and, if necessary, by means of the microscope. This instrument should
{719} always be employed in cases of doubt. At times it bears
resemblance to eczema and seborrhoea, and to psoriasis. From eczema it
may be distinguished by its circular or annular form, its
sharply-defined margins, its tendency to clear up in the centre, its
slight desquamation, and its history and course; the itching is usually
less marked than in eczema. Seborrhoea, when occurring on the chest and
back, often consists of circular patches similar in general features to
ringworm, but the scales are greasy, and are seated upon non-inflamed
skin; the scaliness of ringworm is the result of inflammation, while
that of seborrhoea consists of dried sebaceous matter. Moreover, in the
latter affection the sebaceous follicular openings are perceptibly
enlarged, and are indicative of the nature of the disease. In psoriasis
at times the patches clear up in the centre, and in such instances a
mistake in diagnosis might occur. The scaliness of psoriasis, however,
is always a marked feature; it is usually insignificant in ringworm.
Moreover, the characters of the scales are different. Occasionally the
circinate tubercular syphiloderm has been confounded with ringworm, but
the nature of the patch in the former disease, consisting of an
irregular and incomplete ring of elevated tubercles or infiltrations,
with, at times, ulceration, is so entirely different from the latter
affection that an error should not occur. It can scarcely be confounded
with favus if the peculiar yellowish, cup-shaped crusts of that disease
are kept in mind; the clinical features of the two affections are also
in other respects dissimilar.
The treatment consists in the application of the milder parasiticides,
the disease rarely proving obstinate. In exceptional cases, where the
affection is persistent, it will sometimes be found that the general
nutrition is below the standard; and in such instances constitutional
remedies of a tonic nature, as cod-liver oil, iron, quinine, and
arsenic, are serviceable. In children the skin is delicate and strong
remedies are not well borne; nor are they, as a rule, necessary. The
parts should be first washed with soap and water, and then the remedial
applications made; the lotion or ointment should be applied two or
three times daily. If a lotion, it should be dabbed on thoroughly; if
an ointment, it should be thoroughly rubbed into the patches. The
sulphite or hyposulphite of sodium, in lotion or ointment form, a
drachm to the ounce; sulphurous acid, full strength or diluted;
ammoniated mercury, thirty to sixty grains to the ounce of lard or
vaseline; corrosive sublimate, two to four grains to an ounce of
alcohol or water; an ointment of sulphur, a drachm or two to the ounce;
tar ointment, a drachm or two to the ounce; carbolic acid, ten to
thirty grains to the ounce of water or lard,--are all parasiticides of
value which may be employed in this disease. In obstinate cases
chrysarobin, five to thirty grains to the ounce of lard, may be
cautiously used, or it may be applied in collodion or gutta-percha
solution, 5 to 10 per cent. strength. In tinea circinata cruris
applications such as the above, but stronger, are serviceable. R. W.
Taylor speaks well of a solution of corrosive sublimate in tincture of
benzoin, two to four grains to the ounce, painted over the parts. The
chrysarobin ointment or solution already mentioned may also be
especially referred to. Hebra's modification of Wilkinson's ointment
(see Scabies for formula) is useful in these cases. In tinea
trichophytina unguium the nail should be pared or scraped, and one of
the parasiticides applied.
* * * * *
{720} TINEA TONSURANS.--Tinea tonsurans, or ringworm of the scalp, is
characterized by circular or irregularly-shaped, variously-sized,
scaly, more or less bald patches, showing the hair to be diseased and
usually broken off close to the scalp. It is met with in children,
especially in those under the age of twelve years; it is rarely seen
after puberty. It begins as one or more small, round, erythematous,
scaly spots, which may be minutely papulo-vesicular or vesicular about
the periphery. Soon by peripheral growth typical circular patches of
various sizes are formed, averaging about an inch in diameter. More or
less itching is usually complained of. A typical patch is
circumscribed, slightly elevated, reddish, grayish or slate-colored,
with more or less scaling, usually thin or bran-like in character, with
the hairs broken off close to the scalp. The color varies with the
complexion of the individual; in marked blondes it has usually an
inflammatory tint, while in those of dark hair and skin it is
bluish-gray or the color of slate. The hairs on the affected areas are
involved early in the disease, becoming lustreless, dry, brittle,
twisted, breaking off close to the skin, with their free extremities
ragged and uneven, having a gnawed or nibbled look. They are easily
extracted, or often break off within the follicles, appearing then as
blackish dots. A variable degree of baldness occurs, which, however, is
rarely permanent. In some instances the patch is non-inflammatory and
free of scales, the loss of hair, which is more or less complete,
taking place rapidly, such cases bearing resemblance to alopecia
areata. As a rule, several patches varying in duration and size are
present. They may remain discrete, or coalesce and form irregular
areas. The vertex and parietal regions are favorite localities,
although any region of the scalp may be invaded. It is not uncommon to
see patches of the disease on the non-hairy portions of the body at the
same time.
