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Treatment of the Common Skin Diseases in An Army Hospital in the Tropics
TREATMENT OF THE COMMON SKIN DISEASES IN AN ARMY HOSPITAL IN TH E TROPICS CAPTAIN THOMAS
W.
CLARK
MEDICAL CORPS, ARMY OF THE UNITED STATES
Methods used to treat the common skin diseases in an Army hospital operating for over a year and a half in the South and Southwest Pacific will be described. The disorders most commonly encountered at these stations are epidermophytosis, dermatitis venenata, insect and mite bites. Their characteristics are much the same as in the temperate zones but they tend to be more persistent and more severe. Secondary infection is a complicating factor in nearly every case, and it is not too much to say that it is most often the infection and not the primary disease that leads to hospitalization. The general care of these patients is of great importance. Difficult living conditions, a hot climate, and lack of appetizing food undoubtedly act to reduce men's stamina and resistance to infection. It is not uncommon to find that a chronic ulcer started as a trivial scratch or a cellulitis as a simple fissure. Rest, clean surroundings, well prepared foods, and vitamins in full doses are essential parts of the program of treatment. There is no question that these patients do far better in a dry fly-proof building where the details of cleanliness, asepsis and general nursing care are easier to attend to than in the ordinary ward tent as it is set up in the field. However, when only a ward tent is available, every effort is made to approximate the conditions of the better installation. The therapy as outlined in this paper is not original. It consists of measures that have proved satisfactory after a year and a half of experience in a tropical climate. Invaluable aid was obtained from the Manual of Dermatology by Pillsbury, Sulzberger and Livingood. 1 EPI DERMOPHYTOSIS
Epidermophytosis is one of the most persistent enemies of our men. In the tropics, where conditions are ideal for its development and spread, their difficulties with this disease are worse than in any other climate. It incapacitates them despite all efforts with soap and water, boiled socks and foot powder. The disease is frequently advanced and secondarily infected by the time the patients reach the hospital. Overtreatment is the commonest error in management. Strong solutions and strong ointments tend to irritate an already damaged skin, to hinder recovery, and even to aggravate the disease process. The tendency 1532
TREATMENT OF COMMON SKIN DISEASES
153 3
of doctors to adopt a routine course of treatment is often the reason why many cases of "athlete's foot" fail to improve. Treatment has to be individualized. It has to be cautious, and guided by the character and progress of the disease. The acute stage, characterized by fissures, vesicles, broken blisters and denuded areas between the toes and under the feet, is generally complicated by secondary infection. Control of this secondary infection is the first and foremost aim of treatment. The patient is put at complete bed rest. The diseased areas are gently debrided of all loose epidermis and the tops removed from the large blisters every day. The feet are cleaned with a mild sterile soap solution. Warm soaks in a weak fungicidal solution are started. Potassium permanganate is usually available, and a solution of 1: 10,000 (0.30 gm. in 3000 cc.) is quite strong enough. Solutions of stronger than 1: 5000 are irritating and harmful. The feet are soaked for twenty minutes three times a day and dried. If the disease is widespread or if there is extensive secondary infection, continuous warm compresses of the same solution are to be preferred. Between soaks, the feet are left uncovered. In cases with extensive weeping, the feet are exposed to dry heat under a cradle or in the sunlight to dry the skin and prevent maceration. When blisters or fissures between the toes are present, the opposing surfaces are separated with sterile powdered gauze. This again helps to prevent maceration of the skin. It is often desirable to put light sterile dressings over the affected areas during the night. In many cases the secondary infection disappears and the original fungous infection subsides after two to four days of rest and soaks. The vesicles, fissures and macerated areas dry up and the thickened epidermis slowly peels off. The feet are kept clean and dry with foot powder and the patient is watched until desquamation is complete and all evidences of activity have disappeared. More often, the. secondary infection subsides and the vesicles and blisters of the acute epidermophytosis are replaced by patches of thickened epidermis, with scaling and oozing from under the patches. A few more days of soaks with potassium permanganate solution sometimes control this condition. If no more improvement occurs within this time, one of the dyes in solution such as Castellani's paint'*' or 2 per cent gentian violet in 70 per cent alcohol is applied. Frazer's solutiont or tincture of iodine is ·Castellani's Paint: tFrazer's Solution: Saturated alcoholic solution of basic fuchsin 10.0 Salicylic acid ....... 2.0 Aqueous solution of phenol, 5% ............ 100.0 Benzoic acid ....... 2.0 Filter and add: Tincture of iodine 10.0 Boric acid ................................... 1.0 Spirits of camphor to After two hours, add: make ............. 60.0 Acetone ........... ....................... 5.0 After two hours, atlJ: Resorcin ......................... ,'........ 10.0 Keep in darri: stoppered bottle.
