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Penicillin in Skindiseases 387 Postgrad Med J: first published as 10.1136/pgmj.23.262.387 on 1 August 1947. Downloaded from PENICILLIN IN SKIN DISEASES By I. R. MARRE, M.R.C.S., L.R.C.P. Skin Physician to the Metropolitan, Evelina and Acton Hospitals It is now well recognized that penicillin is To these should be added Treponema no panacea, but nevertheless it is a remarkable Pallidum and Spirochaetes (susceptible) and drug, and clinicians in every branch of medicine Monilia, Yeasts and Moulds (insusceptible). have good reason to be thankful for its useful- It will thus be seen that most of the gram ness in their own spheres. It is superior to the negative bacteria are insusceptible, except for sulphonamides in that it has a greater range of the gonococcus and the meningococcus, but effectiveness against bacterial diseases, in that that the main pyogenic cocci, which are the it is virtually non-toxic, in that it rarely causes usual cause of septic skin diseases, are highly sensitization, in that its action is not inhibited susceptible. The viruses are unaffected by by serum, pus or blood. penicillin, and there seems no point in using Certain bacteria are highly susceptible to the drug in conditions such as herpes zoster penicillin, and others less so, while there is and herpes simplex. Indeed I shall show later unfortunately a long list of' insusceptible that in the latter disease it may actuallyr be un- organisms. wise to use penicillin. Again in allergic and The Medical Research Council' list the constitutional skin conditions, unless infected, Protected by copyright. principal bacteria as follows. one would expect no favourable response and this is in fact what happens. The fungus in- Susceptible fections form a large group' of skin troubles Gram positive cocci: which are also unaffected by penicillin. Staphylococcus Aureus. Penicillin may be administered in a number Streptococcus Pyogenes. of ways. Injections may be given intra- Other streptococci (except entero- venously, intramuscularly or subcutaneously, coccus). either by continuous drip or three-hourly Pneumococcus. intermittent injections. The three-hourly in- Clostridia: jections are given in aqueous solution of I5,000 Cl. welchii. to 20,000 units. For most skin diseases it is Cl. septicum. sufficient to admi'nister penicillin, where in- http://pmj.bmj.com/ Cl. oedematiens. jection is indicated, twice daily, either 300,000 Cl. tetani. units in aqueous solution per dose, or I50,000 Neisseria: units in oil and wax suspension. Mv own pre- N. gonorrhoeiae. ference is to give aqueous solutions as there N. meningitidis. seems to be a 'rather more rapid clinical Miscellaneous: response and no liability to local reactions B. anthracis. from the suspension which occurs occasionally. on September 24, 2021 by guest. Actinomyces bovis (variable). Local infiltration and injection have' been C. diphtheriae. described, especially for abscesses and car- buncles, but I prefer general administration. Insusceptible Local treatments are of particular' im- Proteus. portance in skin diseases and penicillin may be Ps. Pyocyanea. applied by means of creams, ointments and Coli-typhoid-dysentery group. sprays. Creams and sprays are fairly unstable Pasteurella and Brucella. and have to be kept in a cool place or in a Str. faecalis (enterococcus). refrigerator, and renewed at least every seven M. tuberculosis. days. Cremor-penicillini B.P., is a lanette wax -388 POST GRADUATE MEDICAL JOURNAL A4ugt 1 947 Postgrad Med J: first published as 10.1136/pgmj.23.262.387 on 1 August 1947. Downloaded from cream made up to 500 units per gramme, but I Impetigo Contagiosa prescribe the cream made up to ii,ooo units per This extremely common disease is to be gramme, and I think the results are better. found in infants as impetigo (pemphigus) The spray should be made up in sterile water neonatorum, a bullous staphylococcal eruption at the same strength (i,ooo units per c.c.), and which spreads rapidly, and is vety contagious. kept in an all glass spray, which should be In older children and adults the typical boiled between changes of penicillin solution. streptococcal impetigo with its honey-coloured Penicillin ointment B.P., is an ointment of 'stuck-on,' crusts isjmore usual, or the deeper wool alcohols (500 units per gramme) which is bullous staphylococcal type. Early cases said to keep for months at room temperature, respond well to local therapy in the shape of owing to its anhydrous constitution. This is a cream or ointment applied three times daily, greasy ointment and must be used with care, but in more severe cases injections as well may and again I use this at double strength. be needed. In impetigo neonatorum careful Although the spray is perhaps the most snipping of the blisters before applying the difficult to keep at home, I find it the most cream