In some cases, especially in those ill nourished and scrofulous, the
inflammation may be of a higher grade, resulting in the production of
discrete or grouped pustules, terminating in crusting; or the disease
may assume the condition known as tinea kerion. This latter is seen
most commonly in scrofulous subjects. Beginning ordinarily as a simple
patch of ringworm, the affected area soon becomes inflamed, swollen,
oedematous, elevated, red, shining and boggy, covered with a mucoid
secretion which is poured out from the openings of the hair-follicles.
The stubby hairs soon fall out, leaving the patch more or less bald.
The surface is uneven and studded with the foramina, or small cavities,
containing the mucoid or sero-purulent secretion, corresponding to the
dilated hair-follicles. It bears resemblance to abscess and carbuncle.
An analogous condition is not uncommon in tinea sycosis. It may occur
with the usual form of tinea tonsurans or alone. Occasionally the
disease cures itself in this way. It may, however, be chronic. Its
causes are not understood: it may be due to the presence of the fungus
in the deeper portions of the hair-follicles, or at times to
over-treatment. It is a rare manifestation.
Other unusual forms of the disease are occasionally noted. The spots
may in the early stages be merely scaly, with or without inflammatory
symptoms, and the hairs long and firmly seated, resembling eczema or
seborrhoea. Later, however, the hairs break and the characteristic
stumps are the result. As ringworm becomes chronic (its usual course)
the clinical features become different. The disease exists in irregular
areas--as {721} a rule, non-inflammatory and more or less scaly,
especially about the follicles. The hairs are short, stubby, and broken
off near the skin or in the apertures of the follicles; in the latter
case the skin has a punctate or dotted appearance. This condition is
noted especially in brunettes; in blondes the hairs are somewhat longer
and apt to drop out insidiously. Or, the disease may be disseminated,
involving here and there over the scalp small groups of follicles, the
hairs being short, the follicles slightly enlarged, with a tendency to
scaliness; in these cases the disease may be easily overlooked.
Ringworm of the scalp is a common affection, and is observed among the
rich as well as the poor, but is most frequent in those suffering from
malnutrition. It may be communicated by means of caps, combs, brushes,
and the like. It is frequently seen in schools and children's asylums,
sometimes affecting a large proportion of the inmates. The fungus
(trichophyton) invades the epidermis, hair-follicle, bulb, and shaft.
The follicle becomes distended and raised; the hairs are permeated with
the fungus (spores markedly predominating), are disintegrated, and
destroyed. The perifollicular tissue may, in severe cases, be invaded.
The spores are present in great abundance, the mycelium existing
scantily.
As a rule, there is no difficulty in recognizing the disease. The
presence of stumps of hair having a gnawed or nibbled look, the
prominent follicles, more or less baldness, and slight or decided
scaliness, together with the history and course, constitute a clinical
picture that is scarcely mistakable. If necessary, microscopical
examination of the hair will give positive information. For this
purpose one or two of the short, stubby hairs should be selected,
placed upon a slide, a drop of liquor potassæ added, allowed to stand a
few minutes, and then examined with a power of two to five hundred
diameters; the hairs will be found full of spores, the shafts being
completely disintegrated. If a few drops of chloroform are poured upon
a patch of ringworm of the scalp and allowed to evaporate, the hairs
and follicular openings affected become whitish or light-yellow, which,
according to Duckworth, is pathognomonic. It is to be differentiated
from squamous eczema, seborrhoea, psoriasis, and alopecia areata. The
history of eczema is different: it rarely begins as circular spots,
spreading peripherally; the margins are always more or less irregular;
the hairs are not involved, but remain seated firmly in the follicles;
the itching is marked, whereas in ringworm it is usually slight.
