disease of the face, invading especially the nose and cheeks,
characterized by redness, dilatation and enlargement of the
blood-vessels, more or less acne, and hypertrophy. The course of the
disease divides itself naturally into three stages. There is at first
simply a hyperæmia, due to passive congestion. In young subjects the
affection is seen in this stage, and rarely passes beyond it. In other
cases, however, sooner or later, dilatation and enlargement of the
vessels (telangiectasis) take place, and acne papules and pustules are
scattered over the parts, constituting the second stage of the disease.
This stage is frequently met with, and illustrates the acne rosacea
usually seen. Exceptionally, however, the disease progresses, the
vessels increase in calibre, the glands are enlarged, and there is more
less hypertrophy of the connective tissue and the third stage is
developed. The nose may become much enlarged, even lobulated, and in
some portions pendulous (rhinophyma). The nose and its immediate
neighborhood are the favorite localities for the development of acne
rosacea, but it is not infrequently confined to the cheeks, and
sometimes is localized upon the forehead, while all these parts are not
infrequently affected simultaneously. As a rule, there are no marked
subjective symptoms, although in some instances burning or a sense of
fulness is complained of.
It is seen in both sexes, but is more frequent in males; in women it
rarely, if ever, reaches the same degree of development as in men. It
is most common about middle life. The causes are varied. Chronic
stomachic and intestinal derangements, anæmia, and chlorosis are common
causes. The habitual use of spirituous liquors is not infrequently a
source of the disease. Long-continued exposure to excessive cold or
heat is in some cases a causative agent. In women, menstrual and
uterine difficulties are often the responsible factors; hence in this
sex it is much more common at the climacteric period. When occurring in
the young about the period of adolescence, it is frequently associated
with seborrhoea, and rarely advances beyond a condition of hyperæmia.
Pathologically, in the first stage of the disease there is simply a
hyperæmia--a stasis; in the second, hypertrophy and dilatation of the
vessels are superadded, together with acne and slight hypertrophy of
the sebaceous glands; in the third stage there is, in addition,
hypertrophy of the connective tissue of the corium.
Acne rosacea is to be distinguished from the tubercular syphiloderm,
lupus vulgaris, and acne vulgaris, to which affections it at times
bears resemblance. The tubercular syphiloderm is comparatively more
rapid in its course; does not necessarily involve the sebaceous glands;
has frequently as a consequence ulceration and crusting; is usually
confined to a part of the nose; and is unaccompanied with dilatation
and enlargement of the blood-vessels. Its history, the firmer
consistence, and the more {648} dusky color of the tubercles, and
frequently the presence of other evidences of syphilis, are also points
of difference. In lupus vulgaris the characteristic soft, yellowish-red
papules, the absence of the hypertrophied blood-vessels, the
degeneration, ulceration, and cicatricial-tissue formation, the more or
less limited character of the eruption, and the history of the case,
will serve to distinguish it. A simple case of acne vulgaris can
scarcely be confounded with acne rosacea: in many cases, however, the
dividing-line is far from being marked; in fact, the disease under
consideration is often acne with hyperæmia and dilated blood-vessels
superadded.
TREATMENT.--The affection may in all cases be more or less favorably
influenced by treatment. The milder cases, although at times obstinate,
are curable; but when the disease has advanced to marked dilatation and
hypertrophy of the blood-vessels and connective tissue, the prognosis
is not so favorable. In all stages of the affection, however, as
stated, a great deal can be accomplished by appropriate remedies.
External and internal treatment are required in the majority of cases.
The former usually proves the more valuable.
Concerning internal remedies, there is no drug that exerts a specific
influence. The guide to constitutional treatment should be a study of
the etiological causes of the disease. Constipation is frequently
present, and hence laxatives, especially the salines, are indicated.
Chlorosis in the female is often the predisposing cause, and such
remedies as iron, quinine, and strychnia will be found useful.
Dyspepsia is one of the most frequent causes, and treatment directed
toward a removal of that condition will often be of considerable aid in
curing the disease. Menstrual irregularities should be inquired into
and the appropriate remedies employed.
