Among the most common as well as perplexing cases of skin disease met with by the dermatologist and general practitioner, eczema justly occupies a prominent place, assuming as it does a multitude of forms, general and local, acute and chronic, and appearing so universally among all classes of society, the rich as well as the poor, the ignorant and the well educated, and arising from the most varied causes.
An accurate and at the same time concise description of eczema is impossible in view of the fact that the disease presents so many forms and phases and that of a dozen consecutive cases no two may look alike or even bear what ordinarily would be termed a family resemblance. These differences are due to the occurrence of lesions which may be quite dissimilar in character and appearance, and combined in ways and proportions almost with- out number. The aspect, too, of the individual lesions varies somewhat with the location they occupy, the degree of activity they present, and the length of time they have lasted.
The varieties of eczema dependent on the primitive or characteristic lesion are six in number-namely, erythematous, vesicular, pustular, nodosae, papular, and fissured; and these in their progress may undergo changes and become complicated with or give place to certain secondary lesions.
The varieties of eczema dependent on the activity of the process may be classed as acute and subacute, while those that run but a short course may also be termed acute, and those of longer duration chronic.
Location greatly influences the appearances presented by eczematous lesions, and the principal modifications met with in this connection are those seen on the scalp, face hands and feet, genitals, and about the anus. Eczema may also invade the follicular apparatus of the skin, and give rise to an eczematous affection of the hair-follicles and of the sebaceous glands.
We will best understand the appearances presented by this protein malady if we trace the course of a simple acute eczema of the general surface. It commences with a local congestion, or erythema, followed in a few hours, perhaps, by a crop of minute, closely aggregated vesicles filled with a clear, transparent serum. It often takes a sharp eye, and even a lens, to distinguish their separate contours. When closely examined, we find them to consist of a very thin and delicate epidermic covering, which for a brief period retains the lymphy exudation that is seeking an exit. Rubbing, scratching, or other violence from without, or the pressure of the exudation from within, soon ruptures the epidermis, and usually in twenty-four or thirty-six hours the vesicles have disappeared, and we find in their place a red and exposed surface more or less moist with exudation. If exposed to the air, the watery portions of the exudation evaporate, and light, straw colored crusts remain. As the exudation continues, the crusts thicken until they drop off, or are purposely removed. After a varying period (days or weeks as the case may be) the crusts lessen or cease to form, and nature makes an attempt to cover the part with a new layer of horny epithelial cells.
It may be weeks before this effort is entirely successful, and the affected surface presents in the interval a reddened and somewhat glossy surface scantily covered with loosely attached scales of small size, the scales being composed of embryonic horny cells which have not yet attained a normal character and consistence. Those first formed are less visable than the normal cell, and are quickly shed, to be replaced by others of more natural character and aspect, until finally we find a complete regeneration of the epidermis, and a return to the condition which existed before the appearance of the attack. In eczema pure and simple we never have ulceration or loss of tissue, and recovery takes place without the least trace of scarring.
For practical convenience the course described above may be divided into three stages: the first being that of congestion and vesicle formation, the second that of exudation and crusting, and the third that of dryness and scaling.
The pustular variety of eczema pursues the same course and passes through the same stages as the vesicular, and differs from it only in the character of the exudation and the color of the crusts in the second stage. Instead of transparent, lymphy exudation we have a purulent one, and the crusts are of a greenish color. In the vesicular form the number of leucocytes in the exudation is limited, while in the pustular they are abundant. The third stage of both varieties is identical, and if a case be seen in this stage it is impossible to determine, except by the patient’s recital, whether the eruption had been characterized by vesicles or pustules.
The nodosae, or exfoliative form differs from, the preceding forms by the fact neither vesicles not pustules are observed, but instead a rapid loosing and exfoliation of the horny layer over the whole or greater part of the affected area. The succeeding exudation may be serous, sero-purulent, or purulent and crusts form as already described. In the second and third stages the appearances are the same as those presented by the two first- named varieties.
In the papular variety an area of congestion becomes the seat of small scattered or aggregated papules, with little if any tendency to exudation unless the papules be wounded by scratching. In this case a small quantity of lymph may exude and dry into a minute scale or lamina.
