PSORIASIS (LEPRA ALPHOS, ALPHOS, PSORIASIS VULGARIS)

Synonyms.   Lepra alphos, alphos, psoriasis vulgaris.

Psoriasis is a common chronic, recurrent, inflammatory disease of the skin characterized by rounded, circumscribed, erythematous, dry scaling patches of various sizes covered by grayish-white or silvery-white, im­bricated and abundant scales. The lesions have a predilection for the scalp, nails, extensor surfaces of the limbs and the sacral region. The eruption is usually symmetrical and may vary from a solitary spot to countless patches. The eruption usually develops slowly but may be exanthematic, with the sudden onset of numerous guttate lesions, or may consist of a few inveterate patches. Subjective symptoms such as itching or burning may occasionally be present. The cause of the disease is unknown.

The early lesions are guttate erythematous macules or maculopapules, which from the beginning are covered with dry silvery scales. By periph­eral extension and by coalescence, the spots increase in size, and through the accumulation of scales they become thicker. Nummular (coin-shaped) lesions are common. In this variety certain distinctive features may be easily demonstrated: (1) The scales are micaceous, and looser toward the periphery of the patch while adherent at the center; (2) upon re­moval of the scales, bleeding points occur. After the patches reach a diameter of about 5 cm., they cease spreading and tend to undergo in­volution in the center, so that annular, lobulated and gyrate figures are produced.

Old patches may be thickened and tough, and covered with lamellae of scales so that they resemble the outside of an oyster shell (psoriasis ostracea). Various other descriptive terms are applied to the diverse ap­pearances of the lesions: psoriasis guttata, in which the lesions are the size of drops; psoriasis follicularis, in which tiny scaly lesions are located at the orifices of the pilosebaceous follicles; psoriasis figurata, psoriasis annulata, and psoriasis gyrata, in which curved linear patterns are pro­duced by central involution; psoriasis discoidea, in which central involu­tion does not occur and solid patches persist; psoriasis rupioides, in which crustaceous lesions occur resembling syphilitic rupia; psoriasis arthro-pathica, a particularly inveterate form associated with chronic arthritis. This is a polyarthritis of the small joints of the hands and feet.

Extensive cases of long duration may develop a universal erythroderma. In a review of over 2200 cases of psoriasis, Coeckerman and O'Leary were able to find 22 cases (about 1 per cent) of erythroderma psoriaticum. Auto-sensitization may account for this universal exfoliative erythroderma. Rarely, bullous lesions have been observed during acute exacerbations, and cases have been reported in which generalized eruptions of flaccid bullae later developed features characteristic of psoriasis. Pustular psoriasis was described by Schaffer in 1921 and later by MacLeod. The typical psoriatic patches become covered with small pustules. This change sometimes pre­cedes the development of generalized exfoliative dermatitis. Pustular psoriasis of the extremities, as described by Barber and Ingram, is a differ­ent clinical expression of the disease, which is considered separately. Flexural psoriasis is a definite regional type.

The course of psoriasis is inconstant. It usually begins on the scalp or on the extensor surfaces of the elbows, and may remain localized to the original region for an indefinite period, or completely disappear, recur, or spread to other parts. The beginning may be over the sacrum, where the patch slowly extends to form an inveterate lesion. At other times the onset is more sudden and widespread, as already described; or in other cases the first lesions may be limited to the fingernails.

One of the chief features of psoriasis is its tendency to recurrences. These are commonly manifest over and over again throughout the life­time of the patient. Rarely, however, psoriatics may remain completely free of the disease for years, and may be considered, in at least a practical sense, cured. On the scalp it does not cause loss of hair. The lesions are sometimes easily irritated—even the chronic ones—and when this takes place they are liable to spread by the development of satellites, or new spots in other regions. In acute guttate or nummular spreading eruptions, if irritat­ing remedies arc applied, a generalized exfoliative dermatitis may result. Although psoriasis affects both children and adults, the course of the disease is comparatively mild in children.

The Koebner phenomenon is the appearance of typical lesions of psori­asis at sites of injuries. Tins is a characteristic feature of the disease and accounts for the frequent appearance of typical psoriatic patches on scars and at sites of operations and burns. Occasionally the initial patch is upon the site of such a trauma. In the presence of early lesions, new lesions can be produced by scratching the skin. The Koebner phenomenon occurs in many other skin diseases, such as lichen planus, lichen nitidus, verruca plana and infectious eczematoid dermatitis.

