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A highly contagious skin disease, ringworm in particular is most intractable, and only prolonged and careful treatment can cure it.
Ringworm is a widely spread contagious disease produced by a vegetable fungus. It affects animals, e.g. horses, cattle, cats, canaries, etc., as well as human beings, and is communicable from one to the other. It occurs in two chief forms, body ringworm and scaly ringworm. Body ringworm, unless it attacks some hairy region like the beard area, is usually easily cured. Scaly ringworm, which affects children almost exclusively, and is almost never met with in adults over the age of eighteen, is very common among school children is highly contagious, extremely intractable to tratment, and often interferes seriously with a child's education.
Causal Organisms
The parasite which produces ringworm is a vegetable fungus, and is met with in two chief varieties; the small spored fnngus (microsporon) and the large spored fungus (megalosporon). The commonest variety of small-spored ringworm found in this country is the microsporon Audouini, so called after its discoverer. It is the commonest cause of scaly ringworm in children. The spores are small, and may be seen under the microsoope in clusters like a mosaic, arranged for the greater part round the hair. Various forms of small-spored fungus are found on the cat, dog, horse etc. and they may produce ringworm of the scaly and body in children. The large spored ringworm fungus is known as the trichophyton. There are two chicf kinds of this fungus, the trichophyton endothrix, which lies wholly inside the hair it affects, and the trichophyton endo-ectothris, which lies both within and without the affected hair. The spores are arranged in chains.
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Body Ringworm
Body ringworm, ringworm of the hairless skin, tinea circinata. affects adults and children. The fungus is usually the trichophyton, but sometimes the microsporon (small-spored fungus) may produce the condition. The eruption consists of one or more reddish or fawn-coloured lesions, circular or oval in shape, with scaly, slightly raised edges. The lesions spread peripherally, clearing up in the centre, and may run into each other, so that lesions with an irregular outline are produced.
This variety of ringworm is readily cured, since the fungus is easily accessible, lying in or on the horny layer of skin. A thorough application of tincture of iodine for three or four days is usually enough to destroy it. Thereafter a weak aloe vera ointment will complete the cure. The underclothing worn during the attack should be disinfected with care.
Sometimes fungus of the endo-etothrix variety may cause a pustular form of body ringworm producing a large, swollen red lesion, oozing pus from many follicular openings. This type of ringworm is known as conglomerative folliculitis, and is usually due to an infection from the horse. In the tropics and the last a variety of ringworm, dhobie itch (q.v.), occurs in the groins and adjacent parts. 'The fungus which causes it is highly resistant to treatment.
Ringworm on the palms and soles often resembles a chronic scaly eczema.. The skin becomes dry, dirty-looking, thickened and fissured, and the condition is often regarded as a chronic eczema until a microscopical examination reveals the ringworm fungus.
Rinqworm of the nails is common among those who suffer from ringworm of the hands, and is also met with among parents, nurses or others who have had to treat a person suffering from the disease. The fungus is always of the large-spored variety. The affected nails are raised from their beds by a mass of dirty-grey horny material which accumulates beneath them. The nail-plate itself becomes thickened, furrowed and brittle, loses its normal translucency and becomes dirty yellow in hue. The only reliable and speedy method to cure ringworm of the nails is to remove them completely under a general anaesthetic, and thereafter disinfect the nail-bed thoroughly by scraping and applying strong tincture of iodine to prevent the infection of the new nail. A slower treatment of twice daily applications of castor oil, 1 ounce, mixed with several drops of tincture of iodine and tea tree oil mixed together can be tried first, making sure the oil penetrates under the nail plate.
Fungi in hairs, magnified. Above, microsporon Audouini, which causes the ordinary scaly ringworm of children; the spores are spread out on the surface of the hair and closely grouped. Below, large spored fungus, which causes ringworm on animals, but is transmissible to man. The spores are outside the hair in chains and also within it.
Scaly Ringworm (tinea imbricata)
There are three varieties of ringworm of the scalp: the scaly type, '" black-dot" ringworm (tinea capitis due most commonly to Trichophyton tonsurans or T. violaceum.), and suppurating ringworm or Kerion [Greek, kerion, honeycomb; a skin disease].
