The treatment of diseases of the skin differs in no particular from that of other diseases and all that pertains to general medical science properly belongs to dermal therapy. Dermatology is a branch of general medicine and in fact more closely approaches it than any other specialty. The successful treatment of skin diseases necessitates a sound knowledge of general medicine and a ripe experience in the treatment of general cases as well as in the diagnostic methods employed, in ordinary practice. It should be the aim of the physician to treat the individual rather than the particular skin condition. In doing this, relief will be afforded the local symptoms or, if relief is impossible, their severity mitigated and the patient made more comfortable. Prophylaxis is no doubt a more scientific achievement than the treatment of present conditions but necessarily it is with the latter that we are most concerned. However, any advice that may be given which enables the patient to protect himself from the extremes of heat and cold, trauma, toxic and contagious elements will naturally enable him to resist many of the minor invitations to disease. The danger of “driving in” certain diseases of the skin and the importance of “driving out” others has been much overestimated. There are few if any diseases that do not call for relief as promptly as safety will permit. Placing the skin, which is one of the important emunctories of the body. in a healthy condition not only relieves the patient of annoying local symptoms and produces a more healthy systemic condition but also assists the other eliminative organs of the body in their effort to accomplish an abnormal amount of work.
Skin diseases, like other morbid conditions of the body, may be divided into three classes. The first group includes all diseases which run a natural course ending in a favorable termination. These call for protective treatment and it is often exceedingly difficult to refrain from active measures. Such a judicious course is really scientific but not spectacular. The second class includes those skin affections which are hopeless from a remedial standpoint or must be expected to end fatally. The relief from pain and the correction of deformity, together with the hope that the physician can inspire, are all that can be accomplished. These cases call for an abundance of patience and usually invoke a like amount of censure. All affections not included in the first two groups may be included in the third class. Here it is that the most pronounced successes and deplorable failures of the dermatologist are seen. The treatment suggested will prolong or shorten the course of a disease, make it more or less endurable, make it run an acute or chronic course, or allow it to become inveterate. The treatment of all cutaneous conditions naturally divides itself into internal methods, whether they be medical or dietetic, and external which includes all varieties of local therapeutics. However, it is possible that a combination of these methods is usually employed. For many years the German authorities have held to the opinion that skin diseases were purely local conditions and therefore controllable by external measures and naturally their opinions have spread to our country. However, at the present time most of the English, French and American writers take a conservative view believing that, while external remedies are essential in almost all cases, constitutional or internal treatment is likewise important in many diseases.
Physiological methods embrace all those items which, when properly, used and regulated, contribute to the health. As has been remarked before, the skin plays a most important part in the physiology of the system along with the lungs, kidneys and intestinal tract. However, the last two chiefly concern us because functional deficiency on the part of the skin is compensated to a certain degree by these organs, and the opposite holds true as well. Thus when inflammation of the skin is present, treatment, which increases the action of the kidneys and intestinal tract by causing a free urinary flow and fecal discharge, will lessen the cutaneous disturbance. In this connection all etiological factors must be considered and the examination of the excreta as well as a study of the family history and personal tendencies will often disclose an underlying disease or diathesis. Many people want all the passive enjoyments of life and very few of the active. It is to regulate this desire that proper food, hygienic living, well-ventilated sleeping quarters, an out-of-door life, exercise, especially in those of sedimentary habits, rest in some cases and diseases and often change of scene and climate may be considered as important.
Diet. Gastrointestinal influences. The regulation of food is often most important although it is true that purely local diseases, such as verruca, many of the benign new-growths and parasitic affections such as scabies, do not call for dietary regulation. It is as emphatically true that many of the generalized skin conditions, in which a diathesis is causative, must have proper regulation of food. Many skin eruptions are simply surface manifestations of abnormal systemic conditions due to errors in diet or to toxemias, the result of the absorption of abnormal products in the digestive tract. Thus the regulation of the intake is quite as important as the observation of the output. There are few conditions, except purely local processes, which are not to some extent the result of faulty nutrition or delayed excretion of waste products. The by- products of digestion should not be allowed to remain in the system long enough to change the color or condition of the skin. This is well shown in the pasty or muddy complexions of those who possess hepatic derangements. Gastrointestinal influences are directly responsible for many of the acute dermatoses such as urticaria, miliaria and erythema multiforme. Many subacute, recurrent or chronic diseases such as eczema, psoriasis, lichen ruber and acne are expressions of the so-called rheumatic or gouty diathesis which is but another way to express a want of balance between the intake and the output. This latter may be in the shape of faulty assimilation or delayed excretion but the skin manifestations are not necessarily different. Doubtless many diseases, due to the invasion of microorganisms, could not thrive if it were not for systemic poisoning from fecal or other abnormal absorption.
