Pearls of Neonatal Intertrigo in Ancient Greek and Byzantine Medicine

Historical article Review article Acta Medica Academica 2018;47(1):131-138 DOI: 10.5644/ama2006-124.223

Gregory Tsoucalas1, Konstantinos Krasagakis2, Constantinos Pantos3, Marianna Karamanou1

1University Institute of History of Objective. Confirmation of knowledge of neonatal intertrigo in an- Medicine, Claude Bernard University cient Greek and Byzantine medicine. Method: A search of Thesau- Lyon, France, 2Department of rus Linguae Graecae was conducted with the following terms as key Dermatology, University General words, “syggama”, “xyggauma”, “paratrimma” and “ektrimma”. Results: Hospital of Heraklion, Heraklion, Crete, Ancient Greek medico-philosophers introduced therapeutic meas- Greece, 3Department of Pharmacology, ures based upon herbs and minerals, while a similar therapeutic ap- Medical School, National and Kapodistrian proach was also used by the Byzantines. Hippocrates of Kos (460-377) University of Athens, Athens, Greece was among the first to introduce written instructions, also proposing preventive treatment with palliative and aromatic herbs. Cataplasms, Correspondence: thalassotherapy, and fumigation were used, combined with hygienic [email protected] measures in the affected area. Chalk powder was also prescribed to Tel.: + 30 694 529 8205 absorb moisture. Conclusion. The main principles in the treatment of Fax.: + 30 242 107 8160 intertrigo remain the same, celebrating the ancient Greeks’ methodol- Received: 22 January 2018 ogy and rationalism. Accepted: 14 May 2018 Key words: Ancient Greece . Byzantium . Intertrigo . Botanology . Paediatric dermatology.

Introduction of bacteria (S. aureus, Strep. pyogenes) and fungi (Candida albicans), contribute to the Neonatal intertrigo is an inflammation of development of erythema, pruritus, mac- the skin folds, of irritant or infectious aeti- eration and erosions, which may be quite ology. Neonates and infants are more pre- persistent. Therapeutically, gentle cleaning, disposed towards intertrigo as they have keeping the affected area dry, and topical abundant subcutaneous tissue which pre- barrier agents (zinc oxide paste) can be very vents the folds from airing out. Prolonged effective. In some cases, imidazole lotions contact with an irritant, mainly detergents, and antibacterial agents, such as mupirocin urine, faeces and fragrances, affects the skin cream, and topical corticosteroids may also properties and enhances permeability to ex- be administered. However, the importance ogenous materials, thus increasing transepi- of prevention, in terms of cleanliness, dry- dermal permeability and susceptibility to ness and use of protective barriers, should friction. Therefore, friction between the skin be always stressed (1-3). folds, coupled with maceration, due to re- Intertrigo, as a term, comes from the Lat- duced evaporation of sweat and overgrowth in words “inter” which means “in between”

and “terrere” which means “to rub” (4). It and litharge. A palliative watery poultice was was a well-recognized affliction in Ancient used as a cataplasm; aromatic oils, or even a Greece, as Hippocrates (460-377) and his powder of minerals and dried natural herbs followers were among the first authors to were also applied (9). Dioscorides’ view was describe it, in the “Corpus Hippocraticum” adopted by Galen (130-201), who was con- (5). The terms used by the Greek medico- sidering litharge to be an amazing “remedy philosophers in antiquity were “syggama” for the human flesh” (Greek: σαρκωτικό) (On (Greek: σύγκαμα) or “xyggauma” (Greek: the Composition of Drugs According to Plac- ξύγκαυμα), which means “friction burn”, es) (10). In his turn, the Byzantine physi- “paratrimma” (Greek: παράτριμμα), which cian Oribasius (320-400), having mentioned means “rubbing between two surfaces” and both Dioscoride’s and Galen’s views, sug- “ektrimma” (Greek: έκτριμμα), which means gested that intertrigo lesions “should be cov- “a lesion caused by friction” (6). ered with dry Myrtus, Cyperus Rotundus and With the goal of discovering the knowl- rose hip, all stirred with some aroma” (Greek edge of the ancient Greeks and Byzantines fragment: Τα δε κατά μηρούς εκτρίμματα regarding intertrigo, our study gathers all μυρρίνη ξηρά διαπάσσειν και κυπέρω και the text fragments found in the TLG (The- ρόδοις προσμίγουσάν τι των αρωμάτων) saurus Linguae Graecae), a digital collection (11). The famous Byzantine physician and of surviving texts written in Greek, after a medical writer, Aetius of Amida (502-575), search using those terms as key words. proposed exactly the same treatment (Greek fragment: Μυρσίνην ξηράν λείαν επίπασσε, Neonatal Intertrigo in Ancient Greek η κύπερον μετά ρόδων) (12). Paul of Ae- gina (625-690), whose paediatric work was and Byzantine Dermatology based upon Oribasius’ treatise, also had the Neonatal intetrigo has been recognized since same opinion. According to his work, he antiquity, and ancient Greek physicians pro- proposed the topical application of “Balaus- posed various therapeutic approaches (6). tium” (Greek: Βαλαύστιον, Latin: Punica In the 5th century BC, Hippocrates and his granatum, varietas plena major), the double followers first mentioned the importance flowered pomegranate tree, a plant with as- of prevention, and proposed cataplasms tringent properties in its bark, leaves and based on a mixture of aromatic herbs (On blooms, to cure intertrigo (13). Diseases, 4th Book) (7). Furthermore, he in- Oribasius and the Arab-Islamic physi- troduced seawater bathing, or steam bathing cian Al Rhazi (854-925) mentioned that (boiled seawater) for alleviation of pruritus Soranus of Ephesus (98-138), the founder (On the Use of Liquids) (8). In his opinion, of obstetrics and gynaecology, and an ex- precautionary measures should be admin- pert in paediatrics, had dealt with neona- istered soon after birth to avoid intertrigo tal intertrigo in his treatise entitled “On the (Greek fragment: Επήν τα παιδία γέννηται, care of the small child” (Greek: Περί κομιδής ψωμίζουσιν αυτά αι γυναίκες τα αυτά παιδιού, Arabic: Tadbir al atfal) (11, 14). In φάρμακα... και μη ξυγκαυθή) (7). his turn, Avicenna (980-1037), adopted and Centuries later, the distinguished Greek proposed the ancient Greek treatment for pharmacologist and leading expert in thera- intertrigo in his masterpiece, “The Canon of peutic botanology, Dioscorides (40-90) pro- Medicine” (Arabic: al-Qanun fi al-Ṭibb) (15, posed, for treatment of intertrigo, a mixture 16). Centuries later, the Swiss physician and of Myrtus communis, Lycium barbarum, alchemist Philippus Aureolus Theophrastus Plumbago capensis, chalcopyrite, white lead, Bombastus Von Hohenheim (1493-1541),

