Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from 9sTeTIHE G&ADuIITE MEDICAL JOU1NAL VOL. IV; MAY, I929. No. 44. CONTENTS PAGE PITFALLS IN DERMATOLOGY ... ... ... ... ... ... ... 127 By A. C. ROXBURGH, M.D., M.R.C.P. PYELO-NEPHRITIS IN CHILDREN ... ... ... ... ... ... 135 By HAZEL H. CHODAK GREGORY, M.D., M.R.C.P.LOND. FIBROSIS OF LUNG IN CHILDREN ... ... ............. 140 By L. S. T. BURRELI., M.D., F.R.C.P ... ... ... .. ... ... 143 SURGICAL RESURRECTIONS-IV. ....... ... ... .......... ... ... 141 EDITORIAL .. .. ..... ... I43 copyright. POST-GRADUATE NEWS ... ... ... ... ... ... ... ... 143 FELLOWSHIP 'OF MEDICINE AND POST-GRADUATE MEDICAI, ASSOCIATION.- SPECIAL COURSES .. ... ... ... ... ... PITFALLS IN the diagnosis which he is at first inclined http://pmj.bmj.com/ to make, and with the points in favour of DERMATOLOGY. each. I propose therefore to talk to you about A POST-GRADUATE LECTURE DELIVERED TO THE' 'ELLO\\'- the differential of a number of SHIP OF MEDICINE AT THE MIEDICAL SOCIETY OF ,0ONDON, diagnosis FEBRUARY 18, 1929. conditions commonly met with which are apt to be confused one with another. You on September 29, 2021 by guest. Protected ,3y A. C. ROXBURGH. will realize, of course, that the list is far MI.D., M.R.C.P.., from complete. Physiciant - itn - Chargc of the Skinl Depalrtmenlct, St. Take first the common condition, small- Bartholomew's Hospital; Physicilan to St. .lohn's Hospital spored ringworm of the scalp. This is for Discases of the Ski,n. often confused with alopecia areata. The principal points to remember are, first, that IN the diagnosis and treatment of skin small-spored ringworm does not occur in disease there are many pitfalls for the un- persons over the age of I4 years. The wary, especially for those who are not next point is the character of the skin accustomed to see many skin cases in the surface. In ringworm this is scaly, and in course of their daily work. Many mistakes alopecia areata smooth and shiny. The in diagnosis arise from the unfamiliarity of third point is the character of the hair the physician with possible alternatives for stumps. In ringworm these are plentiful Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from 128 PITFALLS IN DERMATOLOGY and are present all over the surface of the light, while the normal hair looks only as affected patch. In alopecia areata they are though it had been lightly dusted with flour. usually scanty and only found near the By this means even one infected hair on periphery of the patch. The stumps them- an otherwise healthy scalp can be easily selves in ringworm are dull, inelastic, often identified. bent in the middle and, if examined in Hairs infected with large-spored ringworm liq. potassa under in. objective, are seen are not nearly so easy to see, as they fluoresce to have a coating of spores in the form of less brightly and with a bluish tint. A pit- a mosaic. In alopecia areata the stumps fall in this method is that if the hairs have are shiny and elastic like normal hair, that been recently painted with iodine or silver is, they spring back to their previous niitrate, or have had chrysarobin ointment positlOio if the finger is drawn over them applied, they will not fluoresce. against the lie of the hair. They are also A form of ringworm which sometimes of the shape called " exclamation mark " (!), causes difficulty is due to a large-spored that is, they are of the normal thickness at endothrix fungus, and is known as " black- the free end and very thin and depigmented dot" ringworm. In these cases the stumps at the inserted end. are broken off level with the skin surface Remember that not all the hairs in a and appear as black dots somewhat re- patch of ringworm are infected, and it is no sembling comedones. They have to be use sending hairs to a laboratory for micro- extracted wvith a needle or a comedo ex- scopic examination unless you are able to presser for microscopic examination. This select with the aid of a hand lens the hairs type does not die out at pubetty and maycopyright. which are probably infected. A good be found in adults. method is to rub the suspected patch well Difficulty may arise in the diagniosis with ether on a swab, to remove all grease, between alopecia areata and syphilitic and then examine with a hand lens in a alopecia. In alopecia areata there are g.ood light and look for short, dull, or usually a small number of completely bald whitish, bent hairs. Pull some of these out patches with sharply marked margins, and http://pmj.bmj.com/ and, if you are goinig to examine them your- possibly exclamation-mark hairs. In syphi- self, place them on a slide in liq. potassa litic alopecia there are a large