Liq. potassae, ........................ f[dram]ij
Liq. ammonii acetat., .... q.s. ad ... f[Oz]iij. M.
SIG.--f[dram]j-f[dram]ij t.d., largely diluted.
#State the character of the local treatment in acne.#
This must vary somewhat with the local conditions. Cases which are acute
in character, in the sense that the lesions are markedly hyperaemic,
tender and painful, require milder applications, and in exceptional
instances soothing remedies are to be prescribed. As a rule, however,
stimulating applications may be employed from the start.
The remedies are, for obvious reasons, most conveniently applied at
bedtime.
#What preliminary measures are to be advised in ordinary acne cases?#
Washing the parts gently or vigorously, according to the irritability of
the skin, with warm water and soap; subsequently rinsing, and sponging
for several minutes with hot water, and rubbing dry with a soft towel;
after which the remedial application is made. In sluggish and
non-irritable cases sapo viridis or its tincture may often be
advantageously used in place of the ordinary toilet soap.
The blackheads, so far as practicable, are to be removed by pressure
with the fingers or with a suitable instrument (see Comedo), and the
superficial pustules punctured and the contents pressed out. Scraping
the affected parts with a blunt curette is a valuable measure, but is
temporarily disfiguring. As a rule, however, cases do just as well
without puncturing and scraping, and these methods sometimes leave
behind scarring.
#State the methods of external medication commonly employed.#
By ointments and lotions. If an ointment is used, it is to be thoroughly
rubbed in, in small quantity; if a lotion is employed, it is to be well
shaken, the parts freely dabbed with it for several minutes and then
allowed to dry on.
#State the object in view in local medication.#
To hasten the maturation and disappearance of the existing lesions, and
to stimulate the skin and glands to healthy action.
If slight irritation or scaliness results, the application is to be
intermitted one or two nights; in the meantime nothing except the
hot-water sponging, with or without the application of a mild soothing
ointment, is to be employed.
#Is it usually necessary to change from one external remedy to another in
the course of treatment?#
Yes. After a certain time one remedy, as a rule, loses its effect, and a
change from lotion to ointment or the reverse, and from one lotion or
ointment to another, will often be found necessary in order to bring
about continuous improvement.
#Name the various important remedies and combinations employed in the
external treatment of acne.#
Sulphur is the most valuable. It may often be applied with benefit as a
simple ointment:--
[Rx] Sulphur, praecip., .................... [dram]ss-[dram]j
Adipis benz.
Lanolin, ............ [=a][=a] ....... [dram]ij.
Or it may be used as a lotion, as in the annexed formula:--
[Rx] Sulphur, praecip., .................... [dram]iss
Pulv. tragacanthae, ................... gr. x1
Pulv. camphorae, ...................... gr. xx
Liq. calcis, ........ q.s. ad ........ f[Oz]iv. M.
Another lotion, especially useful in those cases in which an oily
condition of the skin is present, is the following:--
[Rx] Sulphur, praecip., .................... [dram]iss
Etheris, ............................. f[dram]iv
Alcoholis, ........................... f[Oz]iijss. M.
A compound lotion containing sulphur in one of its combinations is also
valuable in many cases:--
[Rx] Zinci sulphatis,
Potassii sulphureti, .... [=a][=a] ... [dram]ss-[dram]iv
Aquae, ................................ [Oz]iv. M.
(The salts should be dissolved separately and then mixed; reaction takes
place and the resulting lotion, when shaken, is milky in appearance, and
free from odor; allowed to stand the particles settle, the sediment
constituting about one-fourth to three-fourths of the whole bulk).
At times the addition to this formula of several drachms of alcohol and
of five to ten minims of glycerin is of advantage.
An external remedy, often valuable, is ichthyol. It is thus
prescribed:--
[Rx] Ichthyol, ............................ [dram]ss-[dram]j
Cerat. simp., ........................ [dram]iv. M.
The various mercurial ointments, especially one of white precipitate,
five to fifteen per cent. strength, are sometimes beneficial.
A compound lotion, containing mercury, which frequently proves
serviceable, is:--
[Rx] Hydrarg. chlorid. corros., ........... gr. ii-viij
Zinci sulphatis, ..................... gr. x-xx
Tinct. benzoini, ..................... f[dram]ij
Aquae, ............ q.s. ad ........... f[Oz]iv.
