Psoriasis

“ Thimm gives the history of a patient, a man aged 36 years, who had been under his care for five years. He had an obstinate recurring extensive psoriasis eruption of the skin of the trunk and limbs, typical psoriasis lesions of the upper and lower lips, extending on to the mucous membranes of the mouth and nasal cavities. In addition, the mucous membrane of the mouth showed, while he was under observation, various circumscribed diseased patches, setting in synchronously with the eruption on the skin, which also disappeared at the same time after general treatment with arsenic. ”

“ Exceptionally this may be wanting in cutaneous psoriasis patches, but its absence is, as a rule, or even always, characteristic, in psoriasis of mucous membranes. In certain sections, however, the uppermost epithelial layers, one found, to a depth of three cell layers, were pressed together to form a dark-coloured narrow band, but having regard to the smooth contour of the surface this could hardly be looked upon as a partly developed scale. The pathological characters of any lesions are to a certain extent altered according to the position in which they occur. ”

“ Diseases of the skin tend to manifest themselves in certain parts of the body; i.e. certain diseases exert a selective influence on the sites of their eruption. Symmetry is characteristic of eczema, psoriasis, drug rashes and the eruptions of specific fevers, while others, such as herpes zoster, ring-worm, tertiary syphilis and new growths, tend to be asymmetrical. Eczema selects the flexor aspect of the limbs and the neighbourhood of folds of skin and opposed surfaces, while psoriasis favours the extensor surfaces and the outer side of the elbows and knees. ”

“ Here, again, married life is the best cure for this disease, as it is for so many others.
214It is very interesting to note during the question we are now discussing that persons suffering from psoriasis feel relief from their affection when they have had a good opening of the bowels, or when they perspire freely; hence in hot summer weather they suffer less inconvenience than in the winter; also by following a certain diet this disease may be favorably influenced; that is to say, such persons have fewer psoriatic patches when the toxic products are eliminated by the intestines or kidneys. ”

“ Psoriasis, another harmless, non-contagious, and very common skin disease, is often mistaken for syphilis. Gross injustice and often much mental distress are inflicted on unfortunates who have some skin trouble by the readiness with which persons who know nothing about the matter insist on thinking that any conspicuous eruption is syphilis, and telling others about it. Even with an eye trained to recognize such things on sight, in the crowds of a large city, one very seldom sees any skin condition which even suggests syphilis. ”

“ From psoriasis, scaly eczema, and the other inflammatory scaly disorders it may be distinguished by the absence of inflammation.
The prognosis of the affection, as already intimated, is unfavorable as regards its cure. In only a few cases has a cure been noted. Hebra reports two such cases, the disappearance of the affection having followed an attack of one of the exanthematous fevers. Internal treatment is very rarely, if at all, of any benefit. ”

“ Treatment consists in the removal of the redundant nail-tissue by means of the knife or scissors; and, when dependent upon eczema or psoriasis, the employment of remedies suitable for these diseases. When it is the result of syphilis, the medication appropriate to this disease is to be employed. ”

“ In psoriasis the epidermis separates in flakes at various spots which have not been subjected to pressure, and to cure it ointment Inflammation.containing tar or other products of the dry distillation of wood is employed. When the true skin is inflamed various appearances may arise, according to the intensity and extent of the inflammation, and the eruption may be papular, vesicular, pustular, tubercular, bulbous or ulcerative. To lessen irritation the skin is protected by dusting powders, such as oxide of zinc, starch, fuller’s earth, &c., or by ointments. ”

“ Pregnancy cannot be regarded as a cause of psoriasis. When that affection exists, however, it is usually aggravated. The elder Hebra24 in 1872 described a rare form of skin disease occurring in the course of pregnancy which he called herpes impetiginiformis, and of which he encountered five cases. Grouped vesicles upon inflamed bases appear about the genitalia, and subsequently diffuse themselves by successive crops over the body. Great prostration, rigors, and intense fever accompany the eruption. ”

