so thorough a knowledge of general medicine for its successful
management as does eczema. The exciting cause of the affection is to be
ascertained and to be properly treated. It is the specialist who has as
the groundwork a comprehensive knowledge of general medicine who is
best able to cope successfully with the disease under consideration. In
the management of eczema both constitutional and local treatment will
be necessary. It is true that some authorities depend upon external
applications alone, but, judging from our own experience, a combination
of external and internal treatment promises decidedly better results.
In those cases in which the exciting cause has disappeared and the
eczema persists from habit, as it were, the simplest local treatment
may bring about a cure. But these are, unfortunately, exceptional
instances. In almost all cases external treatment is indispensable.
Constitutional Treatment.--There are no specific remedies for eczema.
Arsenic, it is true, acts in some cases admirably, but these instances
are rather exceptional; the proportion of cases in which it may be
prescribed with the hope of advantage is not very large. It not
infrequently proves positively injurious. It is in the dry, scaly, and
papular forms of the disease, and especially those in which the
inflammation is of a low grade, that it acts most happily. The drug is
to be given in sufficiently large doses to obtain slight evidences of
its physiological action; toxic effects are to be avoided. It should
never be given in acute cases. In small doses (one or two minims of
Fowler's solution) arsenic is frequently of value as a tonic, acting
then in the same manner as other tonics. When the physiological effects
of the drug are desirable the dose should be gauged accordingly,
beginning with two or three minims three times daily, and increasing
gradually up to five or six or even more minims; as soon as the action
of the drug becomes evident, as shown by a slight conjunctival
injection and puffiness about the eyelids, the dose should be
diminished and its administration continued for an extended period.
In the management of eczema attention should be given to the subject of
diet. The food should be nutritious but plain, avoiding such articles
as pork, salted meats, pastry, cabbage, gravies and sauces, pickles,
cheese, condiments, beer and wine, etc. In anæmic and debilitated
individuals a moderate use of stimulants may prove useful. Fresh air
and exercise are often of aid in the treatment. The various remedies to
be employed internally will depend upon the cause or causes which have
brought about the attack. In robust persons and those of full habit
laxatives or purgatives will prove of positive service. A useful
formula for such cases, and also for those in whom constipation is
present, is the following:
Rx. Magnesii sulphatis, ounce iss;
Potassii bitartratis, drachm iv;
Sulphuris præcip., drachm ij;
Glycerinæ, fluidrachm ij;
Aquæ menthæ pip., q. s. ad fluidounce iv.
M.--S. A tablespoonful in a tumblerful of water a half hour before
breakfast. If this dose of the mixture fails to produce one or two free
evacuations daily, then as much as double the quantity may be taken or
a dose may be taken morning and evening. In many cases an aperient
combined with a tonic is indicated. This is the case in those who are
{633} dyspeptic and debilitated, and in whom there is more or less
constipation present. The following formula is available for such
cases:
Rx. Magnesii sulphatis, ounce iss;
Ferri sulphatis, gr. iv;
Acidi sulphurici dilut., fluidrachm ij;
Aquæ menthæ pip., fluidounce iv.
M.--S. A tablespoonful in a tumblerful of water a half hour before the
morning meal. In some cases the acid is contraindicated, and then the
mixture may be prescribed without this ingredient. Although this
formula is found to agree with most individuals, there are some who are
either not able to take it or in whom it is found to aggravate the
dyspepsia or to cause more or less gastric disturbance. In these cases
the following formula has proved of value:
Rx. Ext. cascaræ sagradæ fl., fluidrachm iv;
Acidi muriatici dilut., fluidrachm ij;
Elix. calisayæ, fluidounce iij drachm ij.
M.--S. A teaspoonful in a large wineglassful of water before or after
meals. The laxative effect of the mixture is more marked when it is
taken twenty or thirty minutes before meals. In some cases it will be
found necessary to increase the proportion of the cascara sagrada,
while, on the other hand, not infrequently a less quantity may be
sufficiently active. In acute eczema laxatives, especially the salines,
are of great service. The various mineral-spring waters may also be
mentioned as useful. Of these Friedrichshall, Hunyadi Janos, the
Hathorn and Geyser Springs of Saratoga, are the most serviceable. A
tonic aperient where there is only slight constipation is the
following:
Rx. Sodii phosphatis, drachm vj;
Acidi phosphorici dilut., fluidrachm iij;
Syr. zingiberis, fluidounce j;
Infus. gentianæ comp., fluidounce iiss.