The patient should be consulted as regards his diet because appetites, idiosyncrasies and real wants are not entirely imaginary and the psychic and nervous facts that contribute to a good digestion must not be overlooked. The diet need not always be a rigid one but rather should be selected for the individual case. Thus many patients with eczema, psoriasis or acne need a change from a nitrogenous to a vegetarian diet or possibly meat once daily may suffice. In others a pure milk diet or a rice and water regimen may be demanded. Alcohol is directly damaging to many inflammatory conditions especially the erythemata, eczema and acute psoriasis. It cannot always be eliminated but may be limited, depending upon the age and habits of the patient. In the old and feeble it is often necessary. Tobacco, tea, coffee and cocoa produce external flushing of the superficial vessels and increase the congestion of the skin much in the same way as alcohol so that the same warning may be given concerning these. The question of water-drinking is most important. Many people drink too little or it is not of the correct temperature or they drink it at the wrong time. Water should be drunk freely, apart from the meals at a natural temperature, cooled but not iced. The action of water is to flush the gastrointestinal tract thus relieving constipation and to stimulate the kidneys thus affording a diuretic action. There are many foods which might be deleterious in individual cases but in general the following show the greatest possibility of detrimental influence. All fried or greasy foods, pork in all forms, veal, shell fish, hot and fresh breads, buckwheat and other similar cakes, waffles, pastry, candy, cake, sweets in general, rich cheese, dressed salads, acid fruits, seeded berries, condiments, nuts, cereal foods, potatoes, beans, peas and corn in excess, and cauliflower, cabbage, sprouts and onions in a few instances. It will be noted from what has been said that the mucous membranes rather than the skin demand attention in many diseases of cutaneous interest. Sedatives or bland applications can contribute to the patient’s external comfort but the gastrointestinal tract calls for the real treatment. Thus an alveolar pyorrhea may poison the system because its products lodging in the stomach set up a gastric catarrh; a chronic gastritis due to errors in diet may produce a catarrhal condition which will affect the liver as well as the small intestines and the stomach; or fecal accumulations in the colon may produce systemic poisoning by gradual absorption. The fact that a patient has a daily bowel movement, occasionally more than one does not signify that the evacuation is sufficient. It is the quantity rather than the frequency of the movements that indicates the proper result. Thus it will be seen that the treatment of many skin diseases is often the scientific relief of chronic constipation.
Physiological medication embraces all those remedies, natural and artificial, prescribed purely on an empiric basis in an effort to restore the functions of organs or tissues to a normal condition. It is fortunate that present-day teachings tend toward milder dosage for often, when physiological means are indicated, new and milder methods are just as efficacious and not so harmful as the violent dosings of the past. To one who knows and appreciates the virtues of symptomatic prescribing, many of the agents, about to be mentioned, are unnecessary and interfere with homoeopathic medication. However, in some diseases and at times in almost any disease, aperients, diuretics, tonics and alternatives may be needed.
Aperients occupy a useful sphere in cutaneous diseases. If possible milder methods should be employed such as dietary changes including the eating of laxative fruits and the drinking of water between meals or the use of aromatic liquid albolene or other oils, because these simpler items have a food value as well as an eliminative virtue. Aperients often improve digestion. In this particular salines are useful except in anemic individuals, although they should not be used strong enough to cause active purging. Magnesium sulphate, sodium sulphate, sodium phosphate and the natural aperient waters may be used. If liver or other glandular torpidity is suspected, calomel in 1/10 grain doses (repeated at fifteen-minute intervals) may be administered to advantage. Antacid magnesia is a valuable laxative when gastro-intestinal complications are present. The extract or the fluid extract of cascara is the most useful of the vegetable laxatives but for infants and young children castor oil is frequently ideal. Low or high enemata with or without soapsuds or if necessary, containing a solvent, are to be recommended if flushing of the lower bowel is desired. Rectal atony can often be relieved by dilation of the sphincter, stimulation by the high- frequency currents or with soap or gluten suppositories.
Gastrointestinal antiseptics such as charcoal, salol, sodium salicylate, antacid magnesia or minute doses of calomel are valuable in urticaria, erythema multiforme and other diseases due to autointoxication. I can speak enthusiastically about the results accomplished in these conditions with a culture of the bacillus Bulgaricus. This microorganism produces a large percentage of lactic acid, displaces the microorganisms causing intestinal putrefaction and relieves or cures diseases created by intestinal autointoxication.
