“The treatment of eczema of the genital organs and anus does not differ from that of eczema in general, except in so far as we must bear in mind the predisposing causes, and endeavor to remove them if possible.”
This general advice is good as far as it goes, but perhaps the most important of the predisposing local causes is the dependent position of the parts, and their constant exposure to friction, to say nothing of the natural moisture of the parts. As these causes can not be conveniently removed, we must confine ourselves to a partial mitigation of their effects. This can be accomplished, so far as the scrotum is concerned, by a properly – fitting and snugly-applied suspensory bandage. The bag should be applied in such a way as to keep the parts as elevated as possible, and with as much pressure as can be conveniently borne- without, however, constricting the upper part so as to impede the venous circulation. If there is much infiltration, the first efforts should be toward its reduction.
There are three principal methods by which we may seek to accomplish this end; First, by a few scarifications of the scrotum, permitting the parts to bleed freely, care being taken not to cut any of the larger veins. After scarification the patient should sit for some minutes in a warm antiseptic sitz-bath to encourage bleeding and exudation. After the parts are dried, a little tincture of benzoin or other antiseptic lotion may be sprayed over them, and the suspensory applied. In a week or two the scarifications may be repeated. The relief afforded by this is sometimes surprising. Many patients, however, have such a dread of cutting operations about the genitals that some other procedure must generally be advised. The second means that we have is galvanization. The constant current, applied daily or on alternate days, will sometimes reduce the infiltration and relieve the itching. The testicles should be pushed well up, and the scrotum held between two good-sized sponge-covered electrodes, and a current of eight or ten cells passed for five to ten minutes, the strength and duration of the current being regulated according to the susceptibility of the patient. The third method of reducing the infiltration is the one most commonly employed, and consists in the application of liquor potassae. This should be mopped on with a small tuft of absorbent cotton wrapped around the end of a stick.
This application should be made by the surgeon himself, and not intrusted to the patient. After its immediate effects have passed off the parts may be dressed with zinc ointment and the suspensory adjusted. From six to a dozen applications, made at intervals of four or five days, will frequently produce very marked reduction of the infiltration. Eczema of the penis, however, may exist alone, and if met with in persons passed middle life, and especially if the glans and inner surface of the prepuce is involved, the presence or absence of glycosuria should be ascertained. If this condition is present, the parts should be carefully washed after urination if the water comes in contact with them and an antiseptic lotion or powder applied. The general treatment should be that which is appropriate to the diabetic condition.
Eczema in the vulva is rarely met with until the climacteric or later. In some cases it is doubtless excited by irritating uterine or vaginal discharges, but in perhaps the majority it is due to glycosuria. In either case the preliminary treatment is clear, and, probably, the best local application is the peroxide of hydrogen.
Eczema of the palmar and plantar surfaces, frequently accompanied with great thickening of the epidermis and with fissures, requires special treatment.
The thickened epidermis must be removed mechanically with knife, file, or sand-paper. After all that is possible has been removed in this way, a five per cent. solution of salicylic acid in flexible collodion should be applied. After several daily applications have been made, it will be found that still more of the epidermis may be easily removed. If infiltration be present, liquor potassae should be applied, taking care not to let it get into the fissures, if any be present. The fissures themselves should be dressed with graphite, and white precipitate or citric ointment applied to the entire diseased surface.
If, however, there be little infiltration or epidermic proliferation, tar or its equivalent is indicated if the surface is dry and scaling; while some of the less stimulating ointments should be applied if the surface be moist and exuding. At best, eczema of the hands, if already chronic, is an exceedingly obstinate affection, and one difficult to remove.
Eczema of the leg is very frequently dependent on pre- existing varicose veins, and when such is the case is difficult to manage, unless the diseased veins can themselves be brought under control. If the varicose condition be at all severe, the general nutrition of the skin of the leg seems to suffer greatly, and a slight wound from scratching may degenerate into an ulcer. The cutaneous tissues, which are the site of the lesion, and for a considerable space around it, may be greatly thickened, and the surface present a bluish tint from impeded circulation. When this condition exists, the utmost benefit will be secured from the systematic use of the rubber bandage applied so as to bring firm but even pressure to bear upon the parts. The bandage should, in the first instance, be applied by the physician, and the mode of its application taught the patient. The bandage should, when practicable, be applied morning and night, and, if it becomes soiled by discharges of any kind, should be replaced by a fresh one, while the first one is permitted to soak in cold water till again needed. After the leg has been restored to its natural size, the bandage may be discarded, but an ordinary elastic stocking should be worn habitually. The direct applications to be made will depend on the stage of the eruption and condition of the lesion.
Eczema of the leg, however, is not always of varicose origin, but sometimes presents itself as a chronic subacute circumscribed lesion, with or without much infiltration. If scaling be a notable feature-that is, with decided epidermic thickening and proliferation-a few applications of salicylic acid will prove of great service as a preliminary application, and a ten or fifteen grain solution in flexible collodion should be painted over the spot. This may be repeated a few times until the tendency to scale formation has notably diminished. If there be but little infiltration, tar, or some of its preparations, is indicated; but if infiltration is marked, potash or scarification should be employed and afterward zinc or white precipitate ointment.
Acute eczema of the leg requires different treatment. If the greater part of the leg or both are involved, rest in bed or on a lounge, with the limbs elevated, is a sine qua non. The parts, being inflamed, hot, red, swollen, and exuding, need rest and soothing treatment. Absolute rest must be insisted on, and when secured apply a diluted solution of peroxide of hydrogen. The best method of applying it is with an atomizer. Purulent exudation is brought under immediate control, and offensive odors are destroyed. After two or three days, as a rule, the inflammation will be lessened, the area of denuded surface diminished, and attempt at healing be apparent. Now, some of the medicated plasters containing oxide of zinc or ammoniated mercury should be applied. These may be left undisturbed for several days, and if covered with an elastic stocking the patient may be permitted to take moderate exercise. If no indiscretions be committed, steady progress toward cure may usually be expected.
Eczema of the inner surface of the thigh not unfrequently appears in the papular form, and may best be treated with permanently attached dressings containing zinc or white precipitate.
Eczema of the anus is an insidious affection, and is frequently of long standing before it is brought to the notice of the physician. Thickening and fissures often coexist, and should first be treated and healed by cauterization, peroxide of hydrogen, graphite ointment, or power, etc., before any attempt is made to reduce the infiltration by strong alkaline applications. One of the most effective applications to the fissures is the fine point of a Paquelin cautery at a white heat.
Eczema of the mammae and nipples is a very frequent accompaniment of scabies in the female, and when met with the latter disease should be suspected and sought for, and the scabies, if present, receive the first attention.
In obese persons an eczema may arise from the irritation produced by the confinement of the cutaneous secretions by overlapping folds of skin, as under pendulous breasts and in the groin between the thigh and genitals. In these, simple dusting powders, with separation of the parts by linen, will often accomplish all that is required.
