For a quick examination of the fungus, some of the epidermic scales are scraped off with a knife, moistened a drop or two of liquor potassae over which the cover-glass is lightly placed. After an interval of five or ten minutes the glass cover is firmly pressed down to flatten out the scales. If a hair root is to the examined, it should first be soaked for half an hour in the potash solution and then flattened out under the glass cover. An oil immersion lens is best suited but the fungus can usually be seen with a 1/6 inch dry lens.
Diagnosis. Typical cases of tinea circinata may be distinguished by the circular and ring-like patches. It is most important, however, when the disease arises in schools or institutions or in any place where it is likely to spread from child to child, that there should be no question as as to the diagnosis. On the scalp, dry scaly patches and broken hairs twisted in various directions, matted or entangled with the scales are diagnostic. The simple test of Duckworth may help. This consists in placing a few drops of chloroform on the suspected patch and allowing it to evaporate, when the hair affected with the fungus turns white or yellow, while the sound hairs are unaffected. Ringworm of the body and scalp may simulate eczema, psoriasis, dermatitis seborrhoica, favus, pityriasis rosea and alopecia areata.
Squamous eczema is not as sharply defined as ringworm, does not spread with an elevated and advancing border but merges gradually into the surrounding skin with more even distribution, greater infiltration and without healthy areas between nearby patches. Eczema does not affect the hair of the scalp nor do eczematous patches of the scalp extend by peripheral growth. Eczema is non- contagious, chronic in course, attended with marked itching and no fungus can be found on examination.
Psoriasis on any surface will develop by peripheral growth but the lesions are more numerous and symmetrically distributed, chiefly on the extensor surfaces, and the scales are thick, pearly-white and more abundant. On the scalp the hairs are unaffected. Psoriasis shows no history of contagion, is generally chronic and the parasitic fungus is absent.
Dermatitis seborrhoica may develop in well-defined, round or circular patches, but the scales are greasy and the open orific of the follicle can be readily seen. Seborrhea of the scalp is diffuse and symmetrical. It is often an affected of adult life and, while there may a general thinning of the hair affected, there are none of the characteristic broken-off stumps of ringworm.
Favus may be distinguished by its cup-shaped crusts, their color and odor.
Pityriasis rosea will show widely distributed lesions, mostly on the trunk, of a rose-red or yellowish color. It is not actively contagious, presents little scaliness, and disappears in from two weeks to three months.
A parasitic alopecia areata, if not identical with bald tinea tonsurans, may so closely resemble it that it may be necessary to discovery other lesions, to detect fungus in the diseased hair of the marginal patch, or to investigate the contagious history of the case before one can be sure.
Carbuncle may resemble kerion of the beard or scalp, but it lacks the fungus and history of ringworm and invariably shows pronounced necrosis. Ringworm of the beard, when superficial, may be recognized by similar diagnostic features as pertain to tinea circinata but, when the hair-follicles become invaded, it may be mistaken for ordinary sycosis or eczema of the beard.
Pustular sycosis begins with the formation of pustules at the mouth of the follicles with a firmly implanted hair piercing each. Suppuration may be free but generally it is superficial, and the extraction of the hair is painful. Some variety of burning or itching is usually noted. It is very common and often affects the upper lip, which tinea sycosis seldom involves. A macroscopic examination may be necessary to differentiate.
Eczema of the beard may involve the interpilarly surfaces with profuse discharge and crusting but the nodular, lumpy swellings are absent, and the hairs remain unaffected and cannot be extracted without discomfort and pain.
Prognosis. Tinea circinata is readily curable in from one to two weeks. Tinea tonsurans and barbae can ultimately be cured by judicious and persistent treatment, but it is difficult to foresee how much time may be required; from five weeks to as many months might represent the extremes.
Treatment. There can be no question as to the necessity of external causal treatment as the local causative factors are known and must but the strength of the same and its particular applicability to certain portions of the body, that are most important.
