Skin Diseases of Children/Eczema

by George Henry Fox

PLATE VI

Eczema

From the collection of photographs of

Dr. George Henry Fox.

ECZEMA.

Eczema is at all ages the most important skin disease which the physician is called upon to treat. In infancy and childhood it is especially common, and usually a source of great discomfort to the patient. A full discussion of the subject would require much time and space, and in the few pages allotted to it here only a few points Can be briefly mentioned and a few practical suggestions offered.

Eczema is an inflammation of the skin, of which the symp- toms are commonly redness, thickening, moisture, crusting, and itching. The disease may present a great variety of appearances, according to the locality involved and the duration and severity of the inflammation. It may bear a resemblance to nearly every other skin affection, but in most cases, especially in childhood, the disease is readily recognized. Unlike many other cutaneous affections, it has no characteristic lesion, but may be erythematous, papular, vesicular, or pustular at the outset and gradually become crusted, scaly, fissured, or ulcerated. As regards the grade of inflammation, the disease may be observed in an acute, subacute, or chronic form, and as regards duration it may in one case be insignificant and ephemeral while in another case it may persist or recur year after year.

A multitude of adjectives have been applied to the numerous and varied clinical forms of eczema, and are useful for purposes of description, but the main thing for the physician to learn is to recognize the eczematous nature of the eruption, and to remember that different clinical forms may coexist upon different portions of the body and that one form is very likely to develop into another as the eruption becomes better or worse.

Eczema in childhood, as in later years, may occur in either an acute or chronic form. These terms, as commonly used, indicate the grade of inflammation rather than the length of time which the eruption has existed. In the acute form there is much redness, heat, and swelling, while in the chronic form there is usually more thickening of the skin. An acute eczema often runs a typical course, which may be divided into three stages. These are, first, the stage of congestion and vesiculation; second, the stage of moisture and crusting; and third, the stage of desquamation. The vesicular condition is always transitory, and in many cases is not present. The effusion of serum may be so intense as to loosen and wash away the epi-

Fig. 21.—Eczema squamosum.

dermis in a mass, thus leaving the typical raw, red, exuding surface; or, on the other hand, the serous effusion may be so slight as not to appear upon the surface, and the eruption passes directly from the congestive into the squamous stage. The outbreak of acute eczema is attended by more or less fever and restlessness. Repeated exacerbations often characterize the course of a chronic eczema, during which the eruption assumes an acute form.

There are four types of eczema which it is well to differentiate and of which a brief description may be given. The first is erythematous eczema, in which redness and slight scaling are the chief features. It is usually a dry and mild form of the disease, and was formerly described as a distinct affection under the name of pityriasis. It is frequently seen upon the face and hands of children, and appears like a roughened or chapped con-

Fig. 22.—Eczema squamosum.

dition of the skin. About the genitals and wherever folds of skin are in apposition it is apt to follow the affection known as erythema intertrigo, and in many cases, indeed, it is difficult to distinguish between the two, as one gradually develops from the other. In erythema we have simply congestion of the skin, while in eczema erythematosum there is a slight thickening from serous infiltration of the cutaneous tissues and a tendency to the development of a moist surface when the skin is scratched or rubbed. Neither papules nor vesicles are present in this form of the disease. The eruption is usually limited in extent, although it may occur acutely in the form of numerous small, rounded or oval patches scattered over the face, trunk, and extremities (Figs. 21 and 22).

In the erythematous eczema of childhood itching is not apt to be severe, although in adults this form occurring upon the

Fig. 23.—Eczema rubrum.

forehead, about the eyes, and elsewhere is apt to produce considerable thickening of the skin and a most intolerable pruritus.

In papular eczema, which was formerly described under the head of lichen simplex, we find irregular groups of bright-red, acuminate papules, many of which become excoriated and tipped by a minute blood crust, and some of which tend to run together, when sufficiently numerous, and form a thickened, scaly, or crusted patch. The accompanying plate shows a well-marked case of this form of the disease.

