7. PAPULAR INFLAMMATIONS OR DISEASES



Lichen Simplex.

Lichen simplex includes as its sub-varieties, L. circumscriptus, L. agrius, and L. pilaris.

Lichen simplex is often seen in the summer, sometimes recurring in the same person several times; the papules are flesh-colored, red, smallish, sometimes very minute, and more or less pointed, lasting a week or so, and followed up by the development of others; the papules are usually seen on the back of the hand, the outer aspect of the forearm, the neck, and the thighs. They are accompanied by a good deal of itching. The papules disappear by resorption, and never become vesicles or pustules. This lichen may last for weeks and months. The disappearance of the papules gives rise to a little desquamation. The skin generally is dry and thickened. The disease is rare. L. circumscriptus is the name given to the disease when the papules are collected together into little round or roundish elevated patches; the border of the diseased patches in such cases is well defined and papular, the surface elevated, rough and dry to the feel; its area increases by circumferential enlargement, and its centre presently clears somewhat; there are generally several circles, and their most usual situation is the back of the forearm or the hip; at other times the back of the hand or calf may be affected, or the inside of the thigh. The patches after a while get more or less scaly, or inflamed and cracked, simulating eczema, but never actually discharging; or in consequence of the centre healing, assume a circinate form; but the history, absence of moisture, and the dry red roughened base are distinctive.

Lichen agrius, or the inflamed form of lichen, differs from the above in the presence of secretion, and hence approaches eczema; but it is, as its name implies, an acute, inflamed lichen. The local manifestation consists of clustered or closely packed red papulae, accompanied by intense itching and burning, causing the patient to scratch violently; this in its turn sets up additional irritation, the torn and excoriated papulae are inflamed, and exude a thin fluid; the whole patch thickens, fissures, and becomes covered over with thin scales, not the yellow puriform scales of eczema. Lichen agrius may also arise by inflammation of the chronic stage of any of the other forms of lichen, and not primarily as an acute form. The acute state lasts about ten or fifteen days, the chronic weeks or months; this variety of lichen is observed about the back, neck, legs, arms, and shoulders; it constitutes one aspect of grocers’, bricklayers’, and bakers’ itch. Vesicles and pustules may, however, form; and then there is an inflamed, raised, reddened, excoriated, discharging, fissured patch, the seat of intense and often intolerable itching and burning, made worse by stimulation of all kinds, especially the warmth of bed. The disease either subsides or increases by the development of fresh crops of papulae.

Lichen pilaris.- Occasionally one sees, either alone or in conjunction with ordinary lichen, or other disease where the skin in hyperaemic, little elevations like papulae, which are, however, seated at the hair follicles; the hair in fact piercing the centre of the papule. A distinct lump is felt by the finger. Hyperaemia of the follicular plexus is followed by fibrous deposit outside the follicle, forming a papule.

When this is accompanied by inflammatory deposit, then solid papules at the hair follicles and constitute lichen pilaris.

Lichen pilaris is then ” fibrous inflammation” seated at the upper part of the hair follicles the effusion of plastic lymph taking place around the follicular, walls, and producing, according to its degree, more or less well marked and distinct papulation, each elevation being perforated by a hair. It must not be confounded with pityriasis pilaris, which is merely a desquamation of cuticular cells into, and distending, the hair follicles, preventing the formation of the hair, and producing a blocking up of the follicles, the collected cells forming “a knot” in the upper part of each follicle, a state of things that may occur after pityriasis rubra, or as the result of an inactive state of skin, especially about the thighs, and which latter only needs the free use of soap and water for its removal.

Prognosis.- As a rule, the simple forms get well, with proper treatment, in two or three weeks. L. circumscriptus and agrius are often very obstinate.

Lichen appears to be common in those of nervous temperament and in summer time. It attacks all ages, and is evoked by local and reflex irritation, by a deficiency of alkali in the system; irregularities-mental, physical, alimentative, etc.; hereditary tendency; certain occupations e.g., cooks, bakers, grocers, bricklayers, etc.; hot climates, all seem to be causative factors of this disease.

