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i 6z Postgrad Med J: first published as 10.1136/pgmj.23.257.162 on 1 March 1947. Downloaded from

SEBORRHOEIC By I. R. MARRE, M.R.C.S., JL.R.C.P. ( Physician to the Acton and Evelina Hospitals)

Seborrhoeic dermatitis is an acute or chronic Description inflammatory condition of the skin, occurring mainly in certain areas of the body, but able to On the this may consist in the mild spread to any part. It is commonly associated form of a powdery scaly condition known as with a scaly eruption of the scalp. . Other cases may show a yellowish, greasy scaliness on an erythematous base, which may develop into oozing crusting Etiology lesions, diffuse or in patches. There is a Malassez in I874 described the Pityrosporon, varying amount of itching, sometimes severe, a yeast-like . (the ' Flask' bacillus), and the condition is often associated with the found constantly in pityriasis capitis and loss of hair, which in the affected areas becomes seborrhoeic dermatitis, but not in other scaly frayed and brittle, and tends to fall out. This Protected by copyright. lesions of the body. It is thought by many is particularly found about the temples to be the cause of the condition; by some to and . be a saprophyte. Accompanying the acute condition of the There are other factors which have an scalp, the are often affected. Redness, undoubted etiological significance. Some scaliness, fissuring, oozing and crusting occur, people have a type of skin associated with an especially in the post-auricular region, and increased output of sebum or grease (sebor- may spread down the neck. The scalp erup- rhoea oleosa). The skin is muddy and some- tion may extend below the hair margin in a what thickened, with enlarged pilosebaceous sharply defined inflammatory line covered with follicles, and is particularly liable to ' sebor- crusts, known as the Corona Seborrhoica: rhoeic' , such as pityriasis capitis, The condition is contagious and spreads by seborrhoeic dermatitis and . The con- scales shed from the scalp on to the glabrous http://pmj.bmj.com/ dition is functional and often familial, and skin. It may also be spread by infected affects particularly the forehead, nose, sternal combs and brushes. The may retnain and interscapular regions, and genital confined to the scalp for months or years, or organs. may spread rapidly to the adjacent areas, or An endocrine disturbance or imbalance is to other parts of the body. strongly suggested by the fact that seborrhoea On other parts of the body the condition and its associated complicatiofis often start first appears as round or oval scaly macules or on September 26, 2021 by guest. about . A dietary factor is sometimes , pinkish-yellow in colour, and develop- present, as certain foods undoubtedly act as ing into two main types of lesions: (i) a scaly' a contributing factor. erythematous type, which affects the sebor- Macleod and Muende define the nature of rhoeic areas especially; (2) an oozing fissured seborrhoeic dermatitis: ' Seborrhoeic der- type which occurs in the flexural regions. matitis is. probably due to an with a On the the first type is more common, yeast-like fungus, the pityrosporon, which wvith greasy scales on an erythematous base, finds a suitable soil for its growth in a skin affecting the cheeks and forehead. The con- naturally greasy from an excessive sebaceous dition tends to become moist, oozing and flux.'1 crusting about the nose and behind the ears. March, 1947 SEBORRHOEIC DERMATIr IS j63 Postgrad Med J: first published as 10.1136/pgmj.23.257.162 on 1 March 1947. Downloaded from Protected by copyright. http://pmj.bmj.com/

(Photograph by Dr. L. B. Bourne)

Acute seborrhoeic dermatitis of the , together with characteristic enlarged pilosebaceous follicles of the face. on September 26, 2021 by guest.

-2 I64 POST-GRADUATE MEDICAL JOURNAL March, 1947 Postgrad Med J: first published as 10.1136/pgmj.23.257.162 on 1 March 1947. Downloaded from Protected by copyright.

(Photograph by Dr. L. B. Bourne) Crusted seborrhoeic dermatitis of the scalp. http://pmj.bmj.com/ on September 26, 2021 by guest. March, I1947 SEBORRHOEIC DERMATII IS- I65 Postgrad Med J: first published as 10.1136/pgmj.23.257.162 on 1 March 1947. Downloaded from A reddened scaly state of and eyelid In , pink oval plaques in the margins is common. distribution of the rib lines are found, otten On the trunk the frequent situations are the with a herald patch. The essential lesion sternal and interscapular areas, where is found shows a pink scaly border, with a fawn- the 'characteristic ' flannel-' or petaloid coloured crinkled centre, and the disease runs type of eruption with polycyclic gyrate figures, an acute course of about six weeks. Ringworm of a brownish-yellow colour, enlarging peri- patches are usually well defined, with a clearing pher'ally. The centre tends to become clear, centre and a vesicular or scaly edge, in which but sometimes remains scaly, and the spread- the fungus is found on microscopical examina- ing reddish border may be covered with scaly tion. Pityriasis Versicolor is a fine scaly papules. Greasv, scaly, yellowish patches on condition of cafe-au-lait macules or patches an inflamed base also occur, and it is common on the trunk, caused by the Microsporon to find papular and macular satellite lesions furfur, which can be recognized micro- surrounding the larger areas. scopically. Erythrasma, a rare condition, caused by a fungus, the Microsporon minutis- In the flexures the condition usually becomes simum, gives rise to reddish or brownish moist and oozing and often spreads rapidly to plaques in moist areas, with no central clearing. the adjacent areas. Trauma and rubbing may Other forms of dermatitis do not show pity- convert the condition into an acute eczematous riasis capitis, or the greasy circumscribed one, or even to an exfoliative dermatitis. lesions, with a tendency to spread peripherally. On the limbs the flexures are also commonly