M.--S. A tablespoonful in a wineglassful of water three times daily.
The following aperient mixtures may be prescribed for children:
Rx. Syr. rhei aromat.,
Olei ricini, aa. fluidounce ij.
M.--S. A teaspoonful two or three times daily, according to the effect.
Rx. Ext. cascaræ sagradæ fl., fluidrachm ij;
Syr. aurantii cort., fluidrachm vj.
M.--S. A teaspoonful in water at bed-time.
Occasional laxative doses of calomel are often valuable both in
children and adults. Dyspepsia, if present, should receive appropriate
treatment. The bitter tonics, mineral acids, alkalies, and the various
artificial aids to digestion may be employed as seem indicated. Where
malaria is suspected, full doses of quinine and small doses of arsenic
should be prescribed. In these cases, as also in those in which there
may be anæmia or chlorosis, the preparations of iron may be prescribed.
If a gouty diathesis appears to be at the foundation of the attack,
purgatives, the alkalies, and colchicum are to be advised. In these
cases, if of an acute or subacute type, the following formula is
serviceable:
Rx. Potassii acetatis, ounce j;
Liquor, potassæ, fluidrachm vj;
Aquæ menthæ pip., fluidounce iij drachm ij.
{634} M.--S. A teaspoonful in a half gobletful of water an hour before
meals. In cases of a chronic type the following may sometimes prove of
benefit:
Rx. Potassii iodidi, drachm v gr. xx;
Liquor. potassii arsenit., fluidrachm iss;
Liquor. potassæ, fluidrachm vss;
Aquæ, fluidounce iij.
M.--S. A teaspoonful in a half gobletful of water after meals.
In some gouty and rheumatic cases wine of colchicum may be added to the
above two prescriptions with advantage. Where a scrofulous tendency
exists cod-liver oil is a valuable remedy; also in all cases of
impaired nutrition, in moderate doses, long continued, it will often
prove useful, especially in children.
External Treatment.--The local treatment of eczema is based upon the
pathological conditions present. The acute disease requires entirely
different management from that employed in chronic cases. The stage of
the disease and the amount of skin involved, whether in the form of a
circumscribed patch or as a diffuse eruption, are points to be taken
into consideration in the selection of a remedy and the mode of its
application. The several varieties, the erythematous, papular,
vesicular, pustular and squamous, and also the secondary forms rubrum,
fissum and verrucosum, all demand applications appropriate to the
condition. In acute erythematous or vesicular eczema caution is to be
exercised in the selection of remedies. Only the milder applications,
as a rule, are tolerated. That which will agree with one may not agree
with another. It is advisable to try the remedy upon a small portion of
the diseased surface to see if it is acceptable to the skin. In these
varieties also soap and water should, as much as possible, be avoided.
For the average case, especially of the vesicular variety, the most
successful plan of treatment is with lotio nigra and oxide-of-zinc
ointment. The lotion is to be dabbed on by means of a sponge or cloth
every three or four hours, ten or fifteen minutes at a time; as soon as
dry a small quantity of oxide-of-zinc ointment is to be gently smeared
over. In many instances this method furnishes immediate relief to the
itching, and under its use the inflammation is soon relieved. Powdering
the surface with dusting-powder will sometimes afford ease, starch or
lycopodium powder, either alone or together, equal parts, being useful.
Subnitrate of bismuth is also of value, proving a more stimulating
powder. In some cases a half drachm of finely-powdered camphor to the
ounce may be advantageously added to one or another of the simple
powders. Powdered Venetian talc is also sometimes useful alone or in
combination with starch, a drachm or two of the former to the ounce of
the latter. Dusting-powders should in all cases be used freely and
often, their chief object being to afford protection to the inflamed
surfaces.
Another lotion frequently employed in acute cases of vesicular eczema
with free discharge, especially in cases where there is oedema or where
the skin is irritable, is one containing calamine and zinc oxide; for
example,
Rx. Pulv. zinci oxidi,
Pulv. calaminæ, aa. drachm iiss;
Glycerinæ, fluidrachm j;
Liq. calcis,
Aquæ rosæ, aa. fluidounce iij.
{635} The following may also be mentioned as being useful in similar
cases:
Rx. Pulv. calaminæ,
Cretæ præparatæ, aa. drachm j;
Acidi hydrocyanici dilut., fluidrachm ss;
Glycerinæ, fluidrachm ij;
Aquæ,
Liq. calcis, aa. fluidounce iij.
