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 hyperæmia 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, seborrhœa, sycosis, scabies and ringworm.
How would you exclude psoriasis in a suspected case of eczema (squamous eczema)?
Psoriasis occurs in variously-sized, rounded,sharply-definedpatches, 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 seborrhœa (eczema seborrhoicum) in a suspected case of eczema?
Seborrhœa 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 prominentsymptom. 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?
The extent of disease, its duration and previous behavior, the removability of the exciting and predisposing causes, and the attention the patient can give to the treatment.
In eczema involving the lips, face, scrotum, and leg, and especially when this last-named exhibits a varicose condition of the veins, a cure is effected, as a rule, only through persistent and prolonged treatment.
Does eczema ever leave scars?
No. Upon the legs, in long-continued cases, more or less pigmentation usually remains.
How is eczema treated?
As a rule, eczema requires for its removal both constitutional and external treatment.Certain cases, however, seem to be entirely local in their nature, and in these cases external treatment alone will have satisfactory results.
What general measures as to hygiene and diet are commonly advisable?
Fresh air, exercise, moderate indulgence in calisthenics, regular habits, a plain, nutritious diet; abstention from such articles of food as pork, salted meat, acid fruits, pastry, gravies, sauces, cheese, pickles, condiments, excessive coffee or tea drinking, etc. As a rule, also, beer, wine, and other stimulants are to be interdicted.
Upon what grounds is the line or plan of constitutional treatment to be based?
Upon indications in the individual case. A careful examination into the patient's general health will usually give the cue to the line of treatment to be adopted.
Mention the important remedies variously employed in the constitutional treatment.
Tonics—such as cod-liver oil, quinine, nux vomica, the vegetable bitters, iron, arsenic, malt, etc.
Alkalies—sodium salicylate, potassium bicarbonate, liquor potassæ, and lithium carbonate.
Alteratives—calomel, colchicum, arsenic, and potassium iodide.
Diuretics—potassium acetate, potassium citrate, and oil of copaiba.
Laxatives—the various salines, aperient spring waters, castor oil, cascara sagrada, aloes and other vegetable cathartics.
Digestives—pepsin, pancreatin, muriatic acid and the various bitter tonics.
Are there any remedies which have a specific influence?
No; although arsenic, in exceptional instances, seems to exert a special action. Cod-liver oil is also of great value in some cases.
Upon the whole the most important remedies are those which keep in view the maintenance of a proper and healthful condition of the gastro-intestinal tract, and especially with regular and rather free action of the bowels.
In what class of cases does arsenic often prove of service?
In the sluggish, dry, erythematous, scaly and papular types.
In what cases is arsenic usually contraindicated?
It should never be employed in acute cases; nor in any instance (unless its action is watched), in which the degree of inflammatory action is marked, as an aggravation of the disease usually results.
What should be the character of the external treatment?
It depends mainly upon the degree of inflammatory action; but the stage of the disease, the extent involved, and the ability of the patient to carry out the details of treatment, also have a bearing upon the selection of the plan to be advised.
What is to be said about the use of soap and water in eczema?
In acute and subacute conditions soap and water are to be employed, as a rule, as infrequently and as sparingly as possible, as the disease is often aggravated by their too free use. Washing is necessary, however, for cleanliness and occasionally, also, for the removal of the crusts. On the other hand, in chronic, sluggish types the use of soap and water frequently has a therapeutic value.
How often should remedial applications be made?
Usually twice daily, although in some case, and especially those of an acute type, applications should be made every few hours.
Mention several remedies or plans of treatment to be used in the acute or actively inflammatory cases.
Black wash and oxide-of-zinc ointment conjointly, the wash thoroughly dabbed on, allowed to dry, the parts gently smeared with ointment; or the ointment may be applied spread on lint as a plaster.
Boric-acid wash (15 grains to the ounce) and oxide-of-zinc ointment, applied in the same manner as the above.