The various theories concerning the etiology of psoriasis are too volu­minous to be covered adequately in the space permitted. Present tendencies favor a metabolic disturbance of phosphorylation, often inherited, which may be influenced by stress and focal infection. There is a history of family incidence in about 25% of the cases. The frequent association of this combination of factors with arthritis is noteworthy.

ERYTHRODERMA DESQUAMATIVA & DERMATITIS EXFOLIATIVA NEONATORUM

ERYTHRODERMA DESQUAMATIVA

This disease was first described by Leiner in 1908 and since then has been mentioned frequently as occurring abroad but rarely has been ob­served in this country. According to Leiner, the disease occurs chiefly in nursing infants as a general exfoliative dermatitis with marked redness of the skin and scaling, usually suggesting a severe type of seborrheic derma­titis. The lesions involve particularly the anogenital region, scalp and face but are also diffuse on the trunk and extremities. At first there is a dif­fuse inflammatory redness that may cover the whole body, which later becomes covered with grayish-white scales that may be fine and branny, or very large so that sheets are exfoliated. The supraorbital areas are red and swollen and may be crusted. In fact, as the process develops there may be general exfoliation, cracking, and thickening of the skin. These infants usually are in a poor general condition. They may be in a state of athrcpsia, and diarrhea is commonly present. There is general glandular enlargement. The nails are destroyed. About one third of the cases die.

At autopsy Leiner found degeneration of the heart muscle, fatty degen­eration and infiltration of the liver, and catarrhal changes in the intestinal mucosa. In the skin there were a dilatation of vessels in the papillary region and an increase of leukocytes, with slight inflammation, edema, and parakeratosis of the epidermis.

The disease is probably a severe type of erythroderma due to pyogenic cocci and superimposed upon seborrheic dermatitis.

DERMATITIS EXFOLIATIVA NEONATORUM

This condition, which is also known as keratolysis neonatorum or Bit­ters disease, is a rare septic exfoliative condition of the newborn which runs a severe course and has a high mortality. The onset is usually during the first few weeks of extrauterine life, being marked by localized redness about the mouth which becomes universal and is accompanied by exfolia­tion and eczematization. Vesicles, bullae, and impetiginous lesions may be present, and cultures from these have shown hemolytic streptococci. The disease is possibly related to impetigo of the newborn. Wiener reported two cases in fraternal twins that started simultaneously at 5 weeks of age and suggested that an attack of severe poison ivy dermatitis near the end of the mother's pregnancy produced antibodies that, passing through the placenta into the bodies of the twins, could account for the occurrence of the exfolia­tive dermatitis in them. The skin of newborn and, particularly, premature infants is refractory to antigen antibody stimuli which might account for the delayed onset.

Dermatitis exfoliativa neonatorum is commonly seen in vigorous and breast-fed infants. The first lesions usually occur in the course of the second week after birth. Although the earliest lesions generally appear as red spots on the lace, particularly about the mouth and on the chin, the initial patches may rarely occur on other areas such as the neck, shoulders and chest. Generally the erythema spreads eccentrically over the lower parts of the face and then in two or three days over the rest of the body. Fissures radiate about the mouth. The skin becomes scarlet, and vesicles and bullae

Dermatitis exfoliativa neonatorum 

may be superimposed upon it. Denudcment of the superficial layers ol the epidermis in large pieces may begin before the erythema has become gen­eralized. Yellow crusts are .sometimes present. Small vesicles may occur on the lips. Stomatitis, rhinitis and corneal ulcers have been reported. In un­complicated cases there is usually no fever but secondary infections such as-subcutaneous abscesses, pyoderma, gangrenous lesions, and bronchopneu­monia are frequently observed.

