DERMATITIS SEBORRHOICA

Synonyms.—Eczema seborrhoicum; Seborrhœa corporis (Duhring; some cases);
Pityriasis capitis; Seborrhœa sicca (some cases).

Definition.—A dermatic inflammation of slight or moderate
grade, beginning usually primarily upon the scalp, characterized by
greasy scaliness, and, especially outside of the scalp region, not infre­
quently presenting a tendency to segmental or irregular shapes.

This definition of this disease, compared to the more comprehen­
sive one inferentially given by Unna,¹ and which was later accepted
by some others, notably Elliot² in this country, is a narrow one, and
is intended to cover cases which may well be considered to present
the combined symptomatology of a mild eczematous inflammation
and seborrhea. Along with the majority of my colleagues I believe
that most of the papular and moist types which Unna especially would
also include are more properly to be placed under eczema. Indeed,
I am inclined to share, in part at least, Duhring‘s opinion³ that “it often
exists as a variable combination of these two diseases, partaking in some
cases more of the nature of seborrhea than eczema, as shown by the gland­
ular involvement, the regions affected, and the well-established observa­
tion that it often yields readily to the sulphur preparations, so useful in
affections of the sebaceous glands.”

Sabouraud‘s brilliant investigations⁴ tend to show that the several
conditions usually described under the heads seborrhea and derma­
titis seborrhoica of the scalp represent, in fact, several etiologically
diverse conditions: (I) Seborrhea—one form, the oily form, or seborrhcea
oleosa, due to the microbacillus; (2) pityriasis simplex capitis—hair
usually dry and lusterless with small white or gray scales scattered over it,
clinging to the hair like powder, or thin small flattened bran-like scales;
there is no inflammation, some itchiness, but the disease does not cause
baldness; caused by the spores of Malassez, identical with the bottle
bacillus of Unna; the disease being a hyperkeratosis; (3) pityriasis stea-
todes—the scalp covered with distinctly greasy, coarse, yellowish, usually
adherent scales or crusts, in moderate to considerable amounts; there are
no inflammatory signs, but, as a rule, tending to variable hair loss; pru­
ritus of mild degree; oiliness is often a complication; and the malady may
develop into a dermatitis seborrhoica or even into an eczema; Sabouraud
considered this type as the result of a secondary infection of his pityriasis

¹ Unna, “Seborrheal Eczema,” Jour. Cutan. Dis., 1887, p. 449; and later paper in
Volkmann's klinische Vorträge, No. 79, Sept., 1893—full abstract translation in Brit.
Jour. Derm., 1894, p. 23.

² Elliot, New York Med. Jour., 1891, vol. liii, p. 174, and Morrow‘s System, vol. iii
(Dermatology), p. 273.

³ Duhring, Cutaneous Medicine, part ii, p. 323.

⁴ Jackson and McMurtry, “Seborrhœa Capitis,” Jour. Cutan. Dis., 1912, p. 608,
give a good account of Sabouraud‘s views; also in their recent book, Diseases of the
Hair, 1912.

332                                      INFLAMMATIONS

simplex with his polymorphous coccus with gray colonies (considered iden­
tical with Unna's morococcus); every case shows, therefore, these two or­
ganisms—the spores of Malassez and the polymorphous coccus; the lat­
ter appears as a morococcus, a diplococcus, or in groups of four, and oval,
club, or dumbbell in shape. (4) Dermatitis seborrhoica, characterized
by small or large patches, discrete, grouped, or coalescent, often forming
serpiginous or polycyclic areas, with more or less greasy, adherent, gray­
ish or yellowish scales or crusts, with the underlying skin red or yellow­
ish red; the whole scalp may be involved or only in parts; and it frequently
spreads to other parts of the body; the malady is attributed to the
presence of a combination of the three organisms already named—the
microbacillus, the spores of Malassez, and the polymorphous coccus.