The scaly type is the commonest in and is due to the microsporon Audouini. It is essentially a disease of childhood, especially of school-children, and tends to disappear spontaneously at puberty. It is communicated from child to child either by direct contact or by intermediate agents. The school-child should be allowed to use a brush, comb or towel used by other children, and ao child should be pernitted to wear another's cap or hat.
The disease usually appears between the ages of five and twelve. One or more round or oval scaly patches develop on a child's scalp. The patches spread from the centre outwards. The skin involved is slightly reddened and covered by fine, dry, slightly adherent grey scales, which teem with the fungus. The affected hairs lie irregularly, are broken off short, are very brittle and have lost their natural lustre. On microscopic examination they are found to be covered by a welt of fungus in the form of a sheath of fine round spores, arranged like the stones in a mosaic pavement. By altering the focus of the microscope, one may see in the substance of the hair, short rods like pieces of bamboo. This is the mycelium, the fungus proper, the spores being its fruit.
"Black-dot" ringworm- a rarer variety is due to the brichophyton megalosporon endothrix. A child suffering from this variety of ringworm infection presents one or more bald patches on the scalp. On minute examination they are seen to be stippled over with many minute dots-the broken stumps of hairs left in the follicles. This variety of the disease is very intractable to treatment, and through failure to recognize it promptly more than one epidemic in a school has resulted.
Pustular ringworm of the scalp, or kerion, is due to suppuration occurring in the hair follicles. A patch of kerion constitutes a boggy swelling on the scalp, which oozes pus from many follicles. The fungus is usually the endo-ectothrix variety, but it may be the endothrix, or very occasionally the microsporon. Kerion usually undergoes spontaneous cure, the suppuration loosening the hairs, which fall out, bringing with them the ringworm fungus. Depressed scars and sometimes small areas of permanent baldness follow this form of the disease. Though kerion tends to cure itself if left alone, the cure may be hastened by treatment. Probably the best treatment is the daily application of tincture of iodine to the boggy swelling, followed by the application of starch and boraoic poultices.
In treating ringworm of the scalp, certain general principles must be observed. In the first place everything should be done to prevent the spread of the mischief, either in the sufferer's own scalp or to other children in the family. With this obiect in view, the scalp of the sufferer should be shaved and kept shaved weekly. If there is only one patch of ringworm on the scaly it may suffice to shave this patch and a margin of the sound hair for half an inch round it. In this case the rest of the hair should be clipped short, if there are two or more patches, the whole scaly should be shaved.
The sufferer must wear constantly a cap with a removable cotton lining, This lining should be changed daily. The patient must not attend school, nor mix, except under the most guarded conditions, with other children under the age of puberty.
In a family, if one child suffers, the other members may be protected from infection by clipping their hair short, washing their scalps once or twice a week with some antiseptic soap and anointing their heads daily with an ointment such as stainless iodine ointment. No mere superficial smearing on of an ointment will suffice; it must be rubbed in thoroughly for 15 to 20 minutes to promote penetration; for much of the ringworm fungus lies buried in the hair follicles, and much of it is in the hair.
Washing of the scalp of an affected child is not advisable unless the whole scalp has been shaved. If the scalp has been shaved it may be washed once a week with an antiseptic soap, dried carefully and then painted all over with liniment of iodine, which will destroy any fungus that may have been transferred in washing from one affected area of the scaly to a healthy one.
In children, ringworm of the scaly usually occurs as oval or circular pinkish patches, covered with dry, greyish scales and studded over with broken hairs. The patches spread out all round their edges.
Bearing the general principles in mind, one must now consider actual treatment.
An old and efficient method of treatment was to try to induce artificially the development of kerion. For this purpose croton oil may be painted on the patch; or croton oil may be introduced into the affected hair follicles with a fine needle; or the patch may be rubbed daily with an ointment consisting of equal parts of vegetable oil and common salt. The suppurative process set up by these treatments loosens the affected hairs and causes them to fall out. Less painful methods of treatment consist in the daily inunction of ointments such as iodine ointment, sulphur iodide ointment, non-staining iodine ointment, or oily preparations containing iodine in a colloidal form with essential oils like tea tree.
Other ointments that are of use are sulphur ointment, salicylic acid ointment, or a mixture of these two in equal parts. Mercurial ointments or ointments containing carbolic acid are not to be recommended because of the danger of toxic absorption. Ointments made up with natural fats, such as lanolin or lard have the best penetrative power.
