(Tetter: Salt rheum)
Definition. An acute, subacute or chronic, non-contagious, inflammatory, catarrhal disease of the skin, characterized primarily by erythema, papules, vesicles and pustules, and secondarily by a variable amount of infiltration, thickening, scaling and crusting, accompanied by pronounced subjective sensations.
Symptoms. Eczema is a many sided disease; but for purposes of study four elementary varieties, the erythematous, the papular, the vesicular and the pustular are recognized. These lesions constitute the peculiar type which may remain distinctive, or at least predominate throughout the course of the disease, though the secondary forms, such as eczema rubrum, eczema, squamosum and eczema fissum, may develop. This technical division of a disease which constitutes between ages, in all countries, in all seasons, in both sexes and in all conditions of life, is necessary for the convenience of description, but it is well to again emphasize that even in the mixed types one lesion usually predominates.
Eczema erythematosum. This variety occurs in the extremes of life, in infancy and old age, usually on the face, palms, toes, or genitalia, and while the least common of the primary forms, is very pronounced. The erythematous spots may remain isolated or, rapidly spreading over a large surface, coalesce. There may be swelling, or even edema, about the eyes. There may be rough scales or fissures, or a general weeping of the surface may appear whether vesicles are visible or not. If this scaling persists to any degree, the condition becomes eczema squamosum or eczema exfoliativum. If the eruption remains well defined in small patches throughout its course, it is called eczema circumscriptum. If on opposing surfaces, as between the genital folds, it is known as eczema intertrigo and is usually associated with a muciform secretion. Erythematous eczema may be associated with other forms, especially at its borders. It may be persistent or respond rapidly to treatment, only to reappear in a short time. It is always associated with itching and burning, and in a short time. It is always associated with itching and burning, and is nearly always worse from marked changes of temperature, cold wind or excessive heat.
Eczema vesiculosum is the most typical catarrhal inflammation of the skin, and one of the most common transitional forms. While if may occur on any surface, it is often seen upon the faces of infants and young children, and upon the fingers, hands, necks and flexor surfaces of older people. Ordinarily the eruption is preceded by sensations of itching and burning, followed by a diffused local erythema, upon which, within a short time, closely aggregated pin-point to pin-head-sized vesicles appear; these may enlarge, coalesce, or rupture spontaneously or from friction, but in the end of a sticky serum is exuded which stains and stiffens linen brought in contact with it. The subjective sensations are usually improved with the rupture of the vesicles, only to become more aggravated when new vesicles are forming and always at night during the entire course of the eruption. Scratching or rubbing naturally increases the weeping so typical of most eczema. It not disturbed, the fluid exudation forms yellowish-brown crusts beneath which a moist surface is evident. When the fluid ceases to exude, and scales take the place of crusts, a squamous form of eczema may persist for a time, or a severe form may ensue from the increased inflammation and the discharge, with aggravations from itching and scratching, and eczema rubrum, with its intense red and angry appearance, is established. In a great majority of cases of vesicular eczema, the vesicular type is permanent, although the area involved may be large, because fresh vesicles develop at the margins, or because it becomes generalized. Limited to one region it is apt to run an acute course.
Eczema papulosum Lichen simplex). Pin-head-sized rounded or acuminated, bright or dull red, discrete or closely aggregated papules commonly situated on the flexor surfaces of extremities, less often on the trunk, or even generalized, but never involving the scalp, present the description of this type. It was formerly thought a form of lichen because of its tendency to remain papular throughout, and the frequent situation of the papules in the hair-follicles. A careful search may reveal tiny vesicles at the apex of some of these papules, but more often they are blood capped as the result of scratching. Closely aggregated papules may develop into a weeping patch as the result of vesiculation, or they may become scaly, lose their papular character and become a squamous eczema, which is commonly noted on the dorsal surface of the hands and on the extensor surfaces f the extremities, while the rest of the eruption remains papular. Papular eczema is often refractory to treatment, frequently relapses, and is especially memorable because of its intense itching.
Eczema pustulosum begins in the same way as the vesicular form white local erythema upon which there appears closely aggregated pustules, or there may be an intermediary vesicular state, or the vesicles and pustules may commingle in varying proportions, or neither lesion may be distinct, and yellowish or brownish crusts may cover the whole or part of the affected area. On the hairy surfaces, such as the bearded portion of the face of males, the follicles become inflamed and secondary folliculitis complicates the process, and it may even persist after the eczematous manifestation has ceased. Pustular eczema is especially fond of the strumous, cachectic patient, and appears to favor children, appearing on the face and scalp. In adults, it is sometimes found on the thighs and lower legs as well as upon the beard.
Eczema rubrum is a secondary form, and is due to an aggravation or modification of one of the primary types, especially the vesicular or pustular varieties. Redness, swelling, infiltration, exudation, bleeding, and consequent crusting are pronounced. It is most common on the face of infants, where originally it may have been a mere dermatitis, but neglect or irritation has caused this development, and upon the legs of middle-aged or old adults, especially men, who suffer from marked varicosities and often show the common varicose ulcer. The name eczema madidans has been given to that aggravated form of red, raw and weeping eczema in which the moisture constantly oozes from the surface with pronounced burning and itching.
Eczema squamosum. Scaling and infiltration are the pronounced features of this development from the chronic erythematous or papular types. The erythematous eczema is especially apt to terminate in this form, but it is well to remember that the later stages of all eczemas will show a certain degree of scaling. The scales are usually grayish-white, thin and flaky, and are scantier and more easily detached than those of psoriasis. They may involve large areas or small patches, and are frequently not typical of true eczema unless the previous history be known. In one variety of this type, eczema tyloticum, in which the palms of the hands and the soles of the feet become enormously thickened, the horny appearance will lead one to think of keratosis plantaris et palmaris.
In any type of eczema in which there is much induration, or in a location where there is a natural crease, there may be a separation of the surface leading to the condition known as eczema fissum. A mild form of eczema, usually of a squamous or fissured nature, is presented in the condition known as chapping due to cold winds, cold water, or any irritating substance even ordinary soap if too frequently used. If the infiltration of the skin is unaccompanied by inflammation, but is chronic, indolent and leathery almost to the degree of scleroderma, it is called eczema sclerosum. If characterized by watery excrescences, it is known as eczema verrucosum, or eczema papillomatosum if the papillary hypertrophy is exaggerated. The clinical feature of eczema are much modified by location, due not alone to anatomical differences, but also to external influences such as temperature and friction to which the different portions of the body are subject. To avoid repetition, the description of eczema by anatomical location is best left to the consideration of the regional treatment of the disease.
Etiology. There is not one cause of eczema. It is not respecter of persons or age and although more common in the over and under nourished, and more frequent in the extremes of life, it can occur in any period, during any season, and in any land. It is not a parasitic disease, although various bacteria may influence its course. The difference between a dermatitis caused by external irritants and an eczema excited by the same irritants rests wholly in the existence of a predisposition in the latter condition and an absence of the same in the former. Hence we consider that the cause of eczema are two-fold: constitutional or predisposing, working from within, and local or exciting, working from without. It is possible that either one might cause the development of a case of eczema independently of the other, but usually they are associated in the causation. If the predisposition exists, local irritants which ordinarily would cause no damage might bring about the disease.
For convenience the local causes have been grouped as chemical, thermal and mechanical. Chemical irritants comprise a host of medicinal agents, such as surgical antiseptics, iodin, arnica, mustard, dyestuffs, etc. In this class must also be included the trade eczemas, seen in tanners, bakers, washerwomen, chemical worker, cattle-men, etc., or the professional eczemas, found in dentists, surgeons, nurses and veterinaries. Under the thermal group must be included the eczemas from the natural sun;s rays and artificial heat from any source whatsoever, hence an eczema of firemen and stokers would be included in this causal group. Winds, especially a cold wind, are likewise an important factor. The mechanical irritants include parasites, friction, scratching and pressure from various articles of clothing including human harness of any sort.
The constitutional or predisposing causes are the most important, and in this connection abnormalities of exercise, clothing, bathing and diet must be considered. The lack of a proper ration in the assimilation and elimination of food, leading as it might to absorption of toxins and other poisons, and showing itself in the form of constipation, gastrointestinal indigestion, or renal insufficiency, is all important. Almost any improper functional activity of one or more internal organs may be a causative factor, but most authorities are agreed that the gouty, rheumatic or catarrhal diatheses are the most frequent constitutional causes. However, there are types which are distinctively neurotic, as may be found in case of neurasthenia or in the secondary nervous condition resulting from anemia. Among the other predisposing causes may be mentioned nephritis, diabetes, utero-ovarian diseases, tuberculosis, acute fevers, dentition, pregnancy and lactation.
Pathology. The connecting link between the causes of eczema and its pathological anatomy is nearly always trophoneurotic in character, causing a catarrhal inflammation on the skin very similar to the catarrhs of the mucous membranes. In general it may be said that the blood vessels are dilated, that there is a cellular exudation of the tissues with round cell infiltration in the papillary layer of the corium. In the papular form, the changes take place around the follicles, especially the hair-follicles, and the rete cells become separated by fluid exudations and swell up. In the vesicular form, there is a further liquefaction of the cells, the contents of which unite in small accumulations beneath the corneus layer, while a pustule is formed by the emigration of leucocytes into the cavity formed by the contents of the liquefied cells. The rete mucosum is exposed when the horny layer is cast off without vesiculation, as occurs in eczema rubrum. Cell infiltration extends almost to the subcutaneous tissue in chronic indurated eczema, and the papillae become markedly hypertrophied.