A lotion containing calamine and zinc oxide, the sediment drying and coating over the affected surface:—
℞ Calaminæ,Zinci oxidi, .................āā.................. ʒ ij-ʒ iijGlycerinæ,Alcoholis, ...................āā................. fʒssLiq. calcis, .................................... f℥ijAquæ, .............. q.s. ... ad ................ f℥vj. M.
Another excellent lotion somewhat similar to the last, but of oily character, is made up of three drachms each of calamine and zinc oxide, one drachm of boric acid, ten to thirty drops of carbolic acid, and three ounces each of lime-water and oil of sweet almonds.
Carbolic-acid lotion, about two drachms to the pint of water, to which may be added two or three drachms each of glycerin and alcohol; or, if there is intense itching, carbolic acid may be added to the several washes already mentioned.
A lotion made of one or two drachms of liquor carbonis detergens[A]to four ounces of water.
The following wash, especially in the dry form of the disease:—
℞ Ac. borici, ...................................... ʒivAc. carbolici, ................................... ʒjGlycerinæ, ....................................... ʒijAlcoholis, ....................................... ʒijAquæ, ............... q.s. ad. ................... Oj. M.
[A]Liquor carbonis detergens is made by mixing together nine ounces of tincture soap bark and four ounces of coal tar, allowing to digest for eight days, and filtering. The tincture of soap bark used is made with one pound of soap bark to one gallon of 95 per cent. alcohol, digesting for a week or so. Instead of the proprietary name above, Prof. Duhring has suggested that of tinctura picis mineralis comp.
[A]Liquor carbonis detergens is made by mixing together nine ounces of tincture soap bark and four ounces of coal tar, allowing to digest for eight days, and filtering. The tincture of soap bark used is made with one pound of soap bark to one gallon of 95 per cent. alcohol, digesting for a week or so. Instead of the proprietary name above, Prof. Duhring has suggested that of tinctura picis mineralis comp.
Dusting-powders, of starch, zinc oxide and Venetian talc, alone or severally combined, applied freely and often, so as to afford protection to the inflamed surface:—
℞ Talci venet,Zinci oxidi, ...............āā.................... ʒivAmyli, ........................................... ℥j. M.
If washes or dusting-powders should disagree or are not desirable or practicable, ointments may be employed, such as—
Oxide-of-zinc ointment, cold cream, petrolatum, plain or carbolated, diachylon ointment (if fresh and well prepared), and a paste-likeointment, as the following, usually called “salicylic-acid paste”; in markedly itchy cases, five to fifteen grains of carbolic may be added to each ounce:
℞ Ac. salicylici, .................................. gr. v-xPulv. amyli,Pulv. zinci oxidi, ...............āā.............. ʒijPetrolati, ....................................... ʒiv M.
Or the following ointment:—
℞ Calaminæ, ........................................ ʒjUngt. zinci oxidi, ............................... ʒvij. M.
Name several external remedies and combinations useful in eczema of a subacute or mildly inflammatory type.
The various remedies and combinations useful when the symptoms are acute or markedly inflammatory (mentioned above), and more especially the several following:—
℞ Zinci oxidi, ..................................... ʒijLiq. plumbi subacetat. dilut., .................. fʒvjGlycerinæ, ...................................... fʒijInfus. picis liq., .............................. f℥iij M.
A lotion containing resorcin, five to thirty grains to the ounce.
Solution of zinc sulphate, one-half to three grains to the ounce.
An ointment containing calomel or ammoniated mercury, as in the annexed formula:—
℞ Hydrargyri ammoniat. seu Hydrargyrichloridi mit., ................................. gr. x-xxxAc. carbolici, ................................... gr. v-xUngt. zinci oxidi, ............................... ℥j. M.
Another formula, more especially useful in eczema of the hands and legs, is the following:—
℞ Ac. salicylici, .................................. gr. xxxEmp. plumbi,Emp. saponis,Petrolati, ...................āā.................. ℥j. M.
