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. penicillin, either by local or general medica- Local treatment with the first group usually tion, or both. Many of the cases are associated Protected by copyright. shows a dramatic response with little tendency with a seborrhoeic dermatitis and on that to recur unless the condition' is long standing, account do not respond. In others there is an and the deeper parts of the hair follicle have associated otitis media which needs attention. become infected. In these more chronic The largest group, however, has neither middle conditions treatment must be persisted with ear disease nor seborrhoeic dermatitis, and is for weeks or even months, and for some time often complicated by recurrent furuncles in after apparent cure, and the final result is the meatus, but nevertheless does not seem to satisfactory. In the second group an equally respond to penicillin, possibly because of the satisfactory result is obtained temporarily, great meatal swelling and interference with the but unless the primary focus is appropriately blood supply. I find packing and the antiseptic treated the condition will of course recur. In dyes a more satisfactory treatment.

the third group the secondary folliculitis shows http://pmj.bmj.com/ great improvement for a few days, but fre- Echthyma quently at this stage the seborrhoeic condition This is not an uncommon condition found (see seborrhoeic dermatitis below) becomes usually in children suffering from malnutrition, exacerbated by the local application of peni- but occasionally in adults as well. It is seen cillin with the production of an acute as isolated lesions chiefly on the legs and thighs, dermatitis. In cases therefore with a primary commencing as a reddened papule which

seborrhoeic basis, after four or five days of becomes vesicular and then covered with a on September 24, 2021 by guest. local treatment with penicillin, vigorous anti- dirty looking crust. When this falls off or is seborrhoeic treatment3 will complete the cure. removed, a small superficial indolent ulcer is formed, often surrounded by an inflammatory Acne Vulgaris halo, and healing is usually slow. If the crusts Acne is a constitutional disease, and does are removed, however, and penicillin is applied not itself respond to penicillin. In the in- locally two or three times'daily, healing is fected, pustular types of acne a short pre- greatly accelerated with satisfactory results. liminary course of local treatment is useful to clear up secondary infection, but must be Leg Ulcers immediately followed up by attention to the In this country these are mostly due to acne. circulatory disturbances, and particularly to Postgrad Med J: first published as 10.1136/pgmj.23.262.387 on 1 August 1947. Downloaded from 390 POST GRADUATE MEDICAL JOURNAL August 1947 varicose veins. I have found penicillin cream ment with penicillin of secondary sensitization of great use in these cases if used for a period eruptions due to fungus often leads to an of some seven to ten days, when the ulcer exacerbation of the condition. becomes much cleaner. After this time I dis- continue penicillin and revert to the more Virus Conditions usual treatments (always including some form Whereas there is some proof that infected of bandaging to reduce oedema) with good virus conditions of the skin may be improved results. To continue for longer than two by penicillin, and a case of infected herpes weeks with penicillin leads, in my experience, zoster6 was so treated, uncomplicated cases of to a slowing down of the healing processes. zoster and varicella are unaffected. I have Granulation tissue seems to become inhibited now come across four cases of herpes simplex and there is also a tendency for penicillin treated previously with local penicillin where resistant organisms to grow in the ulcer. the condition has spread under the influence of Where there is much dermatitis surrounding the treatment. One case I saw after three the ulcer penicillin must. be used with care, as weeks of treatment had an extensive herpes occasionally an exacerbation of the dermatitis simplex spreading over almost half the fore- is caused by the penicillin. Reports4 on the head. In endeavouring to account for this it treatment of tropical ulcer with penicillin seemed to me logical to assume not that the have been very favourable, and this seems to virus lived better in an atmosphere of peni- be the treatment of choice in this condition. cillin, but that the normal mild secondary Infectious Eczematoid Dermatitis infection which usually occurs when the Protected by copyright. vesicles rupture, was prevented by the action This is a condition of acute dermatitis in of the penicillin. It is very possible that the the form of a plaque or plaques, made up of virus is killed by the secondary pyogenic erythema, vesicles, pustules and crusting and organisms in the normal event, and when this spreading peripherally. The edge is often is prevented by penicillin, the virus spreads. undermined or raised, and exudes seropurulent fluid. The patient may be undernourished or Other Conditions give a history of some small trauma. The condition often proves resistant to treatment, Conditions such as psoriasis, lichen planus, and although penicillin has improved the Pityriasis rosea and pemphigus, where the position, most of the cases still respond very aetiology is unknown, are unaffected by slowly, and if the condition is at all extensive or penicillin. affects the legs, treatment is best carried out in http://pmj.bmj.com/ bed. I have a personal preference for the Venereal Diseases antiseptic dyes, together with rest and tonics. Details of these treatments must be sought elsewhere, but gonorrhoea usually responds Eczema dramatically to penicillin, as does the early Eczematous eruptions generally of whatever (treponema positive, sero-negative) case of types do not do well on penicillin. Unless in- syphilis. Late primary, secondary and tertiary fected, conditions such as infantile eczema, syphilitics are also given a full preliminary dose on September 24, 2021 by guest. exogenous (contact) dermatitis, nummular of penicillin, with considerable clinical im- eczema and the eczematides are either un- provement, but this is now usually followed up affected or exacerbated. Cases have been by treatments of varying lengths with arsenic described5 of vesicular eruptions actually and bismuth. occurring during the administration of peni- cillin, and it is wiser, in the absence of specific Reactions indication, to avoid the drug in these cases. These are uncommon but do occur. Some of the reactions have been put down to im- Fungus Diseases purities in the drug, and as the purer penicillin These appear to be totally unaffected by comes to be used, these may become less. penicillin, unless secondarily infected. Treat- True contact dermatitis has been reported, Postgrad Med J: first published as 10.1136/pgmj.23.262.387 on 1 August 1947. Downloaded from August I947 MARRE: Penicillin in Skin Diseases 391 especially with workers with penicillin, but the generalized urticaria, which fortunately res- usual manifestations are erythema, urticaria ponds well to ' Benadryl' capsules (50 mgms. and a serum sickness type of reaction. three times daily). Herxheimer reactions have been reported in REFERENCES cases treated for syphilis. Patients with I. M.R.C. War Memorandum No. I2. 1944. Reprinted, 1946. 2. MARRE, I. R., 'General Treatment of Skin Diseases,' Post seborrhoeic dermatitis often respond badlv to Grad. Med. Y., Vol. xxiii, No. 255. 3. MARRE, I. R., Seborrhoeic Dermatitis,' Post Grad. Med. J7., penicillin, as do others with allergic or sen- Vol. xxiii, No. 257. 4. HAMM, W. G., and QUARY, G. (I944), 'Penicillin Therapy in sitization eruptions, resulting in an exacerba- Phagedenic Ulcer,' U.S. Natv. M. Bull., 43, 98I, November. tion of the condition. On a number of 5. GRAVES, W. N., CARPENTER, C. C., and UNANGST, R. W. (1944), 'Recurrent Vesicular Eruptions Appearing occasions, I have seen a local urticaria with During the Administration of Penicillin,' Arch. Derm. Syph., Vol. 5o, No. i. July. penicillin in oil and wax suspensions, but the 6. COHEN, T. M., and PFAFF, R. 0. (I945), 'Penicillin in Dermatological Therapy,' Arch. Derm. Syph., Vol. 5I, No. usual reaction to the drug is a widespread and 3. March.