affected, and here the rubbing of clothes, Treatment Protected by copyright. associited with constant movement, often leads to a thickened lichenified condition of It is wise in every case of seborrhoeic the skin. The flexor aspects may show dermatitis to treat the scalp thtoroughly and follicular patches. systematically. In mild cases it may be sufficient to rub in the following lotion once Diagnosis or twice daily: R Acidi Salicylici ...... gr. 20 On the scalp pityriasis has to be distin- Hydrargyri Perchloridi ...... gr. I Liq. Carbonis deterg...... m. I 5 guished from , in which the lesions Olei ricini ...... M. I O are more circumscribed, the scales are not Spirit vini rect. or spirit meth. greasy, and typical patches may be found indust...... ) 3 elsewhere on the body. Psoriatic scales do Aq. ad...... I not show the pityrosporon. In children and the hair out once or twice weekly http://pmj.bmj.com/ ringworm of the scalp gives partly bald patches with Spirit Sqap with typical hair stumps, in which the fungus R Saponis viridis can be demonstrated. Spiritus meth. industrialis.... a.a. p. aeq. On the face it may be necessary to In the more greasy and crusted lesions of differentiate erythematosus. This the scalp, the following ointment may be used,

aff&cts chiefly the central butterfly area of the and should be persevered with even in the on September 26, 2021 by guest. face; the scales are dry and tenacious, and eczematous type: the typical plugging of the enlarged follicules R Sulphuris praecipitati ...... gr. iO are diagnostic. pityrodes or fur- Acidi Salicvlici ...... gr. io furacea occurs in dry circinate patches on the Adeps Benzoinat ...... ad. i face, is not inflammatory and does not usually Resorcin may be substituted for the pre- occur near the scalp. cipitated sulphur, but darkens fair hair. This On the trunk psoriasis has dry and silvery should be massaged well in twice daily and scales which, when scraped off, leave the shampooed out once or twice weekly. Later, characteristic velvety oozing surface. Psoriasis when the scalp is drier, the lotion may be tends to affect the extensor surfaces; sebor- substituted and persisted with for some time. rhoeic dermatitis, the flexor. In the frankly weeping eczematous condition i66 POST-GRADUATE MEDICAL JOURNAI, March, I947 Postgrad Med J: first published as 10.1136/pgmj.23.257.162 on 1 March 1947. Downloaded from of the scalp, the hair should be clipped, and R Sulphuris praecipitati...... gr. S the moist areas treated with very frequent Lotio calaminae oleosa (N.W.F.) ad. i)I applications of lead lotion (made by adding Ichthyol may be substituted for the sulphur. i drachm of liquor plumbi subacetat. fort. to For the seborrhoeic the two a pint of cold tap water) for a day or two. per cent. yellow oxide of mercury ointment When dry, the ointment should be substituted. applied twice daily clears up the eruption. On the glabrous skin the following lotion is suitable for mild conditions: General Treatment IR Sulphuris praecipitati ...... gr. 5 When mild, seborrhoeic dermatitis responds Tr. quillaia ...... m. I0 readily to local treatment, but there is a ten- Lotio calaminae B.P.C...... ad. 3 i dency to recur especially in the scalp. More More severe conditions will respond to: severe conditions may prove difficult and R Sulphuris praecipitati ...... gr. io indeed almost intractable, and general Acidi salicylici ...... gr. io measures should be instituted. Unguentum i aquae rosae ...... ad I A holiday with plenty of fresh air should be or the following ointment: advised, or general irradiation with ultra- R Hydrargyri ammoniati ...... gr. io violet light. The diet should be restricted in Acidi salicylici ...... gr. io carbohydrates, and often small doses of Zinci oxidi ...... 2 I Paraff. molle album I thyroid (Tabs. thyroid. sicc. gr. b.d.). are ...... ad 3 useful. Sutton and Sutton2 advise a low fat In the acute, weeping, flexural type moist