1534
THOMAS W. CLARK
also effective at this stage. It was found best to start off with a quarter to one-half strength solutions and to increase slowly until the full strength is applied twice daily. If any evidence of irritation appears, the medications are stopped. Most cases clear up entirely with potassium permanganate soaks alone or with potassium soaks followed by one of the medications mentioned above. A few enter a chronic stage characterized by thickened plaques of epidermis, scaling and fissuring. These lesions are resistant to treatment and characteristically relapse time and again. It is important to treat them cautiously because they are apt to flare up acutely when irritated. Solutions containing iodine from 1 to 7 per cent in strength often yield good results. These are painted on the lesions twice a day. If no improvement with iodine takes place within two weeks or if iodine irritates the lesions, other medications such as Castellani's paint or Whitfield's ointment are tried. Many weeks of continuous treatment are sometimes necessary before the lesions heal completely. Ointments have been widely used against all stages of this disease. There is no question that they are valuable at times, but by and large they are best avoided in the tropics. They favor the spread of secondary infection when applied over contaminated lesions. Whitfield's ointment is very valuable for softening up the dry scaling epidermis of the subacute and chronic stages. When applied it is rubbed into the lesions thoroughly. No dressings are placed over it. It is never used in the acute stage or when secondary infection is present. Treatment is started with mixtures of a quarter to half strength in order to avoid irritation of the skin, and full strength is reached gradually. Sulfur ointment proved to be of no value in this disease. Ammoniated mercury was mildly antiseptic but relatively ineffective against the fungi of epidermophytosis. Dermatophytids on the hands and ears are common complications of epidermophytosis of the feet or groin. They are characterized by vesicles, scaling eczemato id patches, fissures and varying degrees of erythema, and are· very similar to other dermatoses. They are often far more prominent than the primary lesion. The commonest error is to overlook the primary lesion on the foot or the groin and to mistake the "id" for a separate and distinct disease. The uncomplicated "id" will heal only when the primary disease is cured, therefore when confronted with such lesions it is important to look for epidermophytosis elsewhere on the body and to treat it as described above. The "ids" are treated symptomatically with mild medications. Potassium permanganate soaks are useful for drying up the oozing from broken vesicles. When there is much scaling and fissuring present, boric acid ointment or petroleum jelly is used to soften the lesions. When secondary infection is present it is treated as described above. After the disease has been controlled and the patient is ready for
TREATMENT OF COMMON SKIN DISEASES
1535
duty, he is rehearsed in the care of his feet with emphasis on the use of soap and water and foot powder. His shoes are fumigated by placing them in an air-tight container for twenty-four hours along with a sponge soaked in 30 per cent formaldehyde. Following this they are aired for twenty-four hours in the sunlight. The patient is told that recurrences may take place no matter how conscientious he might be and that at the first sign of renewed activity he should report for treatment. DERMATITIS VENENATA
The tropical forests are full of plants and trees whose leaves and barks .contain substances irritating to the skin. Contact with these substances results in conditions varying from momentary burning and reddening of the skin to the severest forms of dermatitis in which all layers of the skin become damaged. The very nature of the lesions increases greatly the likelihood of secondary infection unless care is taken to avoid contamination. Itching is usually intense and distressing to the patient. Treatment demands all the ingenuity at our command. As an example of the difficulties encountered the following case is cited. W. 0., a private in the Marine Corps, developed an area of burning and itching on the left wrist following contact with the black sap of the "Wannarla" tree (native name). Within a short time vesicles developed over the involved part. He was treated as an ambulatory patient for nine days. First, calamine lotion was applied, then tannic acid ointment and then salicylic acid ointment. The disease continued to progress and appeared on the right hand. The patient was admitted to sick bay and treated with continuous soaks of potassium permanganate solution of unknown strength. Blebs, tenderness and swelling rapidly developed on both hands. He was sent to the hospital two weeks after the onset of the disease. On admission the backs of the hands and wrists were covered with vesicles and blebs, many of which were broken. Large areas were denuded of epithelium and were covered with shreds of epidermis and pus. The surrounding tissues were swollen and red. The axillary and epitrochlear lymph nodes were enlarged and tender. There was no fever present although a pyodermia and cellulitis had clearly become superimposed on the original dermatitis (Fig. 135). A strict aseptic regimen was immediately instigated. The hands were debrided of all loose epidermis and crusts. The tops were removed from the larger blisters. The skin was cleaned with sterile solutions. Continuous warm saline compresses were applied and sulfathiazole was given by mouth, 2 gm. immediately and 1 gm. every four hours. In twenty-four hours the involved parts had become distinctlSr cleaner. Crusts and loose epidermis were carefully cleared away. The compresses were reduced to one hour twice a day, and sulfadiazine ointment was smeared generously over the lesions after the compresses were applied. All lesions were covered with sterile gauze bandages. This treatment was continued on both hands for five days. At the end of this time there was marked improvement although a few islands of infection still remained. The sulfonamides were discon-
1536
THOMAS W. CLARK
Fig. 135.-Appearance of the hands and anus of W. 0., a private in the Marine Corps, on admission to the hospital. The discoloration was due to potassium permanganate soaks applied before admission. Large blebs filled with pus and loose shreds of epithelium can be seen on the palms and fingers of both hands. The denuded and ulcerated areas are less distinct bill: visible as pale patches on the left hand and wrist.