The best diuretic is water which may be drunk copiously on an empty stomach to promote the free flow of urine. Among the medicinal diuretics, the salines such as potassium acetate and potassium bicarbonate are the best. Most of these remedies are antirheumatic or antilithemic in character, and may be employed to advantage in such diseases as eczema, psoriasis, acne, rosacea, dermatitis exfoliativa and other inflammatory disorders. Sodium salicylate, ammonium salicylate, salophen, small doses of belladonna and other vegetable diuretics may occasionally exert a favorable influence but upon the whole it may be said that diuretics are less valuable in skin conditions than in other diseases.
Tonics have a nutritious as well as a stimulating effect and may be indicative in many skin diseases. The most valuable nutritional tonic is cod-liver oil but other oils and emulsions may prove equally efficient. Anemic conditions may call for iron, manganese, the hypophosphites, quinine, strychnine and small doses of arsenic. The ordinary digestive and bitter tonics may serve the same purpose as the above by improving the appetite. Laxatives may be required in connection with some of these times.
Alternatives are remedies that restore, often in an unknown way, the functions of an organ or of the system. These remedies are sometimes divided into general alternatives and special alternatives depending upon whether they do or do not possess the quality of improving nutrition independently of any other power. No doubt the alleged action of many of these drugs may be referred to their germicidal influence. Mercury is well known for its efficient work in the early and late stages of syphilis. The choice of a mercurial and the method of its administration will be considered in the treatment of syphilis. The iodine preparations, especially potassium and sodium iodid, are useful in late syphilitic conditions, strumous affections, actinomycosis, blastomycosis, psoriasis and other diseases. Tar, phenol and phosphorus have been prescribed internally for psoriasis, eczema, lupus erythematosus and lupus vulgaris. Antimony, turpentine and copaiba have been suggested for eczema and psoriasis. Quinine is apparently useful in diseases where there is an underlying malarial taint such as some cases of erythema multiforme, erythema nodosum, elephantiasis, eczema and herpes zoster. There are few remedies given empirically like the above which probably have any direct effect on the skin. If any one might be said to have special cutaneous affinities, it is arsenic. It is possible that this drug acts both directly and indirectly through the nervous system and its chief value is for indolent dermatoses such as psoriasis, lichen planus and some dry eczemas, as well as neurotic disturbances such as pemphigus and dermatitis herpetiformis. Arsenic has been administered in various forms for many years and its chief preparations are arsenious acid in the form of tablet triturates, Fowler’s solution, Donovan’s solution, de Valangin’s solution and the Asiatic pill. Many combinations of arsenic with other medicinal substances have been in vogue recently. Sodium cacodylate is an organic compound of arsenic often administered hypodermically. Atoxyl has given good results in the treatment of syphilis and other affections, and salvarsan and neosalvarsan do not need description here because their methods of administration are described under syphilis. Jaborandi or its active principle pilocarpin may be useful in cases where stimulation of the sweat function is desired, such as ichthyosis and generalized psoriasis.
It is not probable that any remedy administered internally is germicidal but many of those mentioned and some others contribute to make the tissues an unfavorable home for microorganisms, or at least are antidotal in their effects. The efficiency of quinine in malaria, mercury in syphilis and potassium iodid in actinomycosis is partially based upon the germicidal theory. Sulphur probably exerts a similar influence in respect to many diseases of germ origin and the action of calcium sulphid in furunculus, acne and seborrhea is well known.
Animal extracts, especially the preparations of the thymus, thyroid and suprarenal glands of the larger animals, have been employed with indifferent success in the treatment of skin conditions. Thyroid extract has proved its worth in myxedema and has benefited occasional cases of ichthyosis, psoriasis and lupus vulgaris. Suprarenal gland extract has been urged for vitiligo. Thymus gland extract has some virtue as a remedy for dermatoses with a rheumatic or lithemic causation. It may be said that some of these animal extracts have a general alterative effect as well as a special alterative action.
Vasomotor constringents have been employed forrosacea, purpura, pruritus and a few other diseases. Ergot, ichthyol, thiol and adrenalin chloride have been variously suggested for their action upon the cutaneous vessels leading to a contraction of the vessels themselves and the consequent reduction of hyperemia.