number of under a cover glass. Warm over a flame irregular small patches, none completely anid then examine with - in. objective. You bald, involving most of the back and sides will see, in infected hairs, parts where the of the head and running into one aniother. hair is encased in a sheath of small, uniform- The result is to give a " moth-eaten " sized, perhaps polygonal, spores. Fat appearance. Other sigins of syphilis such on September 29, 2021 by guest. Protected dr-oplets sometimes provide a pitfall, but as adenitis, a rash, or mLcous patches will these are always of various sizes and never probably be present and will assist materially polygonal. in the diagnosis. In neither of these forms Examination by Wood's light in a dark of baldness is the skin scarred. There are, room is a great assistance. This is light however, a number of conditions leadinig to from a mercury-vapour lamp or other patchy baldness in which the affected areas source of ultra-violet light passed through are scarred, the skin being atrophic and the Wood's glass, the latter being a dark violet follicles absent. Some of these are as glass containing oxide of nickel. It allows follows:- certain of the long-wave ultra-violet to pass, Pseudopelade or cicatricial alopecia, a but very little else. This ultra-violet causes rare condition in which numerous small hairs infected by small-spored ringworm to atrophic bald patches occur, which coalesce fluoresce and shine brightly with a greenish to form irregular areas, generally on the Postgrad Med J: first published as 10.1136/pgmj.4.44.127 on 1 May 1929. Downloaded from PITFALLS IN DERMATOLOGY 129 vertex. There may be a faint pink or viol'et the commonest causes of diffuse fall of hair. halo about the hairs at the periphery of the The areas affected are the vertex and frontal patches. regions. These are also the areas from Lupus erythematosus causes depressed which the hair first falls in men who have an bald scars on the scalp, generally an inch or- hereditary tendency to early loss of hair. two in diameter. The follicles have dis- In hereditary early baldness and in the oily appeared in the centre and at the periphery type of seborrhoea the prognosis is not are filled with horny plutgs. There is usually good, but in the dry scaly type a good deal some erythema at the margini of the patch. can be done. Diagnosis is easy if typical lupus erythemina- Diffuse fall of hair in women after the tosus is present on face, ears, or hands, but m-enopause is often associated with hypo- occasionallythe disease is limited to the scalp. thyroidism, of which there will probably be Localized scleroderma (morphcea) may other signs to assist in the diagnosis. also cauise depressed bald scars on the scalp, Remember that alopecia areata sometimes possibly pigmented, and perhapswith a violet- involves the whole scalp very rapidly anid coloured border, but there is nio plugginig is the commonest cause of complete of the follicles as in lupus erythematosus. baldness. When the hair has been missinlg Herpes zoster frontalis may cause scars in for six months the chances of its return the distribution of the supra-orbital branch become progressively worse. of the fifth cranial nerve, but there will Scaliness of the scalp is due usually to probably be scars on the forehead, too, one of three causes: ringworm, seborrhoea, which will assist in the diagnosis. or psoriasis. Ringwor-m of the scaly type copyright. Favus may cause extensive scarring on is uinlikely to be found in adults. In the scalp of an irregular type. Some of the seborrhoea the scaliness is usually diffuse, yellow " favus cups" may still be present iln or if patchy the patches fade gradually into places, and the "mousy" odouir of the disease lhealthy skin. There may be lesions of may be noticeable. seborrhwea corporis over the sternum and Kerion, an acute purulent inflammatory between the scapulae, or of seborrhceic http://pmj.bmj.com/ reaction to ringworm infection, may cause dermatitis in the flexures. bald patclhes which are occasionally per- Psoriasis of the scalp is usually patchy, manent. In the active stage the inflamma- and the patches have absolutely sharp tion is obvious and infected hairs may be margins. There is generally psoriasis on the foulnd at the periphery. Wounds and boils body or limbs also, which gives away the nay also leave permanently bald scars. diagnosis. Permanent baldness due to over-dosage Pustular lesionis on the scalp are not neces- on September 29, 2021 by guest. Protected with] X-rays in the treatinent of ringwormii sarily boils; they may be patches of kerion, can ustually be recogniized by the presence of that is, inflammatory ringworm.