TREA T~lEXT OF COMMON SKIN DISEASES
1537
tinued and 2 per cent gentian violet in 70 per cent alcohol was painted over the hands and forearms. In a short time several of the infected areas flared up. The gentian violet was stopped and warm compresses followed by sulfadiazine ointment were resorted to once again. [n three more days, all evidence of infection had disappeared. Scattered spots continued to weep clear scrum. These were touched with gentian violet every day until they healed. Gradually new epithelium grew over the denuded areas. Twenty-six days after admission the patient was discharged to duty.
i\lost of the patients with dermatitis venenata who are admitted to the hospital exhibit severe skin damage such as that described above. The condition of the skin is similar in many ways to a first or second degree burn and the same principles of treatment are followed. Sterile instruments for debriding, sterile solutions for washing, sterile ointments and gauze for dressings are all essential for the \vork. From the start, the diseased areas are protected with sterile coverings. First, the lesions are carefully debrided of all crusts and loose epidermis. The tops of blisters are removed. The involved areas are cleaned \vith green soap, sterile \\'ater and alcohol and then covered with a sterile ointment spread thinly. Boric acid ointment and petroleum jelly both are satisfactory for this purpose. Gauze impregnated \\'ith either ointment and autoclaved affords a neat method for applying these medications. The ointment not only protects the damaged skin from infection but also soothes the burning and itching that often causes great distress. When secondary infection is present it is treated promptly and according to its severit y-. If it is a simple superficial infection, the above regimen is usually enough to control it. A sulfonamide drug is sometimes added to the protective ointment. Five per cent sulfadiazine in a water-soluble base* is frequently used \\'ith excellent results. If a widespread pyodermia has developed with an underlying cellulitis and fever, more vigorous treatment is prescribed. The lesions are carefully debrided and cleansed as before. Warm saline compresses are applied for an hour every four to six hours. The moist compresses help to clear away the pus and crusts and also to combat the cellulitis. Between soaks the lesions are covered with dr:-' sterile dressings. When the dressings are removed they are soaked off in order not to damage any regenerating epithelium. The compresses are continued until the infection is well controlled. Generally, twent\--four to thirti--six hours are sufficient. Then ointment and gauze dr~ssings are applied as described above. As long as they are present, oozing and crusting lesions are covered in order to avoid the recurrence of infection. The more severe cases require sulfathiazoIc or sulfadiazinc bv mouth. The usual course prescribed for each drug is 2 gm. iIl1\J;cdiatcly, ''''arer-Soluble Rases: 1. Aquifor. 2. Hydrogcnatcd \- egetable Far. Other ointlllCilt bases llIay be found in the Manual of Dcrmatology.'