Seborrhoea is non-inflammatory; the scales are greasy; the hairs are
not broken off; and the margins of the patch are ill defined. In
psoriasis the scaling is a marked feature; the hairs are not involved;
and the disease is usually to be found typically expressed on other
parts of the body. From alopecia areata ringworm may be differentiated
by its clinical features; in the former disease the baldness is usually
complete, the skin devoid of scales, non-inflamed, smooth, shining, and
the follicles, as a rule, less prominent than normal; the absence of
the characteristic stumps of ringworm may also be noted. In obscure
cases the microscope is to be employed.
An opinion regarding the length of time required to cure ringworm of
the scalp should always be guarded; while some cases respond in several
weeks, in others several months or more may be required. Relapses are
liable to occur. External remedies are, as a rule, alone required. In
{722} chronic cases, however, where a condition of malnutrition exists,
proper food, fresh air, and suitable internal remedies, as cod-liver
oil, iron, and arsenic, are to be advised; cleanliness is of
importance. The patches should be washed frequently with warm water and
castile soap or sapo viridis, the frequency depending upon the scaling
and the amount of disease, and also somewhat upon the remedies
employed. Occasional washing of the entire scalp is also to be advised.
Remedial applications should be, as a rule, made twice daily. In acute
or recent cases, in which the fungus has not penetrated deeply into the
hair-follicles, it often yields to the ordinary parasiticides, without
the necessity of epilation. In cases commonly encountered, however, the
disease has already lasted some length of time, and epilation becomes
essential. The main difficulty in the treatment of tinea tonsurans is
to bring the remedy in contact with the fungus; otherwise the affection
would be as easily curable as that occurring on the general surface. To
a great extent epilation aids in overcoming this difficulty, as the
parasiticide is then able to permeate the emptied follicle; and in
addition to this advantage the extracted hairs take with them the
fungus contained within their structures. The hair within and around
the affected areas should be clipped short, or, if the patches are
numerous, the hair of the entire scalp should be cut, or, what is
preferable in many cases, shaved. If the scalp is shaved, a few days
elapse before epilation is possible. On a shaved head there is no
chance for any diseased area, however small, to escape observation; in
the treatment of the disease as met with in institutions this procedure
is almost essential. In epilation the loose hairs on the patches and
about the borders should first receive attention. For this purpose a
small, broad-bladed, short forceps may be employed, a few hairs at a
time being seized. A portion of the diseased area should be carefully
gone over each day until all are removed. After each epilation the
parasiticide is to be applied.
Corrosive sublimate, two to four grains to the ounce of alcohol or
water, is a reliable remedy; also oleate of mercury, in the form
preferably of a 25 per cent. ointment. An ointment such as the
following is serviceable in many cases:
Rx. Ugt. picis liquidæ,
Ugt. hydrarg. nitrat., aa. drachm ij;
Ugt. sulphuris, drachm iv.
M. Ft. ugt.
Or, in place of the tar ointment in the formula, carbolic acid in the
same or less quantity may be substituted. The officinal tar, sulphur,
and ammoniated mercury ointments may also be referred to as useful. In
small disseminated patches carbolic acid in glycerin, one to three
drachms of the former with enough of the latter to make an ounce, will
often prove serviceable. Thymol sometimes proves of value, and may be
prescribed as advised by Malcolm Morris:
Rx. Thymolis, drachm ss;
Chloroformis, drachm ij;
Olei olivæ, drachm vj. M.
Coster's paste is also serviceable:
Rx. Iodinii, drachm ij;
Olei picis, ounce j. M.
{723} This is painted on the patch, and permitted to remain on until
the crust comes off, then is reapplied: a few applications are
sometimes sufficient. In tinea kerion the hairs are extracted and a
mild parasiticide applied: sulphurous acid, a weak solution of
corrosive sublimate, carbolic acid, ten to twenty grains to the ounce
of water, or a weak ointment of the oleate of mercury or of white
precipitate, may be employed.