These lotions, as will be seen, contain more or less insoluble powder,
and they are to be applied in the same manner as advised when speaking
of the use of black wash.
There are other lotions which are often of service. Carbolic acid, one
or two drachms to the pint of water, to which may be added a like
quantity of glycerin, is in many cases of value, especially in those in
which itching is marked. A saturated solution of boric acid, with or
without the addition of glycerin, may also be employed in these cases,
especially in erythematous eczema. It is one of the most useful of the
milder remedies. In this variety, particularly when confined to the
flexures, constituting eczema intertrigo, the following formula
containing acetate of lead may be prescribed in some cases with
benefit:
Rx. Plumbi acetatis, drachm ss;
Acidi acetici dil., fluidrachm ij;
Glycerinæ, fluidrachm iv;
Aquæ, q. s. ad fluidounce vi. M.
In those cases where lotions do not seem to act happily a mild ointment
of salicylated suet (2 or 3 per cent. strength) will often relieve the
condition. The fluid extract of grindelia robusta, one or two drachms
to six ounces of water, seems to suit some cases, but it should be
applied cautiously, as in some instances it tends to aggravate. Weak
alkaline lotions, a drachm of the bicarbonate of sodium or borate of
sodium to the pint of water, and a drachm of the solution of subacetate
of lead to the pint, may be also mentioned. Tarry lotions of weak
strength are sometimes useful. A drachm of the liquor carbonis
detergens to two or four ounces of water, or the liquor picis
alkalinus, a drachm to the half pint of water, may afford relief. The
former tarry preparation is made by mixing together nine ounces of
tincture of soap-bark[2] and four ounces of coal-tar, allowing to
digest for eight days and filtering. The formula for the liquor picis
alkalinus, the other tarry preparation referred to, is as follows:
Rx. Potassæ, drachm j;
Picis liquidæ, drachm ij;
Aquæ, fluidrachm v. M.
A lotion made up of two drachms of zinc oxide, two drachms of glycerin,
six drachms of lead-water, and three ounces of infusion of tar is
sometimes valuable in the erythematous form.
[Footnote 2: Tincture of soap-bark is made by digesting for eight days
one pound of soap-bark in one gallon of alcohol.]
As a rule, ointments are not so well borne in acute eczema as lotions,
but as soon as the more acute symptoms have subsided, and in some
instances even during the acute stage, they may be used with benefit.
The oxide-of-zinc ointment is well known, and is one of the most
soothing; sometimes it is well to reduce the proportion of zinc oxide.
{636} Oleate of zinc, in the proportion of one or two drachms to the
ounce of vaseline or lard, is somewhat similar to oxide-of-zinc
ointment, but is more astringent and stimulating. The oleate of
bismuth, pure or with an equal part of vaseline or other fatty base, is
also at times of service. The same may be said of the oleate of lead
melted with an equal part of lard or vaseline, in this form
constituting a soothing and astringent application similar to the
well-known diachylon ointment. The latter ointment, if properly
prepared, is in the subacute stage often exceedingly valuable. The same
objection to this holds as with the different oleates named--that is,
the difficulty of securing properly-made preparations. Many are vaunted
as such, but our experience is that good preparations are exceptional,
and those furnished, instead of acting as expected, often give rise to
irritation or marked aggravation. For the acute and subacute stages of
the disease the ordinary cold-cream ointment may be in some cases
advantageously prescribed. An ointment of equal parts of diachylon
plaster and one of the petroleum ointments, as vaseline, constitutes an
elegant preparation, useful when a mild, soothing application is called
for.
A paste made up as follows may also be recommended for the subacute
condition, and at times suits even during the active inflammatory
stage:
Rx. Pulv. zinci oxidi, ounce ss;
Mucilag. acaciæ,
Glycerinæ, aa. fluidounce j.
M.--S. Apply with a brush two or three times daily. To this formula, if
there is considerable itching present, carbolic acid or salicylic acid
in the proportion of 2 per cent. may be added. Glycerite of tannic acid
sometimes proves of value, especially in the erythematous varieties of
the disease, more particularly when occurring about the face. In like
cases glycerite of subacetate of lead may be prescribed. The following
is Squire's formula: Acetate of lead, 5 parts; litharge, 3½ parts;
glycerin, 20 parts, by weight. Mix and expose to a temperature of 350°
F., and filter through a hot-water funnel. The fluid resultant contains
129 grains of the subacetate of lead to the ounce, which is to be
diluted with from two to six parts of glycerin or with water. This
preparation may sometimes be used with benefit in chronic eczema of the
legs applied on strips bound on with a bandage. In these cases the
following paste, suggested by Unna, proves useful:
Rx. Kaolini,
Ol. lini, aa. drachm vj;
Zinci oxidi, ounce ss;
Liq. plumbi subacetat., fluidounce ss. M.
