The Treatment of Dermatitis Uerpetiformis 
BY 
LOUIS A. DUHRING, M.D., 
PKUKESSUK OF SK.IN DISEASES IN THE UNIVERSITY OF PENNSYLVANIA 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
February, 1891. Reprinted from 
The American Journal of the Medical Sciontca for February, 1891. 
THE TREATMENT OF DERMATITIS HERPETIFORMIS.1 
PKorRNMOR or AKIN lUAKAARA IN THE I‘KI VRIUHTY or PENNSYLVANIA. 
Louis A. Ddhrino, M.D., 
In the several communications on this disease that have been pub- 
lished by me during the past five years, no special' remarks have been 
made concerning its treatment. The subject-matter of these papers has 
been largely confined to a statement of the cases observed with the view 
of setting forth the symptoms and the more important clinical facts, in 
the hope that the disease might become better known. A number of 
cases (perhaps ten or twelve) have been reported by me, and others 
have been observed in my private and public practice, so that now it 
seems appropriate that something be said about the treatment of this 
exceedingly rebellious disease. At the same time, I would state here 
that in many cases the remedies employed, both external and internal, 
seemed to exert but little or no beneficial effect. In severe cases, and 
especially during an exacerbation, no form of local treatment used 
appeared capable of making a favorable impression on the skin. In 
such instances the disease is the most difficult to influence of all the 
inflammatory affections, surpassing even inveterate eczema. 
'Phe internal treatment may first receive attention. The generally- 
recognized observation that the disease may arise from and be dependent 
upon several distinct or even diverse causes, precisely, for example, as 
occurs in the case of eczema, precludes positive statements as to reme- 
dies. Each group of cases, based on the etiological factors at work, requires 
special handling, and hence I believe no class of remedies can l>e recom- 
mended which would be suitable to all cases. The origin of the disease, 
where this is ascertainable, should ever be kept in mind, and the treat- 
ment be pursued in this direction on general principles. With a disease 
which in most instances is exceedingly persistent and chronic in its 
course,a speedy cure is uot to be looked for, cither from internal or local 
remedies. 
I shall make my remarks jis practical as possible and be brief. The 
local treatment may first be considered. It must be remembered that 
the disease, as a rule, is multiform in character, and that, as in the case 
of eczema, we have to deal with varied lesions, at one time erythema, 
at another vesiculation or postulation. 'Phe several varieties of the 
disease, therefore, naturally call for different formulae, certainly as to 
strength, and sometimes even for different remedies. Thus, my exj>eri- 
1 Read before the American Dermatological Association, September 3, ISBO. 2 
HU HH 1 NO, DERMATITIS HERPETIFORMIS. 
ence has shown that milder preparations are required for the erythema- 
tous than for either the vesicular or bullous, and I would here remark 
that this (erythematous) variety is the most difficult of all to control by 
local means, while the vesicular is the most easily influenced. It is not 
my purpose at present to take up the treatment of the several varieties 
of the disease specially, but rather to ask attention to the principles of 
treatment applicable to the disease as a whole. From a therapeutic 
standpoint the affection may he considered under the headings of acute, 
subacute, and chronic, the two latter stages being those we are generally 
called upon to treat. It must he kept in mind that the disease involves 
in most cases the greater part of the general surface; that therefore 
there is a good deal of cutaneous surface requiring attention, and that 
the remedies must he selected and prepared to meet that end. Another 
difficulty that we have to contend with is that the eruption tends to 
repeat itself in the form of more or less frequently recurring outbreaks 
or crops, a new one often coming out before the old one has disappeared, 
the skin thus being in a peculiar state, interfering with and complicating 
the treatment. It is this condition and the variety of elementary and 
secondary lesions generally present at the same time that render the 
treatment so difficult. Almost all the ca>*es that have been under my 
observation have been chronic,and previously had undergone all manner 
of treatment; in some instances at the hands of competent dermatol- 
ogists. Long experience has taught me that the disease is most difficult 
to control, and that some of the remedies from which good results might 
be looked for—such, for example, as are useful in eczema—exert hut little 
or no influence in arresting the process. The milder so-called soothing 
preparations, ns boric acid, calamine and oxide of zinc lotions, ointments, 
and pastes, sometimes so useful in acute or subacute erythematous and 