1538
THOMAS W. CLARK
1 gm. every four hours for forty-eight hours, and then 1 gm. four times a day until the infection improves. Sodium bicarbonate is given in equal amounts with each dose of the sulfonamide. The common precautions are observed, and at the first sign of an untoward reaction the drugs are stopped. Medications which form eschars over excoriated surfaces have often been applied on a weeping dermatitis. Tannic acid and gentian violet were both used in the case described above. However, they are not recommended in this disease. The eschar may seal over an area of secondary infection and encourage its spread, as in this case. The eschar had no effect on the course of the disease and the protection it afforded to the denuded skin could have been given better and more safely with a bland ointment and bandages. Itching is generally present in all stages of this disease. It causes great distress and is difficult to control. Scratching is an important source of secondary infection and must be prevented. In the milder cases with little excoriation of the skin, the lesions are treated frequently with antipruritic lotion and covered with sterile dressings for protection. A clean and effective lotion is the following: ~
Phenol ....... ......................................... 2.0 Glycerine .............................................. 15.0 Lime Water ............................................ 120.0
Ointments are also soothing and helpful again~t itching. Even more effective in some patients than the lotions and the ointments are phenobarbital, aspirin and codeine. These are used freely. Corn starch and oatmeal baths are effective in relieving the intense itching in a few patients with extensive dry exfoliating lesions on the trunk and thighs. Baths are never used in the presence of secondary infection. One half to 1 pound of cornstarch is ample for a 40-gallon tub of water. Warm baths are better tolerated than cold. Even in a hot climate patients become chilly if left in the tub much over thirty minutes. It has been found best to limit the procedure to twenty to thirty minutes and to repeat it two to three times a day. INSECT AND MITE BITES
Fleas, mites and mosquitoes are present in great numbers and their bites are a constant source of annoyance to the troops. Mite bites on the ankles and legs are particularly troublesome. Secondary infections from scratching these lesions are common and persistent and often require hospitalization for treatment. Measures for the prevention of bites are taken whenever possible. Orders were issued to apply insect repellents liberally over the exposed parts. Formula 612, made by the National Carbon Co., Inc., is in our experience the best of these. Smeared frequently over the
1539
TREATMENT OF COMMON SKIN DISEASES
ankles and legs, "612" is very effective against mite bites. Sulfur preparations, recommended against the "chiggers" of the Southern United States, have not proved so satisfactory. Protective clothing is worn at all times. Beds are aired and sprayed frequently. While these measures do not completely eliminate the bites, they reduce the number. Treatment of insect bites is directed toward relief of the itching, thus reducing the incentive to scratch. Antipruritic lotions and pastes are helpful, although they are messy and their effects last only an hour or so. Nevertheless, they are well worth trying when an individual is suffering a great deal. The following lotion proved very useful: 1 :ij
Zinc Oxide ..... , ......... , .............................. Talc ............................. , ...................... Bentonite or Kaolin ...................................... Camphor ............................. , ............... ,.. Menthol ........................... ..................... Water .................................................. Alcohol, 95 per cent ..................... ,...............
25.0
25.0
5.0 5.0
0.5
30.0
30.0
Some persons cannot control their scratching and in these it is necessary to cover the bites with a protective bandage. Scratch infections are common and are extremely resistant to treatment. They vary anywhere from small pustules to furuncles and ulcers. If the lesions do not heal after a week of dispensary care, the patient is hospitalized and the same care is given as has been described for other secondary infections. The patient is put to bed. The lesions and surrounding skin are cleansed well with green soap, sterile water and alcohol. If the infection is severe and cellulitis is present in surrounding tissue, continuous hot saline compresses are applied for about twenty-four hours. Then the lesions are covered with a sterile ointment or gauze impregnated with an ointment. Sulfadiazine in a watersoluble base, boric acid ointment and petrolatum are all satisfactory for this purpose. The use of adhesive tape on the skin is avoided because it favors the development of satellite lesions. If no improvement occurs in a week with the above treatment, a full course of sulfadiazine or sulfathiazole is given by mouth. Experience shows that these infections once established tend to persist indefinitely even in the milder forms until the patient is put to bed and the lesions are protected from dirt and trauma. X·RAY
Facilities for the use of x-ray therapy were of necessity limited and our experience with this form of treatment was not great. In general, it was used most often against the chronic forms of epidermophytosis. The results were disappointing, although it was effective against the secondary infections that complicated this condition. Secondary in-
1540
THOMAS W. CLARK
fections can be managed by less risky means, and therefore the x-ray was not considered for routine treatment. CONCLUSION
The skin diseases most comlllonly found in soldiers on duty in the tropics are epidermophytosis, dermatitis venenata and insect and mite bites. Secondary infections sometimes complicate these conditions and cause prolonged hospitalization. Strong and irritating medications often aggravate the acute process. Good general care, strict adherence to aseptic surgical technics and the judicious use of local therapy are important factors in the treatment of these diseases. REFERENCE 1. Pillsbury, D. M., Sulzberger, M. B., and Livingood, C. S.: Manual of Dermatology. Issued under the auspices of the Committee on Medicine of the Division of Medical Science of the National Research Council. Philadelphia, W. R. Saunders Company, 1942.
