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.
[Illustration: Fig. 19. Dermatitis Exfoliativa.]
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.
[Illustration: Fig. 20. Papular Eczema (leg).]
#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 hyperaemic 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.
[Illustration: Fig. 21. Eczema Rubrum.]
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.
[Illustration: Fig. 22. Eczema Squamosum et tissum.]
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 preexisting
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.
[Illustration: Fig. 23. Eczema of the Face and Scalp.]
#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.
#State the nature of the subjective symptoms in eczema.#
Itching, commonly intense, is usually a conspicuous symptom; it may be
more or less paroxysmal. In some cases burning and heat constitute the
main subjective phenomena.
#Is eczema accompanied by febrile or systemic symptoms?#
No. In rare instances, in acute universal eczema, slight febrile action,
or other systemic disturbance, may be noted at the time of the outbreak.
#Is the eczematous eruption (patch or patches) sharply defined against
the neighboring sound skin?#
No. In almost all instances the diseased area merges gradually and
imperceptibly into the surrounding healthy integument.
#What is the character of eczema as regards the degree of inflammatory
action?#
The inflammatory action may be acute, subacute or sluggish in character,
and may be so from the start and so continue throughout its whole
course; or it may, as is usually the case, vary in intensity from time
to time.
#State the character of eczema as regards duration.#
As a rule, it is a persistent disease, showing little, if any, tendency
to spontaneous disappearance.
#Is eczema influenced by the seasons?#
Yes. With comparatively few exceptions the disease is most common and
much worse in cold, windy, winter weather.
#To what may eczema be ascribed?#
Eczema may be due to constitutional or local causes, or to both. It may
be considered, in fact, as a reaction of the skin tissues against some
irritant, and the latter may have its origin from within or without.
#Name some of the important constitutional or predisposing causes.#
Gouty diathesis, rheumatic diathesis, disorders of the digestive tract,
general debility or lack of tone, an exhausted state of the nervous
system, dentition and struma.
#Is a constitutional cause sufficient to provoke an attack?#
Yes; but often the attack is brought about in those so predisposed by
some local or external irritant.
#Mention some of the external causes.#
Heat and cold, sharp, biting winds, excessive use of water, strong
soaps, vaccination, dyes and dyestuffs, chemical irritants, and the
like. There is a growing belief that some cases presenting eczematous
aspects are probably parasitic in origin. In fact, some observers hold
to the microbic view of all cases of eczema.
Contact with the rhus plants, while producing a peculiar dermatitis,
usually running an acute course terminating in recovery, may, in those
predisposed, provoke a veritable and persistent eczema. In fact, in our
examination as to causes in a given case, especially of the hands and face,
all possible exciting factors should be inquired into, such as the handling
of plants, chemicals, dyes, etc.
[Illustration: Fig. 24. Eczema of Face.]
#Is eczema contagious?#
No. The acceptance of a parasitic cause for the disease, however,
necessarily carries with it the possibility of contagiousness under
favoring conditions. Such is not supported, however, by practical
experience.
#What is the pathology?#
The process is an inflammatory one, characterized in all cases by
hyperaemia and exudation, varying in degree according to the intensity
and duration of the disease. The rete and papillary layer are especially
involved, although in severe and chronic cases the lower part of the
corium and even the subcutaneous tissue may share in the process.
#Do the cutaneous manifestations of the eruptive fevers bear resemblance
to the erythematous type of eczema?#
Scarlatina and erysipelas may, to a slight extent, but the presence or
absence of febrile and other constitutional symptoms will usually serve
to differentiate.
#What common skin diseases resemble some phases of eczema?#
Psoriasis, seborrh[oe]a, sycosis, scabies and ringworm.
#How would you exclude psoriasis in a suspected case of eczema (squamous
eczema)?#
Psoriasis occurs in variously-sized, rounded, _sharply-defined_ patches,
usually scattered irregularly over the general surface, with special
predilection for the elbows and knees. They are covered more or less
abundantly with whitish, silvery or mother-of-pearl colored imbricated
scales. The patches are always dry, and itching is, as a rule, slight,
or may be entirely absent. Eczema, on the contrary, is often localized,
appearing as one or more large, irregularly diffused patches; it merges
imperceptibly into the sound skin, and there is often a history of
characteristic serous or gummy oozing; the scaling is usually slight and
itching almost invariably a prominent symptom.
#How would you exclude seborrh[oe]a (eczema seborrhoicum) in a suspected
case of eczema?#
Seborrh[oe]a of the scalp is more commonly over the whole of that region
and is relatively free from inflammatory symptoms; the scales are of a
greasy character and the itching is usually slight or nil. On the other
hand, in eczema of this region the parts are rarely invaded in their
entirety; there may be at times the characteristic serous or gummy
oozing; inflammatory symptoms are usually well-marked, the scales are
dry and the itching is, as a rule, a prominent symptom. These same
differences serve to differentiate the diseases in other regions.
#How does scabies differ from eczema?#
Scabies differs from eczema in its peculiar distribution, the presence
of the burrows, the absence of any tendency to patch formation, and
usually by a clear history of contagion.
#How would you exclude ringworm in a suspected case of eczema?#
Ringworm is to be distinguished by its circular form, its fading in the
centre, and in doubtful cases by microscopic examination of the
scrapings.
#How does eczema differ from sycosis?#
Sycosis is limited to the hairy region of the face, is distinctly a
follicular inflammation, and is rarely very itchy; eczema is diffused,
usually involves other parts of the face, and itching is an annoying
symptom.
#State the general prognosis of eczema.#
The disease is, under favorable circumstances, curable, some cases
yielding more or less readily, others proving exceedingly rebellious.
The length of time to bring about a result is always uncertain, and an
opinion on this point should be guarded.
#Upon what would you base your prognosis in the individual case?#