Vesicular eczema is a form rarely met with, since the natural duration of a vesicle rarely extends over a few days, and the itching which accompanies the eruption is certain to cause the lesions to be torn and the surface to become crusted by the drying of the serous exudation. And yet this aggregation of numerous minute, rounded, glistening vesicles upon a red and swollen surface of skin is perhaps the most characteristic phase of the disease. It was formerly believed that this was essentially a vesicular disease and that these lesions must be

Fig. 24.—Eczema impetiginosum.

present at the outset in every case of true eczema. The vesicular stage, when present, is attended with great heat and burning. The vesicles quickly rupture or coalesce, the epidermis cracks, and a surface exudation of a clear serum takes place. This is of a mucilaginous character, stiffens hair or linen with which it comes in contact, and dries like a varnish upon the inflamed surface, which quickly cracks, however, and thus allows the discharge to ooze out at many points. When the inflammation is very severe the greater portion of the inflamed surface, instead of being crusted, appears swollen, moist, and of an angry red hue (eczema rubrum) (Fig. 23).

Pustular eczema results from an inflamed surface of skin becoming infected by pyogenic cocci. The characteristic oozing or "weeping" surface may gradually become purulent, and the exudation may dry into an extensive, thick, yellowish or honey-like crust (eczema impetiginosum) (Fig. 24); or a group of isolated follicular pustules or minute superficial abscesses may develop and become crusted, in which case the

Fig. 25.—Eczema pustulosum.

eruption bears a strong resemblance to contagious impetigo. This form of the disease is especially liable to occur in children of a strumous habit and among those who are not distinguished for their personal cleanliness (Fig. 25).

The squamous form of eczema is secondary to one of the preceding types. Indeed, a more or less scaly condition of the skin is seen in every patch of eczema before recovery takes place, and this may be regarded as the final stage in the course of the eruption. The amount and persistence of the scaling depend upon the extent of the infiltration of the skin. The desquamation in eczema is always slight as compared with psoriasis, and the margin of the scaly patch usually shades off gradually into the surrounding healthy skin, instead of being circumscribed and abrupt as is always the case in the latter disease.

In the eczema of infancy, which is a very common and often a very obstinate affection, the face and scalp are usually affected, and frequently portions of the trunk and extremities suffer to a less degree. The characteristic tendency of the eruption to assume the moist form usually manifests itself, and the face appears either inflamed and angry or covered by dried exudation in the form of yellowish or blackish crusts. The little patient often suffers intensely from the oft-recurring pruritus, rolling his head in vain attempts to alleviate it by rubbing the inflamed skin against his clothing, or, if old enough to use his hands, tearing the face and causing it to bleed by sudden, fierce, and unexpected dabs with his sharp finger nails.

The cause of eczema might be discussed at great length and still little light thrown upon the subject, for it is certainly an obscure one. It may suffice to assert that improper food and imperfect digestion are the most frequent causes of the affection as it is met with in infancy.

Infantile eczema has usually nothing to do with the teeth. It often appears before teething begins, and a similar eruption may occur in old age when all the teeth are gone. Furthermore, it is always amenable to proper treatment, whether the child has one or twenty teeth. When the process of cutting teeth interferes with the general health of an infant, it is possible for the eruption to be indirectly aggravated by the condition of the gums, but in no case is "teething" ever to be regarded as the sole cause of eczema.

The "coming-out" of eczema is never a source of thankfulness, unless it happens to come out on some other baby than our own. We might be thankful if it were to come out in the baby's clothing, and it is about as likely to do this as it is to affect any of the internal organs. Eczema is essentially a disease of the skin, and cannot be transferred to the brain or lungs any more than the ruddy glow of a healthy cheek can be "driven in." It is true that sometimes an ointment is applied to an eczematous scalp or face, the eruption quickly disappears, and shortly after the baby may die of brain or lung disease. This may appear at first thought as though the eruption had been driven in, but the facts admit of a more reasonable explanation. When from exposure to cold or some other cause an inflammation of the brain or lungs results, the blood flows in an unusual quantity to the affected organ, and any eruption upon the skin soon begins to fade and disappear. This, of course, takes place whether any ointment be applied or not. In such a case it might be said, with perhaps more truth, that the eruption has been drawn in, but it is evident that the disappearance of the skin disease is the result and not the cause of the internal inflammation.