W.
CLARK
MEDICAL CORPS, ARMY OF THE UNITED STATES
Methods used to treat the common skin diseases in an Army hospital operating for over a year and a half in the South and Southwest Pacific will be described. The disorders most commonly encountered at these stations are epidermophytosis, dermatitis venenata, insect and mite bites. Their characteristics are much the same as in the temperate zones but they tend to be more persistent and more severe. Secondary infection is a complicating factor in nearly every case, and it is not too much to say that it is most often the infection and not the primary disease that leads to hospitalization. The general care of these patients is of great importance. Difficult living conditions, a hot climate, and lack of appetizing food undoubtedly act to reduce men's stamina and resistance to infection. It is not uncommon to find that a chronic ulcer started as a trivial scratch or a cellulitis as a simple fissure. Rest, clean surroundings, well prepared foods, and vitamins in full doses are essential parts of the program of treatment. There is no question that these patients do far better in a dry fly-proof building where the details of cleanliness, asepsis and general nursing care are easier to attend to than in the ordinary ward tent as it is set up in the field. However, when only a ward tent is available, every effort is made to approximate the conditions of the better installation. The therapy as outlined in this paper is not original. It consists of measures that have proved satisfactory after a year and a half of experience in a tropical climate. Invaluable aid was obtained from the Manual of Dermatology by Pillsbury, Sulzberger and Livingood. 1 EPI DERMOPHYTOSIS
Epidermophytosis is one of the most persistent enemies of our men. In the tropics, where conditions are ideal for its development and spread, their difficulties with this disease are worse than in any other climate. It incapacitates them despite all efforts with soap and water, boiled socks and foot powder. The disease is frequently advanced and secondarily infected by the time the patients reach the hospital. Overtreatment is the commonest error in management. Strong solutions and strong ointments tend to irritate an already damaged skin, to hinder recovery, and even to aggravate the disease process. The tendency 1532
TREATMENT OF COMMON SKIN DISEASES
153 3
of doctors to adopt a routine course of treatment is often the reason why many cases of "athlete's foot" fail to improve. Treatment has to be individualized. It has to be cautious, and guided by the character and progress of the disease. The acute stage, characterized by fissures, vesicles, broken blisters and denuded areas between the toes and under the feet, is generally complicated by secondary infection. Control of this secondary infection is the first and foremost aim of treatment. The patient is put at complete bed rest. The diseased areas are gently debrided of all loose epidermis and the tops removed from the large blisters every day. The feet are cleaned with a mild sterile soap solution. Warm soaks in a weak fungicidal solution are started. Potassium permanganate is usually available, and a solution of 1: 10,000 (0.30 gm. in 3000 cc.) is quite strong enough. Solutions of stronger than 1: 5000 are irritating and harmful. The feet are soaked for twenty minutes three times a day and dried. If the disease is widespread or if there is extensive secondary infection, continuous warm compresses of the same solution are to be preferred. Between soaks, the feet are left uncovered. In cases with extensive weeping, the feet are exposed to dry heat under a cradle or in the sunlight to dry the skin and prevent maceration. When blisters or fissures between the toes are present, the opposing surfaces are separated with sterile powdered gauze. This again helps to prevent maceration of the skin. It is often desirable to put light sterile dressings over the affected areas during the night. In many cases the secondary infection disappears and the original fungous infection subsides after two to four days of rest and soaks. The vesicles, fissures and macerated areas dry up and the thickened epidermis slowly peels off. The feet are kept clean and dry with foot powder and the patient is watched until desquamation is complete and all evidences of activity have disappeared. More often, the. secondary infection subsides and the vesicles and blisters of the acute epidermophytosis are replaced by patches of thickened epidermis, with scaling and oozing from under the patches. A few more days of soaks with potassium permanganate solution sometimes control this condition. If no more improvement occurs within this time, one of the dyes in solution such as Castellani's paint'*' or 2 per cent gentian violet in 70 per cent alcohol is applied. Frazer's solutiont or tincture of iodine is ·Castellani's Paint: tFrazer's Solution: Saturated alcoholic solution of basic fuchsin 10.0 Salicylic acid ....... 2.0 Aqueous solution of phenol, 5% ............ 100.0 Benzoic acid ....... 2.0 Filter and add: Tincture of iodine 10.0 Boric acid ................................... 1.0 Spirits of camphor to After two hours, add: make ............. 60.0 Acetone ........... ....................... 5.0 After two hours, atlJ: Resorcin ......................... ,'........ 10.0 Keep in darri: stoppered bottle.
