DERMATOLOGY

BASIC THERAPEUTICPRINCIPLES

andMANAGEMENT

361st STATION HOSPITALTOKYO. JAPAN

COLONEL J. T. R STRODE, M. C.

Commanding Officer

DERMATOLOGY SECTION

CAPTAIN E. P. SCHOCH, JR. , M. C.

Chief of Section

CONTENTS

I Introduction 1

II Types of Dermatologic Agents 2

III Pharmacology of Topical Drugs 10

IV Special Preparations 14V Basic Management of the Ten

Most Common Skin Diseases 17VI Summary 33

REPRO BY THE 64TH ENGR BASE TORO BN

This guide is intended to review afew of the basic dermatological principlesand to give one workable example of themany methods of managing each of the tenmost common skin diseases.

Caution is to be stressed constantlyto avoid over treatment which is the mostcommon complication necessitating hospitali-zation of dermatological conditions.

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DERMATOLOGYBasic Therapeutic Principles and Management

Introduction

In no specialty is the range of possibleremedies greater than in dermatology. Thetechnique of external local treatment consti-tutes the most potent weapon in the managementof most cutaneous diseases.

Topical dermatologic therapy depends notonly on the chemical action, but also the phy-sical properties of the agents applied. Forthis reason, the choice of the vehicle and theform of medication — even the mere manner ofapplication and removal — are as important asthe selection and quantity of active ingredientsand will often decide the success or failure oftopic therapy.

In each individual case, the choice ofboth remedies and vehicles depends largely onthe appearance and the course of the dermatoses.In this manual, we will attempt to discusstherapy that can be carried out with just thebasic preparations available and with the stan-dard formulary. The medications will bediscussed as to the types of dermatologicalagents, the pharmacology of topical drugs,special preparations and plans of treatmentfor the common skin diseases encountered ineveryday practice.

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TYPES OF DERMATOLOGICAL AGENTS

Cleansing Measures

It is often necessary to cleanse thelesions which are to be treated. In cleansingirritable conditions such as oozing and crust-ing eczemas, impetigo contagiosa, and otherpyodermas, and in removing the residues oflocal medication, mild nonirritating methodsare to be used.

Useful measures are gentle sopping orbathing with solution of hydrogen peroxide orboric acid, application of wet dressings, orthe use of oil (mineral or olive) to removepastes and ointments.

Mechanical removal of crusts and scalesmay be necessary and is often more readilyaccomplished after the use of one of the afore-mentioned measures.

After each cleansing procedure, the se-lected topical remedy is applied.

Cleansing of torpid thickened and chroniclesions can be effected by more vigorous methodssuch as scrubbing with a brush, hot water andsoap (tincture of green soap), soapless deter-gents, macerating and occlusive dressings, ordirect painting with strong keratolytic agents.

BATHS

Baths affect even the normal skin. Manyyouthful individuals, whose skins tend to begreasy and to have a greater supply of naturaloils than the skins of infants or of the aged,may benefit from frequent hot baths with plentyof soap and scrubbing; yet such baths may be

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harmful to individuals with dry skin, such asis common in infancy, early childhood, and inold age. There is no doubt that certain casesof excessive dryness of the skin and of itchingare made worse by bathing and may sometimes beattributed to the excessive use of hot bathsand soap.

It is equally true that skin eruptionssuch as eczemas of the hand, monilia infec-tions, and other irritable or widespread der-matoses are often aggravated by alkalis andparticularly by soap and water. Nevertheless,therapeutic baths often constitute the bestmethods for applying mild medication to theentire skin surface.

A. Cleansing Baths

This form is used to remove accumulateddirt, debris, crusts, scales, and the adherentremains of previous medications.

If soap is not irritating, one can useplain white soap. Soaps that are made fromtallow and corn oil are generally less irrita-ting than those of coconut oil, olive oil,whale oil, or sesame oil. Soap must be com-pletely rinsed off. The skin is dried bypatting rather than rubbing. It is advantage-ous to apply topical remedies immediately afterbaths.

B, Medicated Baths

These baths achieve soothing effects,antipruritic action, decongestive and inflam-matory and specific effects of active medicinal

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ingredients including antiparasitic, anti-seborrheic, antieczematous and macerating andsoftening. As a rule, COOL baths are moreserviceable.