There are mainly two classes of external remedies which are used in the
treatment--namely, the mercurials and the sulphur preparations. The
latter are by far the more valuable, precipitated and sublimed sulphur,
the hypochloride of sulphur, and the sulphuret of potassium being the
most serviceable. They are prescribed either in the form of lotions or
ointments. The officinal sulphur ointment, an ointment of the
precipitated sulphur and of the hypochloride of sulphur, of the
strength of one or two drachms to the ounce, may be referred to as
valuable applications. Sulphur may also be used as a dusting-powder or
in the form of a paste, as in the following formula:
Rx. Mucilag. acaciæ, fluidrachm ij;
Glycerinæ, fluidrachm ij;
Sulphur, præcip., drachm iij.
M.--Sig. Use with a brush as a paint.
A lotion containing one to four drachms of precipitated sulphur, twenty
or thirty grains of camphor, thirty to sixty grains of tragacanth, in
two ounces each of lime-water and orange-flower water, or one of the
same quantity of sulphur, two or three drachms of ether, and three and
a half ounces of alcohol, will in many cases prove serviceable. A
lotion of one or two drachms each of sulphide of potassium and sulphate
of zinc, in four ounces of water, is one of great value.
Concerning the mercurials, corrosive sublimate, calomel, and white
precipitate are in some cases of service. Corrosive sublimate is
prescribed {649} as a lotion of the strength of one-half to four grains
to the ounce of water or water and alcohol. Calomel and white
precipitate are prescribed in ointment, twenty grains to two drachms of
either to the ounce, or they may be used in the form of a powder, full
strength or weakened with starch powder, dusted over the surface.
To a great extent, the treatment of acne rosacea is the same as simple
acne, and for other formulæ and for the method of applying the various
remedies the reader is referred to that disease. When dilated
blood-vessels are present, however, other measures, in addition to
those advised above, are to be adopted. There are two methods of
destroying the blood-vessels. One plan is by the knife, cutting across
the vessels at several points or slitting their whole length,
permitting them to bleed; subsequently cold water may be applied. The
other method is by means of electrolysis, according to the procedure
fully described in the treatment of hypertrichosis. If the vessel is
long, inserting the needle at several points along its length will be
necessary; if short, insertion at one or two points will suffice. While
either of these methods will, if properly managed, destroy the vessels,
neither will prevent the growth of new vessels. In those cases,
however, in which the cause has long ceased to operate destruction of
the existing vessels may not be followed by new growth. Excessive
connective-tissue hypertrophy may require ablation by the knife.
Sycosis.
Sycosis (syn., sycosis non-parasitica, folliculitis barbæ) is a chronic
inflammatory, non-contagious affection, involving the hair-follicles,
appearing generally upon the bearded region, and characterized by
papules, tubercles and pustules perforated by hairs. The disease is
seen, as a rule, only on the bearded part of the face, either about the
cheeks, chin, or upper lip, involving a small portion or the whole of
these parts. The hairy portion of the neck may also be invaded. The
disease may begin by the formation of papules and pustules about the
hair-follicles on previously healthy skin, or chronic hyperæmia, or
even eczema, may have preceded. The lesions generally occur in numbers,
in close proximity, and, together with the accompanying inflammation,
make up a patch of disease involving a greater or less area. The
pustules are discrete, flat or acuminated, small in size, yellowish in
color, perforated by hairs, show no disposition to rupture, and are, as
a rule, apt to appear in crops. They dry to thin yellowish-brown
crusts. There is more or less swelling and infiltration. Papules and
tubercles may usually be seen intermingled with the pustules, or the
former may constitute the greater part of the eruption. At first the
hairs are firmly seated, but later, when suppuration has involved the
follicles, they may be easily extracted. Not infrequently the
hair-follicles are completely destroyed, in which case scarring and
alopecia result. The process is chronic, it being of a subacute or
chronic character, with, usually, acute exacerbations. Burning
sensations, and at times pain or itching, accompany the disease.
According to Robinson, the affection is primarily a perifolliculitis,
{650} the first changes, which are those usually observed in vascular
connective-tissue inflammations, taking place around the follicle.