If the disease proves obstinate, resisting the above treatment, it may
be necessary to adopt stronger applications with a view of producing an
acute inflammation in the part. To be efficacious the inflammatory
action should be marked. For this purpose croton oil is used. It should
never be employed when the disease is extensive; or if used in such
cases a small area only, not exceeding that of a quarter dollar, should
be treated at one time. Although valuable, the remedy is severe, and
must be used cautiously. It may be applied pure or weakened with two or
three parts of olive oil. An application requires but a small quantity,
as it is apt to involve the skin beyond the area of application. In
some cases a single application is sufficient; in others several or
more are necessary before the requisite amount of follicular
inflammation and suppuration results. The applications should be made
by the physician, as it is not a safe remedy to entrust to attendants.
After the application the part should be poulticed, and subsequently
epilation practised and mild parasiticides employed. Instead of using
croton oil, the patches may be painted with glacial acetic acid or
cantharidal collodion once a week, and mild parasiticides, as
sulphurous acid, carbolic-acid lotion, or sulphur ointment, applied in
the interval. From time to time in the treatment of the disease,
usually at intervals of from three to four weeks, applications should
be discontinued a few days, and a microscopic examination of the scales
and hairs made: if fungus is found, treatment is to be resumed.
* * * * *
TINEA SYCOSIS.--Tinea sycosis, or parasitic sycosis, is a disease
confined to the hairy portions of the face and neck in the adult male,
involving the hair and hair-follicles, with inflammation of the skin
and subcutaneous connective tissue, and the formation of tubercles and
pustules. It is popularly known under the name of barber's itch. It
usually begins as one or more small, red, scaly spots, similar, in
fact, to ringworm on the non-hairy portions of the surface. The redness
and scaliness increase, and swelling and induration are noticed. In a
short time the hairs are involved, become dry, brittle, inclined to
break, and begin to fall out, the same changes occurring as noted in
ringworm of the scalp. The fungus passes to the hair-follicles;
perifollicular inflammation is set up, and results in the formation of
deep-seated tubercles, varying in size from a pea to that of a cherry,
giving the part a distinct nodular appearance. These coalesce and give
rise to lumpy patches. The surface is of a deep reddish or purplish
color; pustulation is noted about the openings of the hair-follicles.
More or less crusting may take place; if removed, the hairs may come
away with it. The amount of suppuration depends upon the grade of
inflammation. Sometimes the hair-follicles are destroyed and permanent
alopecia results.
The disease may involve a small area, appearing as a
sharply-circumscribed, prominently-raised, deep-seated, nodular,
coin-sized patch, with or without a purulent discharge from the emptied
hair-follicles or with {724} crusting; or the whole bearded region of
the neck and chin may be invaded. It is not common on the upper lip or
the upper bearded portion of the cheeks. Burning and itching are
usually present, but are variable as to degree. The disease tends to
chronicity. It is not uncommon at the same time to see patches of
ringworm on other portions of the body. It is markedly contagious,
although individuals differ as to susceptibility. It is often
contracted at the hands of a barber. The fungus (trichophyton) which
gives rise to the disease invades the same parts as when seated upon
the scalp--the epidermis and the hair and hair-follicles; the latter
are usually found permeated with spores, the mycelium being scanty.
The affection is not common, its frequency varying in different
countries. It is to be distinguished from simple (non-parasitic)
sycosis, pustular eczema, and the vegetating syphiloderm. In simple
sycosis the process is comparatively superficial and confined to the
hair-follicles; the hairs are not involved, and in the beginning, at
least, are seated firmly in the follicles. In tinea sycosis the skin
and subcutaneous connective tissue are extensively involved, resulting
in the formation of nodular masses--a condition that is characteristic;
the hairs are affected, are loose, and often fall out. In doubtful
cases the microscope will determine. From pustular eczema it may be
differentiated by its history and course: its clinical features are
entirely dissimilar. Eczema is never attended with the nodular and
tubercular formation peculiar to this disease, nor are the hairs
affected. The absence of ulceration will distinguish the disease from
the vegetating syphiloderm. Tinea sycosis when occurring as a
circumscribed patch may sometimes resemble carbuncle.
In the treatment epilation with the use of parasiticides is employed;
as a rule, the disease yields readily to treatment. Crusts, if present,
are to be removed by means of oily applications and washings with
castile soap (or if necessary sapo viridis) and warm water. The parts
should be clipped or shaved, preferably the latter. Although this
operation is painful at first, later it may be accomplished without
much discomfort; shaving every second or third day is frequent enough.