aids recovery. Improvement should be effective treatment if used often enough- noted after the first day or two, and recovery three or four times daily, and allowed to dry should be almost complete within five or six on. It is certainly very effective in the super- days. If penicillin has had no effect in this ficial coccal infections. All the preparations time, the treatment should be changed, as the should not be contaminated with the finger or organism is likely to be insensitive. It should be borne in mind that impetigo is often an unsterile spoon or spatula, for fear of intro- Protected by copyright. ducing insusceptible organisms. Cream or secondary to scabies, pediculosis capitis or ointment can be removed from the container vestimentorum, a discharging ear or some with some instrument which has been held in other focus of infection, and that the impetigo boiling water, and then cooled rapidly in the will recur unless the primary condition is air. If crusting is severe, this may be gently treated subsequently. All cases of impetigo removed by oil packs or boro-starch poultices,2 should be carefully investigated for infestation but mild crusting may be left to dry or fall off or foci of infection. in the course of treatment. Furunculosis Penicillin appears to be absorbed by the Boils are staphylococcal abscesses originating gastro-intestinal tract, but to obtain any sort in and around a hair follicle. Carbuncles may of concentration in the blood it is necessary to be described as a group of boils in close give very large quantities, at least five times proximity, becoming one large circumscribed http://pmj.bmj.com/ that by injection. The method is uncertain, mass with a few openings through which pus and is not used routinely, although work is discharges. Where the boil is single and small, being carried out in this direction. Mouth in- local application of penicillin cream or oint- fections do respond to lozenges (Trochiscus ment may effect a cure, and will prevent the Penicillini B.P.), which contain 500 units per spread of secondary boils in the area. Where gramme, but persistence with this form of boils are multiple and large, systemic penicillin treatment for more than a few days results in a should be administered, possibly accompanied on September 24, 2021 by guest. glossitis. by local treatment as well. After the attack Cultures of organisms from septic skin has been dealt with, an autogenous or stock areas should be routine in hospital, together staphylococcal vaccine is of great value in with testing for penicillin sensitivity, but raising resistance against the organism, and treatment of severe and acute cases should not should be given routinely in a case of any be held up on this account, but should be severity. The patient should also be thoroughly started as soon as the culture has been taken. examined for any systemic disorder rendering In general practice it will be difficult to do this, him more liable to septic infection, such as and, in view of the fact that most pyodermias diabetes, nephritis, dysentery or general de- are caused by sensitive organisms, full treat- bility. Septic foci should be sought and dealt ment may be given at once. with if present, and tonics prescribed. Pedicu- 'Agt- I947 uMARRE: Penicillin in Skin Diseases.'.89 .3-89 Postgrad Med J: first published as 10.1136/pgmj.23.262.387 on 1 August 1947. Downloaded from losis capitis is a common cause of boils on the Seborrhoeic Dermatitis scalp, neck and back in school girls and even in This too is a constitutional disease, and one women. would not therefore expect it to respond' to penicillin. In many cases there is no effect, Sycosis Barbae but in a number of cases, patients with this This is a staphylococcal folliculitis of the condition show a marked sensitivity to peni- bearded area, and is often known as barber's cillin, with an acute exacerbation of the disease. rash. The response to this disease is on the Where the seborrhoeic dermatitis is infected it whole good, and local treatment is usually is justifiable to use local'penicillin for a few sufficient, unless the degree of infection is un- days only, to be followed up by the usual usually severe. For the purposes of treatment seborrhoeic treatments. It is my practice it is sufficient to divide sycosis into three never to use penicillin in uncomplicated groups. seborrhoeic dermatitis, and, when infected, (a) Primary infection, or following on a only under the strictest supervision and for a superficial infection such as impetigo. limited period. (b) Infection secondary to other local foci, particularly septic conditions of the mouth and Otitis Externa gums, of the nose and nasal sinuses, and of the ear. This common and acutely uncomfortable (c) Infection following on seborrhoeic condition has not, in my hands, responded to dermatitis.
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