(This is to be applied as a plaster, spread on strips of lint, and changed every twelve or twenty-four hours.)
The paste-like ointment, referred to as useful in acute eczema, may also be used with a larger proportion (20 to 60 grains to the ounce) of salicylic acid.
The following, containing tar, may often be employed with advantage:—
℞ Ungt. picis liq., ................................ ʒjUngt. zinci oxidi, ............................... ʒvij. M.
What is to be said in regard to the use of tarry applications?
Ointments or lotions containing tar should always be tried at first upon a limited surface, as occasionally skins are met with upon which this remedy acts as a more or less violent irritant. The coal tar lotion (liquor carbonis detergens) is the least likely to disagree and may be used as a mild ointment, one or two drachms to the ounce, or it may be diluted and used as a weak lotion as already referred to.
What external remedies are to be employed in eczema of a sluggish type?
The various remedies and combinations (mentioned above) useful in acute and subacute eczema may often be employed with benefit, but, as a rule, stronger applications are necessary, especially in the thick and leathery patches. The following are the most valuable:—
An ointment of calomel or ammoniated mercury; forty to sixty grains to the ounce.
Strong salicylic-acid ointment; a half to one drachm of salicylic acid to the ounce of lard.
Tar ointment, official strength; or the various tar oils, alone or with alcohol, as a lotion, or in ointment form.
Liquor picis alkalinus[B]is a valuable remedy in chronicthickened, hardandverrucouspatches, but is a strong preparation and must be used with caution. It is applied diluted, one part with from eight to thirty-two parts of water; or in ointment, one or two drachms to the ounce. In such cases, also, the following is useful:—
℞ Saponis viridis,Picis liq.,Alcoholis, ....................āā................. ʒiij. M.SIG. To be well rubbed in.
[B]℞ Potassæ ,......................................... ʒjPicis liq., ...................................... ʒijAquæ, ............................................ ʒv.Dissolve the potash in the water, and gradually add to the tar in a mortar, with thorough stirring.
[B]
℞ Potassæ ,......................................... ʒjPicis liq., ...................................... ʒijAquæ, ............................................ ʒv.
Dissolve the potash in the water, and gradually add to the tar in a mortar, with thorough stirring.
In similar cases, also, the parts may be thoroughly washed or scrubbed with sapo viridis and hot water until somewhat tender, rinsed off, dried, and a mild ointment applied as a plaster.
Lactic acid, applied with one to ten or more parts of water is also of value in the sclerous and verrucous types. Caustic potash solutions, used cautiously, may also be occasionally employed to advantage in these cases.
Another remedy of value in these cases, as well as in others of more or less limited nature, is thex-ray. Exposures every few days, of short duration and 4 to 10 inches distance, with medium vacuum tube. This method has served me well in occasional cases; caution is necessary, and it should not be pushed further than the production of the mildest reaction. The repeated application of a high-frequency current, by means of the vacuum electrodes, is a safer and sometimes an equally beneficial method.
Is there any method of treating eczema with fixed dressings?
Several plans have been advised from time to time; some are costly, and some require too great attention to details, and are therefore impracticable for general employment. The following are those in more common use:—
Thegelatin dressing, as originally ordered, is made by melting overa water-bath one part of gelatin in two parts of water—quickly painting it over the diseased area; it dries rapidly, and to prevent cracking glycerine is brushed over the surface. Or the glycerine may be incorporated with the gelatin and water in the following proportion: glycerine, one part; gelatin, four parts, and water eight parts. Medicinal substances may be incorporated with the gelatin mixture.
A good formula is the following:—
℞ Gelatin, ......................................... ℥jZinci oxidi, ..................................... ℥ssGlycerini, ....................................... ℥issAquæ, ............................................ ℥ii-℥iij.
This should be prepared over a water-bath, and two per cent. ichthyol added. A thin gauze bandage can be applied to the parts over which this dressing is painted, before it is completely dry; it makes a comfortable fixed dressing and may remain on several days.