1534
THOMAS W. CLARK
also effective at this stage. It was found best to start off with a quarter to one-half strength solutions and to increase slowly until the full strength is applied twice daily. If any evidence of irritation appears, the medications are stopped. Most cases clear up entirely with potassium permanganate soaks alone or with potassium soaks followed by one of the medications mentioned above. A few enter a chronic stage characterized by thickened plaques of epidermis, scaling and fissuring. These lesions are resistant to treatment and characteristically relapse time and again. It is important to treat them cautiously because they are apt to flare up acutely when irritated. Solutions containing iodine from 1 to 7 per cent in strength often yield good results. These are painted on the lesions twice a day. If no improvement with iodine takes place within two weeks or if iodine irritates the lesions, other medications such as Castellani's paint or Whitfield's ointment are tried. Many weeks of continuous treatment are sometimes necessary before the lesions heal completely. Ointments have been widely used against all stages of this disease. There is no question that they are valuable at times, but by and large they are best avoided in the tropics. They favor the spread of secondary infection when applied over contaminated lesions. Whitfield's ointment is very valuable for softening up the dry scaling epidermis of the subacute and chronic stages. When applied it is rubbed into the lesions thoroughly. No dressings are placed over it. It is never used in the acute stage or when secondary infection is present. Treatment is started with mixtures of a quarter to half strength in order to avoid irritation of the skin, and full strength is reached gradually. Sulfur ointment proved to be of no value in this disease. Ammoniated mercury was mildly antiseptic but relatively ineffective against the fungi of epidermophytosis. Dermatophytids on the hands and ears are common complications of epidermophytosis of the feet or groin. They are characterized by vesicles, scaling eczemato id patches, fissures and varying degrees of erythema, and are· very similar to other dermatoses. They are often far more prominent than the primary lesion. The commonest error is to overlook the primary lesion on the foot or the groin and to mistake the "id" for a separate and distinct disease. The uncomplicated "id" will heal only when the primary disease is cured, therefore when confronted with such lesions it is important to look for epidermophytosis elsewhere on the body and to treat it as described above. The "ids" are treated symptomatically with mild medications. Potassium permanganate soaks are useful for drying up the oozing from broken vesicles. When there is much scaling and fissuring present, boric acid ointment or petroleum jelly is used to soften the lesions. When secondary infection is present it is treated as described above. After the disease has been controlled and the patient is ready for
TREATMENT OF COMMON SKIN DISEASES
1535
duty, he is rehearsed in the care of his feet with emphasis on the use of soap and water and foot powder. His shoes are fumigated by placing them in an air-tight container for twenty-four hours along with a sponge soaked in 30 per cent formaldehyde. Following this they are aired for twenty-four hours in the sunlight. The patient is told that recurrences may take place no matter how conscientious he might be and that at the first sign of renewed activity he should report for treatment. DERMATITIS VENENATA
The tropical forests are full of plants and trees whose leaves and barks .contain substances irritating to the skin. Contact with these substances results in conditions varying from momentary burning and reddening of the skin to the severest forms of dermatitis in which all layers of the skin become damaged. The very nature of the lesions increases greatly the likelihood of secondary infection unless care is taken to avoid contamination. Itching is usually intense and distressing to the patient. Treatment demands all the ingenuity at our command. As an example of the difficulties encountered the following case is cited. W. 0., a private in the Marine Corps, developed an area of burning and itching on the left wrist following contact with the black sap of the "Wannarla" tree (native name). Within a short time vesicles developed over the involved part. He was treated as an ambulatory patient for nine days. First, calamine lotion was applied, then tannic acid ointment and then salicylic acid ointment. The disease continued to progress and appeared on the right hand. The patient was admitted to sick bay and treated with continuous soaks of potassium permanganate solution of unknown strength. Blebs, tenderness and swelling rapidly developed on both hands. He was sent to the hospital two weeks after the onset of the disease. On admission the backs of the hands and wrists were covered with vesicles and blebs, many of which were broken. Large areas were denuded of epithelium and were covered with shreds of epidermis and pus. The surrounding tissues were swollen and red. The axillary and epitrochlear lymph nodes were enlarged and tender. There was no fever present although a pyodermia and cellulitis had clearly become superimposed on the original dermatitis (Fig. 135). A strict aseptic regimen was immediately instigated. The hands were debrided of all loose epidermis and crusts. The tops were removed from the larger blisters. The skin was cleaned with sterile solutions. Continuous warm saline compresses were applied and sulfathiazole was given by mouth, 2 gm. immediately and 1 gm. every four hours. In twenty-four hours the involved parts had become distinctlSr cleaner. Crusts and loose epidermis were carefully cleared away. The compresses were reduced to one hour twice a day, and sulfadiazine ointment was smeared generously over the lesions after the compresses were applied. All lesions were covered with sterile gauze bandages. This treatment was continued on both hands for five days. At the end of this time there was marked improvement although a few islands of infection still remained. The sulfonamides were discon-
1536
THOMAS W. CLARK
Fig. 135.-Appearance of the hands and anus of W. 0., a private in the Marine Corps, on admission to the hospital. The discoloration was due to potassium permanganate soaks applied before admission. Large blebs filled with pus and loose shreds of epithelium can be seen on the palms and fingers of both hands. The denuded and ulcerated areas are less distinct bill: visible as pale patches on the left hand and wrist.