Later, the follicle and its sheath become involved, the pus and
transuded serum finding their way into these structures. At times pus
does not enter within the follicle, the changes observed therein being
due to the transuded serum. The pus reaches the surface by forcing its
way through the epidermis close to the hair. The causes of the disease
are not understood. It is usually seen in those between the ages of
twenty-five and fifty, in all classes of society, and in those in good
or bad health. Persons with eczematous skin and those having thick and
stiff hair are especially predisposed to the disease. Local irritation
may serve as the exciting cause. The affection is not common. It is not
contagious.
The disease is to be distinguished from tinea sycosis and eczema. Tinea
sycosis usually begins as a circular scaly patch--in fact, as simple
ringworm--later invading the hairs and follicles and giving rise to
papules and tubercles. These lesions are larger than in simple sycosis,
and appear and feel like lumps and nodules. Moreover, the changes in
the hairs in the parasitic disease are characteristic: they become
opaque, brittle, loose, and can be readily extracted. If necessary, a
microscopical examination of the hairs may be resorted to. In eczema
there is either an oozing, red, crusted surface, or it is dry and
scaly; the lesions, as a rule, do not remain discrete, are not
perforated by hairs, and the eruption is apt to involve other parts of
the face. It is scarcely possible to confound the disease with
syphilis.
The disease is essentially a chronic one, and under the best management
is often rebellious. Relapses are not uncommon. The treatment consists
mainly of external measures. Suitable internal remedies are, however,
in some cases, as in plethoric or in broken-down subjects, of value.
The digestive apparatus is to be looked after. The extremes of heat and
cold are to be, as far as possible, avoided. Clipping the hair, or
shaving if not too painful, will permit a more thorough application of
remedies. If the disease be of an acute type, soothing applications are
at first to be advised. If there is crusting, it should be removed by
poultices or oily applications. The use of lotio nigra, and
subsequently a cloth spread with oxide-of-zinc ointment, as in acute
vesicular eczema, may be advised to allay inflammation. Cold cream,
vaseline, or applications of lead-water and like remedies, will also be
found useful in the acute stage. As a rule, however, astringent and
stimulating ointments may be prescribed when the case first comes under
observation. As an astringent ointment there is in the average case
nothing superior to a good unguentum diachyli. It should be spread
thickly on muslin and bound down to the parts, renewing every six or
twelve hours. If stimulation is permissible, twenty grains to a drachm
of ammoniated mercury or calomel to the ounce of ointment may be
prescribed.
If the process be chronic in character, the parts may be washed with
sapo viridis and water, and then diachylon ointment applied, repeating
the washing every day and the application of the ointment twice or
thrice daily. Sulphur, one to three drachms to the ounce of ointment,
is a valuable stimulating remedy, and should be applied thoroughly
twice daily; citrine ointment, two or three drachms to the ounce of
lard or cold cream, will sometimes have a good effect. Shaving will be
found useful in many cases. In {651} some instances epilation proves a
valuable adjunct to the treatment. In acute stages the hairs should be
extracted from the pustules only--in the chronic stage both from
papules and pustules. The operation will be rendered less painful by
previously steaming or applying hot water to the parts. After the
operation the surface should be dressed with a mild ointment. Epilation
at the proper time will often save follicles from irreparable
destruction; if for any reason it is not advisable, the pustules should
be incised, so that free egress may be given to the pus.
Impetigo.
Impetigo is an acute inflammatory disease, characterized by the
formation of one or more pea- or finger-nail-sized, rounded and
elevated, usually firm, discrete pustules, seated upon an inflammatory
base. The affection is at times preceded by slight malaise. The lesion
is pustular from the beginning, and when well advanced may be of the
size of a pea or finger-nail, is rounded, or semiglobular, markedly
elevated, yellowish or whitish in color, with at first a more or less
pronounced areola, which as the lesion matures becomes less and less
marked, and finally almost entirely subsides. The pustule is usually
distended, shows no disposition to rupture nor to umbilication, and is
characterized by but little surrounding infiltration, and even where
several exist close together they show no tendency to coalesce. Ten,
twenty, or more lesions are usually present, and are most common about
the face, hands, feet, and lower extremities. They dry to crusts of a
yellowish or brownish color, which are usually thin and drop off, no
pigmentation or scar remaining. The process is of brief duration, is
benign in character, and is rarely attended with subjective symptoms.