The common belief that a skin disease is the outlet of some poisonous or vicious material in the blood is quite erroneous, and, in the light of modern pathology, a most absurd idea. An eruption can never be justly considered as either useful or beneficial to a patient. When a physician is unable to cure a case of infantile eczema, it may serve a purpose to claim that the eruption is salutary and that its sudden removal by local applications would be liable to produce disastrous results. The truth, however, is as follows : An eczema ought always to be cured as speedily as possible. This can always be done without the slightest danger of any harm to other organs of the body. Physicians of the largest experience in the treatment of skin diseases will all agree upon this point, and the sooner the old idea of the metastasis or translation of eczema is given up, the better it will be for the health of future babies and for the comfort of those who have the care of them.

In the treatment of eczema in infancy and childhood, it is well to remember that the disease is inflammatory in character, usually acute or subacute, and that our main object should therefore be to soothe the congested skin. If there were a law in this country prohibiting the use of any ointment save the officinal unguentum zinc oxidi, what a blessing it would be to children with acute eczema! As it is now, the physician is usually disposed to regard zinc ointment as little better than a domestic remedy, it being so well known. Familiarity with it has bred contempt. It will not do, he argues, for a man of his experience and reputation to prescribe so common and simple a remedy, and so he adds to it a little ichthyol and a little resorcin and a little carbolic acid, or possibly some one of the "new remedies" with which the general practitioner is usually familiar long before the specialist is willing to try them. The result is that the druggist is called upon to rub up a salve in which the bland, emollient character of the simple zinc ointment is completely lost—a salve which is certain to irritate the delicate and inflamed skin and to aggravate the eruption.

More than a quarter-century ago Erasmus Wilson decided, after years of experience, that in acute infantile eczema the best method of treatment was by laxative doses of calomel and the external use of zinc ointment. While not unmindful of the progress which dermatology has made during this time, and in face of the flood of new remedies which is constantly pouring into our drug market, I defy any one in dermatological or pediatric practice to lay down a general method of treatment which, in the average case of infantile eczema, is practically superior to the one suggested by Wilson. A little starch or talcum added to zinc ointment will stiffen it and cause it to dry upon the skin, and thus obviate the necessity of smearing cloths and holding them in place by a bandage or mask. When a patch of eczema has ceased to exude and is in the final or squamous stage, a little oil of cade (one to five per cent) added to the zinc ointment or paste will greatly increase its efficacy in restoring the skin to a normal condition.

The tendency of soap and water to aggravate a moist eczema and to nullify the best of treatment is now generally understood by the profession. Indeed, the knowledge of this fact often leads the physician to forbid bathing in cases of dry eczema, when a daily bath would tend to improve the condition of the skin and benefit the patient. It is only in acutely inflamed and exuding eczema that water is necessarily injurious.

The regulation of the diet in case of eczematous children is of the utmost importance, as here may generally be discovered the cause of the eruption. With children old enough to go to the table, and especially with those who are apt to get whatever they cry for, a restriction of the diet to pure milk will often do much toward effecting a cure. It is very difficult to lay down dietetic rules of general application, for what will prove best suited to some children will fail to agree with many others; but it is certain that whenever a judicious local treatment appears to have little effect upon the eruption, the closest attention to the diet and condition of the stools becomes imperative. In many cases the local treatment which has produced no beneficial effect will work like magic as soon as the bowels are freely opened and the digestion improved.

The administration of arsenic, antimony, and other powerful drugs may possibly do good in certain cases, but as I have seen arsenic, at least, do harm in a score of cases for every one in which I have seen it do good, I have no hesitancy in dispensing with their use in treating eczema in infants and young children. Arsenic should certain!}- never be given in the acute eczema of childhood nor during the exacerbations of the chronic form.