The papules after a time subside and the surface becomes somewhat glossy and scaly, but not to the extent met with in the varieties already described. The arms and forearms, and the thighs and legs, especially the flexor aspects, are the favorite seats of papular eczema, although it is sometimes met with on the face.
In the fissured variety we have more or less reddened surface without vesicles, pustules, or epithelial exfoliation, but instead presenting small cracks or fissures extending through the stratum corneum, and sometimes through the stratum Malpighii as well. Exudation is slight, crusting is absent, and the skin after a time returns to the normal condition by simply closing of the fissures and disappearance of the congestion. The palms and soles are the favorite seats of this variety.
The erythematous variety is characterized simply a red and congested patch of varying extent, and is not accompanied with vesicles, pustules, papules, or the other lesions of the disease.
Cases of eczema vary in respect to the grade of inflammation present. In one it may exhibit great activity and be accompanied with decided heat, high color, and other evidences of marked inflammatory action, in either the first or second stages or in both; and this activity may continue for an indefinite period, and until the case prepares to enter the third stage. On the other hand, the natural color may be but slightly altered, the increased of local heat be almost inappreciable, and the general process partake of a subacute character from the beginning. In other cases, again, an eruption which is subacute may at any stage of its progress suddenly assume an acute phase, or there may be frequent alternations of activity and comparative quietude. This is a very striking feature of eczema, and one that should always be borne in mind. A case may be progressing nicely under treatment, and with the prospect of early recovery, when suddenly the trouble may relapse into its previous active state, and often apparently without sufficient provocation.
The duration of eczema varies. In some cases it may run its course in a few days or weeks, while in others it may be prolonged for months or years, constituting the chronic form of the affection; or again, there may be frequent relapses, even after complete disappearance of the individual attacks.
The location of an eczema greatly influences its appearance, and exhibits also preference for certain varieties of lesion. Thus, in eczema of the scalp, especially in infants and children, the process is usually acute, with profuse lymphy or purulent exudation, which mats the hair together in a tangled mass, offensive to both sight and smell. If by chance pediculi find lodgment in such a scalp, they multiply rapidly, and by their irritation increase and aggravate the trouble. If proper care and cleanliness are not practiced, the scalp may become a mere mass of animated filth.
When eczema attacks the scalp in children, it frequently extends to the face, presents an active form of inflammation of the vesicular, pustular, or nodosae type, accompanied with a good deal of heat and pruritus. If it extends behind the ears, fissures may form.
In adults, eczema of the scalp is usually of the subacute form, without much exudation; and on the face it may be of the erythematous type, without other lesion.
When the palmar and plantar surfaces are attacked by eczema, we may have a purely erythematous lesion, characterized by a red, dry and glossy surface, on which the natural skin lines are greatly exaggerated as to size and distinctness, and many lines appear which are not noticeable in the normal condition. In addition fissures may form, accompanied with slight exudation. This type of the disease is the most common, and is usually subacute and chronic. On the other hand, we may have an acute eczema of the hands and feet, accompanied with vesicle formation. In consequence of the thickness of the horny epidermis on those parts, the vesicles do not easily rupture, but instead retain their integrity, and even become larger, and remain as vesicles until absorption of the contents occurs, when what was the summit of the vesicle separates as a small scale.
The penis and scrotum usually exhibit the erythematous variety, vesicle and scale formation being rarely met with.
The inner aspect of the thighs and legs is the favorite location of the papular form, a although it may be met with on almost any part of the body, and even on the face.
On the lower extremities below the keen eczema is frequently encountered as a direct result of varicose veins, and, if these latter have given rise to ulcers, a broad and diffuse zone of erythematous eczema will almost always surround them, with scattered patches on the neighboring parts.
Eczema about the anus is frequently marked by radiating fissures of greater or less depth.
Eczema may extend from the skin proper down into the follicular openings, especially those of the face and other hairy parts, except the scalp. In these cases the surface eczema may play a very secondary part. On the one hand, we may have the hair-follicles especially involved. When this appears, the general surface of the patch will be found red, and either dry or exuding, but the inflammation having invaded the lining membrane of the follicles, they will be found swollen and loosened. Slight traction on the hair will extract it, accompanied with its root-sheaths. Frequently the exudation which forms within the follicle comes to the surface, and lifts the epidermis surrounding the hair, and forms a pustule (rarely a vesicle) pierced through the center by the hair. This deep-seated inflammation sometimes results in extension of the action beyond the proper outline of the follicle, and nodules form. This condition must be distinguished from sycosis, with nodules, etc., resulting from parasitic invasion.