1, Corn starch and sodium bicarbonatebaths are used for soothing action in general-ized and itching dermatoses. For corn starchbaths, stir J to 1 lb. of refined corn starchinto a tubful of water, (Starchs are madesoluble through hydrolysis, for example, byboiling.) One-fourth to one-half lbs, ofbaking soda is adequate for each bath.

2. Potassium permanganate baths are ef-fective in exudative, vesicular and bullouseruptions (pemphigus, generalized eczema),pyodermas and superficially infected dermatoses.This bath acts as a disinfectant and by itsoxidizing effect, helps to dry exuding areasand acts as a deodorant in foul-smelling sur-face affections. Potassium permanganate in adilution of 1-9,000 to 1-12,000 is used.

3. Sulfur baths are an adjunct antipara-sitic treatment of pyodermas and of certainseborrheic conditions. Sulfur is a mild fun-gistatic, antiseborrheic, keratolytic parasi-ticide, Sulfur is also an irritant or stimu-lant to skin and a general disinfectant.Liquor calcis sulfuratae NF (Vleminckx’s solu-tion) 150 to 200 cc. per tub.

4, Tar baths are antipruritic in cases ofgeneralized itching dermatoses and in generalizedeczemas and psoriasis. Liquor carbonis detergens120 cc, added to each tub.

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The individual response is the determin-ing factor both as to the measures used andas to the manner and frequency of use. Theurban adult usually washes his hands too often.It is often advantageous to reduce exposure tosoap and water whenever the hands are affectedby irritated, eczematous or other dermatoses.In contrast to this excessive use of soap andwater on the hands, many women never wash theirfaces. They are misled into avoiding soap andwater by the advertising campaigns of those whohave "creams," "skin food," "deep cleanser,"etc., to sell and by the belief that their skinsare too dry. However, in the majority of suchcases of too dry skin in young women, thepatients are suffering from a tallowy form ofseborrheic scaling and not from actual dryness.The surface of the skin will be found to begreasy, not dry, and if the seborrheic scalesare pressed between layers of cigarette paper,grease spots are produced.

Daily soap and hot water scrubbing may atfirst irritate such skins but usually improvethe underlying condition.

It is rare to find an otherwise normalyoung person whose skin will not tolerate soap.In older persons, the tendency to dryness ofthe skin is not uncommon, and many middle agedand older men, and especially women, mustactually dispense with the use of soap. Inthese cases, other methods must be adopted suchas cleansing with oil (mineral or olive oil) orthe use of soap substitutes such as lowila ordermolate.

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Wet Dressings

Wet dressings are one of the most usefulforms of dermatologic therapy. It is one ofthe best means of cleansing the skin of adher-ent crusts and debris. It helps maintaindrainage of infected areas such as furunclesand superficial ulcerations. It is an effec-tive vehicle in local application of heat. Akeratolytic action is manifested by maceratingthe skin surface. Wet dressings prevent rapidchange of temperature at the skin surface —

hence are often good analgesics and antipru-ritics. By relief of superficial inflammation,wet dressings have a soothing action. Wetdressings tend to open blisters and bring medi-cation to the base of ulcerating areas.

1. Physiological saline solution2. Burow's solution (1:10 - 20)3. Potassium permanganate 1:9,0004. Boric acid (saturated solution)

Powders

Powders are most conveniently used in thetreatment of intentrigenous areas (interspacesbetween the toes, in the groih or beneath pen-dulous breasts.) Powders protect from the irri-tation of maceration and friction and also exerta cooling effect.

Powdering of the interdigital spaces andthe liberal use of powder in the shoes, socksand stockings is one of the best measures inhyperhidroses and in the prophylaxis of certainsuperficial fungus infections including’’athlete's feet,*1

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Lotions

Lotions are liquid or semiliquid prepara-tions usually having water or alcohol as abase and containing ingredients in solutionor suspension or both. They are of greateruse in subacute or chronic conditions, wherethere is not too much weeping (otherwise itacts as a cement.) Lotions are advantageousbecause of the ease of application, anti-inflammatory action and they allow passageof a certain amount of secretion. Lotionsare disadvantageous because they are dryingand not penetrating.

It must be remembered that active ingre-dients which penetrate beyond the first fewmillimeters represent potential danger becauseof possible systemic and toxic effects. Thismust be kept in mind when treating large areasor when used for babies and children.