Diagnosis. Eczema is so seldom seen in its primary or initial state that it may easily be mistaken for other diseases unless the main points of diagnosis are always borne in mind. These are a varying degree of redness (inflammation), with development of vesicles, papules or pustules; a serous or purulent exudation sooner or later in the course of the disease; crusting and scaling: a tendency or later in the course of the disease; crusting and scaling; a tendency to coalesce and form patches, and pronounced subjective sensations, such as itching and burning.
Erythematous eczema, in its early stage, might well be confounded with erythema simplex or erysipelas, while vesicular eczema might resemble vesicular erysipelas, herpes zoster, herpes simplex or scabies. Pustular eczema might be mistaken for a pustular syphilid, impetigo contagiosa, sycosis of favus of the scalp; the papular form for a papular syphilid, lichen ruber, lichen planus, or a papular urticaria, while the squamous form might resemble tinea circinata, psoriasis, or a squamous syphilid.
Erythema simplex shows a distinctive hyperemia, absence of inflammation and marked itching. It is short of duration and has little tendency to appear on the face.
Erysipelas is attended with a systemic fever, and the surface affected is deep red, shiny, smooth and well-defines. If vesicles appear they are larger and not grouped as in eczema, and dequamation only occurs after the inflammation subsides.
Herpes zoster presents a unilateral distribution with neuralgic pain, and no constant itching; its vesicles are grouped on an appear base, the clusters following the course of a cutaneous nerve. The limited distribution and short course of the vesicles of herpes simplex, together with the fact that a few are grouped together on a red base, and may dry up without rupture, makes the disease distinctive.
Scabies may become an eczematous dermatitis, and its multiple lesions and itching may closely resemble the vesicopustular and crusted types of eczema, but if the pathognomonic “burrow” be found, or if the acarus scabiei can be located, there is no difficulty in making the diagnosis. In doubtful cases, a few days of antiparasitic treatment will settle the diagnosis, by curing the scabies or conversely by aggravating the eczema.
Pustular syphilids, especially of the scalp, should not be mistaken for eczema, because a syphilitic history, the offensive odor, adherent crusts, superficial ulcers, scars and the absence of itching are totally unlike eczema.
Impetigo contagiosa is an acute disease in which the vesicopustules are larger, more isolated, the crusts thicker and darker, and the skin beneath more normal than is found in a vesicopustular eczema. Under antiparasitic treatment impetigo will disappear in from three to ten days.
Sycosis and the later stage of follicular eczema of the beard are nearly identical, and inasmuch as the treatment is practically the same the diagnosis is unnecessary. It may be said, however, that pustular eczema is not limited to the beard and mustache, it itches more and is less chronic than sycosis.
Favus with its sulphur-yellow, powdery, cup-shaped crusts and the presence of favus fungi microscopically, should be easily differentiated.
Lichen ruber might be mistaken for papular eczema, but ordinarily the unchaining pointed scale-capped papules of lichen ruber are distinct, while its further evolutions are totally unlike eczema.
Lichen planus papules are larger, angular flat and purplish in color, as compared with the small, round, bright red papules of eczema, which also will show excoriations and blood crusts, which lichen does not.
Urticaria papulosa seldom occurs after childhood, its lesions are never grouped, and are of short duration, while wheals or a history of their presence can usually be found.
Psoriasis shows a preference for the extensor surfaces, pearly white scales which if removed show bleeding points, sharply defined borders, a tendency to clear in the center, and little or no itching.
Tinea circinata is asymmetrical, may give a history of contagion, shows a sharply defined margin with central clearance. The microscope may be needed to settle the diagnosis.
Papular and squamous syphilids will always show other signs of syphilis, either from history, or in the way of scars or recent lesions, and may give a history or infection. Subjective sensations are absent or not marked as compared with eczema.
Prognosis. If left alone, eczema tends to continue indefinitely, although there may be spontaneous recovery, or, more commonly, recurrences. Nearly every case of eczema is curable under judicious, persistent treatment; but the duration, extent and type of the disease together with the element of neglect or the inability of the patient to follow directions should be borne in mind.