In extremely sluggish cases the following, used cautiously, is of
value:--
[Rx] Ichthyol,
Saponis viridis,
Sulphur, praecip.,
Lanolin, ............. [=a][=a] ...... [dram]j.
In such instances the application of a strong alcoholic resorcin lotion,
ten to twenty-five per cent. strength, repeated several times daily till
marked irritation and exfoliation occur (a matter usually of one to
three days), will sometimes be followed by marked improvement. Acne of
the back is treated with the same applications, but usually stronger; in
this region applications of Vleminckx's solution and formaldehyde
solution, weakened considerably, at first at least, prove of value.
_Obstinate and indurated lesions_ may be incised, the contents pressed
out, and the interior touched with carbolic acid by means of a pointed
stick. The _x_-ray has proved a most valuable addition to our resources
in the treatment of acne, and is especially serviceable in extensive and
obstinate cases. An exposure should be made about twice weekly, at a
distance of five to ten inches and for from three to ten minutes, and a
tube of medium vacuum used. It must be used with great caution and never
beyond the production of the mildest erythema. The hair, eyes, and lips
should be protected. The _x_-ray treatment is best reserved for
obstinate cases, and then used mildly, and rather as an adjuvant to the
ordinary methods than as the sole measure.
#What precaution is to be taken in advising a change from a sulphur to a
mercurial preparation or the reverse?#
Several days should be allowed to intervene, otherwise a disagreeable,
although temporary, staining or darkening of the skin results--from the
formation of the black sulphuret of mercury.
#Acne Rosacea.#
#Give a descriptive definition of acne rosacea.#
Acne rosacea is a chronic, hyperaemic or inflammatory disease, limited to
the face, especially to the nose and cheeks, characterized by redness,
dilatation and enlargement of the bloodvessels, more or less acne and
hypertrophy.
#Describe the symptoms of acne rosacea.#
The disease may be slight or well-marked. Redness, capillary dilatation,
and acne lesions seated on the nose and cheeks, and sometimes on chin
and forehead also, constitute in most cases the entire symptomatology.
A mild variety consists in simple redness or hyperaemia, involving the
nose chiefly and often exclusively, and is to be looked upon as a
passive congestion; this is not uncommon in young adults and is
often associated with an oily seborrh[oe]a of the same parts. In many
cases the condition does not progress beyond this stage. In other
cases, however, sooner or later the dilated capillaries become
permanently enlarged (_telangiectasis_) and acne lesions are often
present--constituting the middle stage or grade of the disease; this is
the type most frequently met with. In exceptional instances, still
further hypertrophy of the bloodvessels ensues, the glands are enlarged,
and a variable degree of connective-tissue new growth is added; this
latter is usually slight, but may be excessive, the nose presenting an
enlarged and lobulated appearance (_rhinophyma_).
[Illustration: Fig. 25. Acne Rosacea.]
#Are there any subjective symptoms in acne rosacea?#
As a rule, no. Some of the acne lesions may be tender and painful, and
at times there is a feeling of heat and burning.
#What do you know in regard to the etiology?#
In many cases the causes are obscure. Chronic digestive and intestinal
disorders, anaemia, chlorosis, continued exposure to heat or cold,
menstrual and uterine irregularities, and the too free use of spirituous
liquors, tea, etc. are often responsible factors.
It is essentially a disease of adult life, common about middle age,
occurring in both sexes, but rarely reaching the same degree of
development in women as observed at times in men.
#Is acne rosacea easily recognized?#
Yes. The redness, acne lesions, dilated capillaries, and, at times, the
glandular and connective-tissue hypertrophy; the limitation of the
eruption to the face, especially the region of the nose; the evident
involvement of the sebaceous glands, the absence of ulceration, taken
with the history of the case, are characteristic.
It is to be distinguished from the tubercular syphiloderm and lupus
vulgaris, diseases to which it may bear rough resemblance.
#State the prognosis of acne rosacea.#
All cases may be favorably influenced by treatment; the mild and
moderately-developed types are, as a rule, curable, but usually
obstinate. It is a persistent disease, showing little, if any, tendency
to disappear spontaneously.