This disease must be differentiated from erythroderma exfoliativa (Lciner), pityriasis rubra, impetigo neonatorum, erythroderma ichthy osiforme congenitum, epidermolysis bullosa congenitalis and congenital syphilis. Leiner's disease is not contagious and begins in the anogenita) region in the skin folds as an erythematous complication of dermatitis seborrheica. It usually disappears after a duration of three or four weeks. No bullae are observed. However, Cole believes after careful study of eleven cases that both Ritter's and Leiner's disease are variants of the same disease entity. In erythroderma ichthyosiforme congenitum, the first areas affected arc. the face and the articular folds and there may be plantar and palmar keratoderma.

Treatment is by antibiotics, and other remedies suggested for impetigo neonatorum.

ULTRAVIOLET THERAPY ON SEBORRHEIC DERMATITIS

The benefits from ultraviolet therapy on seborrheic dermatitis of the scalp are widely recognized. The sclap should be washed the day hefore the application. Mild erythema exposures to the top and sides of the scalp are given at intervals ol five to seven days. Grenz ray therapy or thorium .\ in alcoholic solution is equally effective if not more so.

For marginal blepharitis, sulfacetamide, Gantrisin or polysporin ophthal­mic ointment is recommended.

Seborrheic dermatitis of the glabrous skin is usually benefited by proper local remedies of which those containing sulfur are the most beneficial. Precipitated sulfur is applied in an ointment or in the form ol lotio alba, to either of which 3 per cent resorcin may be added. As these may be

Seborrheic dermatitis with characteristic involvement
of the eyelids and about die mouth

 

irritating it is necessary to use them with caution. Ointments containing hydrocortisone, sulfacetamide 10 per cent, vioform 1 to 3 per cent, ammoni-ated mercury 1 to 5 per cent, or crude coal tar 10 per cent arc used. Tarstill ointment or 30 per cent precipitated sulfur in white Vaseline, or bacitracin

Seborrheic dermatitis affecting apex of axilla

Seborrheic dermatitis

Configurate type of seborrheic dermatitis of the pubic region

ointment are often of value in difficult cases. Internal remedies that fre­quently are of value are vitamin B complex and B₁₂, riboflavin, nico­tinamide, crude liver extract injections, thyroid extract and in severe acutely inflamed cases, the sulfonamide drugs.

R    Acid salicylic

Sulfur ppt.   ....................................................................... 5a       1.0

Ol. rusci  .............................................. ,................................        0.6

Ol. almond  ............................................................................        3.0

Vaseline....................................................................... q.s. ad     30.0

M. and S. Apply locally.

The effects of fractional x-ray therapy are uniformly excellent, rapid re­sponse following small exposures. The macular and papular scaly eruptions which occur on the trunk, and the more or less generalized pruritic, exu­dative, and psoriasiform manifestations are best treated by a combination of ointments and irradiation.

ETIOLOGY & TREATMENT FOR SEBORRHEIC DERMATITIS

The etiology of seborrheic dermatitis is undetermined. That it is in­fluenced by the relative amounts of androgens and estrogens in the body seems clear. Investigations have confirmed the presence of a lipophylic, pleomorphic fungus, called the Pityrosporum ovale, in profuse numbers in most of the scalp lesions. This fungus is accepted by some as the cause of the disease, and by others is regarded as a saprophyte thriving in the favorable growth conditions provided by the seborrheic skin. Other in­vestigators have demonstrated that the P. ovale is abundantly present on the scalps of patients who have no clinical signs of the disease.

Many patients with the disease have low basal metabolic rates, and eat excessively of sweets, starches, or fats. Alcoholic drinks, chocolate or large amounts of cream, butter, milk, or sweets are harmful. Apparently there is a deficiency of vitamin B in some cases. Probably some of the various

expressions or seborrheic dermatitis are due to different causes, including the staphylococcus and streptococcus which are numerous in the crusts, and cause concurrent staphylococcic folliculitis and Staphylococcic ec/ematoid dermatitis. In some instances the disease seems to be mildly infectious, but is not regularly SO. It is made worse by conditions that increase per­spiration or sebaceous activity. Some cases bear such a close clinical resem­blance to psoriasis that there is some justification in thinking their etiologies must be similar.

The pathologic findings are those of a low grade- inflammatory process,

In the epidermis there are Spotty parakeratosis, acanthosis and spongiosis and occasional vesicle formation. In the corinin the subpapillary vessels are dilated, and there is a moderate! perivascular infiltration with lymphocytes. These changes all vary considerably in different grades of the condition, being more pronounced in the acute and psoriasiform types. It is differen­tiated from psoriasis by the spongiosis and vesicle formation, but often cannot be differentiated from eczema or other low grade inflammations.