TREA T~lEXT OF COMMON SKIN DISEASES
1537
tinued and 2 per cent gentian violet in 70 per cent alcohol was painted over the hands and forearms. In a short time several of the infected areas flared up. The gentian violet was stopped and warm compresses followed by sulfadiazine ointment were resorted to once again. [n three more days, all evidence of infection had disappeared. Scattered spots continued to weep clear scrum. These were touched with gentian violet every day until they healed. Gradually new epithelium grew over the denuded areas. Twenty-six days after admission the patient was discharged to duty.
i\lost of the patients with dermatitis venenata who are admitted to the hospital exhibit severe skin damage such as that described above. The condition of the skin is similar in many ways to a first or second degree burn and the same principles of treatment are followed. Sterile instruments for debriding, sterile solutions for washing, sterile ointments and gauze for dressings are all essential for the \vork. From the start, the diseased areas are protected with sterile coverings. First, the lesions are carefully debrided of all crusts and loose epidermis. The tops of blisters are removed. The involved areas are cleaned \vith green soap, sterile \\'ater and alcohol and then covered with a sterile ointment spread thinly. Boric acid ointment and petroleum jelly both are satisfactory for this purpose. Gauze impregnated \\'ith either ointment and autoclaved affords a neat method for applying these medications. The ointment not only protects the damaged skin from infection but also soothes the burning and itching that often causes great distress. When secondary infection is present it is treated promptly and according to its severit y-. If it is a simple superficial infection, the above regimen is usually enough to control it. A sulfonamide drug is sometimes added to the protective ointment. Five per cent sulfadiazine in a water-soluble base* is frequently used \\'ith excellent results. If a widespread pyodermia has developed with an underlying cellulitis and fever, more vigorous treatment is prescribed. The lesions are carefully debrided and cleansed as before. Warm saline compresses are applied for an hour every four to six hours. The moist compresses help to clear away the pus and crusts and also to combat the cellulitis. Between soaks the lesions are covered with dr:-' sterile dressings. When the dressings are removed they are soaked off in order not to damage any regenerating epithelium. The compresses are continued until the infection is well controlled. Generally, twent\--four to thirti--six hours are sufficient. Then ointment and gauze dr~ssings are applied as described above. As long as they are present, oozing and crusting lesions are covered in order to avoid the recurrence of infection. The more severe cases require sulfathiazoIc or sulfadiazinc bv mouth. The usual course prescribed for each drug is 2 gm. iIl1\J;cdiatcly, ''''arer-Soluble Rases: 1. Aquifor. 2. Hydrogcnatcd \- egetable Far. Other ointlllCilt bases llIay be found in the Manual of Dcrmatology.'