#What is the method of treatment?#
Both constitutional and local measures are demanded in most cases.
#Upon what is the constitutional treatment to be based?#
The constitutional treatment, beyond a regulation of the diet, is to be
based upon a correct appreciation of the etiological factors in the
individual case. There are no special remedies. Iron, cod-liver oil,
tonics, ergot, alkalies, saline laxatives, and similar drugs are to be
variously prescribed.
#What is the external treatment?#
In many respects, both as to the preliminary measures and remedies,
essentially the same as that employed in the treatment of simple acne
(_q. v._). The _x_-ray treatment is not so efficient in this disease,
however, as in acne. In addition to the treatment there found, several
other applications deserve mention:--
In many cases _Vleminckx's solution_[C] is valuable, applied diluted
with one to ten parts of water. Also, a mucilaginous paste containing
sulphur:--
[Rx] Mucilag. acaciae, ..................... f[dram]iij
Glycerinae, ........................... f[dram]ij
Sulphur, praecip., .................... [dram]iij. M.
[Footnote C:
[Rx] Calcis, .............................. [Oz]ss
Sulph. sublimat., .................... [Oz]j
Aquae, ................................ [Oz]x.
To be boiled down to [Oz]vj and filtered.]
Or a similar paste with the glycerine in the foregoing replaced with
ichthyol may be used.
#In what manner are the dilated bloodvessels and connective-tissue
hypertrophy to be treated?#
The enlarged capillaries are to be destroyed by incision or by
electrolysis. Properly managed the vessels may be thus destroyed, but
unless the predisposing causes have disappeared or have been remedied, a
new growth may take place.
If the knife is employed, the vessels are either slit in their length or
cut transversely at several points. The method by electrolysis is the
same as used in the removal of superfluous hair (_q. v._).; the needle
may, if the vessel is short, be inserted along its calibre, or if long,
may be inserted at several points in its length.
Excessive connective-tissue growth, exceptionally met with, is to be
treated by ablation with the scissors or knife.
#Acne Varioliformis.#
(_Synonyms:_ Acne Frontalis; Acne Rodens; Acne Necrotica; Lupoid Acne;
Necrotic Granuloma.)
#Describe acne varioliformis.#
Acne varioliformis is characterized by lesions of a moderately
superficial papulo-pustular type, which in disappearing leave slight or
pit-like scars. The forehead and scalp are the favorite sites, but they
may also occur elsewhere. The eruption is rather scanty as a rule,
consisting usually of ten to thirty lesions. They begin as small
maculo-papules, as papules, or as minute nodules in or on the skin, and
gradually become small pea-sized, with a tendency to slight vesiculation
or pustulation at the central part. The lesion is sluggish in its
course, drying to a thin crust, which finally falls off, leaving a
depressed variola-like scar. New lesions arise from time to time, and
the disease thus continues almost indefinitely. There may or may not be
itching. In what appears to be a variety of this disease, known usually
as _acne urticata_, there is considerable itching just at the time the
lesion is appearing. The malady is not frequent, but occurs in both
sexes, usually in those between the ages of twenty and fifty. It seems
probable that the eruption is parasitic in origin.
The maladies variously known as hydradenitis suppurativa, acnitis,
spiradenitis, folliclis, granuloma necroticum, etc., in which the
lesions, primarily at least, are somewhat deeper seated, sluggish in
their course, and followed by scarring, could be also included under
this head.
#Give the prognosis and treatment.#
The disease is rebellious and tends to recur. The most efficient
applications are those of sulphur and resorcin, the same as prescribed
in ordinary acne.
#Sycosis.#
(_Synonyms:_ Sycosis Vulgaris; Sycosis Non-parasitica; Folliculitis
Barbae; Sycosis Coccogenica.)
#What do you understand by sycosis?#
Sycosis is a chronic, inflammatory affection involving the
hair-follicles, usually of the moustache and bearded regions only, and
characterized by papules, tubercles, and pustules perforated by hairs.
#Describe the symptoms of sycosis.#
Sycosis begins by the formation of papules and pustules about the
hair-follicles; the lesions occur in numbers, in close proximity,
and together with the accompanying inflammation, make up a small or large
area. The pustules are small, rounded, flat or acuminated, discrete, and
yellowish in color; they are perforated by hairs, show no tendency to
rupture, and are apt to occur in crops, drying to thin yellowish or
brownish crusts. Papules and tubercles are often intermingled. More or
less swelling and infiltration are noticeable.