In the interval epilation is to be practised. The milder parasiticides,
as sulphite or hyposulphite of sodium, a drachm to the ounce of water
or ointment; sulphurous acid, full strength or diluted; citrine
ointment, two or three drachms to the ounce of vaseline or lard; and a
weak sulphur ointment,--are all useful. A 10 to 30 per cent. ointment
of oleate of mercury is a valuable remedy; the same may be said of a
solution of corrosive sublimate, two to four grains to the ounce of
water or alcohol. In addition, the other parasiticides mentioned in the
treatment of ringworm of the body or scalp may be referred to. The
applications should be made twice daily; together with epilation they
should be continued until microscopical examinations of the hairs give
negative results.
Tinea Versicolor.
Tinea versicolor is a vegetable parasitic disease due to the
microsporon furfur, characterized by variously-sized,
irregularly-shaped, dry, slightly furfuraceous, yellowish, macular
patches, occurring for the most part upon {725} the trunk and in
adults. The affection may be slight, consisting of several small
patches on the upper part of the chest, or so extensive as to involve
the greater part of the trunk, neck, axillæ, flexures of the elbows,
groins, and in very rare instances the face. It never occurs on the
scalp, hands, or feet. As commonly met with, it is a disease of the
trunk, especially the anterior portion of the thorax. It begins as
small yellowish or brownish, fawn-colored, furfuraceous spots scattered
over the region affected. These gradually increase in size, new spots
may appear, and considerable surface may be invaded. In size they vary
from a pea to large irregular patches, and are scarcely, if at all,
elevated. The larger patches are irregular, and usually formed by
coalescence of several smaller spots. Rarely patches may clear up in
the centre and assume an annular form.
The number of patches varies; as a rule, a half dozen or more are
present; in other cases they may be numerous. They show more or less
furfuraceous scaling, varying with the amount of perspiration and the
frequency with which the parts are washed. The scaling, even when it is
insignificant or when the patches are apparently smooth, may be easily
detected by scratching or scraping the surface. Slight itching is
ordinarily present, especially when the parts are unusually warm; it is
rarely marked. The color is usually a pale or brownish yellow. In
sensitive skins at times the affection causes more or less hyperæmia,
and the spots have a reddish hue. The course of the disease is
variable, sometimes spreading rapidly, while in most cases its progress
is slow. It is, as a rule, persistent, existing years. Relapses are not
uncommon.
The cause of the disease is the vegetable fungus, the microsporon
furfur. It invades the superficial portion of the epidermis. The
affection is but slightly contagious. Those between the ages of twenty
and forty, of either sex indifferently, are most frequently the
subjects of the disease; it rarely if ever occurs in children or in
elderly people. It is commonly observed in those whose nutrition is
below the standard, especially in persons having pulmonary phthisis. It
is a common affection, and occurs, in varying proportions, in all parts
of the world. Scrapings or scales moistened with liquor potassæ may be
examined with a power of three to five hundred diameters, and the
peculiar features of the fungus well brought out, as the fungus exists
in abundance. It consists of mycelium and spores, the former appearing
as short, slender, variously-sized, straight or curved, twisted, wavy,
or angular threads, crossing one another in all directions. In
appearance they are homogeneous or granular, and often contain spores,
especially about the joints. The spores are ovalish or round, sharply
contoured, small in size, with a nucleus and slightly granular plasma.
They show a marked tendency to aggregate and form groups--an
arrangement which is characteristic of this fungus. The growth is found
in every stage of development from mycelium to spores.
There should be no difficulty in recognizing the disease if its
characters and distribution are kept in mind. In doubtful cases the
microscope will prevent error. It is at times confounded with chloasma,
vitiligo, and the macular syphilide. In chloasma, in which there is
merely an increase of pigment in the rete, there is no scaling, the
outlines are ill defined, and it is usually seen about the face--a
region that is practically exempt in tinea versicolor. Moreover, the
coloration in the parasitic disease is due to the {726} fungus, which
has its seat in the superficial epidermis and can be readily scraped
off. With ordinary care it is impossible to mistake vitiligo for the
disease in question. The macular syphiloderm is to be distinguished by
attention to the distribution, character, and size of the lesions.
Tinea versicolor is practically a disease of the trunk; the macular
syphiloderm is usually distributed over the whole surface; and if it is
the latter disease concomitant symptoms of syphilis are almost
invariably present.