“ The history of eczema is different: it rarely begins as circular spots, spreading peripherally; the margins are always more or less irregular; the hairs are not involved, but remain seated firmly in the follicles; the itching is marked, whereas in ringworm it is usually slight. Seborrhoea is non-inflammatory; the scales are greasy; the hairs are not broken off; and the margins of the patch are ill defined. In psoriasis the scaling is a marked feature; the hairs are not involved; and the disease is usually to be found typically expressed on other parts of the body. ”

“ Other valuable applications are: lotions of carbolic acid, of liquor carbonis detergens, of boric acid; alkaline baths, mild sulphur ointment and carbolized oxide-of-zinc ointment, and dusting-powders of starch, zinc oxide, talc and boric acid. A two- to ten-per-cent. ichthyol lotion or ointment is sometimes of advantage; thiol employed in the same manner has also been commended.
Psoriasis.
Give a definition of psoriasis.
Psoriasis is a chronic, inflammatory disease, characterized by dry, reddish, variously-sized, rounded, sharply-defined, more or less infiltrated, scaly patches. ”

“ The disease may also be mistaken for lupus erythematosus in its early stage. The involvement of the sebaceous glands in [p. 617] almost all cases in the latter affection, the character of the scaling, and the fact that the face is the usual locality attacked, will aid in the diagnosis. Ringworm of the general surface may also bear resemblance to psoriasis, especially to the circular form, but the parasitic disease is more superficial and more marginate, is less scaly, and runs a more acute course. In doubtful cases the microscope should always be employed to determine the question. ”

“ Lupus vulgaris may be excluded by the absence of papules, tubercles, and ulceration. The sebaceous involvement and the peculiar atrophy and superficial scarring are, moreover, not seen in lupus vulgaris. Erythematous lupus begins, as a rule, during adult life; lupus vulgaris usually in childhood. In psoriasis the course and symptoms peculiar to that disease will distinguish it from lupus erythematosus. It is scarcely possible to confound the disease with eczema or syphilis. In some cases in the beginning of the affection it may resemble seborrhoea ”

“ Liquid sporokton may be employed for the instantaneous preparation of a bath or lotion of sulphurous acid, to be used, under medical direction, in the treatment of itch, ringworm, chronic eczema, lepra, psoriasis, impetigo, pityriasis, &c., in man, as well as mange, scab, and other skin affections in the lower animals. ”

“ The general practice amongst modern dermatologists is to use only chrysophanic acid, which may be applied externally and given by the mouth in doses of about one grain in cases of psoriasis and chronic eczema. ”

“ In the former, after nerve-injuries more especially, we observe loss of thickness, glossiness, and perverted circulation and secretion; the hairs may fall out or grow abnormally; the nails are slow of growth, thick, rugose, incurvated, and brittle. In other cases, as in cerebral and spinal paralyses, the skin of the paralyzed part is abnormally dry, rough, and furfuraceous, and it loses its elasticity. In some varieties of so-called skin diseases the patches of altered nutrition (eczema, bullæ, herpes, psoriasis, leucoderma, scleroderma, etc.) ”

“ In certain diseases of nervous origin, notably in herpes zoster, the eruption follows the course of a certain nerve. In the face we get erythema, lupus erythematosus, rosacea, eczema, actinomycosis, &c, and syphilitic and malignant ulcers. Rodent ulcer usually selects the face, and generally the nose or orbit. The face too is usually the selective site of lupus vulgaris. The scalp is the chief site oi two varieties of lesion — the pustular, as in pustular eczema and impetigo contagiosa, or the dry and scaly eruptions, as psoriasis, ringworm and squamous syphilides. ”

“ While disclaiming that “Hemo-Therapin is an infallible panacea,” the medical profession is asked to believe that:
“In erysipelas, septicemia, pyemia, the acute fevers, puerperal infection, furunculosis, carbuncles, malaria, acute rheumatism, pneumonia, typhoid fever, and in various skin diseases, such as eczema, psoriasis, herpes zoster, etc., the results have been prompt and gratifying.”
It is “no less effective” in such “chronic ailments” as:
“... ”