1538
THOMAS W. CLARK
1 gm. every four hours for forty-eight hours, and then 1 gm. four times a day until the infection improves. Sodium bicarbonate is given in equal amounts with each dose of the sulfonamide. The common precautions are observed, and at the first sign of an untoward reaction the drugs are stopped. Medications which form eschars over excoriated surfaces have often been applied on a weeping dermatitis. Tannic acid and gentian violet were both used in the case described above. However, they are not recommended in this disease. The eschar may seal over an area of secondary infection and encourage its spread, as in this case. The eschar had no effect on the course of the disease and the protection it afforded to the denuded skin could have been given better and more safely with a bland ointment and bandages. Itching is generally present in all stages of this disease. It causes great distress and is difficult to control. Scratching is an important source of secondary infection and must be prevented. In the milder cases with little excoriation of the skin, the lesions are treated frequently with antipruritic lotion and covered with sterile dressings for protection. A clean and effective lotion is the following: ~
Phenol ....... ......................................... 2.0 Glycerine .............................................. 15.0 Lime Water ............................................ 120.0
Ointments are also soothing and helpful again~t itching. Even more effective in some patients than the lotions and the ointments are phenobarbital, aspirin and codeine. These are used freely. Corn starch and oatmeal baths are effective in relieving the intense itching in a few patients with extensive dry exfoliating lesions on the trunk and thighs. Baths are never used in the presence of secondary infection. One half to 1 pound of cornstarch is ample for a 40-gallon tub of water. Warm baths are better tolerated than cold. Even in a hot climate patients become chilly if left in the tub much over thirty minutes. It has been found best to limit the procedure to twenty to thirty minutes and to repeat it two to three times a day. INSECT AND MITE BITES
Fleas, mites and mosquitoes are present in great numbers and their bites are a constant source of annoyance to the troops. Mite bites on the ankles and legs are particularly troublesome. Secondary infections from scratching these lesions are common and persistent and often require hospitalization for treatment. Measures for the prevention of bites are taken whenever possible. Orders were issued to apply insect repellents liberally over the exposed parts. Formula 612, made by the National Carbon Co., Inc., is in our experience the best of these. Smeared frequently over the
1539
TREATMENT OF COMMON SKIN DISEASES
ankles and legs, "612" is very effective against mite bites. Sulfur preparations, recommended against the "chiggers" of the Southern United States, have not proved so satisfactory. Protective clothing is worn at all times. Beds are aired and sprayed frequently. While these measures do not completely eliminate the bites, they reduce the number. Treatment of insect bites is directed toward relief of the itching, thus reducing the incentive to scratch. Antipruritic lotions and pastes are helpful, although they are messy and their effects last only an hour or so. Nevertheless, they are well worth trying when an individual is suffering a great deal. The following lotion proved very useful: 1 :ij
Zinc Oxide ..... , ......... , .............................. Talc ............................. , ...................... Bentonite or Kaolin ...................................... Camphor ............................. , ............... ,.. Menthol ........................... ..................... Water .................................................. Alcohol, 95 per cent ..................... ,...............
25.0
25.0
5.0 5.0
0.5
30.0
30.0
Some persons cannot control their scratching and in these it is necessary to cover the bites with a protective bandage. Scratch infections are common and are extremely resistant to treatment. They vary anywhere from small pustules to furuncles and ulcers. If the lesions do not heal after a week of dispensary care, the patient is hospitalized and the same care is given as has been described for other secondary infections. The patient is put to bed. The lesions and surrounding skin are cleansed well with green soap, sterile water and alcohol. If the infection is severe and cellulitis is present in surrounding tissue, continuous hot saline compresses are applied for about twenty-four hours. Then the lesions are covered with a sterile ointment or gauze impregnated with an ointment. Sulfadiazine in a watersoluble base, boric acid ointment and petrolatum are all satisfactory for this purpose. The use of adhesive tape on the skin is avoided because it favors the development of satellite lesions. If no improvement occurs in a week with the above treatment, a full course of sulfadiazine or sulfathiazole is given by mouth. Experience shows that these infections once established tend to persist indefinitely even in the milder forms until the patient is put to bed and the lesions are protected from dirt and trauma. X·RAY
Facilities for the use of x-ray therapy were of necessity limited and our experience with this form of treatment was not great. In general, it was used most often against the chronic forms of epidermophytosis. The results were disappointing, although it was effective against the secondary infections that complicated this condition. Secondary in-
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THOMAS W. CLARK
fections can be managed by less risky means, and therefore the x-ray was not considered for routine treatment. CONCLUSION
The skin diseases most comlllonly found in soldiers on duty in the tropics are epidermophytosis, dermatitis venenata and insect and mite bites. Secondary infections sometimes complicate these conditions and cause prolonged hospitalization. Strong and irritating medications often aggravate the acute process. Good general care, strict adherence to aseptic surgical technics and the judicious use of local therapy are important factors in the treatment of these diseases. REFERENCE 1. Pillsbury, D. M., Sulzberger, M. B., and Livingood, C. S.: Manual of Dermatology. Issued under the auspices of the Committee on Medicine of the Division of Medical Science of the National Research Council. Philadelphia, W. R. Saunders Company, 1942.