The sebaceous glands may also become the seat of eczematous inflammation either with or without marked participation of the surface. Under the stimulus of the eczema the glands exhibit increased functional activity, and the eczematous exudation when present becomes mixed with the increased sebaceous secretion, and, instead of a purely lymphy or purulent exudate, we have some thin sebum mingled with it, which usually dries into greasy scales or crusts.
When an eczema persists for any great length of time, and becomes chronic, we find additional features that are important both as regards description and treatment. The chief of these is infiltration. The skin is still red, but usually dry, and appears to possess double or treble its natural thickness, and the patch is very appreciably raised above the surrounding surface.
Dr. Taylor reports three cases of malaria accompanied by an eczematous eruption both making their appearance simultaneously; under proper treatment both conditions were relieved, the remedies given relieving both conditions.
Dr. Stettler reports an interesting case of vulvar eczema as a sequel of the climacteric period.
The extreme prevalence of eczema makes its correct and certain diagnosis of the first importance; and, if the rules laid down in the general chapter be closely followed, there need not in the great majority of cases be any very great difficulty. The history of the attack, the frequently multiple lesions, and their progress as observed or, as related by the patient, should not leave the physician long in doubt.
It is important, however, to distinguish a dry scaly eczema of the scalp in children from a condition sometimes presenting very similar appearances, but due to an entirely different cause namely, the vegetable parasite, trichophyton, which is the etiological factor of ringworm. In cases of doubt the microscope will decide by revealing the presence of the fungus. In like manner eczema of the hair-follicles of the face must be carefully distinguished from ringworm of the same parts, to which the name of barber’s itch is commonly given.
Eczema sometimes resembles psoriasis and psoriasis, sometimes resembles eczema; or, again, we may have an eruption which no one would be justified in pronouncing either on or the other from the appearance only. Usually the history will enable us to decide. On the hands and feet we may have appearances which may present difficulties in diagnosis between eczema, psoriasis, and syphilis.
Lastly we have known a lichen planus to be mistaken for a papular eczema even by gentlemen well versed in cutaneous diagnosis.
Etiology.- It may be regarded as almost axiomatic that the better we understand a disease the better we will be able to treat it. This is especially true as regards eczema. Occasionally cases of acute eczema will be met with that recover under the simplest application, and even under the influence of a plain, non-medicated dressing. Unfortunately, these cases are rare, and in the chronic forms it is often necessary to avail ourselves of every possible aid to recovery. A thorough appreciation, therefore, of all the causes of the eruption, both actuating and contributing, can not fail to greatly assist the therapeutist in the proper selection of the remedial agencies applicable to a given case.
Eczema attacks more frequently light, florid-complexioned individuals, and is a commoner affection in this country than in Europe. Like the individual who makes a failure in life, eczema usually travels from head to foot as age advances. It appears more particularly on the head in infancy and youth, descends to the trunk and genitals as adult life approaches, and appears on the lower limbs as its victim is tottering to the grave.
Among the exciting causes we may mention irritation of the skin by scratching, by friction of the clothing, by irritating ointments, by oils, by bandages, by artificial legs, trusses, etc., by hot baths, by too high a temperature, by alternation of heat and cold, by heat and moisture by the injudicious use of Turkish and Russian baths, by strong potash soaps, and by any exciting cause giving rise to hyperaemia of the skin. In quite a number of cases it seems to be hereditary. It is by no means a rare disease in those who are syphilitic, gouty or strumous.
It is frequently dependent upon renal troubles, menstrual irregularities, dentition, dyspepsia and mal-assimilation, varicose veins and hemorrhoids. Undoubtedly perverted innervation, with general debility and morbid conditions of the blood, is an important cause.
Overfeeding, the habit of feeding the child too frequently, and of allowing children who have passed the milk-diet period to eat frequently of inappropriate food between meals, will prevent the recovery of chronic cases, despite the administration of the well-selected remedy. When the tongue is coated, the breath foul, and the bowels constipated, the diet requires particular attention. Children kept is warm rooms where the air is vitiated are liable to suffer from this affection especially if they catch cold easily from the least exposure. Allowing the child to sleep upon a very soft pillow, into which the head becomes buried at night or feeding “bottle babies” with milk too warm, has seemed to aggravate some cases. Fresh air and sunlight, with attention to hygienic measures, will exert a favorable influence upon this stubborn disease.
