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A Common Skin Inflammation and its Treatment
After a summary of the factors predisposing to a condition the cause of which is not certainly known and a general account of the disease a detailed description is given here of the forms of eczema occurring in specific regions of the body and of those due to infection of areas subjected to friction. Careful instructions are given as to the treatment of all these varieties.
Eczema has been defined as an inflammation or catarrh of the skin, with a marked tendency to relapse, or become chronic, and characterised by the presence, in one or other of its many stages, of redness (hyperaemia), groups of small blisters (vesicles), which soon break down and form" weeping" patches, swelling (oedema), due to leakage of the blood-serum into loose tissue spaces, e.g. the eyelids, and small irritable groups of pimples or papules, which are present in most chronic cases. This somewhat complex definition covers all the special symptoms of this formidable and exceedingly common group of skin diseases.
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Predisposing Conditions
The actual cause of eczema is unknown, but there are certain factors which may be regarded as predisposing to an eczematous reaction. There is little doubt that heredity plavs a part. The occasional association of attacks of asthma, or their alternation with outbreaks of the eruption, suggests that the bronchial tubes may be able to react to the same influences which affect the skin and cause eczema. Severe disturbances of the general health may be the apparent cause of eczematous eruptions.
Apart from the influences above mentioned and the trade eczema types, t,here are cases in which the local condition of the skin from birth is directly responsible for ever-recurring eczema. Chief among these is the dry type, known as xerodermia, or ichthyosis (scaly, like fish-skin). These cases, owing to absence of normal secretions; are prone. to seasonal recurrences of eruptions resembling true eczema. Reference must also be made to the opposite condition of excessive oiliness of the skin, known as seborrhoea (q.r.), which also appears to predispose to eczema.
In eczematous subjects. whether the predisposition be inherited or, acquired, the normal physiological stimuli, such as the sun, hard water soap, east wind, etc.. are able to bring about acute eruptive attacks of may terminate course and duration. These must be regarded as a contributory causes only, and he same applies when the disposition is revealed by the action of a trade chemical and the cause is unknown.
The presence of septic foci in some part of the body, especially in the bowel, teeth, or tonsils, will predispose to or even be responsible for many eczematous conditions. Defective circulation on the skin, as with varicose veins, is another cause, and over and under-feeding also appear to have some influence in the causation. This is particularly obvious in the infant. in which alteration of diet may sometimes be followed by relief or cure.
Trade Dermatitis
Of the greatest importance in consideration of causation are the so-called trade eczemas. All the four types of eruption enumerated in the definition given above can be produced by irritants used by workmen in the pursuit of their employment, and the resulting effects are sometimes indistinguishable from true eczema. The term dermatitis is therefore applied to eruptions in which the cause is assumed to be a substance known to be an irritant and used by the patient in his trade.
Victims of trade eczemas include tar workers, bakers, dyestuff workers, gardeners, washerwomen, french polish users, painters, photographers, and a host of others. The majority of these cases clear up when the patient gives up his work, but a few persist indefinitely these join the ranks of the incurably eczematous, and there is not much point in trying to differentiate them from cases of true eczema, which they so closely resemble.
Signs of the Disease
The aspect of the disease varies with the stage. In acute eczema the eruption often first appears on the face, and is heralded by a feeling of irritability, with redness of the parts involved. Later the itching gives place to burning, there is marked swelling, especially of the eyelids, which may be almost closed, and soon the parts begin to discharge a clear, watery, sticky serum, which stiffens linen and tends to dry into crusts above the eyebrows moustache and scalp.
The disposition to eczema is inherent. Stiumuli which in the normal individual are harmless will elicit the eruptive response in the predisposed. This fact explains the favourite localisation of primary attacks to the face which is always exposed to sunlight (ultra-violet rays), the weather, hard water and soap ---and the tendency of trade eczemas to appear on tire hands.
Uncomplicated eczema leaves no mark or sear, and the skin regains its normal appearance in a week or two. The swelling (oedemas) gradually subsides and is replaced by wrinkling, due to stretching of the elastic fibres of the subcutaneous layers which take some time to recover. Peeling of the upper superficial layers is a common sequel at this stage, and small flakes of skin are shed, as after an attack of scarlet fever.
In the majority of cases the disease is not limited to the face, and tends to spread thence to the neck and upper extremities. These patches dry up but may persist for an indefinite time after the facial manifestations have subsided. The thighs and legs are sometimes affected in the same way, but except in infants, it is very rare for the whole body to become eczematised at the same time.
Chronic eczema is the more common form of the disease. It may develop from an acute attack or arise de novo on a previously healthy skin. The patches may be either moist or dry. In the former case they tend to be crusted as the serum loses its moisture in the latter the small papules of which they are composed become aggregated into groups of a reddish or brownish colour. Thickening or infiltration of the affected skin is produced, and may persist, if scratched or rubbed and left untreated. In the more chronic eases these patches thicken so much that they assume the characteristics of grained morocco leather.