There are several skin diseases which may affect the hairy parts of the face, but the two which are usually attributed to the barber are ringworm and a bacterial infection. The latter is known as sycosis and the former as tinea sycosis, and popularly as barber's rash. Tinea, it may be said, is a general name applied to ringworm affections, so that tinea sycosis simply means ringworm sycosis. The term sycosis is derived from a Greek word meaning a fig and was originally applied to these conditions because swellings with some resemblance to a fig, and particularly the granules inside of a fig, appear on the skin. It should be noted, however, that either disease may he seen at a stage when there are no lumps.
BARBER'S RASH: A SKIN DISEASE In this condition, which is really ringworm of the beard, loose hairs are reinoved by means of epilsting forceps, as shown.
Barber's rash begins as a small scaly patch which spreads, and the border which is expanding on to sound skin is somewhat raised. If there are several such patches they may coalesce and form a patch of considerable size. On these patches and on the sound skin many of the hairs will exhibit at their roots little blisters fllled with matter or pus, and therefore named pnstules. The hairs themselves are invaded by the parasite and become fragile and may break off; when so affected, they may be pulled out easily and painlessly. In the bacterial form of sycosis, which is dealt with under that heading, the hairs themselves are sound, and are not easily pulled out, at any rate to begin with. The skin in the neighbourhood of the pustules is inflamed and may be very painful. When the disorder lasts for a considerable time the skin becomes scarred and hairless.
When an eruption breaks out on the hairy parts of the face of a man who has recently been shaved by a barber, the latter is blamed, and often enough quite justly. A barber's brush may easily pick up infection from one face and transfer it to another.
Properly replacing, the brush ought to be sterilised before being used on a fresh customer, and certainly no prudent barber would fail to do this very thoroughly if he had used a brush on skin which looked in any way unhealthy.
It must not be supposed, however, that this is the only way in which such diseases may be contracted.
Ringworm may be conveyed to the face from horses, cats, or other animals suffering from the complaint, either form of sycosis may be acquired, of course by the use of a common towel.
These diseases of the beard are very obstinate, and their treatment, should always be supervised by a doctor. The first thing that is done is to clip the hair very short, and if, as is generally the case matter from the pustules has dried into crusts or scabs, these must be cleared off before medicaments are applied. This may be done by putting on a boracic fomentation or a starch poultice, or by softening with oil or with boroglyceride. At any stage of the treatment this must be repeated, if necessary, as it is useless to apply ointments or other preparations on the top of crusts.
The scaly patch of ringworm may be treated by repeated applications of tincture of iodine, continued till the skin peels. A lotion of tea tree oil is very satisfactory for washing the parts. Salicylic acid, benzoic acid, and other antiseptics and parasiticides are used.
Favus (tinea favosa or honeycomb ringworm) is a parasitic disease of the skin, hair or nails due to a vegetable fungus known as the achorion (Trichophyton) Schonleinii. The disease is somewhat rare in England, but is not uncommon in some parts of Scotland, e.g. Edinbnrgh. It is common in Northern Africa, the Mediterranean, Southeast Asia, Russia, Poland, Austria and some parts of Germany. It is contagious either by direct contact with a person or animal- for example, a cat, which in its turn may have acquired the disease from a mouse suffering from the disease, or from wearing an article of clothing, such as a cap, which has been worn by a sufferer. This affects the scalp chiefly, though it may be met with on the glabrous; i.e. hairless; skin, and it may also affect the nails of the fingers and toes.
Favus attacks both sexes, and though it may be met with at any age it usually begins in childhood, and is most often seen upon the scalp. The scaly is studded over for a greater or less extent by a number of yellowish or sulphur coloured deposits which look as though they might be pustules. On more careful examination, however, these deposits are seen to be quite dry, and to possess certain definite characteritics. They are roughly circular, except when they have run into and merged with each other; each has a depressed centre so that it looks like a shallow cup, and through the centre of each depression a coarse dull stubbly hair projects. Each of these depositsthe technical name for which is " scutulum" -is tightly bound down to the scalp, being covered by a thin layer of epidermis. Round each of the deposits the skin is somewhat reddened, and so great is the pressure exerted on the scaly by these deposits that the nutrition of the hair roots is interfered with, and many of the hairs are destroyed. Each scutulum consists of an almost pure culture of the actual fungus of the disease.