It is commonly seen in children under the age of ten.
The disease, apparently, is not related to eczema; occurs, as a rule,
in well-nourished subjects, and is not contagious. The lesion is a
typical pustule, the process being distinctly circumscribed. The walls
are somewhat thick, and are probably made up of both the horny and
mucous layers. There is no inflammatory base. Microscopically, the
contents are found to be composed of pus-corpuscles, a few red
blood-corpuscles, epithelial cells, and cellular débris. The disease is
to be distinguished from pustular eczema, impetigo contagiosa, and
erythema. The pustules of eczema are numerous, closely crowded
together, small in size, tend to coalesce, with a decided disposition
to rupture, and are accompanied by itching. The lesions of impetigo
contagiosa are vesicular or vesico-pustular, flattened, superficial,
thin-walled, often umbilicated; if close together they tend to
coalesce, and dry to lamellar crusts of a yellowish color, and the
affection is distinctly contagious. The pustules of ecthyma are flat,
with an inflammatory base and areola; the crusts are brownish or
blackish, and seated upon a deep excoriation; and the affection is,
moreover, usually seen in adults and in those whose general health is
markedly below the standard.
The affection rarely calls for treatment, as it tends to spontaneous
recovery. Incision and evacuation of the matured lesions and a simple
protective dressing of a mild ointment, such as oxide-of-zinc ointment,
{652} may be advised. If slight stimulation is desirable, ten or twenty
grains of ammoniated mercury may be added to the ounce of the ointment.
Impetigo Contagiosa.
Impetigo contagiosa is an acute, inflammatory, contagious disease,
characterized by the formation of discrete, superficial, flat, rounded
or ovalish vesicles or blebs, which soon become vesico-pustular and
pass into crusts. Precursory febrile symptoms, especially in young
children, frequently usher in the eruption. The lesions begin as
discrete vesicles, small in size, becoming vesico-pustular and
increasing by extension peripherally, reaching the size of a pea or
developing into blebs as large as a dime or silver quarter dollar. They
are flat, slightly or markedly umbilicated, the umbilication being more
marked in the older lesions. Several or a few dozen such vesicles or
blebs may be present, and if situated close together may coalesce and
form patches. There is very little areola, and the covering of the
lesion is thin and withered-looking. The superficial character of the
process is a striking feature. In a few days the lesions dry to crusts,
thin, granular, wafer-like in character, light-yellowish or
straw-colored, and but slightly adherent. If the vesicular or bleb wall
or the crust is removed, a slightly excoriated surface is disclosed,
resembling a superficial burn, secreting a thin fluid. The lesions are
seen most commonly about the face and hands, although they frequently
occur on other parts. In some cases one or two dozen lesions are
scattered over the general surface. In these instances the resemblance
of the whole process to an acute contagious systemic disease with
cutaneous manifestations is striking. The lesions of the affection as
ordinarily encountered appear simultaneously or in crops. As a rule,
there is very little itching, and when it exists is usually present
only in the beginning of the disease or at night. The affection is
contagious and auto-inoculable, and at times apparently epidemic; is
seen most frequently in the warm months, and is confined almost
exclusively to children. When occurring in adults it is usually of an
abortive type. In addition to the cutaneous covering, the mucous
membranes of the mouth and conjunctiva are sometimes affected. As a
rule, it runs an acute course, lasting ten days or two weeks. In
exceptional instances the disease is anomalous, as regards not only its
course, but the character and type of the individual lesions.
The causes of the disease are not understood. Some authorities consider
it due to the presence of a parasite,--a view in which we are not
prepared to coincide. A fungus--in fact, several varieties--may be
found in microscopic examinations of the crusts, but the same may be
found in crusts of other diseases, and their presence may be considered
as accidental. There seem to be two varieties of the disease, in one of
which the lesions are for the most part confined to the face and hands,
and in the other the lesions are scattered over the general surface.