[Illustration: Fig. 26.
Sycosis--not infrequently begins in, and sometimes limited to, this
region.]
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. It is also sometimes met with involving the
hair follicles just within the nasal orifice, and may even be limited to
this region.
Occasionally a sycosiform eruption, usually of the side of the bearded
region, leaves behind a smooth or keloidal scar, the disease gradually
extending--_ulerythema sycosiforme_ (lupoid sycosis).
An inflammation of the hair-follicles of the scalp apparently sycosiform
in character, occurring as discrete or aggregated lesions, is sometimes
observed, the follicles being destroyed and atrophy or slight scarring
resulting--_folliculitis decalvans_.
#Does conspicuous hair loss occur in sycosis?#
Ordinarily not; the hairs are, especially at first, usually firmly
seated, but in those cases in which suppuration is active, and has
involved the follicles, they may, as a rule, be easily extracted. In
some cases destruction of the follicles ensues and slight scarring and
permanent hair loss result.
#State the character of the subjective symptoms.#
Pain and itching and a sense of burning, variable as to degree, may be
present.
#What is the course of the disease?#
Essentially chronic, the inflammatory action being of a subacute or
sluggish character, with acute exacerbations.
#State the causes of sycosis.#
Upon the upper lip it may have its origin in a nasal catarrh. Entrance
into the follicles of pyogenic micrococci is now regarded as the
essential factor. This view being accepted, carries with it the
possibility of contagiousness.
It is seen in the male sex only, usually in those between the ages of
twenty-five and fifty; and is met with in those in good and bad health,
and among rich and poor. It is comparatively infrequent.
#What is the pathology of sycosis?#
The disease is primarily a perifolliculitis, the follicle and its sheath
subsequently becoming involved in the inflammatory process.
#How would you distinguish sycosis from eczema?#
Eczema is rarely sharply limited to the bearded region, but is apt to
involve other parts of the face; moreover, the lesions are usually
confluent, and there is either an oozing, red crusted surface, or it is
dry and scaly.
#How would you exclude tinea sycosis in the diagnosis?#
In tinea sycosis, or ringworm sycosis, the history of the case is
different. The parts are distinctly lumpy and nodular; the hairs are
soon involved and become dry, brittle, loose, and fall out, or they may
be readily extracted. The superficial type of ringworm sycosis is
readily distinguished by the ring-like character of the patches. In
doubtful cases, microscopic examination of the hairs may be resorted to.
#Give the prognosis of sycosis.#
The disease is curable, but almost invariably obstinate and rebellious
to treatment. The duration, extent, and character of the inflammatory
process must all be considered. An expression of an opinion as to the
length of time required for a cure should always be guarded.
Ulerythema sycosiforme is extremely obstinate. Folliculitis decalvans is
also rebellious.
#How is sycosis to be treated?#
Mainly, and often exclusively, by external applications.
[Illustration: Fig. 27. Sycosis.]
#Is constitutional treatment of no avail in sycosis?#
In some instances; but, as a rule, it is negative. If indicated, such
remedies as tonics, alteratives, cod-liver oil and the like are to be
prescribed.
#Describe the external treatment.#
Crusting, if present, is to be removed by warm embrocations. If the
inflammation is of a high grade, and the parts tender and painful,
soothing applications, such as bland oils, black wash and oxide-of-zinc
ointment, cold cream and petrolatum, are to be used; boric-acid
solution, fifteen grains to the ounce, may be advised in place of black
wash.
In most cases, however, astringent and stimulating remedies are demanded
from the start, such as: diachylon ointment, alone or with ten to thirty
grains of calomel to the ounce; oleate of mercury, as a five- to
twenty-per-cent. ointment; precipitated sulphur, one to three drachms to
the ounce of benzoated lard, or lard and lanolin; a ten- to
twenty-five-per-cent. ichthyol ointment; and resorcin lotion or
ointment, ten to twenty per cent. strength.
[Illustration: Fig. 28. Sycosis.]