Treatment. The scalp usually should be shampooed once a week, or if excessively oily, twice a week. Selenium sulfide shampoo suspension (Abbott) gives excellent results but tends to make the hair oily if used too frequently. For very oily scalps tincture saponis viridis or a 5 per cent solution of sodium lauryl sulfate (U.S.P.) are better. Sebezon lotion con­taining 10 per cent sodium sulfacetamide (Sehering) is extremely effective both   on   the seal])  and  skin.   It   is  applied   morning  and  night.

The following drugs are commonly incorporated in scalp lotions and pomades. Considerable caution must be exercised to obtain good phar­maceutical preparations which will cllect (he desired clinical results. Hesorcin or betanaphthol should not be used on blond or white hair, and mercury and sulfur should only be combined in the same prescription if the red or yellow oxides ol mercury are used. Sulfur or ainmoniated mercury are effective antiseptics but should never be used in the same prescription. A moderate amount of alcohol in scalp lotions is definitely antiseptic and there is no objection to its use. Any diving action from it may be avoided by the addition of oil to the lotion, castor oil being usually incorporated in small amounts in lotions to be used by men. Oils in seal]) lotions for women are to be avoided because they tend to make the hair stringy. When oils are. used for women they are best applied only immediately before shampooing but, if necessary, may be used more often in the form of brilliantines.

Effective prescriptions for the treatment  of the scalp are as follows:

R     Resorcinol............................................................................. 4.0-15.0

Rctanaphtliol    ........................................................................        2.0

Alcohol   .................................................................................    120.0

Distilled water............................................................... q.S. ad 240.0

Oil of violet or oil of bay.........................................................        0.24

Tincture cudbear  ....................................................................        0.5

M. and S. For dark hair only. Violet color and odor for women. Hay odor and brown :olor for men. Apply above lotion daily.

R     Dilute sulfurous acid   .............................................................      15.0

Alcohol   .................................................................................    120.0

Acetone   ................................................................................       15,0

Distilled water............................................................... q.S. ad 240.0

M. and S. Very drying antiseptic lotion for excessively oily scalp and hair.

R     Tincture capsicum   .................................................................      4.00

Chloral hydrate........................................................................      8.00

Alcohol   ................................................................................     120.0

Oil violet or oil ncroli...............................................................      0.21

Distilled water................................................................ qs. ad     210.0

M. and S. Apply to scalp daily with cotton (or dropper or toothbrush) and massage in, as directed, for three minutes.

Mercury may be substituted in similar prescriptions:

R    Mercury bichloride  .............................................................. 0.12-0.24

Resorcinol   .......................................................................... 4.0-15.0

Spt. formic acid  ......................................................................      15.0

Alcohol.....................................................................................      60.0

Distilled water................................................................ q.s. ad 210.0

M. and S. Apply to scalp daily with dropper and massage in as directed. For use only when hair is dark.

R     Sol. coal tar..............................................................................        8.0

Mercury bichloride..................................................................        0.24

Alcohol   ....................................................................... q.s. ad  240.0

.VI. and S, For oily hair. Apply daily with cotton,

SEBORRHEIC DERMATITIS (SEBORRHEIC ECZEMA, DERMATITIS SEBORRHEICA)

Synonyms.   Seborrheic eczema, dermatitis seborrheica.

Seborrheic dermatitis is an inflammatory disease of the skin that usually begins on the scalp from which it spreads to the face, neck, and body. The disease is characterized by dry, moist, or greasy scales, and by crusted, pinkish-yellow or yellowish patches of various shapes and sizes; by remis­sions and exacerbations, and by more or less itching. The sites of predilec­tion are areas in which sebaceous and sweat glands are present in large numbers. Parts commonly affected are the scalp, supraorbital region, lids, nasolabial crease, lips, ears, sternal area, axillae, submammary folds, um­bilicus, groins and gluteal crease. The disease usually runs a chronic course.

For the sake of clarity the different expressions of seborrheic dermatitis will be considered topographically.