vesicular eczema, are of no value in this disease. I have long since 
arrived at the conclusion that the only class of remedies from which 
benefit is to be exacted is stimulants, especially those which act revul- 
sively. I will first enumerate a few of the more important substances 
that have been employed. These arc: Tar, in tin; form of oil, ointment, 
ami alcoholic and alkaline tarry lotions; carbolic acid, sulphur, Vlem- 
ingckx’s solution of sulphurated lime, thymol, ichthyol, hydronaphthol, 
resorcin, and fluid extract of grindelia robusta. On account of the 
peculiarity of the eruption, including its multiformity, mixed acute, 
subacute, and chronic stages, and distressing subjective symptoms, it is 
difficult both for the patient and physician to estimate the value of any 
remedy. Such sufferers, moreover, arc seldom content to remain long 
under the care of any one physician, hoping continually to derive benefit 
from frequent change of treatment. Of the remedies just referred to, 
the most valuable is sulphur, and in the form of ointment, about two 
drachms to the ounce. I was first led to employ it through the state DUHBINO, DERMATITIS HERPETIFORMIS. 
ment of a patient many years ago, who had derived more benefit from 
it than from any other substance. He had suffered long with the vesicular 
variety, and had sought the advice of many physicians without obtain- 
ing oven temporary relief. On one occasion, in desperation, he rubbed 
himself vigorously with a strong sulphur ointment, made soft by the 
addition of walnut oil. This afforded immediate and gratifying relief, 
such as no other application had ever given, and, moreover, soon caused 
the eruption to disappear. On subsequent occasions he had again em- 
ployed it, and he regarded it as the most valued remedy known to him. 
The remedy and mode of application seemed to me harsh and unlikely 
to succeed, but a trial proved satisfactory and bore out the statement 
made. My experience with it leads me to regard it as especially useful 
in the vesicular and pustular varieties, and also in the bullous, hut that 
in the erythematous variety it usually proves irritating. Let me here 
say, however, that in some cases it has failed to act favorably, and I by 
no means wish to lay too much stress on its value, nor to put it forth as 
a specific. I merely desire to state that in the vesicular variety it is 
the best remedy that we are acquainted with. It should bo applied with 
friction and with sufficient force to break down the vesicles, pustules, 
and blebs as speedily as possible. As already intimated, the ointment 
should be strong, about two drachms to the ounce, and should be used 
in the manner indicated, with the view of making a positive impression 
on the skin, by causing, as it were, local shock to the nerve-endings. 
The rubbing should be long continued and thorough. It is useless 
merely to smear it on, as the object by this means is not accomplished. 
In suitable cases acceptable relief to the itching and burning is usually 
obtained after one or two applications. Remedies of this class, I believe, 
are the kind from which most benefit is to be looked for. They should 
not be too harsh nor too stimulating in their action. The strength and 
the amount of friction must be regulated by the effect. They should be 
applied as early in the attack ns possible, as soon as the lesions begin to 
form. 
In some cases tar, especially in the form of the alkaline solution 
known as liquor picis alkalinis, is useful, es|>ecially in allaying the 
itching. It is, of course, to be diluted, one drachm to about eight 
ounces of water, according to the caustic etfect produced. Another 
equally valuable tarry solution, and one that is safer to use, is that 
known as liquor carbonis detergens, an alcoholic solution of coal-tar. 
This also is to be similarly diluted, though sometimes it may be advan- 
tageously used strong, one drachm to from one to four ounces of water. 
Moth of these preparations are useful in relieving itching, but I do not 
think that they exert much influence in arresting or modifying the pro- 
gress of the eruption, and hence they can hardly be looked ujK>n as 
curative. In the erythematous variety they prove of most value, because 4 
DUHRING, DERMATITIS HERPETIFORMIS. 
here the friction ointments are usually not tolerated. Ichthyol I have 
used in varied strength, in the form of ointments and lotions, and, as in 
the case of tar, the latter have proved more serviceable, but the remedy 
is not so efficient as tar. Nor can I speak favorably of resorcin, thymol, 
and carbolic acid. The last-named remedy, especially, has proved less 
useful than one would expect, considering its well-known powers in other 
allied inflammatory states of the skin. Of the various remedies and 
combinations which have been employed on various occasions none can 
l>e socially recommended, and hence they need not be enumerated. 