While, therefore, Sabouraud's great work has tended to clear up a
much discussed and much disputed class of cases, there is still sufficient

Fig. 74.—Dermatitis seborrhoica, involving sides and angles of the nose, the eye­
brows, and, to a slight extent, the chin and other hairy parts of the face. Slight to
moderate scaliness of a greasy character, with underlying mildly inflammatory condi­
tion. Scalp is also involved.

lack of corroboration and want of unanimity that for the present it seems
advisable to present the subject matter in the same manner and under the
same headings as in the former editions of this treatise.

Symptoms.—The clinical appearances presented by dermatitis seb-
orrhoica are somewhat variable according to the region involved, and
probably also dependent upon the cutaneous irritability of the individual
skin. The special seat of the malady is the scalp. It may consist of mere
branny scaliness, with skin practically of the normal color or slightly
irritated and reddened (pityriasis capitis; some cases of dandruff), or
there may be considerable scale-formation, under which the skin is
found to be somewhat inflamed and even infiltrated. It sometimes
exists in areas of small or large extent, or it may, as it does in some
instances, involve the entire scalp, extending over to the ears and on to
the forehead. The scales are grayish or a dirty white color, and greasy

DERMATITIS SEBORRHOICA

333

or unctuous to the touch. In the mild types—pityriasis capitis—the
scales are often rather dry, as likewise is the hair. As a rule, however,
although the scaliness varies from almost dry to oily, the hair, if the
disease is at all marked, is noted to become oily or greasy and to need
frequent washing. There are exceptional cases, however, in which the
hair seems dry, lifeless, and lusterless throughout. In those of marked
scaliness the hair-shaft, at and near the scalp, is often encircled with thin
scales; and in almost all instances there is more or less scaly dust scattered
through the hair, readily falling on the shoulders. In persistent cases
hair loss, moderate or considerable in extent, is a frequent accompani­
ment. In extreme types the eczematous aspect is the more pronounced,

Fig. 75.—Dermatitis seborrhoica, of more inflammatory type than shown in pre­
ceding illustration, involving the whole face and scalp, but especially pronounced about
the nose.

and there is sometimes serous exudation. The disease is frequently
irregularly diffused, and with a gradual lessening toward the borders,
which is commonly more noticeable toward the forehead; on the other
hand, the edge may be more pronounced, slightly elevated, and gyrate or
irregularly segmental, and when red, as such a border usually is, becomes
quite conspicuous and disfiguring. Exceptionally scattered over the
scalp region, the malady may present segmental or ring-like patches,
slightly inflammatory in character. The disease often remains limited
to the scalp, remaining as a mild pityriasis type throughout, with, in
some cases, an occasional exacerbation in which the skin becomes acutely
inflamed and the scaliness more pronounced, but of a distinctly greasy
character. The skin, instead of seeming to be thickened, often has a

334

1NFLAMMATIONS

thin, inelastic appearance. In some cases in which these exacerba­
tions take place the process extends on to the face, partly or completely
invading it, and with, at times, areas of moist exudation, presenting,
in fact, the appearance of a mildly acute eczema supervening upon a
seborrhea.

While the disease frequently confines itself to the scalp and in most
instances occurs primarily on this region, it is not uncommon for the
region of the side of the nose and the immediate neighboring surface to
show scaliness, merely furfuraceous or crusty in character, with a scarcely
reddened skin beneath or with the part slightly hyperemic and even in­
flamed and somewhat oily; the glandular outlets are frequently enlarged
or patulous, and occasionally the overlying scales show projections, ex­
tending in the duct openings. In some cases, more particularly in chil­
dren, the manifestation on the face consists of several or more small, ill-
defined, rounded, scurfy patches, especially about the mouth region,
sometimes in association with similar lesions on the upper trunk. The
eyebrows are also often the seat of furfuraceous or moderate scaliness, and
in the male adult the mustache and beard often display the same char-

Fig. 76.—Persistent exfoliation of the lips (dermatitis seborrhoica—cheilitis exfoliativa).

acters. The ear canal, as well as the ears themselves, may also be
the seat of the disease. The scales, especially those about the alæ
nasi, are usually quite oily and of a yellowish cast; in fact, this yellow­
ish tinge is often characteristic of this disease not only on this region,
but elsewhere on the surface. Instead of the types just described, the
disease is sometimes quite inflammatory, and has a decidedly eczema-
tous aspect.