On the scalp the least severe phase—pityriasis sicca—manifests itself as a dry flaky branny desquamation, beginning in small patches and rapidly involving the entire surface, with a profuse amount of fine powdery scales. An oily type of dandruff, pityriasis steatoides, at times accompanied by erythema and an accumulation of thick crusts, is also encountered. There is a tendency for the hair in the affected areas to fall out, characteristically beginning on the vertex and frontal regions and progressively receding. It is commonly associated with premature baldness in men. Other types of seborrheic dermatitis on the scalp are more severe and are manifested by greasy, scaling configurate patches or psoriasiform eruptions, exudation, and thick crusting. The disease frequently spreads beyond the hairy scalp to the forehead, ears, postauricular regions and neck. On these areas, the patches have convex borders and a reddish-yellow or yellowish color that is quite characteristic. In extreme cases the entire scalp is covered by a greasy, dirty crust which has an offensive odor. In infancy, yellow or brown scaling lesions on the scalp and accumulated epithelial debris is called cradle cap.

On the supraorbital regions, dandruff is seen in the eyebrows, and the underlying skin is erythematous and pruritic, or may show definite yel­lowish scaling patches. The edges of the lids may be erythematous and granular (marginal blepharitis). The conjunctivae are injected. The lids may be involved by yellowish-pink, finely scaly patches, the borders of which are usually indistinct. More or less pruritus may be present. If the glabella is involved, there may be cracks in the skin in the wrinkles at the inner end of the eyebrow. In the nasolabial creases and on the alae nasi, there is a yellowish or reddish-yellow scaling, sometimes with fissures. In men, folliculitis of the upper lip may occur. There is characteristic scaling

in the aural canals and when the disease is more advanced, there are scaly pruritic patches around the auditory meatus and in the postauricular region, or under the lobe. In these areas the skin often becomes red, fis­sured and swollen. Serous exudation, puffiness of the ears and surrounding parts, and regional adenopathy occur less frequently. In other cases a papular type of eruption is present on the cheeks, nose and forehead, the papules being scaly, greasy, yellowish or yellow-red in color, and 1 to 3 mm. in diameter.

The lips and mucosae are not usually involved but sometimes the changes on the lips are pronounced, resulting in cheilitis exfoliativa. The vermilion surfaces are persistently dry, red, scaly, exfoliative and fissured.

In the axillae, the eruption begins in the folds of skin at the apex and later progresses to neighboring skin. The involvement may vary from simple yellowish erythema and scaling, to more pronounced petaloid or discoid patches with fissures.

Seborrheic dermatitis is common in the groins and gluteal crease whert its appearance may simulate ringworm. The patches, however, are more finely scaly with less definite borders, and are more likely to be bilateral and symmetrical and of the typical color. In these locations, fissures occur and there may be psoriasiform patches with thick scales in the more severe cases.

On the upper and lower extremities the patches are more eczematoid, often lacking the characteristic color and fineness of scale. Vesicular exu­dative and crusted patches are not uncommon. The palms and soles may show a pompholyx-like vesicular eruption or may be diffusely thickened and scaly. Even the nails may be involved, showing longitudinal and trans­verse ridges, brittleness and grayish discoloration.

The lesions may be widely distributed or generalized, with erythema, scaling, oozing, and more or less pruritus. Often for months or years the eruption remains localized to one area, such as the scalp, ears, sternal region or umbilicus. Less frequently subacute or acute types are seen. In the acute stages the inflammation may be intense with profuse swelling of the eyelids and face, moist exudation from the scalp and ears, and papulovesicles on the palms and soles. Secondary infections causing fur-unculosis frequently ensue. On the extremities the cubital and popliteal regions often become lichenified from scratching and the friction of cloth­ing. Generalized eruptions may be accompanied by adenopathy and may simulate mycosis fungoides and leukemic erythroderma.

PRURIGO (CHRONIC ITCHING)

Prurigo is a chronic, itching, papular Skin disease which has a predilection for the lower abdomen, buttocks, and extensor surfaces of the limbs. Some lesions in addition are likely to occur on the trunk, scalp, forehead, face, and neck. Prurigo begins mostly in children from 2 to 5 years of age, being more common in boys. Probably in time all cases of prurigo will be proven to be severe types of papular urticaria caused by insect bites in hypersensitive children.