This is painted on and allowed to dry, and then bandaged for
twenty-four hours. In some skins, however, glycerin invariably
irritates.
In the papular form the tarry lotions named and carbolic-acid lotion
are of most benefit. These cases are from the beginning inclined to
take on the chronic type, and the more stimulating applications are
well borne. Thymol, one or two grains to the ounce of alcohol and
water, is also useful.
In chronic eczema, and, in fact, in all cases of eczema, after the
active inflammatory symptoms have more or less subsided--which usually
takes place soon after the beginning of the outbreak--stimulating
applications are to be resorted to. In fact, the {637} dividing-line
between acute and chronic eczema is difficult to define. The products
of the disease, be they crusts or scales, must be removed in order that
the remedial application may be brought in contact with the diseased
surface. Thoroughly saturating the part with oil, and subsequently
washing with warm water and soap, will usually suffice to remove the
accumulations. On the non-hairy surface a bland oil, lard, or a
non-irritating ointment thickly spread on the parts, will soon be
followed by softening and removal of the crusts or scales. If these
more simple measures are not sufficient, washings with sapo viridis and
warm water are to be advised for this purpose, immediately afterward
applying a mild unguent. On the scalp, instead of the pure green soap,
the spiritus saponatus kalinus is more satisfactory. In patches which
are covered with thickened epidermic masses, as in eczema of the palms,
strong applications are necessary to remove the accumulations. For this
purpose green soap or salicylic acid may be used. Of these, salicylic
acid is in most cases to be preferred. It may be applied as an
alcoholic solution, 5 or 8 per cent. strength, or in ointment form,
fifteen to forty grains to the ounce.
After a removal of the products of the disease the remedies proper are
to be applied. The various ointments already named for the treatment of
the acute and subacute types may also be employed in the chronic cases.
In some instances they may prove sufficient, but in the majority it
will be found necessary to have immediate recourse to the stronger
ointments and lotions. In small patches washing the parts with green
soap and hot water and following with unguentum diachlyi or a similar
ointment will be sufficient.
The mercurials are of great value in the treatment of eczema, used
either alone or in combination with various other remedies. An ointment
of the mild chloride of mercury, twenty to eighty grains to the ounce,
is valuable in many cases. Citrine ointment, weakened, and ammoniated
mercury, in the same proportion as calomel, are also well-known and
very useful preparations, likewise acceptable in many cases. To these
ointments tar may often be advantageously added, in the strength of one
or two drachms to the ounce. Carbolic acid in ointment, ten to twenty
grains to the ounce, may also be mentioned as often proving
serviceable. A compound ointment, prized in the Blackfriars Hospital
for Skin Diseases, London, is composed of acetate of lead, ten grains;
oxide of zinc, twenty grains; calomel, ten grains; citrine ointment,
twenty grains; palm oil, half an ounce; benzoated lard, enough to make
one ounce. Another mildly stimulating preparation is composed of
bisulphide of mercury and red precipitate, each six grains; lard, one
ounce.
Tarry preparations constitute the most generally efficacious
applications in the treatment of all forms of chronic eczema, where
this remedy is at all tolerated by the skin, especially in the squamous
variety of the disease. A good formula, and one that is often of
service even in the subacute variety, is the following:
Rx. Picis liquidæ,
Zinci oxidi, aa. drachm j;
Ugt. aquæ rosæ, drachm vj.
M. Ft. ugt.--This is to be gently but thoroughly rubbed into the {638}
diseased skin. There are three preparations of tar that may be
interchangeably employed: these are the ordinary pix liquida, oleum
cadinum, and oleum rusci. The oleum rusci is the least unpleasant. They
may be employed in the strength of 10 to 50 per cent., either in
ointment form or with alcohol. If used upon the scalp, the lotion form,
with alcohol, is to be preferred. In the use of a tarry preparation, to
be efficient it is to be gently but thoroughly worked into the patches,
so that it permeates the skin; the excess may be wiped off. The liquor
picis alkalinus, already mentioned in speaking of the treatment of
acute eczema, may be used either in the form of an ointment, in the
strength of one or two drachms to the ounce, or in the form of a
lotion, in the strength of two to eight drachms to the half pint. This
tarry preparation may even be employed in full strength to small and
thickened patches, applying carefully and using no other treatment, or
following the application immediately with a simple or tarry ointment.
