[Reprinted from the Philadelphia Hospital Reports for 1892.] 
NOTES ON THE HOSPITAL TREATMENT OF 
PSORIASIS. 
By HENRY W. STELWAGON, M.D. 
There is no service for skin-diseases, I believe, in Philadelphia, 
so rich in well-marked, extensive, and advanced types of psoriasis 
as the skin-ward of this hospital. The mild form so often seen in 
ordinary dispensary and private practice rarely comes under ob- 
servation here. On the contrary, it is the widely-diffused and 
inflammatory forms of the eruption, with more or less thicken- 
ing, which make this ward a rich place for studying the treatment 
of the disease. The various new external remedies which are 
brought forward from time to time have all had here opportunity 
to demonstrate their usefulness, but have almost without exception 
proved of much less value than the remedies which have been in 
routine use for a number of years. The external treatment which 
has been the most successful here, and upon which reliance is 
placed, consists of alkaline baths, salicylated vaseline, tarry oint- 
ments, and chrysarobin applications. The particular plan adopted 
depends measurably upon the type and extent of the disease. 
First, however, a few words as to the constitutional treatment. 
In my experience, and I must believe in the experience of others 
unprejudiced against the remedy also, nothing rates so high as 
arsenic. In the great majority of cases, and especially if it is the 
first attack, or if the patient has never before been placed under 
systematic treatment, the favorable effect of the judicious adminis- 
tration of this drug is often remarkable, the eruption clearing 
steadily and rapidly away. On the other hand, in cases in which 
the disease has recurred several times, and in which the previous 
attacks had been treated with arsenic, the remedy, as a rule, sig- 
nally fails; or, at the best, makes an impression only when pushed 
beyond a reasonably safe dose. The proper dose is that which 2 
NOTES ON THE HOSPITAL TREATMENT OF PSORIASIS. 
stops just this side of active physiological or toxic action; that is to 
say, there is no reason to push the drug to the point of having such 
objective or subjective evidences of its action as puffiness about 
the eyes, injection of the conjunctivae, disturbance of the gastro- 
intestinal tract, restlessness, or other nervous symptoms. In short, 
its good effect upon the eruption must not'be at the expense of 
the general health. Rarely more than fifteen to twenty minims 
of Fowler's solution, or its equivalent of arsenious acid, should be 
given daily. A fact that has been experimentally noted here is, 
that the drug is more valuable and less apt to provoke disagreeable 
symptoms when given in small divided doses, as for instance, one 
to two minims every hour during the day (ten or twelve hours). 
Next in value is the alkaline treatment. This, however, is suitable 
only in individuals in robust health, and more particularly when 
the eruption is of the markedly inflammatory type. The alkalies 
which experience has shown to be the most trustworthy are liquor 
potassae, potassium acetate, and potassium iodide; the first-named 
is given in ten to thirty minims, the second fifteen to forty grains, 
and the last ten to sixty grain doses, three times daily. The 
potassium iodide acts, I believe, as an alkali, and not in virtue of 
its being an iodine compound. 
Another remedy referred to in one or two of the older books is 
the oil of copaiba. This has proved of benefit in several more or 
less extensive and obstinate cases, in the dose of twenty to thirty 
minims three times a day. It is not an important or generally use- 
ful one in the treatment of this disease, but it may be remembered 
as possibly of value in rebellious cases. It need scarcely be stated 
that in those cases in which debility is the apparent and probably 
real predisposing cause of the outbreak, cod-liver oil and similar 
nutrient and other tonics have a curative value. 
The external treatment of the disease is all important and is 
really indispensable. In those patients in whom the disease, 
though extensive, presents itself as small pea- to dime-sized patches, 
a daily alkaline bath alone often suffices. The patient soaks in 
the bath (warm to hot) for fifteen to thirty minutes. The alkali 
used is sodium carbonate, four to eight ounces to the bath. If 
the skin after a few days begins to get harsh and dry, the general 
surface is lightly greased after each bath with salicylated vaseline; 
or this ointment, ten grains of salicylic acid to the ounce, may be 
so used as a routine measure. In cases in which the patches are NOTES ON THE HOSPITAL TREATMENT OF PSORIASIS. 
3 
larger-dime to a palm size, or of greater area-the same plan is 
sometimes successful; if the improvement is slow, then after the 
alkaline bath, instead of greasing with the salicylated vaseline, a 
weak ointment of oil of cade, a drachm to the ounce, or the ordi- 
nary tar ointment weakened with two or three parts of lard, is to 
be thoroughly rubbed into the patches, and starch-powder or rice- 
flour freely dusted over. In the more obstinate cases, the tar 
ointment, officinal strength, or the pure oil of cade is used. This 
method of treatment-by alkaline baths and tarry applications- 
is an extremely valuable one; and it is only in a small proportion 
of cases that a more active plan becomes necessary. The objec- 
tion to tar in private practice does not, of course, hold in hospital 
treatment; and it is yet, all things considered, in spite of the 
various new remedies brought forward to supplant it, the best all- 
around external remedy we possess. 
The plan of external treatment adopted in rebellious and obsti- 
nate cases is that consisting of applications of chrysarobin. There 
are three methods of applying this valuable remedy,-as a paint, 
as a powder, and as an ointment. The paint, the most elegant, 
but, comparatively speaking, least active of the three, consists of 
a drachm of chrysarobin, forty grains of salicylic acid, a fluid- 
drachm of ether, ten minims of castor-oil, and an ounce of collo- 
dion. A more elegant and more active paint is made with the 
solution of gutta-percha, in the same proportion as above, omit- 
ting the ether and castor-oil. Gutta-percha solution is, however, 
too costly for hospital use. As a powder, the chrysarobin is pre- 
scribed in chloroform, a drachm to the ounce, and painted over 
the patches; the chloroform evaporates, leaving a thin film of 
chrysarobin powder, over which, in order to fix it, is painted a 
coating of pure collodion. The collodion paint is that which I 
have most frequently employed here. It is painted on with a fine 
brush about once every two to four days, depending upon how 
long the coating remains intact. In extensive cases the diseased sur- 
face is gone over gradually from day to day. The alkaline baths are 
used as a preliminary measure to free the patches from scaliness, 
but are not used during the period of active painting. The coat- 
ing loosens in a few days, and may be picked off and a repainting 
made; or, if parts of the film crack and become detached, then a 
new coating may be made over the remains of the old; or, at 
the end of several days or a week, the baths may again be used 4 
NOTES ON THE HOSPITAL TREATMENT OF PSORIASIS. 
for a few days to aid in loosening the collodion films, as a prelim- 
inary to another thorough painting. The method by chrysarobin 
ointment, while the least..pleasant, is the most effective of all; it 
is employed when energy of action is desired, or for the reason 
that it is less costly than the paint. It is to be well rubbed into 
the diseased areas immediately following the alkaline bath. All 
methods of using chrysarobin produce more or less temporary 
staining, and after several applications may provoke a mild or 
even severe dermatitis; on the first evidence of the latter the ap- 
plications should be suspended, and the alkaline baths and sali- 
cylated vaseline advised. As soon as the irritation has disappeared 
the chrysarobin applications are resumed, usually in weaker 
strength. These undesirable effects-the staining and dermatitis 
-are much less likely to occur with the paint than with the oint- 
ment. The good effect of the chrysarobin treatment is shown by 
a gradual paling of the areas of disease, and when the inflamma- 
tory hue and thickening have entirely disappeared, the applica- 
tions should be discontinued, to be resumed again if the patches 
are found still active or incompletely removed.