132 Gregory Tsoucalas et al.: Neonatal intertrigo in ancient Greece

known as Paracelsus, mentioned in his work Among them, “Myrtus communis” that the ancient Greeks used herb Helleborus (Greek: Μύρτος ο κοινός) of the family niger (Ranunculaceae family), a well-known “Myrtaceae” represented the main ingredi- plant in antiquity, to treat skin irritations ent for preparations against cutaneous affec- such as intertrigo (17). A reference was also tions. It is an aromatic evergreen perennial made to its rose like flowers, while no other shrub or small tree, with small foliage and such citation is available. deep fissured bark. Its name, “Myrtus”, sig- nifies a common plant growing in groups. Myrtle occupied a prominent place in the Discussion writings of Hippocrates, Pliny (23-79), Di- Ancient Greek medico-philosophers divid- oscorides, Galen and the Arabian writers. ed cutaneous diseases into psoriasic, leprotic According to them, the leaves and fruit were and leichen. The termpsora referred to itch- therapeutic for several diseases, includ- ing and erythema, depicting moist pustular ing intertrigo (21-23). Nowadays, Myrtle is ulcerated conditions and eczematous like known to have antibacterial and antifungal eruptions. The term lepra, from the Greek properties, which exhibit remarkable activi- words “lopos” (Greek: λόπος, the epidermis) ty against several fungal strains (24). Cyperus and “lepo” (Greek: λέπω, remove the outer Rotundus, (Greek: κύπερος) of the “Cypera- layer), referred to scaly conditions, while ceae” family, was used from the Mycenaean leichen represented skin growths held on by era as a purifying agent, a skin reviving, heal- adhesion to the base (5, 18). So, intertrigo ing factor, and herb regulator of the body’s was classified as a “psoriasic” dermatological humours (blood, phlegm, yellow bile, black disease and physicians proposed the treat- bile) (13, 25). It is now known that Cuperus ment of so called neonatal psora, as soon as has antibacterial activities against Staphylo- it appeared (6). coccus epidermidis, Bacillus cereus, Pseudo- Since environmental interaction with the monas aeruginosa, Escherichia coli (26). “Ly- human’s body homeostasis has been known cium barbarum” (Greek: Λυκόμουρο, from from the Hippocratic era (6), there is a great the ancient southern Anatolian region of possibility that Soranus of Ephesus and Paul Lycia) was also widely used by the ancient of Aegina differentiated intertrigo from al- Greeks as an anti-inflammatory agent (9). lergic and irritant contact dermatitis, which Flavonoids isolated from Lycium barbarum usually presented with more intense pru- fruits have anti-inflammatory and anti-an- ritus and signs of eczema (from the Greek giogenic effects (27). “Plumbago capensis” words “ec”: over, “ze”: boiling, and “ma”: re- (Greek: μπλε Γιασεμί), of the “Plumbagina- sult of, thus describing a more superficial ceae” family, was used for the wood’s heal- reaction), a more severe condition than the ing capacities, which are appreciated even simple erythematous lesion of intertrigo. now, as well as its antibacterial properties, Thus, in cases of eczema, they suggested especially against Staphylococcus aureus “hot pads with a rich suffuse of boiled olive (28). Furthermore, some studies mention oil are useful, mixed with a small quantity of its strong antifungal activity, equivalent to melted wax in order for the mix to be thicker, that of voriconazole (29). Rose hip (ancient for longer adherence” (19, 20). Greek: ρόδον, Greek: κυνόροδον, Latin: rosa A series of herbs were harnessed by the canina) is today a product in cosmetics, in- Greeks in antiquity to treat neonatal inter- cluded not only among the fragrance sub- trigo (Figure 1). stances but also in skin conditioning agents (30). On the other hand, Punica granatum

