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.