Plaster-mullandgutta-percha plaster. The plaster-mull, consisting of muslin incorporated with a layer of stiff ointment, and the gutta-percha plaster, consisting of muslin faced with a thin layer of India-rubber, the medication being spread upon the rubber coating.
Rubber plasters.These are medicated with the various drugs used in the external treatment of skin diseases, and are often of service in chronic patches.
Two new excipients for fixed dressings have recently been introduced—bassorin and plasment; the former is made from gum tragacanth, and the latter from Irish moss.
The following is a satisfactory formula for a tragacanth dressing:
℞ Tragacanth, ...................................... gr. lxxvGlycerini, ....................................... ♏ xxxAc. carbolici, ................................... gr. x-xxZinci oxidi, ..................................... ʒiss-ʒiiss. M.
This is painted over the parts and allowed to dry, and a mild dusting powder sprinkled over. It cannot be used in warm weather or in folds, as it is apt to get sticky. The following is a bassorin paste which may be variously medicated.
℞ Bassorin, ........................................ ʒxDextrin, ......................................... ʒvjGlycerini, ....................................... ℥ij.Aquæ, ................................... q.s. ad. ℥iij.
It should be prepared cold.
Another “drying dressing” which may be used in cool weather is:
℞ Zinci oxidi, ..................................... ℥jGlycerini, ....................................... ℥ssMucilag. acaciæ, ................................. ℥ii-℥iv.
It may be variously medicated.
The plaster-mull is used in all types, especially the acute; the gelatin dressing, and the gutta-percha plaster, in the subacute and chronic; and the rubber plaster in chronic, sluggish patches only. Acacia, tragacanth, bassorin and plasment applications are used in cases of a subacute and chronic character.
Define prurigo.
Prurigo is a chronic, inflammatory disease, characterized by discrete, pin-head- to small pea-sized, solid, firmly-seated, slightly raised, pale-red papules, accompanied by itching and more or less general thickening of the affected skin.
Describe the symptoms and course of prurigo.
The disease first appears upon the tibial regions, and its earliest manifestation may be urticarial, but there soon develop the characteristic small, millet-seed-sized, or larger, firm elevations, which may be of the natural color of the skin or of a pinkish tinge. The lesions, whilst discrete, are in great numbers, and closely crowded. The overlying skin is dry, rough and harsh; itching is intense, and, as a result of the scratching, excoriations and blood crusts are commonly present. In consequence of the irritation, the inguinal glands are enlarged. Sooner or later the integument becomes considerably thickened, hard and rough. Eczematous symptoms may be superadded. In severe cases the entire extensor surfaces of the legs and arms, and in some instances the trunk also, are invaded. It is worse in the winter season.
What is known in regard to etiology and pathology?
It is a disease of the ill-fed and neglected, usually developing in early childhood, and persisting throughout life. It is extremely rare, even in its milder types, in this country. Clinically and pathologically it bears some resemblance to papular eczema.
Give the prognosis and treatment of prurigo.
The disease, in its severer types is, as a rule, incurable, but much can be done to alleviate the condition. Good, nourishing food, pure air and exercise are of importance. Tonics and cod-liver oil are usually beneficial. The local management is similar to that employed in chronic eczema. An ointment of β-naphthol, one-half to five per cent. strength, is highly extolled.
Give a definition of acne.
Acne is an inflammatory, usually chronic, disease of the sebaceous glands, characterized by papules, tubercles, or pustules, or a mixture of these lesions, and seated usually about the face.
At what age does acne usually occur?
Between the ages of fifteen and thirty, at which time the glandular structures are naturally more or less active.
Describe the symptoms of acne.