Excluding the trade cezemas and those which are due to external irritants of a chemical or vegetable nature, the commonest types met with in practice are those included within the category of regional eczema, which have their starting point in or around the junction of the skin and mucous membranes of some body cavity or passage.
In order of the frequency of their occurrence, these are eczemas of the anus the ear, the mouth, the scrotum and vulva, the nipple, the nasal orifice and the eyelids.
Anal Eczema
The majority of sufferers from this distressing variety of eczema are to be found amongst middle-aged men of a sedentary habit, a liking for alcohol- especially port wine- and rich arid highly seasoned dishes. They are usually constipated, with a tendency to piles and with their complications, such as hemorrhoids, anal fissure and fistula. The presence of these septic foci in the neighbourhood of the anus is invariably associated with itching (pruritus), and the scratching, which is rarely desisted from, rapidly spreads the infection and enlarges the area of irritation, and more eczema is produced roundabout. This may be of the moist or dry variety, and will tend to persist or recur as long as the anal infection continues. Sometimes, if the patient is an eczematous subject, the eruption may become generalised and spread to other parts of the body, so as to be indistinguishable from the ordinary case of acute or chronic eczema already described, it will differ from it only in having a known cause.
Eczema of the Ear
This usually has its origin in the outer aural passage between the drum and the exterior. Accumulations of wax and amateur attempts to remove them or foreign bodies with matches or hairpins, discharges from middle-ear disease, may be the cause of an irritation which an uncontrolled desire to scratch will soon convert into the usual moist and weeping areas. In the ear, repeated attacks tend to thickening and enlargement of the whole organ. Behind, at its junction with the skull, deep cracks develop, and further complicate the progress of the cause and its treatment.
Eczema of the Mouth and Lips
This, type is fortunately uncommon. Pyorrhoea of the gums may he the starting point, and some cases have been caused by the habitual use of an irritant tooth powder or paste. When the skin is of delicate texture, air cast wind, hard water or a too alkaline soap are possible factors. The lips are usually dry and cracked, and the fissures very painful arid difficult to heal, as the lips are in constant movement and subject to the irritation of hot or pungent foods. Repeated attacks, as with the ear, lead to thickening and deformity which perpetuates the tendency. The cracks in the mucous membrane of the lips are sometimes responsible for outbursts of erysipelas (q.v.). The skin in the neighbourhood is also affected, especially at the month angles, where radiating fissures cause constant annoyance.
Peri-nasal Eczema
Some intra-nasal condition is nearly always responsible for eczema near the nasal orifices and on the upper lip. The appearances are much the same as those met with in the oral variety Eczema of the Eyelids, When this is a local manifestation, and not associated with eczema of the face, it is due to infection of the excessive secretion from the oil glands of hairy regions generally. Secretion of serum leads to sticking of the lids in the morning, and if the case is not vigorously and persistently treated there is eventual destruction of the hair roots and permanent loss of lashes, complicated by thickening, and eversion of the lower lid (chronic marginal blepharitis) and interference with the tear duct mechanism.
Vulval Eczema
This type may be secondary either to an anal eczema, or in more frequently, to vaginal discharges which irritate and cause pruritus and infection of the sensitive skin. Thickening and fissuring, are as common here as on the lips, though more tractable to treatment.
Scrotal Eczema
This form, which may he considered in conjunction with the vulval type, is often very persistent, because the skin is thin, subject to friction in walking, and loosely supported on a sheet of contractile muscle fibres. These are irritated by the abnormal conditions overlying then, and respond by excessive phases of contraction and relaxation which hinder the progress of repair. Deep fissures with marked chronic thickening of the loose tissues, are very commonly associated and render this type of regional eczema one of the most difficult and obstinate to treat.
Eczema of the Nipple
For obvious reasons this form of eczema is most frequently seen in nursing mothers. The nipple, which is naturally congested at this period. may be slightly rubbed and abraded, either by too vigorous sucking or an ill-fitting corset or brassiere. A lack of cleanliness may further complicate by introducing the element of infection. Itching, the natural sequel, leads to rubbing arid scratching, and very soon there is a moist, red oozing patch of skin surrounding all inflamed and much enlarged nipple. Infection of the lining of the milk ducts; below the surface aggravates the surface changes, and is apt to retard convalescence even after the child has been removed from the breast and suitable local treatment adopted.
Eczema of the Palms and Soles
The palms and soles have a structure peculiar to their own needs. The skin of the former is designed for a firm grip of objects seized, of the latter to resist friction and pressure in walking. The horny layers in both are greatly thickened, and rapidly replaced by growth from below than in any other part of the body. It follows that eczema in these situations is entirely different in appearance from that met with elsewhere.
In the acute variety small blisters form on the sides of the fingers and in the finger webs. In very acute cases the blisters are large, and a whole palm or sole may be completely denuded of skin in a very few hours. In the chronic cases the horny layers become enormously thickened, the nails brittle and opaque, and painful cracks are apt to develop along the lines of the normal fissures.