The affection is encountered most frequently among the poor and
ill-cared-for. A relationship to vaccination has at times been noted.
In the diagnosis eczema and simple impetigo are to be excluded. The
history, course, and characters of the lesions of contagious impetigo
are {653} entirely different from those of these two diseases. The
size, growth, isolated character, the non-inclination to rupture, and
the comparative absence of itching will serve to distinguish it from
eczema. The pustule of simple impetigo is prominently raised; that of
contagious impetigo is flat and usually umbilicated; the contents of
the former are distinctly pustular, and the crusts thicker, smaller,
and usually yellowish-brown; of the latter the contents are rarely more
than vesico-pustular, the crust thin, light-yellowish or straw-colored,
and has the appearance of being stuck on. Those cases which resemble an
exanthem may in the early stages be confounded with varicella, but
later the lesions are much larger than seen in that disease. In
exceptional instances the resemblance to the blebs of pemphigus is more
or less pronounced.
As a rule, but little treatment is necessary, as the affection tends to
spontaneous disappearance. In some cases, however, in which there is
more or less itching, auto-inoculation at the excoriated points takes
place, and in this manner the affection may persist. An ointment of
ammoniated mercury, ten or fifteen grains to the ounce, rubbed in the
lesions, will have a curative effect; likewise an ointment or lotion of
carbolic acid, ten grains to the ounce.
Ecthyma.
Ecthyma is characterized by the formation of one or more discrete
finger-nail-sized, flat, inflammatory pustules. The pustules are
usually few in number, vary in size from that of a pea to a large
finger-nail, roundish or ovalish in shape, and are situated on an
inflammatory base, with a marked areola of a bright-red color. In the
beginning they are yellowish, but later, from an admixture of more or
less blood, they become reddish, subsequently drying to brownish but
slightly adherent crusts. If the crust is removed, a superficial
excoriation, secreting a yellowish fluid, is disclosed. The lesions
pursue an acute course, but new pustules are apt to form from time to
time. The lower extremities, shoulders and back are favorite
localities. The subjective symptoms are usually slight, but burning and
pain may be complained of. More or less pigmentation is left to mark
the site of the lesions, which sooner or later disappears. The
affection is seen in both sexes and at all ages, but is more frequently
met with in men.
It is a disease of the poorly-nourished and debilitated; hence it is
chiefly seen in the lower walks of life. All causes that tend to reduce
the tone of the general health are indirectly responsible for the
disease. In such persons external irritants, such as pediculi,
bed-bugs, and similar parasites, may provoke the formation of
ecthymatous lesions. The affection is not contagious. The process is of
a markedly inflammatory type, and tends rapidly to pus-formation. The
lesion is a typical pustule, and the excoriation does not extend deeper
than the papillary layer. Permanent scarring never results. In the
negro, instead of increased pigmentation, loss of pigment results.
The disease is to be distinguished from simple impetigo, contagious
impetigo, and the flat pustular syphiloderm. It differs from impetigo
in the flat form of the lesion and the character of its crust, and in
the more {654} inflammatory nature of the process. The
non-contagiousness of the affection, the character and color of the
crust, the regions involved, and the course will serve to differentiate
it from impetigo contagiosa. In exceptional cases of this latter
disease some of the lesions bear considerable resemblance to ecthyma. A
striking similarity to the large flat pustule of syphilis is often
noticed in ecthyma, and it is here that difficulty in the diagnosis is
most likely to be experienced. The local disturbance, such as pain and
heat, is generally more marked in ecthyma. The syphiloderm is usually
of slower development and runs a more chronic course; moreover,
positive ulceration beneath the crusts does not occur in ecthyma. The
crusts of syphilis are darker in color, and usually have a greenish
hue. Concomitant symptoms of syphilis are almost always present, and
are valuable in the diagnosis. Ecthyma can scarcely be confounded with
pustular eczema, as the size and discrete character of the pustules and
the absence of marked itching are sufficiently distinctive.