Shake lotions do not penetrate as well asointments, but this relatively superficial ac-tion is not always disadvantageous. Many der-matoses, e.g., eczema, seborrheic dermatitis,affect primarily the uppermost layers of theskin, and in these conditions, medicationshould be confined, if possible, to the super-ficial tissues.

e.g., Basic LotionZinc Oxide 20.0Talc 20,0Bentonite 5.0Water qs.

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Emulsions or Liniments

These preparations are oily or fatty sub-stances emulsified and suspended in an aqueousor other liquid or aqueous solution suspendedin an oily medium. Emulsions or liniments area transition between lotions and ointments.The principal use from these preparations liesin the treatment of patients confined to bed.Large areas can be treated with painting medi-cated emulsions. Usually these preparationsare eventually quite drying — probably due tothe alkaline effect (soap),

e.g.. Calamine liniment. N. F.

Ointments

Ointments consist of various fats or oilsinto which oil soluble medicaments are dis-solved or suspended. Fatty substances whichconstitute bases of most salves and ointmentsmay be divided into two groups: (l) animaland vegetable, (2) mineral greases and oils.Mineral greases are preferred because they donot become rancid and have a greater resistanceto growth of bacteria. Animal fats hold morewater so that water and most medicaments whichcan be dissolved in water can be incorporated.Ointments have many properties. They have thecapacity of maceration. They bring medicationinto more intimate contact with the surface ofa lesion. The eraolient and lubricant propertyserves to soften the surface of the skin as wellas the crusts, scales and detritus on the skinsurface so that medicaments reach tissues be-neath, Ointments, greases and oils enable theuse of many therapeutic agents which are fat oroil soluble but which are not water soluble.

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Ointments are disadvantageous because oftheir general messiness and difficulty ofproper application, especially in the case ofextensive dermatoses and in ambulatory patients.Ointments are of great use in dry, scaly,thickened and deep conditions. When the scalesand crusts are removed, penetration is achieved.

Ointments are contra-indicated in oozingareas, infected lesions where drainage is re-quired, and in hairy areas,

e.g.. Petrolatum

Water Miscible Bases

These preparations are water soluble andpermit more rapid release of agents incorpora-ted.

e.g., Ointment Base (emulsion base), USP

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PHARMACOLOGY OF TOPICAL AGENTS

1. Antipruritics

In general, pruritus is relieved by thefollowing methods:

a. Substitution of some other sen-sation for itching

(1) Heat or cold(2) Phenol £ - 1 %

(3) Menthol | - h %

(4) Camphor ?- \ %

(5) Thymol \ - 1 %

b. Anesthesia of sensory nerves(1) Benzocaine 1 %

(2) Nupercaine 1 %

c. Protection of skin from externalinfluences,

(1) Wet compress

2, Keratoplasties

These are agents which tend to produce anincrease in the keratinization of the hornylayer. Agents which have a mild stimulatingeffect in general tend to stimulate horn for-mation if repeatedly applied to an area over asufficient period,

e.g,. Salicylic acid 1 - 3 %

Tars 1 - 5 %

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3. Keratolytics

Agents which tend to remove the hornylayer or reduce its thickness are keratolytics.Removal of the horny layer can be achieved byany form of superficial damage severe enoughto cause destruction or rapid exfoliation —

thus caustics in macerating dressings act askeratolytics. Keratolysis produced by medi-caments is usually the result of withdrawalof fluid — leading to the subsequent throwingoff of the loosened, dried-out horny mass; orof maceration of the horny lamellae and theirimbibition of fluid and subsequent throwingoff.

e.g,. Resorcinol 1-5 %

Salicylic acid 5-40 %

4. Anti-eczematpus Agents

Remedies used in treating eczematous,eczematoid processes and pruritic superficialinflammatory eruptions more or less resemblingeczematoid dermatitis (eczematoid eruptions).Some of the agents relieve itching and thusprevent scratching, some act by keratolysis,some act by cleansing, some by antiphlogisticand cooling effect, some by simple protection,some by ultimate protection achieved throughkeratoplastic effect and increase in thicknessand resistance of the horny layer.

A. Acute Cases

(1) Soothe with wet dressings first—-a. Boric acid solutionb. Burow’s solution (1:10-20)c. Physiologic salined. Potassium permanganate solution

1:9,000

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(2) Antipruritics—menthol andphenol in basic lotion when areas arenot weeping excessively.

B, Subacute to Chronic Cases

(1) Lassar*s paste(2) Tars

a. Liquor carbonis detergens(L.C.D.)

b. Ichthyolc. Crude coal tar

5. Antiseptics

Agents which treat and guard against in-fection are antiseptics.

A. Potassium permanganate 1:9,000B. Ammoniated mercury 2-10$C. QuinolorD. VioformE. TyrothricinF. FuracinG. Penicillin and sulfonamides are not

recommended for topical application because ofthe danger of sensitization of other tissuesof the body.

6, Antimycotics

These preparations are used in the treat-ment of superficial fungus infections.

A. Potassium permanganate 1:9,000 solutionB. Castellan! 1 s paintC. Compound tar ointment (pragmatar)D. Undecenylenic acid ointmentE. Gentian violet 1% solution

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7. Anti-seborrheics

These preparations are used in the treat-ment of seborrhea and seborrheic dermatitis.

A. Sulfur and salicylic acid

(1) Sal - sulfur ointment(2) Compound tar ointment

8. Antiparasitics

A, Scabies

(1) Sulfur (5-2$ ointment)(2) Benzyl benzoate (25% emulsion)

B. Pediculosis

(1) DDT (1$ powder or 2$ solution)

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SPECIAL PREPARATIONS

These preparations are commonly used inthe practice of dermatology:

1. Vleminckx* solution (liquor calcissulfuratae), (for acne)

2. 1-2-3 ointment:gm or cc

Burow 1 s solution 10Lanolin 20Lassar 1 s 30

3. Lotio alba:

Zinc sulfate 4$Potassium sulfuratae 4$Water qs.

4. Scalp lotion #1 (for dark hair)

Resorcinol 4.0Salicylic acid 4.0Mercury bichloride 0.2Glycerin 2,0WaterAlcohol (95$) aa, to make 240.0

5. Scalp lotion #2 (for blond hair)

Chloral hydrate 4.0Salicylic acid 4.0Mercury bichloride 0.2Glycerin 2.0Alcohol (95$)Water aa, to make 240.0

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If hair is too dry, you can replacethe glycerin with 0,5 to L$ castor oil inboth scalp lotions.

6. 3% vioform cream

7. Compound tar ointment

8. Sal sulfur ointment;gm or cc.

Salicylic acid 3%Sulfur 6%Emulsion base qs

9* Sulfur resorcin lotion:

Resorcinol 2$Sulfur k%Basic lotion qs

10. Burow f s solution:

Lead acetate 150Aluminum sulfate 87Water qs to 1000

11. Carron oils

Olive oilLime water aa

12. Boric acid ointment

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13. Silver nitrate; 1-BOO as a wet dress-ing; 5-10g, granulation tissue and pyodermia;50g, strong cautery treatment of warts.

14* Trichloracetic acid (cautery)

15• Phenol (cautery)

16. Scabies ointment:

Balsam Peru %

Sulfur 10gCastor oil lOgLanolinPetrolatum aa qs

17. 20$ olive oil in emulsion base (forasteatosis)•

18, Chrysarobin 1-5$ ointment (forpsoriasis)

19. Psoriasis ointment:

Crude coal tar 3gAmmoniated mercury 3%Salicylic acid 3%Emulsion base qs

20, 20$ podophyllin in alcohol (forverruca acuminata).

21. Whitfields Solution

Acid salicylic 3%Acid Benzoic 6gAlcohol (70%) q.s.

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BASIC MANAGEMENT OF THE TEA MOST COMMON SKINDISEASES

I. acne VULGARIS

1. Instruction of patient regarding dietand skin hygiene (printed directions),

2. Lotio Alba nightly, to be washed offin morning.

3. Alcohol wiping after soap and waterwashing 2-3 times daily,

4. Anti-seborrheic scalp lotion (#1 forbrunettes; #2 for blonds) nightly.

5. Brewer 1 s yeast—9 to 12 tablets daily

For more severe cases:

6, Crushed solid C02 - acetone slush with10$ sulfur applied in clinic weekly.

7. Complicated cases—hospitalize.

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(Instructions for patient)

ACNE

ACNE is a very common skin disease espe-cially in young men.

In the face, neck, chest, and back, aremany small glands which keep the skin oily,in ACNE these become overactive, fill up andget plugged. This causes large pores, oilynose, blackheads, whiteheads and pimples.

ACNE is not catching and is not dangerous.ACNE is not due to sexual continence, master-bation, or sexual excess. It is made worse byinfection, dirt and grease.