Irregularly scattered over the face, and in some cases also over the neck, shoulders and upper part of the trunk, are to be seen several, fifty or more, pin-head- to pea-sized papules, tubercles or pustules; commonly the eruption is of a mixed type (acne vulgaris), the several kinds of lesions in all stages of evolution and subsidence presenting in the single case. Interspersed may generally be seen blackheads, or comedones. The lesions may be sluggish in character, or they may be markedly inflammatory, with hard and indurated bases. In the course of several days or weeks, the papules and tubercles tend gradually to disappear by absorption; or, and as commonly the case, they become pustular, discharge their contents, or dry and slowly or rapidly disappear, with or without leaving a permanent trace, new lesions arising, here and there, to take their place. In exceptional instances the eruption is limited to the back, and in thesecases the eruption is usually extensive and persistent, and not infrequently leaves scars.
What do you understand by acne punctata, acne papulosa, acne pustulosa, acne indurata, acne atrophica, acne hypertrophica, and acne cachecticorum?
These several terms indicate that the lesions present are, for the most part, of one particular character or variety.
Describe the lesions giving rise to the names of these various types.
Blocking up of the outlet of the sebaceous gland (comedo), which is usually the beginning of an acne lesion, may cause a moderate degree of hyperæmia and inflammation, and a slight elevation, with a central yellowish or blackish point results—the lesion ofacne punctata;if the inflammation is of a higher grade or progresses, the elevation is reddened and more prominent—acne papulosa;if the inflammatory action continues, the interior or central portion of the papule suppurates and a pustule results—acne pustulosa;the pustule, in some cases, may have a markedly inflammatory and hard base—acne indurata;and not infrequently the lesions in disappearing may leave a pit-like atrophy or depression—acne atrophica;or, on the contrary, connective-tissue new growth may follow their disappearance—acne hypertrophica;and, in strumous or cachectic individuals, the lesions may be more or less furuncular in type, often of the nature of dermic abscesses, usually of a cold or sluggish character, and of more general distribution—acne cachecticorum.
What is acne artificialis?
Acne artificialis is a term applied to an acne or acne-like eruption produced by the ingestion of certain drugs, as the bromides and iodides, and by the external use of tar; this is also calledtar acne.
What course does acne pursue?
Essentially chronic. The individual lesions usually run their course in several days or one or two weeks, but new lesions continue to appear from time to time, and the disease thus persists, with more or less variation, for months or years. In many cases there is, toward the age of twenty-five or thirty, a tendency to spontaneous disappearance of the disease.
Acne
Acne
Is the eruption in acne usually abundant?
It varies in different cases and at different periods in the same case. In some instances, not more than five or ten papules and pustules are present at one time; in others they may be numerous. Not infrequently several lesions make their appearance, gradually run their course, and the face continues free for days or one or two weeks.
Does the eruption in acne disappear without leaving a trace?
In many instances no permanent trace remains, but in others slight or conspicuous scarring is left to mark the site of the lesions.
Are there any subjective symptoms in acne?
As a rule, not; but markedly inflammatory lesions are painful.
State the immediate or direct cause of an acne lesion.
Hypersecretion or retention of sebaceous matter. Recent investigations point to the possibility of a special bacillus being the exciting cause, in some instances at least. The pyogenic cocci are added factors in the pustular and furuncular cases.
Name the indirect or predisposing causes of acne.
Digestive disturbance, constipation, menstrual irregularities, chlorosis, general debility, lack of tone in the muscular fibres of the skin, scrofulosis; and medicinal substances such as the iodides and bromides internally, and tar externally.
Working in a dusty or dirty atmosphere is often influential, resulting in a blocking-up of the gland ducts. Workmen in paraffin oils or other petroleum products often present a furuncle-like acne.
The disease is more common in individuals of light complexion.
Is there any difficulty in the diagnosis of acne?
Not if it be remembered that acne eruption is limited to certain parts and is always follicular, and that the several stages, from the comedo to the matured lesion, are usually to be seen in the individual case.
In what respect does the pustular syphiloderm differ from acne?
By its general distribution, the longer duration of the individual lesions, the darker color, and the presence of concomitant symptoms of syphilis.