BOOKS RECEIVED The Editorial Board acknowledge with thanks the 'Aids to Qualitative Inorganic Analysis.' By receipt of the following volumes. A selection from R. G. Austin, B.Sc. znd Edition. (Pp. 207, 5s.) these will be made for review. Bailliere, Tindall and Cox. I947. Protected by copyright. 'The Rotunda Hospital, 1745-1945.' By O'Donel 'The Microscope.' By Theodore Stephanides, T. D. Browne, F.R.C.P., F.R.C.O.G. (Pp. 296, M.D. (Pp. i6o, ios. 6d.) Faber and Faber Ltd. 44 illustrations, 42s.) E. & S. Livingstone Ltd. '947. Monographs on the Progress of Research in Holland: 'Mongolism and Cretinism.' By Clemens F. ' A Contribution to the Knowledge of the In- Benda, M.D. (Pp. 330, IO illustrations, 25S.) fluence of Gonadatropic and Sex Hormones on the WVm. Heinemann. Medical Books Ltd. 1947. Gonads of Rats.' By J. H. Gaarenstroom and S. E. de Jongh. (Pp. I 64, I 6s.) Published by 'A Handbook of Diseases of Children.' By Elsevier. Distributors Cleaver-Hume Press. I947. Bruce Williamson, M.D., F.R.C.P. 5th Edition. 'Experimental Embryology.' By M. W. Woerde- (Pp. 408, 86 illustrations, J5s.) E. & S. Livingstone man, M.D., and Chr. P. Raven, Ph.D. (Pp. I32, ltd. T947. 13s.) Published- bv Elsevier. Distributors Cleaver- Hume Press. I947. http://pmj.bmj.com/ Nutritional Disorders of the Nervouts System.' By John D. Spillane, M.D., F.R.C.P. (Pp. 28o, ' Medicine.' Volume I. By A. E. Clark- Livingstone Ltd. 1947. Kennedy, M.D.. F.R.C.P. (Pp. 383, 20s.) E. & S. 20S.) E. & S. Livingstone Ltd. 1947. ' Medical Diseases in Tropical and Sub-Tropical ' Handbook of Diagnosis and Treatment of Areas.' The War Office. 8th Edition. (7s. 6d.) Venereal Diseases.' By A. London: His Majesty's Stationery Office. I947. E. W. McLachlan, M.B., Ch.B., D.P.H. 3rd Edition. (Pp. 375, i6o on September 24, 2021 by guest. illustrations, E. & S. Livingstone Ltd. I947. 'History of the Library.' London School of I5S.) Hygiene and Tropical Medicine, incorporating ' Introduction to Dermatology.' By G. H. The Ross Institute. (Pp. 24) Keppel Street, Percival, M.D., F.R.C.P.E. (Pp. 349, 233 illustra- Gower Street, London W.C.i. 1947. tions, 35s.) E. & S. Livingstone Ltd. I947. 'Clinical Methods of Neuro-Ophthalmologic 'Vital Statistics and Public Health Work in the Examination.' By Alfred Kestenbaum, M.D. Tropics, including Supplement on the Genealogy (Pp. 384, 65 illustrations, 25s.) Heinemann. of Vital Statistics.' By P. Granville Edge, O.B.E., Medical Books Ltd. I947. D.Sc. (Pp. 265) Bailliere, Tindall and Cox. 1947. 'Atlas of Bacteriology.' By R. Cranston Low, 'A Way of Life for the Handicapped Child.' M.D., and T. C. Dodds. (Pp. i68, i68 illustra- By Eirene Collis. (Pp. i83, ios. 6d.) Faber and tions, 32S. 6d.) E. & S. Livingstone Ltd. I947. Faber Ltd. 1947.