In cases of verrucous eczema or in patches of thickened papular or
squamous eczema, used in the manner described, it is often curative. It
is a strong remedy, and is to be employed with caution. The liquor
carbonis detergens, in the strength of one or two drachms to the ounce
of water, is also valuable in these chronic cases. It is a safe plan in
the use of these tarry preparations to begin with a mild strength and
then increase if advisable. An equally efficacious formula for the
thick, leathery patches of chronic eczema is the following:
Rx. Saponis viridis,
Picis liquidæ,
Alcoholis, aa. drachm iv.
M.--S. Rub in twice daily. There is another mildly alkaline tarry
preparation, the goudron de Guyot, somewhat similar in composition to
the liquor picis alkalinus, which at times seems to suit when the other
tarry applications fail to benefit.
In the treatment of eczema rubrum of the legs Hebra was in the habit of
employing the following method: A small quantity of the green soap is
to be rubbed into the parts with a flannel rag, employing considerable
friction, until all the soap has apparently disappeared; then warm or
hot water is to be added and rubbed in in the same manner, an abundant
lather being the result. The parts after being rubbed for from five to
fifteen minutes, according to the effect, are to be thoroughly rinsed
off with simple warm water, and a mild ointment, spread upon cloths,
applied. The best ointment for this purpose is the unguentum diachyli,
but any mild ointment may be employed. This treatment is to be repeated
once or twice daily. In most cases improvement sets in after a few
applications. It is an excellent method of treatment, and can be
recommended. It requires considerable time and trouble, however, and is
therefore not suitable in all cases, for unless the details are
properly carried out it may fail.
Salicylic acid is another remedy that is often useful. In thick,
leathery patches, an ointment of the strength of thirty to sixty grains
to the ounce, applied on cloths or rubbed in, will often produce marked
benefit. In the form of a paste it may be used in many cases of
subacute and chronic eczema with good effects: {639}
Rx. Acidi salicylici, gr. xx;
Ugt. petrolei, drachm iv;
Amyli,
Zinci oxidi, aa. drachm ij.
M.--S. Apply once or twice daily. If it is used upon the scalp, it
should be used with petroleum ointment or lard, the starch and zinc
oxide being omitted. Boric acid in the form of a saturated solution, as
advised in acute eczema, or in ointment of the strength of a drachm to
the ounce, will prove useful in some instances. Sulphur in the form of
ointment may also be mentioned as being frequently of value in cases of
chronic eczema, especially of the leg. In some cases of subacute and
chronic eczema the lotion containing zinc sulphate and potassium
sulphide, diluted, mentioned in acne, will be found serviceable. In
circumscribed and chronic patches blistering with cantharides is
sometimes advisable. In these cases tincture of iodine is also
employed. In thickened patches, rebellious to the usual remedies,
chrysarobin or pyrogallic acid, as used in psoriasis, may sometimes be
applied with benefit.
Mention may here be made of vulcanized india-rubber, used in the form
of bandages, the method proving of most value in eczema of the lower
extremities, especially in those cases which are due to a condition of
varicose veins. It is not suitable in all cases, as in some the disease
is aggravated. Reference may also be made to the use of the so-called
gelatin dressing. The medicinal substance is incorporated with the
gelatin basis, which is made by melting together over a water-bath two
parts of water and one of gelatin; and when the application is made the
gelatin compound is melted over a water-bath and applied while in the
fluid condition; it rapidly hardens and forms an impermeable coating to
the diseased part. The dressing is liable to crack, to avoid which, in
a measure, a small quantity of glycerin is mixed with the gelatin and
water. Another plan is, after the dressing has dried, to brush over the
surface a few minims of glycerin. It has, however, cleanliness in its
favor, and it is undoubtedly of service in many instances. A good basis
formula for the gelatin dressing consists of eight parts of water, four
of gelatin, and one of glycerin.
Another form of fixed dressing for scaly patches is with collodion.
This may often be made use of when tar is employed, the addition of one
or two drachms of pix liquida or one of the tar oils to enough
collodion to make an ounce. Such a preparation may be applied to dry
and scaly patches, and constitutes an excellent method of application;
but tar so applied is not as efficient as when used in solution or in
ointment. The gutta-percha and muslin plasters[3] constitute excellent
methods of applying remedies; they are cleanly, easily applied,
comfortable to the patient, and efficacious.