysarobin; over this is painted flexible collodion. If the patches are few and large, chrysarobin rubber-plaster may be used.

Chrysarobin is usually rapid in its effect, but it has certain disadvantages; it may cause an inflammation of the surrounding skin, and, if used near the eyes, may give rise to conjunctivitis. As a rule, it should not be employed about the head. Moreover, it stains the linen permanently and the skin temporarily.

_Pyrogallol_ is valuable, and is employed in the same manner and strength as chrysarobin. In collodion it should at first not be used of greater strength than three to four per cent., as in this form pyrogallol sometimes acts with unexpected energy. It is less rapid than chrysarobin, but it rarely inflames the surrounding integument. It stains the linen a light brown, however, and is not to be used over an extensive surface for fear of absorption and toxic effect. Oxidized pyrogallic acid, a somewhat milder drug in its effect, has been highly commended, and has the alleged advantage of being free from toxic action.

_Tar_ is, all things considered, the most important external remedy. It is comparatively slow in its action, but is useful in almost all cases. As employed usually it is prescribed in ointment form, either as the official tar ointment, full strength or weakened with lard or petrolatum. It may also be used as pix liquida, with equal part of alcohol. Or the tar oils, oil of cade (ol. cadini), and oil of birch (ol. rusci) may be employed, either as oily applications or incorporated with ointment or with alcohol. Liquor carbonis detergens, in ointment, one to three drachms to the ounce of simple cerate and lanolin is a mild tarry application which is often useful. In stubborn patches an occasional thorough rubbing with a mixture of equal parts of liquor carbonis detergens and Vleminckx's solution, followed by a mild ointment, sometimes proves of value. In whatsoever form tar is employed it should be thoroughly rubbed in, once or twice daily, the excess wiped off, and the parts then dusted with starch or similar powder.

_Ammoniated mercury_ is applied in ointment form, twenty to sixty grains to the ounce. Compared to other remedies it is clean and free from staining, although, as a rule, not so uniformly efficacious. It is especially useful for application to the scalp and exposed parts. It should not be used over extensive surface for fear of absorption.

_[beta]-Naphthol_ and _resorcin_ are applied as ointments, thirty to sixty grains to the ounce, and as they are (especially the former) practically free from staining, may be used for exposed surfaces.

Gallacetophenone and aristol also act well in some cases, applied in five- to ten-per-cent. strength, as ointments.

In obstinate patches the _x_-ray may be resorted to, employing it with caution and in the same manner as in other diseases.

#Pityriasis Rosea.# (_Synonym:_ Pityriasis Maculata et Circinata.)

#What do you understand by pityriasis rosea?#

Pityriasis rosea is a disease of a mildly inflammatory nature, characterized by discrete, and later frequently confluent, variously sized, slightly raised scaly macules of a pinkish to rosy-red, often salmon-tinged, color.

#Upon what part of the body is the eruption usually found?#

The trunk is the chief seat of the eruption, although not infrequently it is more or less general.

#Describe the symptoms of pityriasis rosea.#

The lesions, which appear rapidly or slowly, are but slightly elevated, somewhat scaly, usually rounded, except when several coalesce, when an irregularly outlined patch results. At first they are pale or bright pink or reddish, later a salmon tint (which is often characteristic) is noticed. The scaliness is bran-like or flaky, of a dirty gray color, and, as a rule, less marked in the central portion; it is never abundant. The skin is rarely thickened, the process being usually exceedingly superficial.

#What course does pityriasis rosea pursue?#

The eruption makes its appearance, as a rule, somewhat rapidly, usually attaining its full development in the course of one or two weeks, and then begins gradually to decline, the whole process occupying one or two months.

#To what is pityriasis rosea to be attributed?#

The cause is not known; it is variously considered as allied to seborrh[oe]a (eczema seborrhoicum), as being of a vegetable-parasitic origin, and as a mildly inflammatory affection somewhat similar to psoriasis. It is not a frequent disease.

#How is pityriasis rosea distinguished from ringworm, psoriasis and the squamous syphiloderm?#

From ringworm, by its rapid appearance, its distribution, the number of patches, and, if necessary, by microscopic examination of the scrapings.

Psoriasis is a more inflammatory disease, is seen usually more abundantly upon the limbs, the scales are profuse and silvery, and the underlying skin is red and has a glazed look; moreover, psoriasis, as a rule, appears slowly and runs a chronic course.

The squamous syphiloderm differs in its history, distribution, and above all, by the presence of concomitant symptoms of syphilis, such as glandular enlargement, sore throat, mucous patches, rheumatic pains, and falling out of the hair.