The diet must be carefully looked after and all sweets and confections be strictly prohibited. The sleeping apartments must be properly ventilated. Plenty of exercise in the open air must be taken. The clothing must be adapted to the season. Bathing sufficient to meet the requirements of cleanliness should be insisted on, but too frequent or too profuse use of water is not advantageous. The acute stage of eczema is very intolerant of water. If the surface is raw and discharging, water aggravates the condition. Water, however, is not to be absolutely excluded from the treatment of eczema. It not infrequently happens that very hot water- hot as it is possible for the patent to bear it – will cause immediate cessation of itching; while in chronic cases, with considerable infiltration, systematic use two or three times a day of very hot water will often be followed with the happiest results. A full bath of tepid water with a pound of sal soda added to it, and taken at night will generally exert a soothing influence; while in sluggish and chronic cases ten or twelve pounds of common salt salt added to a full bath will exert a stimulant action and tend to promote the cure.
In all cases search should be made for all possible causes of local irritation, and the first care should be to remove them, if practicable.
The diet of eczematous patients is of the first importance. No hard-and-fast general dietary laws can be adhered to. Each patient must be treated according to his case, and at first be put upon as simple a diet as possible. When this basis is reached, the patient’s taste is to be consulted and his diet made more varied, care being taken to avoid anything that is known to disagree with him. Sometimes, it is advisable to have a patient increase the number of meals in a day, while decreasing the quantity of each one. Some patients do best on solid food alone, leave out tea, coffee, and the like. Sometimes the best results are obtained by having the patient eat only one sort of food at a meal- whatever he fancies. In many cases of chronic eczema a liberal supply of fluid is useful, and this not taken at one, but often in small quantities.
Up to three quarts of water may be taken in this way. The addition of salt to the dietary is also useful. As a rule, you will find that adult sufferers from eczema are decidedly carnivorous in their tastes, eating a good deal of meat with a very scant quota of vegetables and cereals. Many of them are particularly fond of the pleasures of the table, and indulge much more freely than there is any necessity for. As these matters are under the control of the patient himself, no pains should be spared to impress on him the necessity for a change in his habits. It is not well to cut off the supply of meat absolutely, but it should be very decidedly restricted, and a larger proportion of bread, vegetables, and cereals substituted.
Patients often fancy that diet of this sort reduce their strength and incapacitate them for the amount of labor that their daily vocations necessitate. These fears are groundless, and on trial will soon be dissipated.
A very interesting and important question has been raised as to the propriety of healing completely a discharging eczema, and the fear of driving in the disease has often deterred practitioners from affecting a speedy cure.
Hebra and his school laugh at this idea, and no doubt in the majority of cases with good reason.
The question at issue, whether an habitual discharge may be suppressed without danger to a patient, depends upon the patient, and not on the disease.
” I attended a child who had lost two younger brothers from acute tuberculosis. He had a very extensive eczema of the scalp and face, but otherwise appeared in good health. Under appropriate remedies his eczema rapidly got well, but its disappearance was attended with all the signs of acute hydrocephalus, from which he soon died.
With the family disposition to this disease, it is not unlikely that the child might have succumbed to tuberculosis had the eczema not been cured; but I fear my treatment was injudicious, as the child’s disposition to disease of a special and serious kind was not taken into account.” (Simon).
Analogies of the impropriety of rapidly suppressing habitual discharge are common enough. Hemorrhages from the lungs or stomach occur often enough when hemorrhoids, which have been bleeding for years, are suddenly cured, and cases have been recorded in which cerebral hemorrhage has seemed to follow rapid cure of an old ulcer.
The local treatment consists in first allaying the acute inflammatory symptoms, if any exist, and involves the employment of various lotions, glyceroles, ointments, oils, plasters, powders and soaps. It is not always an easy matter to say what will soothe in any particular case. Bran infusion, or decoction of marsh-mallow or poppy heads, to which a little clarified size has been added, are very good applications to start with as lotions night and morning. The linimentum aquae calcis is sometimes efficacious.