Exceptionally the vermilion border of the lips is involved with
other parts, and covered with thin or somewhat thick adherent scales
or crusts, and it may be attended with a slight or marked tendency to
fissuring; there is rarely any puffiness or swelling of the parts, as often
observed in eczema of this region. In rare instances the disease is
limited to the lips, scarcely extending on to the cutaneous surface, usually
with a coexistent eruption of the scalp. In two instances recently under
my care¹ it was limited to the vermilion of the lips (cheilitis exfoliativa),
neither overstepping the mucous portion of the mouth nor the cutaneous

¹ Stelwagon, “A Report of Two Cases of Persistent Exfoliation of the Lips,” Jour,
Cutan. Dis., June, 1900; “A Peculiar Eczematoid Eruption of the Lip Region,” ibid..
Aug., 1904 (illustrated; lips and contiguous cutaneous surface).

Plate X.

An unusual case of dermatitis seborrhoica of a psoriasiform type.

DERMATITIS SEBORRHOICA

335

integument, and consisted of persistent and repeated thin exfoliation;
there was an associated slight involvement of the scalp in both cases, and
in one case transitory mild patches upon the face.

On the breast the disease is frequently limited to one or two irregu­
larly rounded areas over the sternum; it is scaly, with frequently slight
elevation, and the skin reddened to a variable degree. On removing the
crust, projections are frequently noted extending into the sebaceous
gland outlets. It is also not infrequent upon the back, especially be­
tween the scapulae. Instead of only several areas, they may be quite
numerous, and may coalesce here and there, and form patches made up
of irregular segments and circles or festooned areas, often with distinctly
inflammatory base, particularly at the periphery. As thus seen upon the
chest, it constitutes the so-called seborrhœa corporis (Duhring), the
lichen circumscriptus (Willan and Bateman), lichen annulatus (Wilson),
lichen gyratus (Biett and Cazenave), and seborrhœa papulosa seu lichen-
oides (Crocker), seborrhœa figurée (Brocq)—names which convey a fair
portrayal of the clinical appearances. The umbilicus is also a not un­
common seat of a dry, scaly, or oily moist form.

The disease on other parts—as, for instance, the genitocrural and
axillary regions—varies but slightly from its appearance elsewhere,
except that the heat, moisture, and friction of the parts tend to give
it more the appearance of ordinary eczema. It frequently begins as
small, branny, scaly, slightly reddened spots, which often enlarge, and
sometimes have somewhat elevated borders, and occasionally with a
clearing center. They sometimes coalesce, and then a slightly or moder­
ately inflamed area is presented, with scaly or crusted surface, and usually
a rather sharply defined border; the scaliness or crusting being of a yellow­
ish, greasy character, and rarely abundant. The skin itself, both under­
lying the patches and immediately adjacent thereto, often is yellowish or
has a yellowish tinge. In fact, in these regions there is a resemblance to
both erythema or eczema intertrigo and eczema marginatum (tinea
trichophytina). In infants it is not infrequent in the erythema intertrigo
regions; the color is apt to be a brighter red, with often a granular-
looking surface, usually due to the presence of small, moist or greasy,
yellowish or yellowish-gray scales. On the hands and also the feet
the disease is usually of a patchy character, sometimes ill defined, at
other times quite well marked, and the patches rather sharply circum­
scribed. Here, as elsewhere, coalescence sometimes occurs and larger
irregular areas result; and occasionally vesiculation and serous exudation
are noted.

In exceptional instances dermatitis seborrhoica is distinctly psoriasi-
form in appearance, with scattered, variously sized patches over the
general surfaces, usually sparing the extensor surfaces of the elbows
and knees—favorite sites for the true psoriasis lesions. In these cases
patches are commonly seen in the axillae, about the genitalia, and in
other places where psoriasis lesions are not generally observed. Some­
times they are flat, scaly spots or papules, often disk-like or circinate,
with but a slight or moderate amount of scaliness, which is usually
of a yellowish tinge, and greasy or unctuous in character. In excep-

336                                      INFLAMMATIONS

tional instances dermatitis seborrhoica may be quite extensively diffused
and involve large surfaces, and be more or less polymorphous. The favor­
ite localities are, however, those already named—scalp, eyebrows, region
of the nose, sternal and interscapular regions, the genitocrural region,
and axillæ, and in male adults the hairy parts of the face. In most
instances it is upon the upper half of the body. While it begins primarily
on the scalp in most cases, and from here tends to spread downward or
develop on other regions, in the minority of cases it starts at the eyebrows,
axillæ, or the genitocrural region.

As a rule, itching is not a troublesome symptom, and often it is
extremely slight, and sometimes entirely wanting. It is noted most
frequently with the disease on the scalp, and is not uncommon, when
the patient is heated, on the sternal and interscapular regions, and

Fig. 77.—Dermatitis seborrhoica of the sternal region, a not uncommon site; shows
the tendency to irregular, ring-like formation of the patches and scales. The scaliness
is slight and of a greasy character; affected surface reddened and mildly inflammatory.

probably less frequent with the disease in the axillæ and genitocrural
parts. It is sometimes entirely absent with the eruption on the hand.

The course of the malady is usually persistent, varying somewhat
in severity and extent, and exceptionally with periods of relative quies­
cence or abatement.

Etiology.—The disease is quite common, especially in its milder
types on the scalp. It is met with in both sexes and at all ages, although
more frequent between the ages of early youth and thirty or thirty-
five years. Systemic disturbances, especially those of the alimentary
tract,—indigestion, dilatation of the stomach, constipation,—men­
strual disorders, anemia, and general debility are to be considered as
favoring factors. Elliot does not place much importance upon constitu­
tional influences; Unna considers them slightly predisposing. My
own observations place a good deal of stress upon the systemic condition
as an influencing element, especially digestive irregularities; very often,
in the milder cases, a variability can be gauged by the state of the ali-

DERMATITIS SEBORRHOICA

337

mentary tract. Of probably greater importance are the external factors
of lack of care, want of cleanliness, the infrequent use of soap, irritating
barber­shop and patent tonic applications to the scalp, and, on the body,
the wearing of too heavy woolen underwear. Sweating, especially when
retained for a long time in contact with the body, as often observed in
winter in the use of thick flannel, is a potent favoring factor in the disease
upon the sternal and interscapular regions. It is not improbable that the
cautious, and therefore
usually imperfect, wash­
ing of soiled woolen under­
wear to prevent shrink­
ing is not without con­
tributory import on cov­
ered regions.

While the disease is
met with at all times of
the year, it is more com­
mon during the “over-
clad” and indoor season;
in summer the outdoor
life, the better ventila­
tion, and the more fre­
quent bathing are un­
favorable to its produc­
tion. In a measure the
malady is to be viewed
as contagious, and there­
fore parasitic, and bar­
ber­shops, hair-dressing
establishments, the combs
and brushes in the gen­
eral toilet-rooms of hotels,
etc, are doubtless respon­
sible for its communica­
tion in some instances.
As is to be inferred from
the remarks on the de­
scription of the disease,
the scalp is the starting-
point in most cases, and

the disease here has, therefore, an important etiologic bearing upon the
development of the eruption on other parts.

Pathology.—The prevailing view of former years that all the
conditions observed in this affection were the result of functional disease
of the sebaceous glands—a seborrhea—is no longer tenable. Van
Harlingen¹ was the first to demonstrate that pityriasis capitis was not a
true seborrhea, although his careful work has been lost sight of in the

¹ Van Harlingen, “A Contribution to the Pathology of Epithelium,” Amer. Jour.
Med. Sci., July, 1876; “Pathology of Seborrhea,” Arch. Derm., April, 1878.

22

Fig. 78.—Dermatitis seborrhoica of the scalp of
the lightest grade, known commonly as pityriasis
capitis. A somewhat hyperplastic, loosely coherent,
corneous layer, filling up and causing slight funnel-
like dilatation of the follicular opening, and envelop­
ing the hair-shaft at the orifice. Slight inflamma­
tory cell-infiltration in the corium, especially along
the hair-follicle (courtesy of Dr. Geo. T. Elliot).

338                                      INFLAMMATIONS

recent and more complete investigations of Unna, Elliot, and others;
and Duhring first called attention to the fact that the disease on the chest
(his seborrhœa corporis) was associated with, and often followed, the
disease upon the scalp, thus foreshadowing the work of other observers,
although he did not place the same interpretation upon the clinical
facts.

The essential pathogenic factor of dermatitis seborrhoica must be
considered parasitic, and this view is strengthened by the tendency in
many cases to assume the circulate, segmental, and spreading forms.

Its origin primarily in the
scalp in most cases, and its
tendency to develop from
this region to another, and its
infrequent occurrence prim­
arily simultaneously upon
several parts, are also sug­
gestive. Unna and, following
him, Leredde believed that
his morococci and the flask
bacilli (Malassez‘s spores) are
the parasitic agents. The in­
vestigations of Török, Sabou-
raud,¹ and others threw doubt
upon the pathogenic import­
ance of these organisms, and,
as Galloway² and others have
contended, it is more than
probable that this coccus—
morococcus—is a mere sapro­
phyte. Both Merrill³ and
Whitfield⁴ have found a
coccus of variable size, ar­
ranged usually in pairs, and
also in groups and short
chains, grayish white, and
sometimes developing into a yellowish color. Whitfield found it in
12 cases examined by him, but experiments at inoculation on him­
self were without result. Merrill found constantly diplococci, espe­
cially two varieties, one chromogenic and the other non-chromogenic,
and states that in a fair proportion of his inoculative experiments he
succeeded in producing the disease.

The clinical appearances suggest an inflammation of the skin, usu­
ally of a slight or moderate grade,—a mild dermatitis,—and appar­
ently with an associated disturbance of the oil-secreting glands. Unna
claims that the coil-glands are those implicated, and to which the oily

Fig. 79.—Dermatitis seborrhoica, section of a
small papule in the type commonly known as
“seborrhœa corporis.” A hyperplastic horny
layer and dense inflammatory cell-infiltration in
more or less of the entire corium, with slight
edema (courtesy of Dr. Geo. T. Elliot).

¹ Sabouraud‘s views have somewhat changed—see introductory part of this chapter.

²  Galloway, Discussion Harveian Society, Brit. Med. Jour., Feb. 25, 1899.

³ Merrill, New York Med. Jour., 1897, vol. lxv, p. 322; and vol. lxii, 1895, p. 528.

⁴ Whitfield, Brit. Jour. Derm., 1900, p. 406.

DERMATITIS SEBORRHOICA                             339

secretion is due. From his studies he states that there does not exist
any hypersecretion of the sebaceous glands which can clinically be called
dry seborrhea, due to a deposit upon the surface of firm products from
these structures. Dermatitis seborrhoica, in which he includes all forms
of seborrhea except seborrhœa oleosa, is due, he believes, to hypersecre-
tion of oil from the sweat-glands, and not the sebaceous glands, together
with an inflammation of the skin due to parasitic invasion; the oil secre­
tion permeating the cutaneous tissues, as well as mixing with the surface
scales and crusts, and that to this excessive secretion the yellow tinge is
to be attributed. His views as to the sole implication of the sweat-glands
have not, however, found general acceptance.

The pathologic anatomy has been studied by Unna, Elliot, and
others, and with findings, upon the whole, essentially similar. Unna¹
states that four factors are found: (1) Parakeratosis of the epidermis;

Fig. 80.—Dermatitis seborrhoica of the upper part of the back and interscapular
region, a not uncommon site; shows the irregular ring tendency and rather sharply
defined borders. The scaliness is slight and of a greasy character; affected surface
reddened and mildly inflammatory.

(2) epithelial proliferation (acanthosis); (3) inflammation of the derma,
varying in depth; (4) augmentation of the fatty secretion of the skin, to­
gether with increased activity of the coil-glands. The first three are
also typical of eczema. The fourth gives the character to the sebor-
rheic disease, but, as already stated, there is difference of opinion as to
the source of the fat or oil secretion. In addition he notes an increase in
size in the panniculus adiposus; and only after the total disappearance of
the hair that the sebaceous glands take part and the sebum accumulates.
This last he considers is not an essential part and is only observed in
cases of long standing. Elliot² has failed to confirm Unna's observation
as to fatty infiltration in the tissues or in the sweat-glands; he found
disorganization of these glands, but considered this only an evidence of

¹ Quoting from abstract of his paper in Brit. Jour. Derm., 1894, p. 23.

² Elliot, Jour. Cutan. Dis., 1893, p. 205 (with several good histologic cuts).

340

INFLAMMATIONS

their participation in the inflammatory process, but not necessarily in the
line of excessive fat-production.

Diagnosis.—The diagnostic features of dermatitis seborrhoica are
its almost invariable occurrence primarily upon the scalp, its spread
from this region downward, the mildly inflammatory character, the
absence of pronounced infiltration, the greasy nature of the scales or
crusts, and the tendency, in many cases, to disc-like or segmental con­
figuration, and the relatively moderate amount of itching. The disease
is to be distinguished from seborrhea, eczema, pityriasis rosea, ringworm,
and psoriasis. The acceptance of dermatitis seborrhoica as a distinct
entity has almost obliterated seborrhea. But there are still some
cases of this latter, in the scalp especially, in which an inflammatory
element cannot be detected, and which are, therefore, to be distinguished
by the entire absence of inflammatory symptoms and of signs of irritation.
The skin is found paler than normal, extremely oily, and often slate
colored, the scaliness being soft and oily. The oily variety of seborrhea,
not uncommon on the scalp and nose, is distinguished by the entire lack
of scale formation and freedom from inflammatory signs.

Dermatitis seborrhoica is to be differentiated from ordinary eczema
by the absence of markedly inflammatory characters, the practical
absence of infiltration, its tendency to be somewhat sharply marginate
and often segmental or of irregular outline, and by the fact of its first
appearance upon the scalp. The scaliness is less abundant and usu­
ally of yellowish tinge and greasy looking to the sight, and unctuous
to the touch. In cases of any extent the sternal and interscapular
regions rarely escape, parts that are seldom involved in ordinary eczema
except in generalized cases. Upon the hands, especially on the palmar
aspects,¹ the differentiation is sometimes extremely difrieult, but the
scurfy or scaly patch-formation here, irregular outlines, and usually
the presence of the characteristic disease on other parts will be of aid.
In the axillae and genitocrural regions eczema is rarely ever sharply defined,
segmental, or patchy, as generally obtains in dermatitis seborrhoica; and
the latter's frequent mode of beginning here in ringworm-like patches is
unlike eczema. Moreover, seborrheic dermatitis is, on these regions and
also elsewhere, except the scalp, seldom itchy to the extent of being a
troublesome symptom, while in eczema it is constantly so.

Pityriasis rosea begins on the trunk almost invariably, comes out
more or less acutely in the course of a few days, and presents numer­
ous maculosquamous and papulosquamous patches, tending to spread,
and here and there coalesce, rarely involving face, never the scalp, and
seldom regional just over the sternum, as so often observed in dermati­
tis seborrhoica. The early patches of pityriasis rosea are never seg-
mental, as in seborrheic dermatitis, and tend more decidedly to develop­­
ing into spreading rings, and they are not covered with the same greasy
or unctuous scales of the latter disease. Its course, after full develop­
ment, is, as a rule, rapidly toward full recovery, whereas in dermatitis
seborrhoica this natural tendency to a self-limited duration is not ob-

¹ Stelwagon, “Observations Concerning Some Palmar Eruptions” (illustrated).
Jour. Cutan. Dis., Jan., 1905.

DERMATITIS SEBORRHOICA

341

served. Nevertheless it must be conceded that at times the two con­
ditions present puzzling similarity, which is only positively solved by
several days’ or one or two weeks’ observation.

Ringworm patches, especially in their early stage and particularly
in children about the face, resemble patches of seborrheic dermatitis,
but in the former the almost invariable tendency to a complete clearing
up of the central portion as it spreads peripherally, and the usually more
pronounced and elevated border are generally sufficiently character­
istic From eczema marginatum—ringworm of the genitocrural and
axillary regions—the differentiation is not always readily made, but in
ringworm the border is usually quite elevated, distinctly marginate, and
outside of the confluent areas typical ringworm patches are generally to
be found. Moreover, confluent ringworm of these regions is usually
more distinctly inflammatory, and the infiltration more marked, than in
dermatitis seborrhoica. In all suspected and difficult cases an examina­
tion of the scales from the edges will be the crucial test; the ringworm
fungus can be found if it be that disease, if the examination be thor­
oughly and carefully made.

More or less generalized, small, patchy seborrheic dermatitis simu­
lates psoriasis at times quite closely, but the favorite regions of pso­
riasis—the extensor surfaces of the kness and elbows—are rarely invaded
in dermatitis seborrhoica. Moreover, the patches of this latter disease
are rarely so sharply circumscribed as psoriasis patches, and the scales
are usually yellowish and greasy, instead of white, silvery, or grayish,
and hard and dry, as in psoriasis. In such cases of seborrheic dermatitis
the disease on the scalp rarely shows the same character, but on this region
it is more of the nature of a mild or moderate generalized scaliness, and
not patchy, as in psoriasis.

Prognosis.—The disease, is, as a rule, more readily managed
than ordinary eczema, often responding rapidly to treatment. But
there is usually a decided tendency to recurrence, which Unna con­
siders to be due to the fact that the parasitic element may remain
quiescent in the glandular structures (in his opinion, the coil-glands),
and again, favored by some unknown contributory influence, give rise
to a recurrence. Elliot believes there is another reinfection. It is
more probable that the patient's constitutional condition is an import­
ant favoring factor; if in good, strong, vigorous health, with digestion
being well performed and the bowels regular, relapses are not apt to
occur. The application of a weak resorcin lotion, 2 to 5 per cent, strength,
at intervals of several days or a week, and the use of a boric acid or
resorcin soap for shampooing and for occasional toilet washing, are
advisable in those cases showing a strong tendency to recur. The
hair loss which is often observed in connection with the disease on the
scalp can generally be replaced by proper management (see Alopecia),
provided the disease has not been too long continued.

Treatment.—Believing, as I do, that the state of the general
health, and especially the condition of digestion, has in many cases an
important etiologic bearing, the line of constitutional treatment to be
adopted depends upon indications in the individual cases—differing

342

INFLAMMA TIONS

in no respect from the general plan advised in eczema, to which the
reader is referred. The bowels should be kept free, and some attention
given to diet.

The most important external remedies—and, of course, the external
treatment is the essential part of the management of the disease—
are sulphur, salicylic acid, and resorcin. Upon the scalp, resorcin, in
the form of a lotion made up of 5 to 30 grains (0.33 to 2.), 1 to 2 drams
(4.-8.) of alcohol, and water to make an ounce (32.), is one of the most
valuable remedies we possess; it may even be used stronger, but in all
the stronger proportions some care is necessary at first, as exceptionally
irritation is produced. It should be applied once or twice daily. In
some instances the lotion is too drying, and is to be supplemented every
second or third day by an application of plain petrolatum; or an ointment
medicated with 10 to 30 grains (0.7-2.) of resorcin to the ounce (32.)
can be employed, either occasionally in conjunction with the lotion treat­
ment or alone. The objection to resorcin, especially in lotion form, is
that in those with gray or decidedly blonde hair, a dirty yellow staining,
lasting several weeks or longer, sometimes is noticeable after prolonged
use. If employed carefully and in scant quantity, this is not so likely
to occur; in such patients, however, other plans are, for this reason, pref­
erable. Sulphur, the precipitated or sublimed, in the form of an oint­
ment, ½ dram to 2 drams (2.-8.) to the ounce, is often curative, but this
drug irritates in some cases. On the scalp region, too, salicylic acid, 10
to 40 grains (0.65-2.65) to the ounce (32.) of petrolatum, is valuable; and
very often a compound salve containing both resorcin and saliclylic acid
is the best of all. A 0.5 to 2 per cent, solution of salicylic acid in equal
parts of alcohol and water is sometimes useful in the scalp disease. Along
with the remedial applications occasional washing with soap and water
is necessary, the frequency depending upon the rapidity of the scale re-
accumulation and the demands of cleanliness. For this purpose a boric
acid or a resorcin soap may be used; in sluggish cases the tincture of green
soap is permissible, and it can be medicated with 5 to 10 grains (0.33-
0.65) of resorcin to the ounce (32.).

Upon non-hairy regions the conjoint use of a lotion, similar but
somewhat weaker than those named, along with a salve, usually gives the
best result. The ointment for these parts should also be weaker than
for the scalp. In these cases sulphur often irritates unless used very
weak, 10 to 60 grains (0.65-4.) to the ounce (32.). It frequently acts
more satisfactorily and is better borne when prescribed with a paste as:

R. Sulphur, præcip.,                                        gr. xxx-lx (2.-4.);

Ac. salicylici,                                              gr. x (0.65);

Pulv. amyli,

Pulv. zinci oxidi,                                    áá 3iss (6.);
Petrolati,                                                     3iv (16.).

In obstinate patches an occasional application of a 10 to 50 per
cent, alcoholic solution of resorcin, as advised by Frickenhaus,¹ is some­
times valuable, but the stronger proportions are to be used cautiously,

¹ Frickenhaus, Monatshefte, June 1, 1899.

HERPES SIMPLEX

343

as aggravation can occur; exfoliation, usually after a few applications,
results, and then petrolatum or cold cream can be used for a few days,
and, if necessary, the treatment repeated. Occasionally, in obstinate
cases of the disease on the face and trunk, an ointment containing chrys-
arobin, 5 to 30 grains (0.33-2.) to the ounce (32.) of the paste above
named, may be used with advantage, for a time at least, and then other
treatment of milder character employed. About the face this remedy
should, however, be used with great care. In persistent body patches
I have frequently employed chrysarobin in collodion, as advised in psori­
asis. In some face cases which proved obstinate I have found, even
when seemingly quite inflammatory, the cautious use of the compound
lotion of zinc sulphate and potassium sulphuret (see Acne), with an occa­
sional application of cold cream, of signal benefit. Short Röntgen-ray
exposures (two to five minutes, with a soft to medium tube, at a distance
of 8 to 10 inches), at intervals of several days or a week, are a help in ob­
stinate face cases.

In children, as well as in adults, of sensitive skin the applications
should be extremely weak at first; the malady is usually most irritable
on the face and genitocrural region. The disease upon the lips must
also be treated cautiously at first, but in persistent, stubborn cases an
occasional application of the strongest remedies becomes necessary;
strong silver nitrate, resorcin, and lactic acid solutions are useful here
—silver nitrate and resorcin, 2 to 20 per cent, strength, and lactic acid,
at first with 10 to 20 parts water; later, if necessary and not too irritating,
in stronger proportions; in the interim mild ointments are to be used;
daily washing with sapo viridis, and immediately applying diachylon
ointment is of distinct value in some cases. In the auditory meatus
the resorcin lotion, applied scantily, and supplemented with a weak re-
sorcin salve, constitutes the most successful plan, but the disease here is
often obstinate, and frequently requires change of remedies before final
success is achieved.

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