#State the prognosis of pityriasis rosea.#

It is favorable, the disease tending to spontaneous disappearance, usually in the course of several weeks or one or two months.

#What treatment is to be advised in pityriasis rosea?#

Laxatives and intestinal antiseptics, and ointments of salicylic acid (5-15 grains to the ounce), of sulphur (10-40 grains to the ounce); or a compound ointment containing both these ingredients can be prescribed. The ointment base can be equal parts of white vaselin and cold cream; in some instances Lassar's paste (starch powder, zinc oxid powder, each, [dram]ij; vaselin, [dram]iv) seems more satisfactory.

#Dermatitis Exfoliativa.# (_Synonyms:_ General Exfoliative Dermatitis; Recurrent Exfoliative Dermatitis; Desquamative Scarlatiniform Erythema; Acute General Dermatitis; Recurrent Exfoliative Erythema; Pityriasis Rubra.)

#Describe dermatitis exfoliativa.#

Dermatitis exfoliativa is an inflammatory disease of an acute type, characterized by a more or less general erythematous inflammation, in exceptional instances vesicular or bullous, with epidermic desquamation or exfoliation accompanying or following its development. Constitutional disturbance, which may be of a serious character, is sometimes present. It is a rare and obscure affection, running its course usually in several weeks or months, but exhibiting a decided tendency to relapse and recurrence. In many cases it is persistently chronic, with exacerbations and remissions. In some instances it develops from a long-continued and more or less generalized eczema or psoriasis, and in exceptional cases it is started by the careless use of mercurial ointment and of chrysarobin ointment.

In another type of the disease, formerly described as _pityriasis rubra_, the skin is pale red or violaceous-red, but is rarely thickened, continued exfoliation in the form of thin plates taking place. Its course is variable, lasting for years, with remissions.

An exfoliating generalized dermatitis is exceptionally observed in the first weeks of life (_dermatitis exfoliativa neonatorum_), lasting some weeks, and in most cases followed by recovery. There are no special constitutional symptoms, the fatal cases usually dying of marasmus.

As will be seen dermatitis exfoliativa varies considerably in degree; it may be extremely mild, resembling in appearance the scarlet-fever eruption (erythema scarlatiniforme) and running a rapid course; or the skin-condition and the systemic symptoms may be of grave and persistent character.

#Give the treatment of dermatitis exfoliativa.#

General treatment is based upon indications, and externally soothing applications, such as are employed in acute and subacute eczema, are to be used.

#Lichen Planus.#

#What is lichen planus?#

Lichen planus is an inflammatory disease characterized by small, flat and angular, smooth and shining, or scaly, discrete or confluent, red or violaceous-red papules, having a distinctly papular or papulo-squamous course, and attended with more or less itching.

#Describe the symptoms of lichen planus.#

The eruption, as a rule, begins slowly, usually showing itself upon the extremities; the forearms, wrists and legs being favorite localities. It may appear as one or more groups or in the form of short or long bands. Occasionally its evolution is rapid and a considerable part of the surface may be invaded. The lesions are pin-head to small pea-sized, irregularly grouped or so closely crowded together as to form solid patches; they are quadrangular or polygonal in shape, usually flat, with central depression or umbilication, and are reddish or violaceous in color. At first they have a glazed or shining appearance; later, becoming slightly scaly, the scaliness being more marked where solid patches have resulted. New papules may appear from time to time, the older lesions disappearing and leaving persistent reddish or brownish pigmentation. Exceptionally the eruption presents in bands or lines, like rows of beads (_lichen moniliformis_). Very exceptionally a vesicular or bleb tendency in some of the lesions has been noted; doubtless, in most instances at least, this has been due to the arsenic so generally administered in this disease. In rare instances lichen planus lesions are also seen on the glans penis and on the buccal mucous membrane. In some cases, especially in the region of the ankle, the papules become quite large (_lichen planus hypertrophicus_), and in occasional cases there is a tendency in some of the lesions or patches to clear up centrally. There is, as a rule, considerable itching. There are no constitutional symptoms.

#What is the etiology of lichen planus?#

In some cases the disease is distinctly neurotic in character, in others no cause can be assigned. It is more especially met with at middle age, and among the wealthier, professional, and luxurious classes.

Pathologically the first change noted in the epidermis is thought to be an acanthosis, followed by epithelial atrophy, and a hyperkeratosis, intercellular edema, and colloid degeneration of the prickle cells.