There are two forms of prurigo; namely, prurigo mitis, the more com­mon, which is comparatively mild; and prurigo agria or ferox, which is severe though exceedingly rare in this country.

Prurigo is a chronic, itching, papular Skin disease

Prurigo mitis usually begins as papular urticaria and, persistently re­curring, gradually assumes the characteristics of prurigo and lasts indefi­nitely. Prurigo mitis, therefore, can only be distinguished from papular urticaria after the second year of the disease by the uniform type of its primary lesion (the prurigo papule), by the chronicity, severity, scars, Iichenification, and cczematization. The prurigo papules at first are easier to palpate than to see, but later become small, rounded, extremely pruritic, flesh-colored or reddish elevations. The lesions are symmetrically distributed and may be few in number or very profuse. As time progresses the urticarial element is less noticeable but the extreme pruritus persists and leads to even greater secondary changes. The excoriations, lichenifica-tion, and eczematization become more and more pronounced and are ac­companied by enlarged glands and associated constitutional symptoms.

In prurigo agria the hard, excoriated prurigo papules and lichenification are completely predominant, the urticarial elements being sparse or ab­sent. Incessant scratching causes pitted scars and pustulation. The adenop­athy is not pronounced in the groins and axillae, which are free from skin lesions. There is often the history of excessive ingestion of carbohydrates, sweets and raw fruits. The hair is lusterless. Examination of the blood shows eosinophilia. There is usually an allergic family history, and skin tests reveal multiple sensitizations but these have no direct bearing on the etiology or therapy.

Treatment. Treatment includes the development of a hygienic regimen, consisting of liberal and proper diet with green vegetables, meat and cereals but no egg, chocolate, candy or citrus fruit. The addition of cal­ciferol may be indicated. Small doses of phenobarbital have value. Treatment should be given for fleas as advised on pages 166 and 441, or for intestinal parasites if present.

Antihistamine creams and hydrocortisone ointment are beneficial. The combination of tar, sulfur, and green soap, known as Wilkinson's salve, has special value in this condition, being applied in either quarter or half strength. The following formula is beneficial:

R    Prep, chalk..................................................................................      1.0

Beechwood tar...........................................................................      1.5

Sulfur ppt...................................................................................      1.5

Green soap ................................................................................    13.0

Lard...........................................................................................    13.0

M. and S. Apply locally morning and night.

URTICARIA PAPULOSA (CALLED PRURIGO SIMPLEX, LICHEN URTICATUS)

Papular urticaria, also called prurigo simplex, lichen urticatus, and strophulus pruriginosus, i.s a common disease of infancy and childhood. It appears during the wanner monllis, is more common in lower social and economic groups, and usually disappears upon admission to the hospital. Sehaffer, Spencer and Blank in 1948 proved by skin tests with flea and bedbug

Papular urticaria picture

Lichen urticatus. Similar lesions were upon the legs

antigen that papular urticaria is caused by hypersensitivity to flea and bedbug bites in at least 90 per cent of the cases. Their work confirms the suggestions made by Dietrich in Germany in 1938.

Pruritic skin lesions appear every spring or summer, usually in crops. They are distributed mostly on the arms and legs, especially on the extensor surfaces; also on the face and neck and usually least on the trunk. The in­dividual fresh lesions are small urtieated papules which become rubbed, excoriated and secondarily infected or liehenified, .sometimes with im­petiginous crusts or ccthymatous ulcers.

The lesions recur in crops, usually at night. All stages of development and regression of the papules may be noted at the same time. The attack lasts a week or two, but the disease may persist for months or years. Very frequently the attacks are seasonal. Usually tliere are no palpable lymphatic glands and no constitutional symptoms.

Treatment is by prophylaxis against all types of insects. The stool should be examined for intestinal parasites in baffling cases. The amount of candy, sweets, tomatoes and citrus fruits in the diet should be regulated. Anti­pruritic lotions are prescribed. In conjunction it is advisable to give treatment

Papular urticaria

 for fleas by DDT sprayed onto the carpets, floors, overstuffed chairs, in basements and into dog kennels or sleeping places of animals (sec p. 441).