Analgesics and antipruritics play a comparatively unimportant part in internal cutaneous medication. They should be avoided if possible because they not only often aggravate existing conditions but also may cause pronounced damage. While opium or morphine may be indicated for the pains of malignant disease or for the neuralgia of herpes zoster, they should never be employed for pruritic diseases, lest they aggravate the itching. The bromids, chloral, phenacetin, antipyrin, lupulin, belladonna and gelsemium may be employed as sedatives and antipruritics but relief from itching is more sensibly obtained by local applications.
Natural mineral waters have unquestioned value in the treatment of dermal conditions but they are best taken at the various Continental and American springs from which they come because the strict dietary regimen, compulsory exercise, relief from the care and toil of business, change of climate and scene all contribute to the success of the cure. It is questionable if the medicinal ingredients of the waters are of great relative value. In this connection it may be said that chemical laboratories are now placing before the public the constituents of most of the popular mineral waters either naturally or artificially produced. Thus the proper solution of the salts may be made in any pure water and the actual medical result would be the same. No doubt the stronger mineral waters owe their virtue to their laxative action while the milder ones, usually taken at the springs and in larger quantities, serve as diuretics as well as laxatives. When our domestic springs are made attractive, well advertised and controlled by national, state or local authorities, they no doubt will complete in all respects with the foreign establishments which now enjoy a greater reputation, not because of any different inherent value of their waters but solely because of the items of management which our springs lack.
Hypodermic injections of arsenic, mercury, cocaine, phenol, alcohol, the various alkaloids, toxins and antitoxins have been employed in the treatment of skin diseases with varying success. The hypodermic treatment of syphilis will receive due attention at the proper time. Antitoxins, while useful in many general diseases, are of comparatively little effect in dermal conditions. This is due to their uncertain and variable action, for besides tuberculin, which has been successfully used in the treatment of cutaneous tuberculosis, they have been practically abandoned in dermatological practice. The use of thiosinamin will be mentioned in the treatment of keloid and scars.
Vaccines. The theory of vaccine treatment relates to phagocytosis and opsonins which are chemical substances in the blood, possessing the power of destroying bacteria. At the present time, it is not definitely determined whether phagocytes in the presence of the opsonins are responsible for this action or some other combination. According to Wright, “vaccines are any substances that on being inoculated into the body will cause the generation of a protective substance.”The chief disorders treated by vaccines are furunculosis, carbunculosis, acne, sycosis and tuberculosis cutis. To successfully perform this treatment requires much time and the proper laboratory facilities. Briefly stated the process consists in the hypodermic injection of definite quantities of sterilized cultures of bacteria isolated from the affected patient. The two most difficult problems, presented in this method of treatment, are the determination of the proper dosage and the interval of time between the injections. Wright devised a method of measuring the opsonic power of the blood known as the opsonic index which refers to the ratio existing between the amount of opsonins in the serum of the patient with the bacterial infection and the amount in the serum of a normal person. By this method the proper dosage and frequency is approximately figured. It is the continued study of the opsonic index which regulates the further treatment of the disease. But ordinarily the first dose is the smallest and the exact amount of the increase, as well as the frequency of succeeding dose, is absolutely dependent upon the individual findings. Probably vaccine treatment will be perfected in time and will be successfully used in the treatment of many dermal conditions as yet not reached by this means. Stock vaccines, such as are put on the market by the various commercial drug houses, should not be employed when it is possible to obtain the autogenous variety.
Symptomatic medication includes all remedies, no matter what may be their nature or origin, that are prescribed according to symptoms presented by the patient. This method of treatment is based on the same principle wherever and whenever used but varies in its application with the individual. Thus in all quarters of the globe, the homoeopathic physician has the same law of cure but no two cases of the same disease necessarily call for the same remedy. While scientific explanations covering the Hahnemannian theories may not be wholly satisfactory, they at least have the sanction of recent physiological and biological experiments. As a system, empiric medicine with its panaceas, enthroned one day and dethroned the next, presents nothing attractive and has led some of the brightest minds in medicine to embrace therapeutic nihilism.
A prescription based on the totality of symptoms is an ideal but almost impossible task but an attempt should be made to cover the patient’s whole condition as well as his skin manifestations. It is impossible within the scope of this book to offer even a condensed materia medica. Merely as a suggestion, a list of remedies with potencies verified by experience, are given in alphabetical order. After each remedy will be found the name of some diseases whose symptomatology might resemble the provings of the drug in question. I am well aware of the futility of any attempt to outline the use of remedies by such a scheme because any individual with any disease might demand, because of extra- dermal symptoms, a remedy which would not be thought of in a list like the following: