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The Management of Atopic Dermatitis (Eczema)
THE MANAGEMENT OF ATOPIC DERMATITIS (ECZEMA) FRANCIS
W.
lIETREED,
M.D. *
WE need only to mention the name of the dermatosis and difficulties will arise. The preference for either eczema or dermatitis is purely geographical. The more important dissension concerns the definite etiologic adjective, atopic. Many feel that this type of eczema rests not on an allergenic background, but rather on a neurogenic or neurosomatic origin. Much supporting evidence has been demonstrated from both sides, but none that can definitely outmode the other. This controversial opinion in the ranks is, therefore, good, as it is stimulating, and can aid in finally arriving at positive conclusions regarding the etiology of this common and recalcitrant condition. Toward the atopic side, 50 per cent of persons with atopic eczemas have a family history of allergy. Scratch tests have given positive results in approximately the same number of cases. However, in the same percentage, patients were negative to all scratch tests. It is also interesting to note that the scratch-test reactions to inhalants as compared to foods increase rapidly with age. Only one in twenty-five infants (under 1 year of age) will show positive reaction to inhalants, while in the 2- to 12-year group, the ratio increases to one in two and a half. In adults, it is practically even. Withdrawal of allergens showing a positive scratch or intradermal test does not always mean that improvement takes place. Also, some foods giving a negative result to the scratch or intradermal test are known to produce an exaggeration of symptoms when ingested. Sulzberger, a strong proponent of the atopic theory, nevertheless does not hesitate to mention the limitations of it. He states, "Although the mass of clinical evidence suggests the role of exposure to certain allergens, the absolute and conclusive proof of the causal role of any and all of these agents is still lacking." . The neurodermatitis proponents feel that the primary cause is neurosomatic. There is an alteration in the normal responses under delicate thermostatic control which upsets the dermal vasomotor stability. They feel that family history will show more than atopy. There will be familial evidence of spastic colitis, peptic ulcer, chronic pruritus of the genitalia and anus, psychoses, and other evidence of neurocirculatory instability. From the Rush Department of Dermatology, University of Illinois College of Medicine, and the Department of Dermatology, ChiIdrens Memorial Hospital, Chicago. * Associate Attending Dermatologist Childrens Memorial Hospital; Assistant Attending Dermatologist Presbyterian Hospital. ~05
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FRANCI:;; W. HET REED
They find that, in these persons, the skin is the organ to manifest a reaction to their instability. They state that their histories tend to show that persons afflicted with this type of eczema demonstrate an abnormally low incidence of other functional disturbances, such as peptic ulcers, spastic colitis, and psychoses. However, thesc conditions may manifest themselves in other members of the family. About 75 per cent of cases of eczematous eruptions in infancy are atopic in character; the remaining ~.5 per cent include the seborrheic, contact, and mycotic varietie,. CLINICAL PICTURE
In the infant, the most common site of initial appearance is the cheeks' If dissemination occurs, the areas most likely to become involved are the lateral aspects of the forearms, legs then the dorsa of the wrists and ankles, and finally the trunk. The severe type, and fortunately the least common, is the generalized erythrodermic variety which is an eczema uni versa lis . The lesions may be moist or dry, with frequent combinations of the two in the same person. Solitary patches may manifest exudative symptoms at one time and dry, scaling lesions at another. When they are moist, the patches are ill-defined, varying in size and shape, covered by crusts, and evidence of cxcoriation is present. The lesions are frequently seen in the scalp. In the dry type, the patches are flat and some scaling is present. This occurs predominately in the older group. The initial lesion is a pinhead to pea-sized papule. Thcse initial lesions coalesce to form dry, thick patches, usually symmetrical. The areas of predilection are the forehead, anterolateral aspects of the neck, the cubital and popliteal fossae, and the dorsa of thc wrists. The pruritus is usually severe and excoriations and crusts are frequently observed as a result of scratching. Atopic eczema, or dermatitis, in older children from age ~ to adolescence presents the same clinical picture as in adults. Here again a condensation of titles would aid the less experienced. In addition to those previously mentioned, the most frequent terms used are neurodermatitis, lichen simplex chronicus, and flexural eczema. This confusion in terminology can be in part attributed to our inability to categorize each case into an allergenic or psychogenic cause. The proponents of each have much in thEir favor; however, not enough to convince firmly that theirs is the sole cause of the condition. If such a thing as protoplasmic instability were true, it would make one more susceptible to both functional as well as allergenic diseases, and both etiologic concepts could be IIf'Ceptcrl,
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The combination of atopic and seborrheic eczema is not infrequent. Crusta lactea (cradle cap) and greasy yellow, scaling patches in the axilla and groin may be present and associated with typical dry patches of eczema in the usual atopic areas. The association of atopic dermatitis with contact eczema is also commonly observed. In an unruly case observed over a long period of time, it would be most unusual not to have some local medicament produce a flare. These cases are notorious for their unpredictable behavior. We have all seen cases that would tolerate the tars and other anti-eczematous agents at one time and show a failure to respond to their application at a later date.
MANAGEMENT The management of atopic dermatitis can be grouped under the infantile type and a combination of the childhood, adolescent, and adult types. The discussion will elaborate to a greater extent on the infantile variety. However, the principles of management are essentially the same, with the exception of x-ray therapy, which is withheld in the infant group. The percentage of the active medicaments may vary according to age, and there will be greater need for the more stimulating ingredierlts in the older group, as it is here we observe more of the dry, sealing and lichenified lesions. History.-l. The family history of other atopic diseases is important. One can inform the parents promptly of the possible relationship of their infant's trouble with a protracted case of asthma or hay fever in a parent, aunt, or uncle. It brings about a realization of the potential problems involved in treatment. It is quite natural that all parents are seeking an immediate response in the child's condition and if difficulties are anticipated, it is better to forewarn them of the possible trouble that may be ahead of them. ~. Evidence of neurosomatic disturbanee in the parents, such as peptic ulcer, spastie colitis, or pruritis ~ni, vulvae or perinei. Through the course of the interview, the tension state of the parent may be judged. 3. The activity of the baby in utero. If it is the first child, the physician's personal evaluation should be made from the mother's statement, as most primipara are normally apprehensive. If the above two groups would show positive findings, it would indicate sedation in the routine treatment. 4. Date of onset. Some clue may he derived if the eczema followed shortly after the addition of a new food. However, most alert mothers will observe this and withdraw the suspected food. I believe many cases of mild eczema are diagnosed and successfully handled in this fashion by mothers without consulting the physician. If the onset was shortly
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after birth, while the infant was at breast, such a protein as lactalbumin, which is bovine species specific, may be ruled out. Casein, which is not species specific, must still be considered. Topical Care.-l. Prevention of scratching. Loose-fitting garments should be worn, with avoidance of wool, silk, satin, rayon, and nylon. Active restriction is necessary, as infants, as well as adults, can undo the benefit of a week's treatment with a few minutes of intense excoriation. It may be necessary to tie the wrists and ankles to the crib, or simply immobilize the elbows with corrugated cardboard. When the face and scalp are acutely involved in the infant, sandbags, appropriately covered, may be used. 2. Cleansing. Removal of ointments and lotions should be done with simple vegetable or mineral oils. The various soapless detergents may be cautiously tried, with- the advice to make the cleansing process a brief one, as they can be too drying. 3. Local treatment. It is here that much confusion may arise, owing to the multiplication of the number of wet dressings, lotions, and ointments and the medicaments to incorporate into the bases. The foregoing recommendations are far from complete. A simple standard should be followed, and after it is established, individual elaboration can be made. It is important to remember the indication for types of applications. -Wet dressings are indicated for the exudative and vesicular types. Pastes are used in the subacute phases; and the drier the dermatosis becomes, the less powder is incorporated into the ointment, resulting in a softer and more penetrable base. Lotions are indicated in extensive eczemas. In the infant group, the majority of exudative and vesicular types are observed. Wet dressings are of value in this stage, yet, where the indication is so obvious, it is surprising how often this procedure is not initiated. Anyone of the following may be used: Potassium permanganate solution 1: 5000 to 1: 10,000 (indicated also where superimposed secondary infection has occurred) Liquid aluminum subacetatel:15 to 1 :30 in water Liquid aluminum acetate 1: 10 to 1 :20 in water Saturated solution of boric acid
Open wet dressings are preferred in this type. Soft, fine-meshed material is best. At least an hour's application three times daily should be advised. Where crusts are thick and tenacious in the scalp hair, the dressings may be on longer. When exudation has stopped, the next procedure should be the application of protl::ctive pastes. They are less heating, the powder allows
MANAGEM~,NT
0]<' ATOPIC DI<>RMATITIS
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absorption of some secretion. Lassar's paste without salicylic acid is the most popular, and is innocuous. Into this paste one can cautiously incorporate such anti-eczematous agents 'as from 1 to 3 per cent ichthyol or crude coal tar, or from 5 to 10 per cent Naphthalan or its domestic equivalents. A thin coating is advised. Coal tar has a pharmaceutically important position in the treatment of eczematous dermatoses. It is disagreeable mainly from a staining and cosmetic standpoint. In practically all of the distillates and purified products introduccd, some of the therapeutically importan~ phenols and cresols have been removed. A preparation called Zetar* retains all the chemical properties of crude coal tar and yet is readily miscible with water and the usual ointments and suspensions. It may be washed from the body surface without soap and will not stain linens permanently. As the areas become dry, more stimulating remedies in softer bases may be used. Many water-soluble ointment bases are available, such as Aquaphor,t QualatumJ and Hydrosorb,§ which allow at least 20 per cent of water to be added. This is advantageous when used on the scalp. Here the tars, resorcinol, or mercurials may be incorporated, and salicylic acid for scaling, Resorcin or the mercurials should never be used without first patch-testing the patient for these chemicals. When mixed subacute and dry lesions are present, from 1 to 2 per cent of crude coal tar and iodochlorhydroxyquinoline (Vioforrnl!) in the above base is excellent. Both iodine and oxyquinoline applied separately have a reputation for producing a local sensitization eczema. However, their combination in Vioform has produced a surprisingly low incidence of contact dermatitis. It is exeellent for use as an anti-eczematous as well as an antiscptic agent. Unseented vanishing creams sueh as Neobase~ are valuable vehides for the tars. A powder may be dusted on after their application. Where widespread dermatitis exists and a lotion is indicated, a prepared oil in water preparation sueh as Nivea Oil** may be used. One may add antiprurifcs and from 2 to l'j per cent liquor carb'onis detergens to this mixture. This preparation may also be used on the scalp. Antipruritics.-These are used to control itching, and the mode of action is principally to substitute an altered sensation. Menthol, from one-eighth to one-fourth per cent, will produce a cooling effect. Phenol,
* Dermik
Pharmacal Company, Brooklyn, N. Y. Stamford, Conn. t Almay Inc., New York, N. Y. § Abbott Laboratories, North Chicago, Ill. 11 Ciba Pharmaceutical, Summit, N. J. ~ Burroughs~Wel1c()rne, New York, N. Y. ** Duke Laboratories, Starnford, Conn.
t Duke Laboratories,
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FRANCIS W. HETREED
from one-fourth to one per cent, produces a sensation of heat and also acts as an analgesic. The dermatological handling of these cases should not be too difficult if the indications for the various types of application are remembered, plus the knowledge of a few anti-eczematous agents and the bases in which they can be incorporated. One should always keep in mind the fact that individual idiosyncrasy may be present to the mildest of applications, and if it does occur, the application may be withdrawn and another substituted. However, most of the difficulty will arise from the wrong choice of therapeutic preparations, such as the use of a shake lotion on a crusting area, which only accentuates the crusts, or the smothering of an exudative and vesicular type with occlusive ointments. Internal Medication.-Internally, sedation may be necessary in some cases. The antihistamine drugs, both internally as well as topically, should be given a trial. The results are anything but consistent. However, one observation in their favor is that beneficial results will manifest themselves in a few days, and their clinical evaluation in any case ean be determined over a brief period. X-ray Therapy.-I<'ractional doses of roentgen-ray given locally are of great benefit in allaying pruritus and bringing about an involution of an active eczematous state. There should be an accurate tabulation of doses used and exact sites of exposure to preclude any incidence of undesirable roentgen-ray sequelae. Allergenic Management.-Infants under six months avoid: Wool :Feathers Soap
Pets (animal) Silk, rayon, nylon Clothing dyes.
The foods which should be investigated either by scratch-testing or by ehnination are: Milk Egg white Egg yolk Wheat Oranges Tomatoes
Peas Carrots String beans Chocolate Spinach
Temporary elimination of the oil-soluble vitamIn preparation should also be done. Where there is a family history of atopy, it is wise to add one fruit and vegetable at a time, even without evidence of eczema. Avoid strained vegetable soups until all vegetables have been given individually.
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For infants under one year, the forementioned should be investigated, plus Oats Rye Chicken Beef
Fish Bananas Lamb
If the patient is sensitive to egg, give capon or rooster. This avoids feeding the infant an egg protein (conalbumin) which corresponds to serum albumin in the blood of the hen. For patients over one year, if an allergenic investigation is indicated, all foods in the diet, plus the inhalants should be tested. Lard.-Among other forms of therapy from the standpoint of multiple etiological concepts is the oral administration of lard. Some investigators have found a decrease of the unsaturated fatty acids in the blood, and have obtained improvement by producing an increase in this level with the administration of lard. Where the eczema has improved during and following an intercurrent infection, a corresponding rise in the unsaturated fatty acids has been demonstrated. Neurosomatic Factors.-.From a neurogenic viewpoint, adequate history of parental nervous instability may prove interesting and revealing. Frequently we may observe startling improvements, especially in infants, by simply placing them in the hospital. We know that environmental and geographic changes help many 01 the recalcitrant cases. A change in climate could also be attributed to the leaving behind of an offending inhalant. There were many cases of neurodermatitis that had their onset in men while in service. Some of the men with milder chronic cases who were inducted into the armed services had a complete remission. My psychiatric and neurosomatic knowledge is too limited to give satisfactory reasons why a case of eczema will improve in a man who has been forced to leave wife, children, and home to go into service and be subjected to hours of belligerent commands and orations, jetpropelled from a twenty-year-old corporal ten years his junior. The,·e are definite voids in the atopic concept, and it is hoped that the neurosomatic approach will help us in obtaining more tangible facts. It is still felt that the causal concepts are multiple and we must understand this in attempting to manage the chronic cases in particular. ILLUSTRATIVE CASES
Vesicular and Encrusted Eczema (Fig. 96).-This and the exudative type are seen predominantly in the first year of life. Wet dressings are
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the initial procedure. Potassium permanganate, aluminum subaectate, or Burow's solution in their appropriate dilutions may be used. For the first few days the applications are constant, with a change of dressings every three to four hours, depending upon the amount of exudation present. When the weeping has diminished, protective pastes are indicated. Lassar's paste containing 25 per cent each of zinc oxide and starch in petrolatum is commonly used. Pastes are excellent for the subacute stage, protecting the inflamed skin, yet not smothering the integument, as the powder contained in the paste allows any residual
Fig. 96 Fig. 97 Fig. 96 (Case I).-Vesicular and encrusted eczema in an infant seven months of age. A maternal aunt has neurodermatitis. In his second year of life this child was brought to country, a site he had visited the previous summer. An asthmatic attack occurred and upon his return to the city the seizure ended. An acquired sensitivity to poIIens prevalent in that locality was demonstrated .. Fig. 97 (Case II).-Eczema, ex~dative type, in a boy six months of age. Excoriations are visible on the forehead.
exudate to dry. Gradually ichthyol, naphthalan'and its domestic counterand small amounts of tar may be added. Where there has been a superimposed secondary infection, from 2 to 3 per cent vioform may be added. This agent is an antiseptic, and its anti-eczematous usefulness has been domonstrated repeatedly. Eczema, Exudative type (Fig. 97).-In this variety, macroscopic vesicles are not seen, but weeping is evident. The management is the same as in the vesicular stage. Immobilization of the elbows is indicated where scratching is evident, as two minutes' vigorous tearing by the nails may undo a week's benefit from therapy. Antihistaminic drugs, . part~,
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orally, may be tried. In the infant, a daily dose of one and one-half milligrams per pound of body weight should be given before judgment is passed as to its efficacy. The infant illustrated in Figure 97, when given the intradermal test, showed a positive result to lactalbumin, which is bovine species specific. He showed improvement on goat's milk as well as soybean milk.
Fig. 98 (Case III).-Atopic dermatitis in female twins three yearS of age. The girl on the left presented evidence of eczema four days after birth. It was vesicular and had become generalized during the first year and has now receded to the usual flexoral sites seen in older children. The girl on the right had normal skin until shortly after two years of age. It did not go through the vesicular and crusted stages seen in early infancy, but commenced as grouped, pruritic, and scaly papules in the popliteal and cubital spaces. A maternal aunt and paternal grandmother had asthma. Chocolate and eggs would aggravate both, while liver would produce a flare in but one child. Scratch tests did not show a. wheal to either. Intradermal tests were not done. The papules in each child have coalesced to form patches. They are dry, scaling, and becoming lichenified (leathery thickening accompanied by exaggeration of normal skin lines.)
Atopic Dermatitis in Twins (Fig. 98).-In the type illustrated, more stimulating medicaments in soft ointment bases allowing more penetration can be used. Such an ointment may contain salicylic acid (1 to 2 per cent), ichthyol (2 per cent), and crude coal tar (2 to 5 per cent) in an ointment base containing, at first, 20 to 50 per cent inert powder such as zinc oxide. If it is tolerated, the powder can be removed subsequently
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FRANCIS W. HETREED
and thus allow more penetrating action of the ointment. Unscented vanishing creams are an excellent vehicle for the tars, but, if this type of cream is used, the salicylic acid must be omitted. Kaposi's Varicelliform Eruption Complicating Atopic Eczema (Fig. 99).-This can be a serious condition with possible fatal termination. No child with eczema should be vaccinated for the prevention of smallpox. Inoculations may be given for whooping cough, diphtheria and tetanus.
Fig. 99 (Case IV).-Kaposi's varicelliform eruption in a boy with atopic eczema, whose sister had been recently vaccinated.
Even kissing the child should be avoided if either of the parents has herpes simplex. Tlie onset is acute, accompanied by high fever, and the eruption will usually occur over the eczematous areas. The typical umbilicated herpetic vesicles may be seen on the forehead. The vesicular eruption usually proceeds to the crusting stage and marked pitted scarring can remain. No specific remedy is available for this condition, the treatment being supportive. Sulfonamides, penicillin, or streptomycin should be ad-
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ministered to prevent secondary bacterial complications. The eruption is self-limited, and locally a bland antipruritic cream may be applied. Atopic Dermatitis with Seborrheic Features (Fig. 100).-We speak of the areas of the scalp, behind the ears, brows, axillary, and crural regions as seborrheic sites. In the boy illustrated, a combination of this and the atopic areas is present. In the quiescent stages, the sQltling about the ears, brows, and scalp was larger in size and of an oily consistency.
Fig. 100 (Case V).~Atopic dermatitis with seborrheic features in a 3i year old boy who developed an erythema, exudation, and crusting in the retroauricular arvas at the age of 3 months. Subsequently a dermatitis of the cheeks appeared, followed by a similar eruption on the scalp, anterolateral aspects of the neck, left crural region, and the dorsa of the hands. There have been repeated flares and remissions. The boy had a family history of allery or atopy but, food elimination had not produced any decided change.
The mild, oily scaling of the scalp seen in infants (crusta lactea) should be treated, as it may be a prodromal stage for a more recalcitrant seborrheic eczema. One per cent each of salicylic acid and precipitated sulfur in a water-soluble ointment base is prescribed for the infant. If the result is nf.>t manifest, then an increase in the sulfur content is indicated. In the treatment of the boy shown in Figure 100, the exudation on the face, ears and hands should be arrested by wet dressings. This part of the procedure would be the same for both seborrheic and atopic types.
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FRANCIS W. HETREED
When the dry and scaling stage is reached, the hands would be given the usual atopic routine, while the face and scalp would take a mixed routine, combining the eczematous and seborrheic medicaments. On the scalp, an ointment consisting of 3 per cent sulfur and 5 per cent liquor carbonis detergens (solution of coal tar) in a water-soluble ointment base may be applied. The customary anti-eczematous paste routine would follow on the face and ears after the exudation has ceased. If
Fig. 101 (Case VI).-Atopic dermatitis of cubitals, forearms and dorsa of hands and wrists. The child was 4 years of age and the condition had been present since three months after birth. The eruption cleared during the summer months only to return in the autumn. Wool and silk markedly aggravated the pruritus. (Wool will accentuate virtually all cases of pruritus.) Here we see both grouped and discrete excoriated dry papules. Note the remnants of nail lacquer present. The use of nail polish should be discouraged, as a contact eczema from the polish may be superimposed on an atopic site.
improvement is not too apparent about the ear and face, a seborrheic routine should be tried. This is best done by applying a 40 to 50 per cent precipitated sulfur ointment, cautiously at first to test for sensitivity. This may appear as heroic therapy, but the preparation becomes a paste in this strength and is therefore less penetrating than a 5 per cent sulfur ointment. Recently I have observed an infant, six months of age, with a generalized scaly erythroderma simulating Leiner's disease, with
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the exception of severe pruritus that was present. The baby showed a remarkable improvement with the gradual application of 40 per cent sulfur in petrolatum over the entire integument.
Atopic Dermatitis of Cubitals, Forearms and Dorsa of Hands and Wrists ,(Fig. 101).-The child illustrated in the figure demonstrates
some of the problems in therapy that can confront us in the treatment of this condition. She would show an intolerance to crude coal tar at one time and manifest subjective as well as objective improvement to its application at another. At this age, small doses of roentgen ray can be given with marked beneficial results. Soft ointments containing antipruritics, such as one-third per cent menthol and phenol, are indicated. When the water-soluble ointment bases are used, liquor aluminum subacetatis may be incorporated in a strength of 3 per cent for its astringent effect. The following prescription should be found useful: Mentholis, Phenolis, aa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. O. 1 Acidi SalicyIi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0.3 Pix Carbonis. . . . . .. .... .... .. .. .. ...... ...... .... 0.6 Zinci Oxidi. . ............. . 1.5 Hydrosorb. .......... q.s.ad 30.0
SUMMARY No one is completely satisfied with the management of atopic dermatitis. This is not meant to be an aggressive approach to the final answer to its etiological background and therapy. A broader attitude is necessary to understand the reasons behind its origin, and its self-limitation in some and chronicity in others. In the case reports, the dermatologic approach is stressed, not because it is the most vital requirement for cure, but simply to bring out the indications for correct local therapy. In the hospital from which the cases were obtained for this presentation, a definite progran is being established to coordinate the departments of Dermatology, Allergy, Hematology, and Psychiatry on this one subject in a further effort to combine all available facilities in finding some of the answers associated with this condition. We do know that control of diet, environmental readjustment, correct local therapy, and prevention of scratching can result in long periods of freedom in many and permanent cur.es in others. . REFERENCES Becker, S. W., and Obermeyer, M. E.: Modern Dermatology and Syphilology. Philadelphia, J. B. Lippincott Co., 1946. 8
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Combes, F. C.: Coal Tar in Dermatology. Arch. Dermat. & Syph., 56:583 (Nov.), 1947. Finnerud, C. W., Kesler, R. L., and Wiese, H. F.: Ingestion of Lard in Treatment of Eczema and Allied Dermatoses. Ibid, 44:849 (Nov.), 1941. Glaser, J.: Treatment of Atopic Dermatitis in Infancy. J.A.M.A., 137:527 (June 5), 1948. MacKee, G. M., and Cipollaro, A. C.: Skin Diseases in Children. Paul B. Hoeber, New York, 1947. Sulzberger, M. B.: Dermatologic Allergy. Springfield, Ill., Charles C Thomas, 1940. Sulzberger, M. B., and Wolf, J.: Dermatologic Therapy in General Practice. Chicago. The Year Book Publishers, 1947.
W.
lIETREED,
M.D. *
WE need only to mention the name of the dermatosis and difficulties will arise. The preference for either eczema or dermatitis is purely geographical. The more important dissension concerns the definite etiologic adjective, atopic. Many feel that this type of eczema rests not on an allergenic background, but rather on a neurogenic or neurosomatic origin. Much supporting evidence has been demonstrated from both sides, but none that can definitely outmode the other. This controversial opinion in the ranks is, therefore, good, as it is stimulating, and can aid in finally arriving at positive conclusions regarding the etiology of this common and recalcitrant condition. Toward the atopic side, 50 per cent of persons with atopic eczemas have a family history of allergy. Scratch tests have given positive results in approximately the same number of cases. However, in the same percentage, patients were negative to all scratch tests. It is also interesting to note that the scratch-test reactions to inhalants as compared to foods increase rapidly with age. Only one in twenty-five infants (under 1 year of age) will show positive reaction to inhalants, while in the 2- to 12-year group, the ratio increases to one in two and a half. In adults, it is practically even. Withdrawal of allergens showing a positive scratch or intradermal test does not always mean that improvement takes place. Also, some foods giving a negative result to the scratch or intradermal test are known to produce an exaggeration of symptoms when ingested. Sulzberger, a strong proponent of the atopic theory, nevertheless does not hesitate to mention the limitations of it. He states, "Although the mass of clinical evidence suggests the role of exposure to certain allergens, the absolute and conclusive proof of the causal role of any and all of these agents is still lacking." . The neurodermatitis proponents feel that the primary cause is neurosomatic. There is an alteration in the normal responses under delicate thermostatic control which upsets the dermal vasomotor stability. They feel that family history will show more than atopy. There will be familial evidence of spastic colitis, peptic ulcer, chronic pruritus of the genitalia and anus, psychoses, and other evidence of neurocirculatory instability. From the Rush Department of Dermatology, University of Illinois College of Medicine, and the Department of Dermatology, ChiIdrens Memorial Hospital, Chicago. * Associate Attending Dermatologist Childrens Memorial Hospital; Assistant Attending Dermatologist Presbyterian Hospital. ~05
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FRANCI:;; W. HET REED
They find that, in these persons, the skin is the organ to manifest a reaction to their instability. They state that their histories tend to show that persons afflicted with this type of eczema demonstrate an abnormally low incidence of other functional disturbances, such as peptic ulcers, spastic colitis, and psychoses. However, thesc conditions may manifest themselves in other members of the family. About 75 per cent of cases of eczematous eruptions in infancy are atopic in character; the remaining ~.5 per cent include the seborrheic, contact, and mycotic varietie,. CLINICAL PICTURE
In the infant, the most common site of initial appearance is the cheeks' If dissemination occurs, the areas most likely to become involved are the lateral aspects of the forearms, legs then the dorsa of the wrists and ankles, and finally the trunk. The severe type, and fortunately the least common, is the generalized erythrodermic variety which is an eczema uni versa lis . The lesions may be moist or dry, with frequent combinations of the two in the same person. Solitary patches may manifest exudative symptoms at one time and dry, scaling lesions at another. When they are moist, the patches are ill-defined, varying in size and shape, covered by crusts, and evidence of cxcoriation is present. The lesions are frequently seen in the scalp. In the dry type, the patches are flat and some scaling is present. This occurs predominately in the older group. The initial lesion is a pinhead to pea-sized papule. Thcse initial lesions coalesce to form dry, thick patches, usually symmetrical. The areas of predilection are the forehead, anterolateral aspects of the neck, the cubital and popliteal fossae, and the dorsa of thc wrists. The pruritus is usually severe and excoriations and crusts are frequently observed as a result of scratching. Atopic eczema, or dermatitis, in older children from age ~ to adolescence presents the same clinical picture as in adults. Here again a condensation of titles would aid the less experienced. In addition to those previously mentioned, the most frequent terms used are neurodermatitis, lichen simplex chronicus, and flexural eczema. This confusion in terminology can be in part attributed to our inability to categorize each case into an allergenic or psychogenic cause. The proponents of each have much in thEir favor; however, not enough to convince firmly that theirs is the sole cause of the condition. If such a thing as protoplasmic instability were true, it would make one more susceptible to both functional as well as allergenic diseases, and both etiologic concepts could be IIf'Ceptcrl,
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The combination of atopic and seborrheic eczema is not infrequent. Crusta lactea (cradle cap) and greasy yellow, scaling patches in the axilla and groin may be present and associated with typical dry patches of eczema in the usual atopic areas. The association of atopic dermatitis with contact eczema is also commonly observed. In an unruly case observed over a long period of time, it would be most unusual not to have some local medicament produce a flare. These cases are notorious for their unpredictable behavior. We have all seen cases that would tolerate the tars and other anti-eczematous agents at one time and show a failure to respond to their application at a later date.
MANAGEMENT The management of atopic dermatitis can be grouped under the infantile type and a combination of the childhood, adolescent, and adult types. The discussion will elaborate to a greater extent on the infantile variety. However, the principles of management are essentially the same, with the exception of x-ray therapy, which is withheld in the infant group. The percentage of the active medicaments may vary according to age, and there will be greater need for the more stimulating ingredierlts in the older group, as it is here we observe more of the dry, sealing and lichenified lesions. History.-l. The family history of other atopic diseases is important. One can inform the parents promptly of the possible relationship of their infant's trouble with a protracted case of asthma or hay fever in a parent, aunt, or uncle. It brings about a realization of the potential problems involved in treatment. It is quite natural that all parents are seeking an immediate response in the child's condition and if difficulties are anticipated, it is better to forewarn them of the possible trouble that may be ahead of them. ~. Evidence of neurosomatic disturbanee in the parents, such as peptic ulcer, spastie colitis, or pruritis ~ni, vulvae or perinei. Through the course of the interview, the tension state of the parent may be judged. 3. The activity of the baby in utero. If it is the first child, the physician's personal evaluation should be made from the mother's statement, as most primipara are normally apprehensive. If the above two groups would show positive findings, it would indicate sedation in the routine treatment. 4. Date of onset. Some clue may he derived if the eczema followed shortly after the addition of a new food. However, most alert mothers will observe this and withdraw the suspected food. I believe many cases of mild eczema are diagnosed and successfully handled in this fashion by mothers without consulting the physician. If the onset was shortly
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after birth, while the infant was at breast, such a protein as lactalbumin, which is bovine species specific, may be ruled out. Casein, which is not species specific, must still be considered. Topical Care.-l. Prevention of scratching. Loose-fitting garments should be worn, with avoidance of wool, silk, satin, rayon, and nylon. Active restriction is necessary, as infants, as well as adults, can undo the benefit of a week's treatment with a few minutes of intense excoriation. It may be necessary to tie the wrists and ankles to the crib, or simply immobilize the elbows with corrugated cardboard. When the face and scalp are acutely involved in the infant, sandbags, appropriately covered, may be used. 2. Cleansing. Removal of ointments and lotions should be done with simple vegetable or mineral oils. The various soapless detergents may be cautiously tried, with- the advice to make the cleansing process a brief one, as they can be too drying. 3. Local treatment. It is here that much confusion may arise, owing to the multiplication of the number of wet dressings, lotions, and ointments and the medicaments to incorporate into the bases. The foregoing recommendations are far from complete. A simple standard should be followed, and after it is established, individual elaboration can be made. It is important to remember the indication for types of applications. -Wet dressings are indicated for the exudative and vesicular types. Pastes are used in the subacute phases; and the drier the dermatosis becomes, the less powder is incorporated into the ointment, resulting in a softer and more penetrable base. Lotions are indicated in extensive eczemas. In the infant group, the majority of exudative and vesicular types are observed. Wet dressings are of value in this stage, yet, where the indication is so obvious, it is surprising how often this procedure is not initiated. Anyone of the following may be used: Potassium permanganate solution 1: 5000 to 1: 10,000 (indicated also where superimposed secondary infection has occurred) Liquid aluminum subacetatel:15 to 1 :30 in water Liquid aluminum acetate 1: 10 to 1 :20 in water Saturated solution of boric acid
Open wet dressings are preferred in this type. Soft, fine-meshed material is best. At least an hour's application three times daily should be advised. Where crusts are thick and tenacious in the scalp hair, the dressings may be on longer. When exudation has stopped, the next procedure should be the application of protl::ctive pastes. They are less heating, the powder allows
MANAGEM~,NT
0]<' ATOPIC DI<>RMATITIS
':W!)
absorption of some secretion. Lassar's paste without salicylic acid is the most popular, and is innocuous. Into this paste one can cautiously incorporate such anti-eczematous agents 'as from 1 to 3 per cent ichthyol or crude coal tar, or from 5 to 10 per cent Naphthalan or its domestic equivalents. A thin coating is advised. Coal tar has a pharmaceutically important position in the treatment of eczematous dermatoses. It is disagreeable mainly from a staining and cosmetic standpoint. In practically all of the distillates and purified products introduccd, some of the therapeutically importan~ phenols and cresols have been removed. A preparation called Zetar* retains all the chemical properties of crude coal tar and yet is readily miscible with water and the usual ointments and suspensions. It may be washed from the body surface without soap and will not stain linens permanently. As the areas become dry, more stimulating remedies in softer bases may be used. Many water-soluble ointment bases are available, such as Aquaphor,t QualatumJ and Hydrosorb,§ which allow at least 20 per cent of water to be added. This is advantageous when used on the scalp. Here the tars, resorcinol, or mercurials may be incorporated, and salicylic acid for scaling, Resorcin or the mercurials should never be used without first patch-testing the patient for these chemicals. When mixed subacute and dry lesions are present, from 1 to 2 per cent of crude coal tar and iodochlorhydroxyquinoline (Vioforrnl!) in the above base is excellent. Both iodine and oxyquinoline applied separately have a reputation for producing a local sensitization eczema. However, their combination in Vioform has produced a surprisingly low incidence of contact dermatitis. It is exeellent for use as an anti-eczematous as well as an antiscptic agent. Unseented vanishing creams sueh as Neobase~ are valuable vehides for the tars. A powder may be dusted on after their application. Where widespread dermatitis exists and a lotion is indicated, a prepared oil in water preparation sueh as Nivea Oil** may be used. One may add antiprurifcs and from 2 to l'j per cent liquor carb'onis detergens to this mixture. This preparation may also be used on the scalp. Antipruritics.-These are used to control itching, and the mode of action is principally to substitute an altered sensation. Menthol, from one-eighth to one-fourth per cent, will produce a cooling effect. Phenol,
* Dermik
Pharmacal Company, Brooklyn, N. Y. Stamford, Conn. t Almay Inc., New York, N. Y. § Abbott Laboratories, North Chicago, Ill. 11 Ciba Pharmaceutical, Summit, N. J. ~ Burroughs~Wel1c()rne, New York, N. Y. ** Duke Laboratories, Starnford, Conn.
t Duke Laboratories,
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from one-fourth to one per cent, produces a sensation of heat and also acts as an analgesic. The dermatological handling of these cases should not be too difficult if the indications for the various types of application are remembered, plus the knowledge of a few anti-eczematous agents and the bases in which they can be incorporated. One should always keep in mind the fact that individual idiosyncrasy may be present to the mildest of applications, and if it does occur, the application may be withdrawn and another substituted. However, most of the difficulty will arise from the wrong choice of therapeutic preparations, such as the use of a shake lotion on a crusting area, which only accentuates the crusts, or the smothering of an exudative and vesicular type with occlusive ointments. Internal Medication.-Internally, sedation may be necessary in some cases. The antihistamine drugs, both internally as well as topically, should be given a trial. The results are anything but consistent. However, one observation in their favor is that beneficial results will manifest themselves in a few days, and their clinical evaluation in any case ean be determined over a brief period. X-ray Therapy.-I<'ractional doses of roentgen-ray given locally are of great benefit in allaying pruritus and bringing about an involution of an active eczematous state. There should be an accurate tabulation of doses used and exact sites of exposure to preclude any incidence of undesirable roentgen-ray sequelae. Allergenic Management.-Infants under six months avoid: Wool :Feathers Soap
Pets (animal) Silk, rayon, nylon Clothing dyes.
The foods which should be investigated either by scratch-testing or by ehnination are: Milk Egg white Egg yolk Wheat Oranges Tomatoes
Peas Carrots String beans Chocolate Spinach
Temporary elimination of the oil-soluble vitamIn preparation should also be done. Where there is a family history of atopy, it is wise to add one fruit and vegetable at a time, even without evidence of eczema. Avoid strained vegetable soups until all vegetables have been given individually.
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For infants under one year, the forementioned should be investigated, plus Oats Rye Chicken Beef
Fish Bananas Lamb
If the patient is sensitive to egg, give capon or rooster. This avoids feeding the infant an egg protein (conalbumin) which corresponds to serum albumin in the blood of the hen. For patients over one year, if an allergenic investigation is indicated, all foods in the diet, plus the inhalants should be tested. Lard.-Among other forms of therapy from the standpoint of multiple etiological concepts is the oral administration of lard. Some investigators have found a decrease of the unsaturated fatty acids in the blood, and have obtained improvement by producing an increase in this level with the administration of lard. Where the eczema has improved during and following an intercurrent infection, a corresponding rise in the unsaturated fatty acids has been demonstrated. Neurosomatic Factors.-.From a neurogenic viewpoint, adequate history of parental nervous instability may prove interesting and revealing. Frequently we may observe startling improvements, especially in infants, by simply placing them in the hospital. We know that environmental and geographic changes help many 01 the recalcitrant cases. A change in climate could also be attributed to the leaving behind of an offending inhalant. There were many cases of neurodermatitis that had their onset in men while in service. Some of the men with milder chronic cases who were inducted into the armed services had a complete remission. My psychiatric and neurosomatic knowledge is too limited to give satisfactory reasons why a case of eczema will improve in a man who has been forced to leave wife, children, and home to go into service and be subjected to hours of belligerent commands and orations, jetpropelled from a twenty-year-old corporal ten years his junior. The,·e are definite voids in the atopic concept, and it is hoped that the neurosomatic approach will help us in obtaining more tangible facts. It is still felt that the causal concepts are multiple and we must understand this in attempting to manage the chronic cases in particular. ILLUSTRATIVE CASES
Vesicular and Encrusted Eczema (Fig. 96).-This and the exudative type are seen predominantly in the first year of life. Wet dressings are
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the initial procedure. Potassium permanganate, aluminum subaectate, or Burow's solution in their appropriate dilutions may be used. For the first few days the applications are constant, with a change of dressings every three to four hours, depending upon the amount of exudation present. When the weeping has diminished, protective pastes are indicated. Lassar's paste containing 25 per cent each of zinc oxide and starch in petrolatum is commonly used. Pastes are excellent for the subacute stage, protecting the inflamed skin, yet not smothering the integument, as the powder contained in the paste allows any residual
Fig. 96 Fig. 97 Fig. 96 (Case I).-Vesicular and encrusted eczema in an infant seven months of age. A maternal aunt has neurodermatitis. In his second year of life this child was brought to country, a site he had visited the previous summer. An asthmatic attack occurred and upon his return to the city the seizure ended. An acquired sensitivity to poIIens prevalent in that locality was demonstrated .. Fig. 97 (Case II).-Eczema, ex~dative type, in a boy six months of age. Excoriations are visible on the forehead.
exudate to dry. Gradually ichthyol, naphthalan'and its domestic counterand small amounts of tar may be added. Where there has been a superimposed secondary infection, from 2 to 3 per cent vioform may be added. This agent is an antiseptic, and its anti-eczematous usefulness has been domonstrated repeatedly. Eczema, Exudative type (Fig. 97).-In this variety, macroscopic vesicles are not seen, but weeping is evident. The management is the same as in the vesicular stage. Immobilization of the elbows is indicated where scratching is evident, as two minutes' vigorous tearing by the nails may undo a week's benefit from therapy. Antihistaminic drugs, . part~,
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orally, may be tried. In the infant, a daily dose of one and one-half milligrams per pound of body weight should be given before judgment is passed as to its efficacy. The infant illustrated in Figure 97, when given the intradermal test, showed a positive result to lactalbumin, which is bovine species specific. He showed improvement on goat's milk as well as soybean milk.
Fig. 98 (Case III).-Atopic dermatitis in female twins three yearS of age. The girl on the left presented evidence of eczema four days after birth. It was vesicular and had become generalized during the first year and has now receded to the usual flexoral sites seen in older children. The girl on the right had normal skin until shortly after two years of age. It did not go through the vesicular and crusted stages seen in early infancy, but commenced as grouped, pruritic, and scaly papules in the popliteal and cubital spaces. A maternal aunt and paternal grandmother had asthma. Chocolate and eggs would aggravate both, while liver would produce a flare in but one child. Scratch tests did not show a. wheal to either. Intradermal tests were not done. The papules in each child have coalesced to form patches. They are dry, scaling, and becoming lichenified (leathery thickening accompanied by exaggeration of normal skin lines.)
Atopic Dermatitis in Twins (Fig. 98).-In the type illustrated, more stimulating medicaments in soft ointment bases allowing more penetration can be used. Such an ointment may contain salicylic acid (1 to 2 per cent), ichthyol (2 per cent), and crude coal tar (2 to 5 per cent) in an ointment base containing, at first, 20 to 50 per cent inert powder such as zinc oxide. If it is tolerated, the powder can be removed subsequently
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and thus allow more penetrating action of the ointment. Unscented vanishing creams are an excellent vehicle for the tars, but, if this type of cream is used, the salicylic acid must be omitted. Kaposi's Varicelliform Eruption Complicating Atopic Eczema (Fig. 99).-This can be a serious condition with possible fatal termination. No child with eczema should be vaccinated for the prevention of smallpox. Inoculations may be given for whooping cough, diphtheria and tetanus.
Fig. 99 (Case IV).-Kaposi's varicelliform eruption in a boy with atopic eczema, whose sister had been recently vaccinated.
Even kissing the child should be avoided if either of the parents has herpes simplex. Tlie onset is acute, accompanied by high fever, and the eruption will usually occur over the eczematous areas. The typical umbilicated herpetic vesicles may be seen on the forehead. The vesicular eruption usually proceeds to the crusting stage and marked pitted scarring can remain. No specific remedy is available for this condition, the treatment being supportive. Sulfonamides, penicillin, or streptomycin should be ad-
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ministered to prevent secondary bacterial complications. The eruption is self-limited, and locally a bland antipruritic cream may be applied. Atopic Dermatitis with Seborrheic Features (Fig. 100).-We speak of the areas of the scalp, behind the ears, brows, axillary, and crural regions as seborrheic sites. In the boy illustrated, a combination of this and the atopic areas is present. In the quiescent stages, the sQltling about the ears, brows, and scalp was larger in size and of an oily consistency.
Fig. 100 (Case V).~Atopic dermatitis with seborrheic features in a 3i year old boy who developed an erythema, exudation, and crusting in the retroauricular arvas at the age of 3 months. Subsequently a dermatitis of the cheeks appeared, followed by a similar eruption on the scalp, anterolateral aspects of the neck, left crural region, and the dorsa of the hands. There have been repeated flares and remissions. The boy had a family history of allery or atopy but, food elimination had not produced any decided change.
The mild, oily scaling of the scalp seen in infants (crusta lactea) should be treated, as it may be a prodromal stage for a more recalcitrant seborrheic eczema. One per cent each of salicylic acid and precipitated sulfur in a water-soluble ointment base is prescribed for the infant. If the result is nf.>t manifest, then an increase in the sulfur content is indicated. In the treatment of the boy shown in Figure 100, the exudation on the face, ears and hands should be arrested by wet dressings. This part of the procedure would be the same for both seborrheic and atopic types.
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When the dry and scaling stage is reached, the hands would be given the usual atopic routine, while the face and scalp would take a mixed routine, combining the eczematous and seborrheic medicaments. On the scalp, an ointment consisting of 3 per cent sulfur and 5 per cent liquor carbonis detergens (solution of coal tar) in a water-soluble ointment base may be applied. The customary anti-eczematous paste routine would follow on the face and ears after the exudation has ceased. If
Fig. 101 (Case VI).-Atopic dermatitis of cubitals, forearms and dorsa of hands and wrists. The child was 4 years of age and the condition had been present since three months after birth. The eruption cleared during the summer months only to return in the autumn. Wool and silk markedly aggravated the pruritus. (Wool will accentuate virtually all cases of pruritus.) Here we see both grouped and discrete excoriated dry papules. Note the remnants of nail lacquer present. The use of nail polish should be discouraged, as a contact eczema from the polish may be superimposed on an atopic site.
improvement is not too apparent about the ear and face, a seborrheic routine should be tried. This is best done by applying a 40 to 50 per cent precipitated sulfur ointment, cautiously at first to test for sensitivity. This may appear as heroic therapy, but the preparation becomes a paste in this strength and is therefore less penetrating than a 5 per cent sulfur ointment. Recently I have observed an infant, six months of age, with a generalized scaly erythroderma simulating Leiner's disease, with
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the exception of severe pruritus that was present. The baby showed a remarkable improvement with the gradual application of 40 per cent sulfur in petrolatum over the entire integument.
Atopic Dermatitis of Cubitals, Forearms and Dorsa of Hands and Wrists ,(Fig. 101).-The child illustrated in the figure demonstrates
some of the problems in therapy that can confront us in the treatment of this condition. She would show an intolerance to crude coal tar at one time and manifest subjective as well as objective improvement to its application at another. At this age, small doses of roentgen ray can be given with marked beneficial results. Soft ointments containing antipruritics, such as one-third per cent menthol and phenol, are indicated. When the water-soluble ointment bases are used, liquor aluminum subacetatis may be incorporated in a strength of 3 per cent for its astringent effect. The following prescription should be found useful: Mentholis, Phenolis, aa. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. O. 1 Acidi SalicyIi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 0.3 Pix Carbonis. . . . . .. .... .... .. .. .. ...... ...... .... 0.6 Zinci Oxidi. . ............. . 1.5 Hydrosorb. .......... q.s.ad 30.0
SUMMARY No one is completely satisfied with the management of atopic dermatitis. This is not meant to be an aggressive approach to the final answer to its etiological background and therapy. A broader attitude is necessary to understand the reasons behind its origin, and its self-limitation in some and chronicity in others. In the case reports, the dermatologic approach is stressed, not because it is the most vital requirement for cure, but simply to bring out the indications for correct local therapy. In the hospital from which the cases were obtained for this presentation, a definite progran is being established to coordinate the departments of Dermatology, Allergy, Hematology, and Psychiatry on this one subject in a further effort to combine all available facilities in finding some of the answers associated with this condition. We do know that control of diet, environmental readjustment, correct local therapy, and prevention of scratching can result in long periods of freedom in many and permanent cur.es in others. . REFERENCES Becker, S. W., and Obermeyer, M. E.: Modern Dermatology and Syphilology. Philadelphia, J. B. Lippincott Co., 1946. 8
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Combes, F. C.: Coal Tar in Dermatology. Arch. Dermat. & Syph., 56:583 (Nov.), 1947. Finnerud, C. W., Kesler, R. L., and Wiese, H. F.: Ingestion of Lard in Treatment of Eczema and Allied Dermatoses. Ibid, 44:849 (Nov.), 1941. Glaser, J.: Treatment of Atopic Dermatitis in Infancy. J.A.M.A., 137:527 (June 5), 1948. MacKee, G. M., and Cipollaro, A. C.: Skin Diseases in Children. Paul B. Hoeber, New York, 1947. Sulzberger, M. B.: Dermatologic Allergy. Springfield, Ill., Charles C Thomas, 1940. Sulzberger, M. B., and Wolf, J.: Dermatologic Therapy in General Practice. Chicago. The Year Book Publishers, 1947.