HINTS ON THE TREATMENT OF SOME PARASITIC SKIN DISEASES. BY GEORGE H. ROHE, M.D., PROFESSOR OF HYGIENE AND CLINICAL DERMATOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, BALTIMORE; MEMBER OF THE AMERICAN DERMATOLOGICAL ASSOCIATION, ETC. Reprinted from The Mkdical Record, 2> i883- MEW YORK: TROW’S PRINTING AND BOOKBINDING CO., 201-213 East Twelfth Street. I883. HINTS ON THE TREATMENT OF SOME PARASITIC SKIN DISEASES. BY \ / GEORGE H. ROHE, M.D., PROFESSOR OF HYGIENE AND CLINICAL DERMATOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, BALTIMORE; MEMBER OF THE AMERICAN DERMATOLOGICAL ASSOCIATION, ETC. Reprinted from The Mkdicai. Record, June 2^1882. NEW YORK: TROW’S PRINTING AND BOOKBINDING CO., 201-213 Kast Twelfth Street. 1883. HINTS ON THE TREATMENT OF SOME PAR- ASITIC SKIN DISEASES.1 John Hunter is said to have divided skin diseases into three classes : those that sulphur will cure, those that mercury will those the devil himself can’t cure. Most general practitioners seemingly indorse this dictum of the great pathologist. At all events, most practition- ers readily admit the difficulty of diagnosis, and the un- satisfactory results of treatment of many cases of skin diseases seeking relief at their hands. When we reflect that ten years ago less than half a dozen of the medical schools of the United States made any pretence of giving instruction in dermatology beyond one, two, or three lectures, in the didactic course on the practice of medicine, which lectures were chiefly remark- able for the extraordinary number of uncouth words and unintelligible definitions hurled at the students, we can- not wonder that so many physicians should be unfamiliar with the diagnosis, causes, and treatment of the diseases affecting the skin. In this paper it is proposed to consider, briefly, what appears to the writer the best treatment of some of the cutaneous diseases caused by vegetable parasites. 1 Read before the Clinical Society of Maryland, March 16, 1883. 4 It is well known that the diseases known as tinea favosa, or favus, tinea trichophytina, or ringworm, and tinea ver- sicolor, or “ liver spots,” are due to the presence upon or in the skin of microscopic organisms of vegetable ori- gin. It would lead too far from the practical side of the subject to discuss here the botanical relations of these three different parasites. For the present purpose it may suffice to state that clinically the diseases are distinct and easily differentiated, or rather, not at all likely to be mistaken for each other. Favus is comparatively rare in the United States. The disease manifests itself in yellow, cup-shaped crusts, nearly always occurring upon the scalp. The crusts are perforated in the centre by a hair. If one of the crusts is removed, a cup-shaped depression remains in the skin, which gradually fills up to the normal level unless the crust is re-formed. The crusts of favus have a peculiar odor, said to resemble that of mice. If a small portion of one of these crusts be rubbed up with a little liquor potassa, placed on a glass slide and brought into the focus of a one-fourth inch objective un- der a microscope, a number of transparent branched tubes (mycelium), with small spherical or oval bodies (spores) in their interior will be seen. Spores, singly or in groups, will also be seen in various portions of the field outside of the mycelial tubes. This is the fungus upon which the disease depends—the achorion Schoen- leinii of Remak. The hairs which perforate the yellow crust or scab will also be found filled with these spores. The destruction of the fungus cures the disease by re- moving its cause, hence a paraciticide is the proper remedy to use. 5 It will be found, however, that all efforts at treatment will fall short of success unless all the crusts, and the hairs perforating them, are first removed. Soaking the scalp with oil or lard for twelve hours, then washing with warm water and soap to remove the crusts, and afterward pulling out the hairs from the diseased patches, are, there- fore, necessary preliminaries to a successful treatment of the affection. After the crusts and affected hairs have been removed, the application of sulphurous acid, either in full strength or diluted with an equal quantity of water, or a Solution of corrosive sublimate, one to three grains to the ounce of water or alcohol, will be all that is needed. The antiparasitic remedy must be kept constantly applied and the case carefully watched. If a relapse is threat- ened, prompt epilation and removal of the most primitive crusts must be practised. When favus has lasted a long time, baldness is likely to follow over the affected sur- face. The time necessary to effect a cure of favus varies, but complete success should not be expected in less than six weeks to two or three months. The disease