Tinea circinata is often cured by cleansing with soap and hot water or alcohol, plus a simple parasiticide applied daily for five to ten days. Choice may be made of the following: tincture of iodin; 20 per cent. solution of iodin in collodion; boric acid 1 dram, thymol 10 drops, to 3 ounces of alcohol; sodium hyposulphite in saturated or weaker aqueous solution; mercurius chlorid 1 to 3 grains to an ounce of water;; or one of the following ointment: salicylic acid (20 to 50 grains), sulphur sub. (1 to 2 drams), ammoniated mercury ( 1 to 40 grains), each to an ounce of lard or simple cerate. Ointments or lotions may be applied as often as three times daily for the first few days by in cases of children, the younger the patient, the weaker the prescription.
In tinea cruris, if the eczematous inflammation is pronounced, some of the previously mentioned formulas may need to be diluted. In this particular I have found the calamin-zinc-oxid lotion made with a saturated solution of boric acid as a base, with or without 2 to 10 grains of resorcin or carbolic acid, very efficient. Frequently, owing to the luxurious growth of the fungus in this neighborhood it is necessary to use stronger applications, such as:
R Phenolis, gr.vi; 24
Cupr oleatis, gr.x; 6
Ungt. zinci benz; q.s.ad 3j; 30 M.
R Acidi salicylici, gr.xv; 1
Acidi tannici, 3j; 4
Phenolis, mxx; 1 20
Ichthyolis 3j; 4
Zinci oxidi, 3j; 30
Lanolin, q.s.ad 3ij; 60 M.
These prescriptions may be applied twice daily after applying hot water compresses to the parts for a few minutes to cleanse and stimulate the surface. Closely fitting trunks or undershirt are often helpful in keeping the opposing surfaces apart and protecting the outer clothing. Thin rubber or oil silk can be stitches over the inner garments for the same purpose. I know of no form of ringworm which calls for more careful attention than the variety involving the genitocrural and axillary regions.
Tinea unguium may be treated by thoroughly scraping the affected nails with a fine file, sand paper or pumics stone and then covering with lint soaked in a 20 per cent. solution of sodium hyposulphite or sulphorus acid. A thin rubber glove or cap may be worn over this dressing at night. If the hands need to be used during the day, a mercurial plaster, covered with adhesive plaster and a glove can be worn. After parasite seems to have disappeared, applications of an oleate of mercury ointment may be used twice daily until the nail regrows. A very successful method is as follows: after the nail has been well scraped, apply on lint under oil silk a solution of liquor potassae and distilled water, each 2 ounce with 30 grains of potassium iodid. Apply this for fifteen minutes; then remove and dress the parts in the same manner with a solution of 4 grains of mercuric chlorid in equal parts of alcohol and water, which may be worn for twenty-four hours. The process may be repeated until a cure is effected. If the parts become tender a sodium hyposulphite solution may be substituted until the skin heals. Massive doses of the X-rays with or without simple local treatment is the best method when possible.
In tinea tonsurans of short duration, superficial or occurring in infants, the treatment as suggested for tinea circinata may be employed. The hair must be cut short for at least one inch around the infected area and the parts washed with soap and alcohol to remove the scales. Then some antiparasiticide should be well rubbed in or otherwise applied.
When epilation is deemed important the previous use of oleate of copper, 1 part to 8 of lard, renders extraction easier and much less painful. Formerly epilation forceps were commonly used for the extraction of the hairs, which was performed each day over an inch or more of the surface, at the convenience of the patient, or a depilatory consisting of three drams of barium sulphid and 22 drams each of zinc oxid and powdered starch, was employed for the same purpose. However, at the present time, the X-rays offer the easiest and most efficient method not only for epilation but also to assist in the destruction of the parasite. This latter treatment has been brought to such a state of perfection by Sabouraud and others that a patch of ringworm may be cured in one treatment, in a large majority of cases, if the proper technic is used. I am so thoroughly in accord with X-ray treatment of ringworm of the scalp, especially in chronic and persistent cases, that a brief description of the method may not be amiss.
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