Diagnosis.- We frequently find some difficulty here. The chief points to remember in regard to lichen are the dry and thickened state of the skin and the presence of papules, which are always to be found, if the disease is in patches, at the extending edge; the hard feel of the papules, and their tingling or itchiness. Lichen simplex and scabies maybe confounded. Lichen is uniform, scabies multiform. In scabies, besides papules there are vesicles, often pustules, and the papules are not so closely aggregated; the eruption also is in the line of flexion, not, as in lichen, in that of extension i.e., lichen is seen chiefly on the outer aspect of the arm; it may occur on the back of the hands and fingers, but it is not interdigital. Lichen simplex never occurs in the feet; it is common on the face; scabies is not. In scabies, too, there is the characteristic vesicle and sillon, whilst the disease is contagious and easily removed by sulphur treatment.

Phthiriasis may simulate lichen, but it is associated with an unhealthy, relaxed, muddy, dirty state of the skin-flabby is the word, the papules (which are pale) are fewer in number and each is marked at its apex with a dark speck (dried blood) effused as the result of scratching. The skin is not thickened and dry, as in lichen, nor is there any attempt at scaliness, as in lichen, not aggregation of papules into patches or groups. Phthiriasis is essentially a disease of advanced age. It occurs in the uncleanly, and there is often a peculiar urticated state of skin, seen very markedly on the back and chest, produced by an exaggeration of the spaces enclosed by the normal furrows. Phthiriasis does not occur about the face; the sensation is one of formication, and is altogether our of proportion to the local disease, whilst pediculi may frequently be detected in the folds of the linen.

Lichen agrius resembles eczema, but the latter is moist and discharging, occurs in delicate and thin not in harsh dry skins; again, the history and edge of the patch in lichen point to the existence of papules; then the patch is much thicker and harsher than in eczema, and wants its thick yellow crusts; the latter in lichen are thin, pretty few, and “flimsy.”

It is important to remember that scabies may be complicated with lichen, and the latter may be set up as the result of irritation in scabies. One sees this state of things very frequently in the hot season- the irritation of a few scabious spots bringing out a pretty general lichen.

Treatment.- The following ointments are sometimes useful:

Rx Chloroform, M.vjjj

Glycerine, 3 j.

White wax ointment, 3vj.

Cyanide of potassium, gr.iv.

M.sig. Apply night and morning.

Or.

Rx Carbonate or lead, gr. iv.

Glycerine, 3 j.

Simple cerate, j.

M. Sig. Use as above.

For the itching, the prescription mentioned in lichen planus, or,

Rx Dilute hydrocyanic acid, dr. ss.

Brandish’s solution of potash, dr. j

Rose water, vj.

M. Apply as needed.

One of the following internal remedies will generally be indicated:

Alumina.- Red pimples on the face. Pimples on the neck and back. Intolerable itching of the whole body, especially when becoming heated in bed.

Ammonium mur.- pimples on the back of the hands desquamating next day.

Anantherum.- Red pimples with itching and burning. Scarlet skin with burning.

Antimon crud.- Small red pimples on right shoulder. From digestive derangement.

Arsen. alb.- In chronic cases with burning itching.

Belladonna.- Papular eruption on the hands like lichen agrius.

Bovista.- Red pimples on the foot.

Bryonia.- Pimples on the abdomen and hips.

Castanea vesca.- Several small pimples on the right thigh, back of the left ear, and on the left upper lip.

Caladium.- Pimples on the mons veneris. Soreness of pimples to the touch.

Kreasote.- Forehead covered with pimples the size of millet seeds.

Ledum.- Small pimples like red millet seeds over the whole body. In brandy drinkers.

Mercurius.- Pimples on the labia. Voluptuous itching. Itching changes to burning by scratching.

Nabulus serp.- Pimples on the face about the nose, upper lip and chest with itching.

Natrum carb.- Pimples on the face and lips. White pimples on the nose.

Nux juglans.- Red pimples on the face and neck. Pricking itching.

Melford Eugene Douglass
M.E.Douglass, MD, was a Lecturer of Dermatology in the Southern Homeopathic Medical College of Baltimore. He was the author of - Skin Diseases: Their Description, Etiology, Diagnosis and Treatment; Repertory of Tongue Symptoms; Characteristics of the Homoeopathic Materia Medica.