diet. Protected by copyright. dressings or baths are indicated. Baths of i 8,ooo or i : IO,OOO potassium perman- Clothing should be light and warm and wool ganate twice*daily, or continuous wet dressings should not be worn next to the skin. Under *of lead lotion, may be ordered. Alternatively, conditions of increased heat and moisture iI per cent. silver nitrate in distilled water relapses. are common, and the condition is applied twice daily is more than useful. When more difficult to cure in the tropics. dry, these areas may be treated with the Oc6asionally chronic and refractory cases calamine and sulphur lotion. Greasy oint- are improved by shock therapy with non- ments are borne badly in these regions, but if specific proteins, or with autohaemotherapy. the calamine lotion prove too drying the X-ray in fractional doses on resistant patches following liniments may be used: is useful, but in view of the tendency of the IR Sulphuris praecipitati ...... gr. 5 disease to recur, it should not be used in

Calaminae prep...... gr. 30 treating repeated attacks in the same area. http://pmj.bmj.com/ Zinci oxidi ...... gr. 20 REFERENCES Liqor calcisalcs...... - 2 I,iquor ,) M.MACLEOD, J. M. H. and MUENDE, 1. (I940), Pathology of Olei olivae or arachis...... ad. I i the Skin, 83. 2. SUTTON, R. L. and SUTTON, R. L., Jun. (4th Ed., 1941) or Introduction to , 248, 6 I5. on September 26, 2021 by guest. RUTHIN CASTLE, NORTH WALES A Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). The Cginic is provided with a staff of doctors, technicians and nurses. The surroundings are beautiful. The climate is mild. There is central heating throughout. The annual rainfall is 30.5 inches, that is, less than the average for England. The Fees are inclusive and vary according to the room occupied. For particulars apply to THE SECRETARY, Ruthin Castle, North Wales. Telegrams: Castle, Ruthin. Telephone: Ruthim 66. May 1947 COMMON FUNGUS OF THE SKIN 259 to rest in the lukewarm bath for 2o minutes and no fungus can be demonstrated. and to dry in the air. Later both epider- of the nails is usually associated with signs mophyta and trichophyta respond well to elsewhere. Whitfield's ointment or Castellani's paint, and Treatment. Fungus infection of the nails is the monilia to i per cent. gentian violet. The difficult to cure and demands unremitting greatest care to prevent re-infection must be attention on the part of the patient. In early taken. Cotton socks should be worn beneath infection, with only part of the affected, ordinary socks or stockings, and boiled and this part should be scraped away with a piece changed daily. Hyperkeratotic areas may be of broken glass or sharp knife until there is no treated with 6 per cent. ointment, obvious infection. This should be done daily, until they are flat, and later with the usual and Whitfield's ointment is applied under fungicides. strapping each night. Persistence with this Footwear may be sterilized by shutting in treatment, for months if necessary, will result an air-tight box with formaldehyde, so that the in a cure. vapour is allowed to act for four or five days. If much of the nail is affected, surgical evul- sion should be performed, and the thickened 6. The Nails nail bed scraped. After a few days, continuous Ringworm of the nails, or , application of Whitfield's ointment should be may begin independently, but often occurs insisted on until the nail is fully grown. with fungus infection elsewheie on the body. Ringworm fungi of the body, and particu- Infection usually takes place at the free edge of larly of the feet, are capable of sensitizing a the nail, when the nail bed is attacked, and a patient, with the production of an allergic or dirty grey scaly thickening raises the nail from sensitization eruption, which is itself free froft its bed. It spreads down the nail and grows up fungus. A lichenified dermatophytide (or my- into the nail plate, which becomes discoloured cide) has been described on the trunk due to and thickened, and finally crumbles. Infection , but more characteristic in ring- may, however, pass under the lateral border of worm infection is the 'pompholyx' type of the nail, first attacking one side with ridging of eruption on the hands. This consists of tiny the nail, but gradually passing across and vesicles along the sides of the hand, on the affecting the whole nail. The infection is due palms and between the fingers, and these to trichophyta or epidermophyta. vesicles contain no fungus. Treatment of the Diagnosis. Psoriasis of the nails may re- primary focus results in the spontaneous clear- semble fungus closely, but is not so irregular, ing up of the secondary sensitization eruption.

CORRECTION Vol. XXIII, No. 257. March 1947, page I65. SEBORRHOEIC DERMATITIS:- Treatment. The first formula given should be corrected to read:- R Acidi Salicylici ...... gr. 20 Hydrargyri Perchloridi ...... gr. Liq. Carbonis deterg...... m. 15 Olei ricini ...... Io Spirit vini rect. or spirit meth. indust...... ad.