A change from one application to another will be found necessary in
almost all cases.
In obstinate cases the x-ray treatment can be used, as it has proved
itself valuable in some instances; as in other diseases, it should be
employed cautiously.
#What would you advise in regard to shaving?#
When bearable (and after a few days' application of soothing remedies it
almost always is), it is to be advised in all cases, as it materially
aids in the treatment. After a cure is effected it should be continued
for some months, until the healthy condition of the parts is thoroughly
established.
#When is depilation advisable as a therapeutic measure?#
When the suppurative process is active, in order to save the follicles
from destruction; incising or puncturing the pustules will often
accomplish the same end.
Depilation is in all cases a valuable therapeutic measure, but it is
painful; as a routine practice, shaving is less objectionable and, upon
the whole, is probably as satisfactory. Those who make free use of the
x-ray commonly push it to the point of producing depilation.
#Dermatitis Papillaris Capillitii.#
(_Synonym:_ Acne Keloid.)
[Illustration: Fig. 29. Dermatitis Papillaris Capillitii.]
#Describe dermatitis papillaris capillitii.#
This is a peculiar, mildly inflammatory, sycosiform, keloidal, acne-like
disease of the hairy border of the back of the neck, often extending
upward to the occipital region; partaking, especially later in its
course, somewhat of the nature of keloid. Several or more acne-like
lesions, papular and pustular, closely grouped or bunched, appear,
developing slowly, usually to the size of peas; are red, pale red, or
whitish, often enveloping small tufts of hair, and attended with more or
less hair loss. Its course is gradual and persistent. It is an
exceedingly rare condition, the exact nature of which is still obscure.
#Give the treatment.#
Treatment, which is usually unsatisfactory, consists of stimulating
applications--the same, in fact, as employed in sycosis, sulphur and
ichthyol deserving special mention. Depilation is essential.
#Impetigo Contagiosa.#
#Give a descriptive definition of impetigo contagiosa.#
Impetigo contagiosa is an acute, contagious, inflammatory disease,
characterized by the formation of discrete, superficial, flat, rounded,
or ovalish vesicles or blebs, soon becoming vesico-pustular, and drying
to thin yellowish crusts.
#Upon what parts does the eruption commonly appear?#
Upon the face, scalp, and hands, and exceptionally upon other regions.
#Describe the symptoms of impetigo contagiosa.#
One, several or more small pin-head-sized papulo-vesicles or vesicles
make their appearance, usually upon the face and fingers. In the male
adult the region of the neck and beard is a favorite situation. They
increase in size by extending peripherally, but are more or less
flattened and umbilicated, and are without conspicuous areola. The
lesions may attain the size of a dime or larger, and when close together
may coalesce and form a large patch. In some cases distinct blebs
result, and a picture of pemphigus eruption presented; it is probable
that many of the cases of "contagious pemphigus" belong to this class.
New lesions may appear for several days, but finally, in the course of a
week or ten days, they have all dried to thin, wafer-like crusts, of a
straw or light-yellow color, but slightly adherent, and appearing as if
stuck on; these soon drop off, leaving faint reddish spots, which
gradually fade. In some cases there is so decided a tendency to clear
and dry up centrally while spreading peripherally that the eruption has
a ring-like aspect; this seems especially so in the bearded region of
the male adult.
Instead of presenting as described, it may occur as one or more pea- or
finger-nail-sized, rounded and elevated, usually firm, discrete
pustules, scattered over one part, or more commonly over various
regions, such as the face, hands, feet and lower extremities. The
pustules are such from the beginning, and when developed are usually of
the size of a pea or finger-nail, elevated, semi-globular or rounded,
with somewhat thick and tough walls, and of a whitish or yellowish
color; at first there may be a slight inflammatory areola, but as the
lesion matures this almost, if not entirely, disappears. The pustules
show no disposition to umbilication, rupture or coalescence; drying in
the course of several days or a week to yellowish or brownish crusts,
which soon drop off, leaving no permanent trace. This variety was
formerly thought to be a distinct disease, and was described under the
name of _impetigo simplex_.
As a rule there are no constitutional symptoms, but in the more severe
cases the eruption may be preceded by febrile disturbance and malaise.
Itching may or may not be present.
#State the cause of the disease.#