#Does the disease bear any resemblance to the miliary papular syphilide, psoriasis, and papular eczema?#

In some instances it does, but the irregular and angular outline, the slightly-umbilicated, flattened, smooth or scaly summits, and the dull-red or violaceous color, the history and course, of lichen planus, will serve to differentiate.

#State the prognosis.#

Under proper management the eruption, although often obstinate, yields to treatment.

#What treatment would you prescribe in lichen planus?#

A general tonic plan of medication is indicated in most cases, with such remedies as iron, quinine, nux vomica, and cod-liver oil and other nutrients. In many instances arsenic exerts a special influence, and should always be tried. Mercurials in moderate dosage have also a favorable action in most cases. Locally, antipruritic and stimulating applications, such as are used in the treatment of eczema, are to be employed, alkaline baths and tarry applications deserving special mention. Liquor carbonis detergens, applied weakened with several parts water, is a valuable application. In some cases, particularly if the disease is limited, external applications alone often suffice to bring about a cure.

#Pityriasis Rubra Pilaris.# (_Synonyms:_ Lichen Ruber; Lichen Ruber Acuminatus.)

#Describe pityriasis rubra pilaris.#

Pityriasis rubra pilaris is an extremely rare disease, usually of a mildly inflammatory nature, characterized by grayish, pale-red or reddish-brown follicular papules with somewhat hard or horny centres; discrete and confluent, and covering a part or the entire surface. The skin is harsh, dry and rough, feeling to the touch somewhat like the surface of a nutmeg-grater or a coarse file. More or less scaliness is usually present in the confluent patches and on the palms and soles; in these latter regions the papules are rarely seen. The duration of the disease is variable, and relapses are common. It bears resemblance at times to keratosis pilaris, ichthyosis, dermatitis exfoliativa; it is considered identical with the lichen ruber acuminatus of Kaposi, and by many also with the lichen ruber of Hebra. The etiology is obscure.

Treatment, both constitutional and local, is to be based upon general principles; stimulating applications, with frequent baths, such as are advised in psoriasis, are the most satisfactory. It is rebellious, and not much more than palliation can be effected in some cases, in others the outlook is more hopeful.

#Lichen Scrofulosus.#

#Describe lichen scrofulosus.#

Lichen scrofulosus is a chronic, inflammatory disease, characterized by millet-seed-sized, rounded or flat, reddish or yellowish, more or less grouped, desquamating papules. The lesions have their start about the hair-follicles, occur usually upon the trunk, tend to group and form patches, and sooner or later become covered with minute scales. As a rule, there is no itching. It is a rare disease, and but seldom met with in America; it is seen chiefly in children and young people of a scrofulous diathesis. Scarring, slight in character, may or may not follow.

#What is the treatment of lichen scrofulosus?#

The condition responds to tonics and anti-strumous remedies.

#Eczema.# (_Synonym:_ Tetter; Salt Rheum.)

#What is eczema?#

An acute, subacute or chronic inflammatory disease, characterized in the beginning by the appearance of erythema, papules, vesicles or pustules, or a combination of these lesions, with a variable amount of infiltration and thickening, terminating either in discharge with the formation of crusts, in absorption, or in desquamation, and accompanied by more or less intense itching and a feeling of heat or burning.

#What are the several primary types of eczema?#

Erythematous, papular, vesicular and pustular; all cases begin as one or more of these types, but not infrequently lose these characters and develop into the common clinical or secondary types--eczema rubrum and eczema squamosum.

#What other types are met with clinically?#

Eczema rubrum, eczema squamosum, eczema fissum, eczema sclerosum and eczema verrucosum. Eczema seborrhoicum is probably a closely allied disease, occupying a middle position between ordinary eczema and seborrh[oe]a.

#Describe the symptoms of erythematous eczema.#

Erythematous eczema (_eczema erythematosum_) begins as one or more small or large, irregularly outlined hyperæmic macules or patches, with or without slight or marked swelling, and with more or less itching or burning. At first it may be ill-defined, but it tends to spread and its features to become more pronounced. It may be limited to a certain region, or it may be more or less general. When fully developed, the skin is harsh and dry, of a mottled, reddish or violaceous color, thickened, infiltrated and usually slightly scaly, with, at times, a tendency toward the formation of oozing areas. Punctate and linear scratch-marks may usually be seen scattered over the affected region.

Its most common site is the face, but it is not infrequent upon other parts.

#What course does erythematous eczema pursue?#

It tends to chronicity, continuing as the erythematous form, or the skin may become considerably thickened and markedly scaly, constituting eczema squamosum; or a moist oozing surface, with more or less crusting, may take its place--eczema rubrum.