“ It has long been a popular remedy in chronic rheumatism, rheumatic and gouty pains, scurvy, scrofula, syphilis, secondary syphilis, lepra, psoriasis, and several other skin diseases; and, especially, in cachexia, or a general bad habit of body, and to remove the symptoms arising from the injudicious use of mercurials, often falsely called ‘secondary syphilis.’ During its use the skin should be kept warm, and diluents should be freely taken. Its efficacy has been greatly exaggerated. It is, however, much more effective in warm than in northern climates.—Dose. ”

“ Eczema.—This is the most common of all skin affections. It is a non-contagious, inflammatory disease of the skin, sometimes acute, but more often chronic, attended with itching and desquamation or loss of cuticle. With the itching may be a feeling of heat and tension in the part.
Eczema is a local disease, brought about by a local irritation in the skin; but, in addition to this, there is generally a predisposing cause, as some disorders of the digestive tract, a bad condition of the blood, and so forth. The skin, like other organs of the body, depends on the whole system for its nutrition. ”

“ In doubtful cases, an observation of several weeks will always suffice to distinguish it from eczema, erythema multiforme, herpes iris and pemphigus, diseases to which it at times bears strong resemblance.
Give the prognosis of dermatitis herpetiformis.
An opinion as to the outcome of the disease should be guarded. It is exceedingly rebellious to treatment, and relapses are the rule. Exceptionally the bullous and pustular varieties prove eventually fatal. The erythematous and vesicular varieties are the most favorable. ”

“ Another form of eczema is simply a very badly chafed condition accompanied by intense itching, and commonly known as "dry eczema." A very disagreeable form is the pustular variety. One poor little sufferer that was once brought to us had so many pustules on his head that one could not put a ten cent piece on his scalp without touching a pustule. The treatment of these cases, in order to be effective and leave the child's head in normal condition, must be administered with the utmost patience every day for weeks. A doctor's help is always required in combating this sort of skin trouble. ”

“ The hairy portion of the neck may also be invaded. The disease may begin by the formation of papules and pustules about the hair-follicles on previously healthy skin, or chronic hyperæmia, or even eczema, may have preceded. The lesions generally occur in numbers, in close proximity, and, together with the accompanying inflammation, make up a patch of disease involving a greater or less area. The pustules are discrete, flat or acuminated, small in size, yellowish in color, perforated by hairs, show no disposition to rupture, and are, as a rule, apt to appear in crops. ”

“ You also observe that I give them a dose and tell them to return in a week or ten days. When they return they often exhibit a splendid crop of symptoms, and I experience no trouble then in finding the remedy. These cases usually have a history of suppressed eruption. At some time in their lives the itch, or eczema, or some other skin trouble has been driven into their system by external medicaments in the form of ointments, washes, etc. Lifelong ailments, over which the old school have no control, are the result. A large percentage of chronic diseases are due to this cause alone. ”

“ Affections of the Skin.—Although all types of skin affection are met with in the inherited disease, the most important is a papular eruption, the papules being of large size, with a smooth shining top and of a reddish-brown colour. It affects chiefly the buttocks and thighs, the genitals, and other parts which are constantly moist. It is necessary to distinguish this specific eruption from a form of eczema which occurs in these situations in non-syphilitic children, the points that characterise the syphilitic condition being the infiltration of the skin and the coppery colour of the eruption. ”

“ In the pustular and bullous varieties there may be mild or grave systemic symptoms, but even in these types the constitutional involvement is, in most instances, slight in comparison to the intensity of the cutaneous disturbance.
What is the course of dermatitis herpetiformis?
Extremely chronic, in most instances lasting, with remissions, indefinitely. The skin is rarely entirely free. From time to time the type of the disease may undergo change. From the continued irritation and scratching more or less pigmentation results. ”

“ Eczematous symptoms may be superadded. In severe cases the entire extensor surfaces of the legs and arms, and in some instances the trunk also, are invaded. It is worse in the winter season. [Pg 119]
What is known in regard to etiology and pathology?
It is a disease of the ill-fed and neglected, usually developing in early childhood, and persisting throughout life. It is extremely rare, even in its milder types, in this country. Clinically and pathologically it bears some resemblance to papular eczema.
Give the prognosis and treatment of prurigo. ”