In addition to the types of regional eczema enumerated above, cases enumerated as frictional eczema must be mentioned. The term intertrigo (q. v.) covers this group, in which the elements of friction, moisture and warmth, and infection play their respective parts.
Infantile Eczema
Most authorities are agreed that eczema in babies has a dietetic causation, and it is a fact that a change of food will sometimes bring about a rapid cure. The eczema in these infants is mainly of the moist type, and within a few hours of the commencement of an attack the cheeks and forehead will be red and weeping, and a fine papular rash will begin to appear on the extremities. The child will naturally be very irritable, and the control of scratching is very difficult, and only to be secured by fixation of the arms to the bedclothes by bandages and safety pins.
The course of infantile eczema is rather more favourable than that of the disease in the adult. Most cases clear up completely when the child is old enough to be put on a solid diet, and local treatment, diet, etc., are also more easily controlled.
Complications of Eczema
Of the complications in eczema the most frequent is infection by microbes, the commonest being the staphylococci, which abound and increase their virulence in all cases of moist eczema. This particular microbe is the cause of boils, which are nothing more than abscesses in hair follicles. Boils are therefore an exceedingly common complication of eczema.
Another common organism, the virulence of which is similarly increased, is the streptococcus, which is the cause of erysipelas. This is a rare but highly dangerous complication of eczema. Streptococci also flourish in cracks and deep fissure behind the ears and elsewhere.
When the streptococcus infects the deeper layers of the skin, a complication in which the patient's finger-nails play a leading part, acute cellulitis is produced., The infection spreads alono the connective tissue between muscles, and in the loose connective tissue which separates them from the skin, and, unless checked by incision to let out the matter (pus), cause great pain and high fever.
Repeated attacks of eczema of the legs, where varicose veins frequently predispose to the condition, may be complicated by a form of chronic cellulitis and infection of the lymph channels (lymphangitis). The soft tissues become greatly thickened, and the skin itself coarsened in texture. The blood supply is interfered with, and an accidental knock or abrasion is not followed by normal healing, so that deep and intractable ulcers may ensue.
The loss of hair and shedding of the nails which sometimes follow the acute generalised attack of eczema may be regarded rather as a late sequel than as a complication of the disease. The growth invariably occurs a month or two after the attack.
General Treatment
The successiul control and alleviation of the symptoms of eczema depend on a recognition of the stage in which the patient presents himself. There are no specific internal remedies, and the only drugs administered in the acute stages are aperients and nerve sedatives like the herbs valerian, catnip and scullcap. The salicylates are sometimes useful, comparatively harmless, and may be given in the form of aspirin, 5 to 10 grains thrice daily, in all types.
Diet and beverage are of considerable importance. Alcohol and all spiced and seasoned dishes are harmful. The diet must be bland, and should consist mainly of milk and its derivatives, boiled fish, light omelettes, green vegetables and fruits, starchy foods being limited and sugar excluded. Flesh foods must be taken in _ rest moderation. The patient should have as much barley water, still lemonade and the like as he can comfortably consume, and careful attention should be given to daily elimination with the action of the bowels.
In the acute weeping stage the best treatment is by watery lotions. Left, weak lime water lotion used on a covering of soft old linen which is kept constantly moist. Right, when the surface begins to dry and there is a feeling of tension it is well to change to an oil lotion. Here equal parts of almond oil and lime water are being used.
When the acute weeping stage is over and the surface is dry, resort may be had to ointments and creams. Left, the use of zinc oxide cream. Later, when only thickened patches remain the best treatment is to apply a dressing of Aloe vera paste (right). This is an absorbent preparation containing starch as well as a trace zinc oxide.
For the most part, however, the treatment of an acute attack resolves itself into the selection of an appropriate local remedy and its intelligent application. The latter point is of supreme importance.
The acute weeping stage of eczema indicate: the application of a lotion. Care must be taker that the material used is fine and non-irritating. Old linen is as good as anything else, and it must be tept constantly moist and in m circumstances allowed to adhere to the affected parts from which the sticky serum is exuding. One method of ensuring this is an outer layer of oiled silk.
All lotions must be used weak.
Any general condition, such as one of the systemic fevera, which tends to a temporary inhibition of the activity of the sweat and sebaceous glands leads to a transient dryness of the skin. The removal of the natural oil from the skin by prolonged immersion in soap or soda solutions will also produce a local dryness of the skin, e.g. the dermatitis of laundresses.
But there is also a constitutional form of dryness of the skin known as xeroderma. This is a mild variety of ichthyosis (q.v.), or fishskin disease, and is congenital. It is characterised by a branny scaliness of the skin, involving practically the whole integument, though sometimes the face, the palms and soles are spared.
The condition is incurable but much may be done for its amelioration. A hot bath twice a week to which a couple of handfuls of bran have been added often increases the sufferer's comfort. A superfatted soap must be used. Clothing worn next the skin must be nonirritating. Small doses of thyroid gland .4 to 2 grain, twice a day, are sometimes beneficial. A demulcent oiitment, such as equal parts of salicylic acid ointment and glycerin of starch, smeared lightly all over the body every night, is often of great service.