Treatment. All local or exciting causal elements should be removed as soon as possible. If no exciting features are apparent, a careful search should be made in every possible direction to ascertain a possible systemic cause so that the proper constitutional treatment may be instituted. In this particular, it it not sufficient to examine the exercise and sleep, in fact all details that contribute toward the habits of every day living should be investigated. If the cause should be some underlying disease, such as rheumatism, gout or diabetes, the treatment should be directed toward this. In any case, the individual should be treated rather than the disease eczema. There is no combination of symptoms found exactly alike in two individuals, hence it is useless to look for specifics in the treatment of eczema. There is nothing in the entire domain of therapeutics that may not be used to relieve this condition, but the most common measures will be aimed to improve digestion, relieve this condition, but the most common measures will be aimed to improve digestion, relieve constipation and make the urinary excretion normal.
The quantity and quality of food is again an individual question, some patients requiring no restrictions, in fact must be urged to eat, while others must be placed upon a rigid diet, even to the point of starvation. A reduction in quality is found just as desirable as as a reduction in quantity, and the regulation of meal hours and sufficient chewing are important considerations. Speaking broadly, all stimulants should be prohibited, and liquids should be indulged in sparingly at meals, while a reasonable amount of pure water should be drunk between meals. Fresh articles of food, such as the light lean meats, fowl, fish, vegetables, salads, and unsweetened fruit may be urged, while starchy and sugary foods, such as candy, pastry, pie and confection, and shell- fish, salt meats, salt, fish, dried or preserved foods of all kinds, and condiments should be avoided.
Diuretics may be needed in any stage if the kidneys fail to act properly. Renal insufficiency might demand an alkaline mineral water or to to 20 grain doses of potassium acetate, citrate or bicarbonate, given a half hour before meals but ordinarily the free use of water between meals will sufficiently flush the kidneys.
If constipation can be relieved by diet, it is the ideal method, but it is not always possible to do so. It may be necessary to urge the eating of an extra amount of fruit, such as prunes and gigs, or to resort to the regular application of massage or gymnastics aimed at the stimulation of the abdominal functions. Laxatives are to be preferred to cathartics in all cases, mild agents such as olive oil and liquid albolene rather than harsher methods. Cascara, aloin and a host of other well to be torpidity of the liver, pancreas or spleen. Saline waters such as Rubinat, Hunyadi, Apenta or Carabana are often efficient, or a natural effervescent salt such as one of the Carlsbad products may be employed with or seems due to muscular atony, high enemas are preferable, or if due to rectal atony, simple suppositories or dilation of the sphincter may be advisable.
Physiological treatment further demands that the patient have a sufficient amount to bodily exercise, especially if it can be pleasurable, to further the elimination of poisonous accumulations within the system because retention of these is supposed to be a fundamental cause of eczema. Often passive exercise, if not applied to the surface involved, is the easiest means of accomplishing the object. Bathing, like many useful habits, must be regulated to the needs of each individual but the ordinary soaps should never be employed. Hot water is best employed both for its cleansing and therapeutic effects, especially if only used for a few minutes, as it will often relieve irritation and cause a beneficial reaction. The drying of the skin should be more in the nature of a patting than a rubbing, as irritation of all description should be avoided. It is seldom that the addition of alcohol, salt, bran, starch, borax or soda will benefit chronic papular eczema. Occasionally the subject of fresh air and ventilation, especially of sleeping rooms, should be radically changed to improve his general hygiene. Clothing should be selected with care so as not to be too warm, too thin or too irritating. Flannel or wool invariably irritates an eczematous surface, although they may be worn over linen or cotton.
External Treatment. The local treatment of eczema has in view cleanliness, protection, relief of itching, burning or other sensations, and stimulation or counter irritation of indurated patches. Ordinarily mechanical protection may be given by applications of non-medicated powder, oils, ointments, pastes, varnishes, bandaging, etc. When advisable, a weak, non-irritating antiseptic or antiparasitic, such as ammoniated mercury, can be incorporated in the protective prescription. It is most important that a patient be made comfortable, not only because the itching will cause scratching and consequent aggravation, but because the mentonervous state of the patient contributes largely to the course of the attack. Carbolic acid, calamin acid, calamin, tar, mercury, menthol and camphor may be mentioned as antipruritics. Masks, gloves, bandages and even immobilization of various parts may aid to prevent scratching.
When local treatment is not specifically employed for protection or for the relief of itching, it aims to improve the local circulation by stimulation or by counterirritation if necessary. The stage of acute inflammation having passed, the external treatment must be more stimulating, and for this purpose the antipruritics already mentioned may be employed in greater strength. When the skin becomes thick and infiltrated, the stimulating remedy must promote absorption of the exudate and restore the skin to its normal condition, and hence may be classed as a counterirritant. Keratolytic substances may be needed to remove a hard horny epidermic; tar, salicylic acid, itchtyol, soft soap, iodin, chrysarobin or pyrogallol are commonly used for these purposes. Whatever local application may be used in treating eczema, it should be for a definite purpose, and when that is attained a recourse to simple protective methods will usually bring about the best results.