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.
American homeopath, he directed several hospitals in New York.
Professor of dermatology.
Served as Lieut. Colonel during the 1st World War.
See his book online: American homeopathy in the world war