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Figure 1. A: Myrtus communis, B: Cyperus Rotundus, C: Lycium barbarum, D: Plumbago capensis. A, C: colloured illustrations, Flora von Deutschland, Osterreich und der Sch- weiz, 1885, B, D: colloured illustrations, Mills C, Hortus Camdenensis, 1848.

is proposed as an anti-infection and anti- Strangely, the perennial plant is nowadays worm killer in modern female cosmetics (31). considered to be poisonous, while especially Meanwhile, “Heleborus niger” (Figure 2) for its roots may cause a skin irritation and blis- the ancient Greeks was a herb widely used tering. In medieval Europe it was used in a against mild and severe skin diseases, from small dosage as an anti-parasite drug (33). intertrigo to leprosy (32). There is the possibility that there was another

134 Gregory Tsoucalas et al.: Neonatal intertrigo in ancient Greece

Figure 2. Helleborus niger, Kräuterbuch, Actaea spicata, 1914. species in Greek antiquity, less irritating its side effects. It seems that Greek physi- than the “Helleborus niger” noted by Para- cians in antiquity, experts in botanology, celsus, or it was perhaps used in poultices, or observed nature and the properties of herbs, after some process which could have altered used them to treat intertrigo in the form of

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Table 1. Therapeutic ingredients used in ancient Greek and Byzantine dermatology and their current use.

No Ingredient Ancient Greek and Byzantine dermatology Modern dermatology Antibacterial 1. Myrtus communis Skin therapeutic agent Antifungal Skin purifying agent 2. Cyperus Rotundus Skin reviving and healing agent Antibacterial Humour regulator 3. Lycium barbarum Anti-inflammatory Anti-inflammatory Antibacterial 4. Plumbago capensis Healing wood capacity Antifungal Repairing skin liaisons Base in powders Oil ingredient Basic acetate salt of lead as an ingredient in 5. White lead Skin healing agent Water Soft Aluminium Skin whitener Men’s hair colouring Hair colouring Skin healing agent 6. Litharge - Tumours’ lytic activity 7. Thalassotherapy Skin purifying and palliative agent Hypertonic solution of sea minerals Base in powders Moisture absorbent 8. Chalk powder Talc ingredient Astringent agent Cosmetics (eye colouring)

cataplasms, and practised dermatology in an astringent properties, also had the ability to almost scientific manner. absorb moisture locally, but was also used as Thalassotherapy, introduced by the an- a base for the preparation of cataplasms. It cient Greeks, is a method still in use. A hy- was used extensively in the Byzantine era in pertonic solution of sea water penetrates the treatment of intertrigo, skin ulcers and skin lesions. Trace elements of magnesium, burns (6, 36-38). Litharge (lead monoxide) potassium, calcium, sodium and iodide was used as a lytic agent in tumour forma- found in seawater are believed to be ab- tions, and as a healing agent in skin ulcer- sorbed through the skin. Thalassotherapy ations and intertrigo. Dioscorides believed was applied in various forms: as showers of that it also had the property of promoting warmed sea water, inhalation of sea fog, or cicatrisation, and it was also proposed as an fumigation (34). anti-wrinkle agent and skin whitener in cases White lead powder was completely of melasma (9, 13, 39-41). Surprisingly, hon- abandoned during the Byzantine era due to ey and olive oil, which were used in several several deaths provoked by slow lead poi- cosmetic and skin preparations in antiquity, soning, a situation already known at least were completely neglected in the treatment during the age of Pliny (23-79), and it was of intertrigo (6). Finally, it is worth men- replaced by chalk powder, a soft, white, po- tioning that the ancient Greek and Byzan- rous, sedimentary carbonate rock, a form of tine physicians’ treatment for intertrigo (Ta- limestone, composed of the mineral calcite, ble 1) was adopted in the medieval period by well-known for its use in cosmetics in Greek the Orthodox Monasteries in Russia, which antiquity (35). This powder, believed to have operated as health centres (42).

136 Gregory Tsoucalas et al.: Neonatal intertrigo in ancient Greece

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