YOUR SKIN WILL GET BETTER

You must follow all the suggestions givenand take care of your skin EVERY DAY, y0u can-not miss one day in this care. Some ACNE needsmore treatment. Some of these are helped byX-ray. Nc X-ray is given until ordinary treat-ment has been tried. No X-ray treatment isgiven overseas. Penicillin will not cure ACNE,

1. Take a warm shower every day.

2. Wash face gently with warm water andwhite soap FIVE times every day. Take yourtime. Use your hands and do not use roughcloth or brush. Rinse with cold water.

3. Put rubbing Alcohol on face afterwashing each time.

4. Put lotion on face every night. Theskin will get rough and dry but this causes apeeling which opens the plugged glands.

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5, Do not use any cream or grease on face.

6, Shampoo hair every morning,

7, Rub scalp lotion into the hair everynight,

8, Do not use any vaseline or oil on thehair,

9, Eat a low fat diet. Avoid CHOCOLATE,NUTS, PORK, CHEESE, ICE CREAM, BUTTER, MILK,SAUSAGE, FRIED FOODS, COD LIVER OIL, PASTRIES,*CAKES. Limit SUGAR, POTATOES, BREAD, RICE,MACARONI, SPAGHETTI.

10, KEEP HANDS OFF FACE, Do not squeezepimples or try to get out blackheads,

11, Do not wear oily or greasy clothesnext to the skin,

12, Get eight hours sleep. Exercise,Have regular bowel habits. Drink six glassesof water each day.

This treatment outlined by skin special-ists has helped many who have had ACNE, itcan help you, but only if you believe yourface will get better and only if you believeyour Medical Officer can help you. You mustfollow all the suggestions EVERY DAY,

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II A, DERMATITIS VENENATA

1. Acute (weepy, erythematous, vesicular,exudative, ’’hot”.)

a. Wet Dressings (compresses or soaks)(1) Burow's solution (1:20)(2) Physiological saline(3) Boric acid solution (sat’d)(4) KMN04 1:9000 (pyoderraic)

2, Subacute (Less erythematous, vesicula-tion subsiding, no exudation, "warm".)

a. Lotions(1) Basic lotion

b. Liniments(1) Calamine Liniment

c. Pastes(1) Lassar's paste

3* Chronic (no erythema, scaling, no exu-dation, thickening, ’’cold").

a. Ointments(1) Petrolatum(2) Boric acid ointment

Persistent chronic dermatitis shouldbe treated as an eczema.

4, Antihistamics if markedly pruritic orevidence of ”id” reaction:

a, PBZ 50 mg q.i.d.

5. No soap to involved areas (see methodsof cleansing.)

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II B ECZEMA

1. Acute, subacute, early chronic stagestreated like dermatitis venenata,

2. Chronic (or persistent subacute)

a. Ichthyol 3%Lassar*s paste qs,

or

b. Vioform cream 3% (if pustular)

then

c. Crude coal tar 1-5%Lassar* s paste(or emulsion base) qs,

3. Vesicular eczema of hands and feet.

a. Burow*s 1:20 or saline soaks t.i.d,

b, 3% LCD (liquor carbonis detergens)in emulsion base (EM3) t.i.d., daytime

c, Lassar*s paste hs (remove withmineral oil in a.m.)

d. PBZ 50 mg q.i.d.

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DIRECTIONS FOR WET DRESSINGS

Dilute withof water in enamelware,

porcelain or glass dish or pan. (Not in copperor aluminum.) The water should have been pre-viously boiled and allowed to cool. (May usedistilled water.) The mixture should be at acomfortable temperature - if it is too cold,warm it up by heating; or if too warm, add afew pieces of ice.

The pack is made of 8 to 12 layers ofcheesecloth and larger than the area you aretreating. Soak the pack in the mixture andwring out to a point of being soppy, but notrunning.

Evaporation is desirable, you may placewaterproof material (oil cloth or rubberizedsheet) under the pack to protect the beddingor furniture, but do not enclose the entirepack in the material.

Every hour completely remove the pack,rewet it by immersion and replace it, (Pouringsolution over or under the pack is not satis-factory.) If the pack becomes dry before anhour is up, rewet it earlier.

Use the mixed solution until it showssediment or becomes cloudy, then make a freshbatch again.

Fix the pack preferably by overlappingand fastening with large safety pins or tiestraps. Do not wrap it with bandage.