What is the pathology of acne?
Primarily, acne is a folliculitis, due to retention or decomposition of the sebaceous secretion or to the introduction of a micro-organism; subsequently, the tissue immediately surrounding becoming involved, with the possible destruction of the sebaceous follicle as a result. The degree of inflammatory action determines the character of the lesions.
State the prognosis of acne.
It is usually an obstinate disease, but curable. Some cases yield readily, others are exceedingly rebellious, especially acne of the back. Success depends in a great measure upon a recognition and removal of the predisposing condition. Treatment is ordinarily a matter of months.
What measures of treatment are usually demanded in acne?
Constitutional and local measures; the former when indicated, the latter always.
Upon what is the constitutional treatment based?
Upon indications. Diet and hygienic measures are important.
In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin, saline and vegetable laxatives, are variously prescribed. Special mention may be made of the following:—
℞ Ext. rhamni pursh. fl., ......................... fʒij-fʒivTinct. nucis vom., .............................. fʒiijTinct. cardamomi comp., ................. q.s. ad. ℥iij. M.SIG.—fʒ t.d.
Or Hunyadi Janos or Friedrichshall water may be employed for a laxative purpose.
In chlorotic and anæmic cases the ferruginous preparations are of advantage. Cod-liver oil is often a remedy of great value, and is especially useful in strumous and debilitated subjects. Calx sulphurata in pill form, one-tenth to one-fourth grain four or five times daily, is said, acts well in the pustular variety. In some instances, more particularly in sluggish papular acne, arsenic, especially the sulphide of arsenic, acts favorably. Upon the whole, the line of
Acne of back
Acne of back
treatment that keeps in view proper and healthy action of the gastro-intestinal canal is the most successful.
In inflammatory cases occurring in robust individuals the following is often of service:—
℞ Potassii acetat., ................................ ʒivLiq. potassæ, ................................... fʒijLiq. ammonii acetat., ............ q.s. ad. ..... f℥iij. M.SIG.—fʒj-fʒij 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 hyperæmic, 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, itis 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:—
℞ Sulphur, præcip., ................................ ʒss-ʒjAdipis benz.Lanolin, .....................āā.................. ʒij.
Or it may be used as a lotion, as in the annexed formula:—
℞ Sulphur, præcip., ................................ ʒissPulv. tragacanthæ, ............................... gr. x1Pulv. camphoræ, .................................. gr. xxLiq. calcis,........ q.s. ad. ................... f℥iv. M.
Another lotion, especially useful in those cases in which an oily condition of the skin is present, is the following:—
℞ Sulphur, præcip., ................................ ʒissEtheris, ........................................ fʒivAlcoholis, ...................................... f℥iijss. M.
A compound lotion containing sulphur in one of its combinations is also valuable in many cases:—
℞ Zinci sulphatis,Potassii sulphureti, ................āā........... ʒss-ʒivAquæ, ............................................ ℥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:—
℞ Ichthyol, ........................................ ʒss-ʒjCerat. simp., .................................... ʒiv. 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:—
℞ Hydrarg. chlorid. corros., ....................... gr. ii-viijZinci sulphatis, ................................. gr. x-xxTinct. benzoini, ................................ fʒijAquæ, ................... q.s. ad. .............. f℥iv.
In extremely sluggish cases the following, used cautiously, is of value:—
℞ Ichthyol,Saponis viridis,Sulphur, præcip.,Lanolin, .......................āā................ ʒj.
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'ssolution and formaldehyde solution, weakened considerably, at first at least, prove of value.
Obstinate and indurated lesionsmay be incised, the contents pressed out, and the interior touched with carbolic acid by means of a pointed stick. Thex-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. Thex-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.
Give a descriptive definition of acne rosacea.
Acne rosacea is a chronic, hyperæmic 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 hyperæmia, 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 seborrhœa of the same parts. In manycases 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).
Fig. 25.