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FAVUS: SKIN DISEASE Left, hair infested with the achorion Schonleinii, the parasitic fungus of favus. Right, the fungus. Yellow cups characterise the disease.
Symptoms of Favus. When the disease persisted for some time upon the scalp the signs and symptoms are as follows:
(1) There is a considerable loss of hair from the affected area- and this loss is permanent. The hairs left on the affected area are coarse, dull and brittle, and on touch suggest coconut fibre. They are loose and easily pulled out.
(2) The skin of the scaly in the affected area is of a dull red colour. lt looks thin and glazed and is more or less firmly bound down to the underlying structures.
(3) In every case of favus of the scaly there is a characteristic stale odour which resembles that given off by a cage of mice, and this "mousy odour" is an easily recognized symptom of the disease.
Patients with favus of the scaly may feel no discomfort, but often there is a considerable amount of itching, and it is in seeking to relieve this itching by scratching that they may infect their finger nails. Favus of the nails may occur in two forms, either as a circumscribed yellowish or discoloured deposit in the substance of the nail, or the whole nail becomes deformed, friable, opaque and thickened, and is raised up from its bed by an accumulation of brittlc debris rich in fungus.
Favus on other parts of the body is not common, but it may be met with on the neck and shoulders of neglected children whose scalp is affected.
Favus of the scalp runs a long and chronic course and may persist for many years.
Treatment of the Disease
Treatment must be attended to with very great thoroughness if good results are to be obtained, and ought to be continued for some months after all evidences of the disease have disappeared. A sufferer must be kept from school, and should constantly wear a cap with an interchangeable and washable linen, which should be changed daily. The hair, all over the head; should be cut short. The deposits of fungus should be softened by means of an ointment.
Apply thickly at night and cover with lint. In the morning the scaly should be washed thorougltly with green soft soap, or other antiseptic soap, and the treatment should be repeated daily till all the visible scutula are removed. Scutula removed by washing should be destroyed. Even after the removal of the scutula, however, the fungus still persists inside the hair follicles and in the hairs themselves.
Sulphur ointment is an effective medicament. This should be applied freely every night. Or the affected area may be thoroughly disinfected by the copious and frequcnt use of tincture of iodine.
Favus of the nails is difficult to deal with. The best method is to have the affected nails removed by a surgeon, and after removal the nail bed should be thoroughly disinfected with tincture of iodine.
In the horse there are two forms, tricophytosis and microsporosis; the sores of tricophytosis usually occur on the head, neck or withers. The hair falls off, and small raised patches appear, which may extend until about the size of a fivc-shilling piece. When it reaches this stage the scab is formed. The disease is spread by grooming and rubbing and causes great irritation. Microsporosis is generally soon under saddles, etc. It does not extend so much and forms smaller patches. It causes virtually no itching. Both conditions may be transmitted to dogs and cats.
In cattle trichophytosis causes local lesions as in horses, but in young animals there is considerable irritation and often great unthriftiness. It is transmissible to horses, dogs and cats. In dogs and oats trichophytosis and microsporosis occur as in the horse, but neither is so common as favus (q.v. ).
All infected animals must be isolated and all litter and bedding destroyed by burning. The quarters must be thoroughly disinfected all walls, etc., being treated with a painter's blow lamp and then washed with lime wash to which carbolic disinfectant has been added.
The hair must be clipped from the affected spots and the crust softened with a warm solution of washing soda. The scabs must be removed and burned. The affected lesions may be dressed with one of the following ointmnents: iodine ointment or zinc oxide ointment. If the sores are in a position where the animal can lick them, it is better to dress them with tincture of iodine. It is important to remove all infected hair, as otherwise the dressing caunot reaeh the fungus to destroy it. Good feeding is necessary.
FAVUS: In Animals
Favus, or boneycomb ringworm, due to achorion Schonleinii, is common in rodents, and is occasionally seen in dogs, cats and rabbits, especially in young animals.
Cats appear to be infected by direct contact with mice and so pass the disease to man. The ringworm develops from the opening of the hair follicle, especially on the paws, scaly and ears. The scabs are removed, after softening with oil if necessary. The spots are then treated with dilute tincture of iodine or salicylic ointment (1 in 10). This is applied daily till cured, washing, or, in the case of cats, rubbing with bran before each applicatio