Baths, for the most part simple and hot, have been used with some 
benefit in relieving the burning and itching. A patient exhibiting the 
erythemato-vesicular variety, recently under my care, regarded a hot 
bath of an hour’s duration at night as grateful, but he did not seem to 
sleep better than when it was omitted. The same patient had, during a 
previous severe attack, endured a fortnight’s experience with the con- 
tinuous bath, which had afforded a certain amount of case and comfort, 
but had not proved in any degree curative. 
Concerning the internal treatment not much that is favorable can at 
present l»e said. With a disease tending to pursue an emphatically 
chronic course, speedy cure is hardly to Ikj expected. This observation 
is borne out by experience. Several cases under my notice some years 
ago recovered in a short time under, for the most part, internal treat- 
ment, but I am not prepared to state that the cure was due to the rem- 
edies used. In the relapsing and obstinate form, relief is to be obtained, 
I believe, only from such remedies as favorably impress the nervous 
system. The cutaneous symptoms are such as point distinctly to the 
neurotic nature of the disease. The eruption, as a whole, possesses 
features in common with the well-known and established neurotic in- 
flammatory diseases, such as herpes simplex, herpes zoster, herpes iris, 
and pemphigus. The nervous system, it may be centrally or periph- 
erally, is undoubtedly in some manner and in a variable degree deranged, 
and it is to aid this important function that we must look in the choice of 
remedies. Among such drugs I would first sjHjak of arsenic, which in 
suitable cases offers, I believe, more ho|>e of benefit than any other 
remedy. By suitable cases I mean more particularly the simple, un- 
complicated chronic cases, whose history and cause are obscure, and not 
those manifestly due to a deranged uterus and the like. At the same 
time, from my experience and from that of some other practitioners 
with whom I have l>een in communication on the subject, it must, on 
the whole, l>e regarded as disappointing. No reliance can be placed 
upon it, and sometimes it seems rather to aggravate the disease. 
Upon inquiry I have found that most of the patients who have been 
under my observation had at one time or another previously taken a 
course of arsenic, and without experiencing much, if any, benefit there- UU II RING, DERMATITIS HERPETIFORMIS. 
5 
from. I may add that it has often been a matter of surprise to me how 
little influence, for good or for bad. it possessed over the disease. While, 
therefore, some cases seem to have been benefited, the majority have not 
been so, possibly, in some instances, because the drug had not been ad- 
ministered in sufficiently large doses. In one case, however, very large 
doses of Fowler’s solution (as much as forty or fifty minims a day) were 
tolerated, and seemed for the time being partially to control the bleb- 
formation, but the results, upon the whole, were not beneficial. 1 believe 
it to be well worth a trial in the vesicular and bullous varieties, and 
the dose should be gradually increased. From the well-known power 
of arsenic to relieve and to cure some cases of true pemphigus, one 
would naturally look for good results in suitable cases of the disease 
under consideration, which is, without doubt, allied to the pemphigus 
process. As far as our knowledge of the treatmentof dermatitis herpeti- 
formis extends to-day, no other remedy oilers so much liojhj of benefit 
in suitable cases, and the results, whether beneficial or harmful, should 
be duly chronicled with the reports of future cases. Of the value of 
quinine and strychnine, there is not much to be said beyond that they 
do not appear to possess any special power over the disease. The same 
remark may bo made concerning certain other general remedies that 
have been employed—as, for example, iron, cod-liver oil. and ergot. In 
several oases that are called to mind, it was thought that the hygienic 
influences of change of air and scene might prove beneficial by giving 
tone to the nervous system, but in this the results were not commensurate 
with the trouble incurred. Hut I would by no means undervalue both 
moral and hygienic treatment, both of which should receive full consid- 
eration, for experience with this disease shows that in most cases general 
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