#Describe the symptoms of papular eczema.#

Papular eczema (_eczema papulosum_) is characterized by the appearance, usually in numbers, of discrete, aggregated or closely-crowded, reddish, pin-head-sized acuminated or rounded papules. Vesicles and vesico-papules are often intermingled. The itching is commonly intense, as often attested by the presence of scratch-marks and blood crusts.

It is seen most frequently upon the extremities, especially the flexor surfaces.

#What course does papular eczema pursue?#

The lesions tend, sooner or later, to disappear, but are usually replaced by others, the disease thus persisting for weeks or months; in places where closely crowded, a solid, thickened, scaly sheet of eruption may result--eczema squamosum.

#Describe the symptoms of vesicular eczema.#

Vesicular eczema (_Eczema vesiculosum_) usually appears, on one or several regions, as more or less diffused inflammatory reddened patches, upon which rapidly develop numerous closely-crowded pin-point to pin-head-sized vesicles, which tend to become confluent and form a solid sheet of eruption. The vesicles soon mature and rupture, the discharge drying to yellowish, honeycomb-like crusts. The oozing is usually more or less continuous, or the disease may decline, the crusts be cast off, to be quickly followed by a new crop of vesicles. In those cases in which the process is markedly acute, considerable swelling and [oe]dema are present. Scattered papules, vesico-papules and pustules may usually be seen upon the involved area or about the border.

The face in infants (_crusta lactea_, or _milk crust_, of older writers), the neck, flexor surfaces and the fingers are its favorite localities.

#What course does vesicular eczema pursue?#

Usually chronic, with acute exacerbations. Not infrequently it passes into eczema rubrum.

#Describe the symptoms of pustular eczema.#

Pustular eczema (_eczema pustulosum_, _eczema impetiginosum_) is probably the least common of all the varieties. It is similar, although usually less actively inflammatory, in its symptoms to eczema vesiculosum, the lesions being pustular from the start or developing from preëxisting vesicles; not infrequently the eruption is mixed, the pustules predominating. There is a marked tendency to rupturing of the lesions, the discharge drying to thick, yellowish, brownish or greenish crusts.

Its most common sites are the scalp and face, especially in young people and in those who are ill-nourished and strumous.

#What course does pustular eczema pursue?#

Usually chronic, continuing as the same type, or passing into eczema rubrum.

#Describe the symptoms of squamous eczema.#

Squamous eczema (_eczema squamosum_) may be defined as a clinical variety, the chief symptoms of which are a variable degree of scaliness, more or less thickening, infiltration, and redness, with commonly a tendency to cracking or fissuring of the skin, especially when the disease is seated about the joints. It is developed, as a rule, from the erythematous or papular type. Itching is slight or intense.

The disease is not uncommon upon the scalp.

#What is the course of squamous eczema?#

Essentially chronic.

#Describe the symptoms of eczema rubrum.#

Eczema rubrum is characterized by a red, raw-looking, weeping, oozing or discharging surface, attended with more or less inflammatory thickening, infiltration and swelling; the exudation, consisting of serum, sometimes bloody, dries into thick yellowish or reddish-brown crusts. At one time the whole diseased area may be hidden under a mass of crusting, at other times a red, raw-looking, weeping surface (_eczema madidans_) is the most striking feature. Itching is slight or intense, or the subjective symptom may be a feeling of burning. It is an important clinical type, usually developing from the vesicular, pustular or other primary variety.

It is common about the face and scalp in children, and the middle and lower part of the leg in elderly people.

#What is the course of eczema rubrum?#

Chronic, varying in intensity from time to time.

#Describe the symptoms of fissured eczema.#

The conspicuous symptom is a marked tendency to fissuring or cracking of the skin (_eczema fissum_; _eczema rimosum_). This tendency is usually a part of an erythematous or squamous eczema, the fissuring constituting the most conspicuous and troublesome symptom. _Chapping_ is an extremely mild but familiar example of this type.

It is especially common about the hands and fingers.

#What is the course of fissured eczema?#

It is more or less persistent, the tendency to fissuring varying considerably according to the state of the weather, often disappearing spontaneously in the summer months.

#Describe eczema sclerosum and eczema verrucosum.#

In eczema sclerosum the skin is thickened, infiltrated, hard, and almost horny. Eczema verrucosum presents similar conditions, but, in addition, displays a tendency to papillary or wart-like hypertrophy. In both varieties the disease is usually seated about the ankle or the foot, developing from the papular or squamous type. They are uncommon, and obstinately chronic.