can be made to disappear in a much shorter time, but will al- most certainly return if the parasiticide applications are not continued for at least three or four weeks after any evidences of the disease can be seen. Ringworm presents marked differences as it affects different regions of the body. When it occurs upon the hairy scalp it appears in scaly patches, often having a small-vesicular or pustular border. The hairs upon these patches are dry, brittle, and most of them are broken off a short distance above the skin, giving the patches the appearance of a stubble field, over which the grass or 6 grain has been irregularly cut. The skin under the scales is usually little, if at all, reddened, except at the border, where the disease extends centrifugally. This stubbly appearance of the hairs is characteristic of ringworm of the scalp. In that form of partial baldness termed alo- pecia areata, and which is also held by may to be para- sitic, the bald patches are perfectly smooth, white, and shiny—altogether different in appearance from the scaly ringworm patches. When ringworm remains for a long time untreated, or is improperly treated, it may develop into kerion, a curi- ous, obstinate, tuberculo-furuncular disease of the scalp, which has been very thoroughly observed and graphically described by Dr. I. E. Atkinson, of Baltimore.1 In kerion there is a condition simulating sycosis. The hair- follicles are inflamed, variously sized tumors develop, from which exudes a gummy, honey-like fluid. The hairs fall out and the spot is likely to remain permanently bald —a result not apt to follow simple ringworm, in which the hair is almost always reproduced. In ringworm of the scalp, cleanliness and frictions with carbolized oil have been almost exclusively relied on in the practice of the writer. The strength of the application used is one part carbolic acid to sixteen parts of linseed or olive oil. This should be applied in the following manner : After washing the scalp with warm water and soap, and drying, a little of the oil is poured on a piece of flannel, and rubbed into the dis- eased patch with smart friction. The friction drags out of their follicles the loosened hairs, and has an additional 1 Archives of Dermatology, January, 1881. 7 advantage in opening the mouths of the hair-follicles and allowing the remedy to penetrate deeper, and come in closer contact with the parasite, which gives most trouble when it has penetrated into the hair-follicles. This pro- cedure renders systematic epilation with the forceps un- necessary, and so increases the comfort both of physician and patient. When the diseased patch has thus been well saturated with the carbolized oil, the rest of the scalp should also be rubbed with it, to prevent extension of the infection. Sulphurous acid has also been used with great satisfac- tion in the treatment of ringworm of the scalp. It is used either in full strength, or diluted with a half, or an equal part of water. No other measures have been found necessary in the treatment of simple ringworm of the seal]). Where kerion was present, the boggy tumors were freely incised, and carbolic acid ointment used as a constant application with a favorable result. Ringworm of the body—tinea circinata—usually ap- pears in the form of variously sized scaly patches, with a red papular, vesicular, or pustular border. It extends peripherally until the spots reach the size of a silver dol- lar, rarely getting larger without a break in the regularity of the margin. As it extends peripherally, the normal condition, barring perhaps a slight scaliness, is re-estab- lished at the centre. Auto-inoculation not infrequently takes place, and spots are found on different parts ot the body. The microscope will differentiate it from sebor- rhoea, or localized patches of eczema. The best method of treatment the writer has employed is to apply, once or twice a day, pure sulphurous acid to the spots. No 8 other remedy has given so much satisfaction as this in simple ringworm of the body. Ringworm of the beard, in the majority of cases, does not advance beyond the condition just described as ringworm of the body. It is usually communicated through some of the shaving utensils used by the barber —sponge, brush, or towel. When early discovered and treated, the application of sulphurous acid will give gen- eral satisfaction. A solution of corrosive sublimate, one to two grains to the ounce, also leaves nothing to be de- sired. When it has lasted a long time, however, and produced the disease known as parasitic sycosis—pus- tules, tubercles, and abscesses of the bearded part of the face, with involvement of the hair-follicles—treatment be- comes more active and complicated, and must be pur- sued with vigor and persistence, if a cure is expected or hoped for. In cases of sycosis