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HI DERMATQPHYTOSIS

1. Acute

a, KMN04 1:9000 (compresses or soaks)

2. Subacute

a, KWN04 1:9000 soaks t.i.d. ornormal saline soaks t.i.d,

b. 5 strength sal sulfur ointment hs,

3. Chronic

a. Painting with Whitfield’s solu-tion b.i.d,

b. Abundant foot powder t.i.d,

c. Saline soaks hs,

d. Full strength sal sulfur ointmentor compound tar ointment hs.

e. Fungicidal ointment is helpful inmild cases and in prophylaxis.

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IV PYODERMA

1. Acute

a, KMN04 1:9000 (compresses or soaks)

2. Subacute to chronic

a. Vioform cream 3% or ammoniated mer-cury 3% q.i.d.

3. If extensive:

a. Penicillin aqueous 300,000 unitsdaily or b.i.d. x 5-7 days.

4- Special types

a. Sycosis Vulgaris(1) General measures as for all

pyodermas(2) Mild: sulfur-resorcin lotion

t.i.d,(3) Severe or resistent: quinolor

ointment (watch for sensiti-vity-may use J strength.)

(4) Shave daily with new blades($) Sterilize razor blades with

alcohol(6) Wipe skin with alcohol after

shaving(7) Manual epilation

b. Impetigo Contagiosa(1) Same general measures(2) Careful removal of crusts

before each application ofointment

(3) Prevent community use ofclothing, towels, etc.

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c. Folliculitis Simplex

(1) Sulfur-resorcin lotion t.i.d,(2) Avoid oils and grease to skin

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V SEBORRHEIC DERMATITIS

1. Acute

a, Burow»s solution 1:20 or normalsaline (compresses or soaks.)

2. Subacute to chronic

a. Scalp:(1) Sal sulfur ointment b.i.d. or

compound tar ointment(2) Shampoo every 2 days when

subsiding(3) Scalp lotions (#1 brunettes;

#2 blondes) to scalp daily;plus sal sulfur ointmentweekly

b. Glabrous skin:(1) J strength sal sulfur ointment

b.i.d, or(2) Sulfur resorcin lotion b.i.d,

3. Restrict fat and carbohydrates in diet

4. Vitamin B complex orally

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VI PSORIASIS

1. Acute

a. Basic lotion

b. Calamine liniment

c. Boric acid ointment

2. Subacute to chronic

a. 2$ crude coal tar in petrolatumb.i.d.

b. Daily suberythema ultravioletirradiation (after removal of salve.)

c. Calcium gluconate 10.0 cc IVthree times a week.

d. Autohemotherapy 10,0 cc threetimes a week.

e. Restrict fat in diet,

3. Chronic resistant cases

a. Psoriasis ointment:(1) Ammoniated mercury 3%

* (2) Acid salicylic 3%(3) Crude coal tar 3%(4) EM3 qs.

b. Ultraviolet, as above.

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VII SCABIES

1. Preparation:

a. Benzyl benzoate emulsion 25%

120.00 cc bottle.

2, Directions:

a. Shower, scrub off all crusts andpay special attention to areas of skin withmaximal involvement,

b. After shower, while still wet,apply first coat of Benzyl Benzoate, cover-ing every area of body from neck down, pay-ing special attention to areas where lesionsare most numerous. Allow lotion to dry onskin for 10 minutes. USE NO TOWEL andreapply medicine in same manner from neckdown, allowing medicine to dry and remainon.

c. Wait 24 hours - no bathing orshowering.

d. Reapply lotion from neck down -

1 coat,

e. Allow lotion to remain on for24 hours.

f. Shower, change all clothing, bedclothing, sheets and blankets. Treatmentfinished. Have all worn clothing cleanedor washed. Itching may continue for sev-eral days to several weeks, but as long asno new sores or bumps appear, you may con-

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sider yourself cured. If you think youare not cured, see your medical officerbefore repeating treatment.

3. Caution against repeated applicationsbecause of danger of contact dermatitis fromkenayl benzoate*

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VIII PITYRIASIS ROSEA

1. Avoid hot soapy baths.

2. Sulfur-resorcin lotion t.i.d.

3. Suberythema ultraviolet irradiationtwo or three times a week.

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IX HYPERHIDRQSIS

1. Wash feet at least twice daily.

2. Change socks twice daily.

3. Abundant use of foot powder three orfour times daily,

4. Soak feet inBurow's solution 1:10(Domeboro tablets—U to quart of water) daily,

5. Tannic acid %

Glycerine %

Alcohol (9550Water aa qs.Sig. Painted on feet b.i.d,

6. Occasionally sedation and neuropsy-chiatric evaluation.

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X PEDICULOSIS PUBIS

1, Spray once with DDT aerosol bomb, or

2, DDT 2% in 12benzyl benzoate emul-sion (one application*) May repeat in one ortwo days if necessary. May also be used inthe scalp, or

3, 10$ DDT powder daily x 5 days.

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SUMMARY

1, Make a diagnosis or have the diagnosis madeas early as possible. Diagnosis may be necessaryfor proper treatment.

2, Properly selected topical measures are oftenthe best forms of treatment in cases of uncer-tain or unknown etiology or diagnosis, as well asin the period before determination of the exactdiagnosis and in many cases, with establisheddiagnosis and etiology.

3. The choice of topical measures is oftenlargely determined by the presenting morpholo-gic characteristics, by the stage, and by thesite of the eruption. The physician must,therefore, be able to recognize whether a der-matosis is acute or chronic, dry or exudative,papular or vesicular, infected or not infected,irritable or torpid, superficial or deep, hyper-keratotic or not, spreading or remaining fixed,growing or regressing, improving or not, ofexogenous or of endogenous origin, destructiveor non-destructive (atrophy or scarring), malig-nant or benign.

4. Topical remedies are then chosen to producespecific effects according to the characteris-tics of the lesions (e.g,, soothing, protective,absorbent drying, macerating, keratolytic,penetrating, reducing or destructive effects.)The following hints should prove useful:

a. Use few remedies and know everythingthat is to be known about them. Adopt a few—-say eight—standard eternal medicaments; forexample, two forms of wet dressings (one sooth-ing and one soothing and parasiticidal); two

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shake lotions (one soothing and antipruriticand one antiparasitic and keratolytic); twopastes (one soothing and one antiparasiticidal);two ointments (one soothing and softening andantiecaeraatous and one penetrating, keratolyticand antiparasitic.) Master these eight and youwill have greater prospects of success and forless chance of making costly mistakes than ifyou use 80 different remedies without completeknowledge of their properties, incompatibilitiesand contraindications.

b. Bear in mind the possibility that aremedy may harm rather than help. When indoubt, and in all acute and irritable dermatosisbegin with the mildest and most indifferentagents. When in doubt and using a new medica-ment, observe the effects on a small site beforeproceeding to the treatment of larger areas.

c. Frequent observations on the effectsof medicaments may be necessary not only toprevent ill effects but to select, adjust andmodify the treatment.

d. Do not change to a new remedy as longas the dermatosis is improving satisfactorilyunder the old one. Do not complicate thetherapy by useless modification of, or additionsto the remedies prescribed.

5. When a remedy disagrees with a patient,stop its use at once and try to find the causeof the disagreement. In many patients, allergiceczematous hypersensitivity is the basis of theirritation. When this is the case, considereach of the ingredients and their combinations,as well as the measures and substances used in

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the application and removal of the prescribedmedication. Gritty salves, pastes, or emul-sions, improperly homogenized or unevenly dis-solved or dispersed chemicals may be sourcesof irritation. Therefore, the practitioner ofexternal therapy must have some knowledge ofthe art of dispensing and of the appearancefeel, odor, and other characteristics of everyremedy he prescribes.

6. The action of topical remedies will oftendepend on the mode of application and removal.The physician must, therefore, give adequateinstructions to each patient and must oftenalso demonstrate exactly the correct manner ofuse, application and removal of each prepara-tion.

In addition to following these 6 rules,other practical difficulties must be consideredand overcome. For example, social or occupa-tional duties, lack of funds, and facilitiesor still more commonly, lack of time, mayprevent the patient*s proper use of an agentwhich, on purely medical grounds, would be theremedy of first choice. In such cases, it willbe necessary to substitute a more easily usedremedy.

Moreover, the physician must repeatedlycheck upon the manner in which the remediesare being used. He should at each successivevisit carefully examine the treated areas andclosely question the patient as to the mannerof use and removal of the remedies. With somepatients, no amount of painstaking instructionwill achieve the correct and conscientious useof topical remedies. In such instances, hos-pitalize the patient.

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Despite the difficulties which topicaltreatment may present, no effort can be sparedin the endeavor to accomplish its proper selec-tion and execution. For the abandonment ofcorrect topical treatment means the surrenderof what is often the most powerful weapon ofpresent dermatologic management.