all pustules, tubercles, or abscesses should be freely punctured, the face being gone over every day, or every other day. The hairs of all in- flamed follicles must be extracted with the epilating for- ceps. The patient should shave daily, or at least every other day. An ointment of white precipitate, calomel (or what is probably better than either), oleate of mer- cury (five per cent.), should then be applied, and kept in contact with the diseased surface constantly. In ad- dition, the reddened patches of skin between the pus- tules or nodules should be painted two or three times a week with a solution of carbolic acid, one part to four parts of alcohol. Ringworm of the genito-crural region —called eczema marginatum by Hebra—presents peculiarities which de- mand special consideration. In this affection the 9 diseased part presents all the characteristics of eczema— intense itching, exudation, infiltration of the skin, etc.— but unlike an ordinary case of eczema, there is present a distinctly outlined border, and on careful microscop- ical examination, a fungus resembling, and probably identical with, the ringworm parasite may be discovered. Eczema marginatum demands a somewhat different treatment from ordinary eczema and ordinary ringworm. We must endeavor to combat the inflammatory con- dition on the one hand, and destroy the parasite on the other. Hence the parasiticide employed must be one that is effective, while it produces the minimum of irrita- tion. In many cases the application of sulphurous acid, followed by oxide of zinc or Hebra’s ointment, will pro- duce a prompt cure. In others, no good effect at all will follow. In some cases the continued application of an ointment containing one or two drachms of ammonio- chloride of mercury will produce the effect desired. In cases accompanied by intense itching, and much local inflammation, the writer has obtained the most excellent results from the frequent application of a lotion of benzoic acid, 3 j- to one pint of water. After the itch- ing is controlled by this means, the eczema will usually get well under simple dusting with starch or chalk, and cleanliness. The benzoic acid acts as a parasiticide, and destroys the fungus while promoting the cure of the eczema by relieving one of the chief factors in its con- tinuance—the itching. Tinea, or pityriasis versicolor, called also “liver spots” in the vernacular, has been observed by the writer nearly as frequently as ringworm. It occurs in the form of brownish-yellow, slightly scaly patches and spots, limited 10 to the parts of the body covered by the clothing. It is most frequently localized upon the chest, which is some- times completely covered by a continuous sheet of the eruption. The borders are irregular, and roundish or irregular patches extend beyond with intervals of sound skin between. It sometimes extends down the arm to the wrist, and up on the neck to the collar-band of the shirt—the soap-line, as it may conveniently be termed. Beyond this line the disease is rarely, if ever, seen. The mildest parasiticide suffices to destroy the fungus which causes the disease ; hence it is never found on parts frequently washed with water and soap. The remedy which, in the writer’s hands, has been uniformly success- ful in curing the disease, is a lotion of hyposulphite of sodium in the strength of half a drachm to the ounce of water. The patient is directed to take a bath once a day, using soap freely. After the bath the affected spots are to be mopped with the parasiticide lotion. In a week the discoloration has usually disappeared. The remedy should be continued a week or two longer to prevent relapse. No other than this simple treatment is necessary in the majority of cases of tinea versicolor. It is surprising to what an extent cases of tinea versi- color are treated for syphilis, hepatic derangement, or similar supposed affections of the internal organs. Pa- tients are sometimes compelled to take mercury or po- tassium iodide for months, under the supposition that they suffered from syphilis, when the only trouble was that just described, which, when properly treated, yielded to local remedies alone in the brief space of two weeks. No mention has been made in this paper of the em- ployment of tincture of iodine, chrysophanic acid, and 11 similar active irritants in the treatment of the cutaneous parasitic diseases. The excuse offered for the omission, if any be necessary, is that the writer has never had oc- casion to use them. Patient and intelligent application of the remedies before mentioned will, in most cases, be followed by success. Nearly all patients will likewise be better pleased if a colorless, non-irritant application be used, than if an irritant remedy, staining the skin, and not infrequently causing disagreeable complications, be applied.