Postgrad Med J: first published as 10.1136/pgmj.28.317.165 on 1 March 1952. Downloaded from r65 THE PROBLEM OF ECZEMA IN INFANCY AND CHILDHOOD By REGINALD T. BRAIN, M.D., F.R.C.P. Physician in Charge Skin Departments at the Royal Free Hospital and the Hospital for Sick Children, Great Ormond Street; Physician, St. John's Hospital for Diseases of the Skin The clinical picture of eczema as it appears in infants and young children is sufficiently charac- teristic to be readily recognized. The earliest lesions consist of minute, pale pink papulo-vesicles which erupt in small groups and at first are set in non-inflamed skin, although the pale pink back- ground soon appears. The eruption is usually symmetrical and in infants most commonly first arises on the cheeks just in front of the ears (Fig. i). Friction, or the application of irritants, such as penicillin ointment or cream, usually quickly the affected area of and a aggravates skin, brighter copyright. redness with some oedema indicates that a fric- tional or a contact dermatitis has been added to the eruption. Secondary infection with pyogenic organisms will also produce a similar picture of dermatitis, but the pattern of the primary eczematous eruption and the subsequent changes, to be described, clearly indicate that we are dealing with a hypersensitive skin which presents the of reaction that is called eczema. peculiar pattern http://pmj.bmj.com/ Because erythema, oedema and exudation are almost constant factors in the eczematous reaction, and these are fundamentally inflammatory re- actions, the term 'dermatitis' can also be applied to the eruption. However, for many dermatologists FIG. I.-The early lesion. the term eczema does bring to mind a clinical picture as sharp in its definition as psoriasis or counts for the clinical picture of red papulo- lichen planus, and it is felt that the term is almost vesicles, the vesicular nature of which, if not on October 1, 2021 by guest. Protected universally adopted to designate the eruption visible to the naked eye, is quickly revealed by which is peculiar to a hypersensitive skin. This slight scratching which removes the covering hypersensitivity can be inherited or acquired, but horny layer and leaves a moist, brighter red minute in infants and young children there is good reason macule which proceeds to dry up, to crust or to to believe that the hypersensitivity is largely in- exude vigorously. Mild round-celled infiltration herited and familial cases are common. may be present in the papillae and in the upper part of the dermis, and there is evidence that Pathology sensitivity may be carried by the lymphocytes A focal dilatation of capillaries in the papillae which are present in the infiltrate. Owing to a of the dermis is the earliest histological feature of further increase of the inflammatory reaction under eczema. A larger collection of lymph then collects the stimuli of scratching, treatment or infection, at the tip of the papillae and exudes through the all intensive studies of the histopathology merely epidermis, producing a moderate or marked inter- lead one away from the more characteristic features cellular oedema until it collects as microscopic of the early eruption into the common but more vesicles under the stratum corneum. This ac- marked changes of non-specific inflammation. El Postgrad Med J: first published as 10.1136/pgmj.28.317.165 on 1 March 1952. Downloaded from 166 POSTGRADUATE MEDICAL JOURNAL March 1952 Aetiology troublesome complaint and that the best results The most accepted factor in the aetiology of are likely to ensue if consideration is given to every eczema at all ages is the inherited or acquired point of view. hypersensitivity commonly called allergy, and Naturally endocrine preparations have been many observations have been made on the reaction tried out in the treatment of various types of of the skin to various allergens. This may be done eczema. As many cases of Besnier's prurigo have by intradermal injections or by scratching the very dry skins they seemed to offer an indication clean surface of the forearm and rubbing in pre- for thyroid treatment, but xeroderma of congenital pared solutions of food or other common allergens, origin is really due to a defect in the development but a simpler procedure is the use of the patch of the sweat glands, and one cannot stimulate test. To perform this test, i in. squares of adhesive absent glands by giving thyroid extract. Further, plaster are prepared with a centrally attached thyroid may make a reactive child more nervous dressing of a in. square of plain open mesh and reactive and this hormone is of little use in bandage. On this central fabric a little powder or infantile eczema. Cortisone and ACTH have now solution of a suspected irritant is applied and the been used fairly extensively, and although there is dressing is then affixed to the clean surface of the some evidence that they diminish the sensitivity of skin. A number marked on the outside of the the skin and in experimental animals diminish or plaster serves to record the nature of the allergen inhibit the response to allergens, they of en fail to which is being tested. Some dermatologists use produce any lasting benefit in the treatment of this method to test a patient's reaction to a eczema. Whether some more potent fraction will number of common medicaments before they are be discovered remains to be seen, but at present used in treatment, and while this is a sensible pre- there is no endocrine which has any constant caution, experience usually enables one to decide specific effect in the treatment of infantile eczema, upon a suitable bland preparation. It is some- so no rational indication for their use exists. times more speedy and equally satisfactory to treat Much thought has been given to dietetic factors. several areas of the with different medica- In our the incidence of eczema is body experierce justcopyright. ments and note which produce the best clinical as common in breast fed babies as in those who response and which, if any, act as irritants. It is a are bottle fed. Since mother's milk is far less curious fact that while many enthusiastic allergists likely to contain offending allergens than any other obtain evidence to support their thesis, an equally food it is obviously wiser to let the mother nurse large number of practicing dermatologists almost the child as long as possible. One disadvantage, entirely ignore the complicated ritual of the cult of however, is the emotional bond which develops allergy and get equally good results by using the between mother and child more strongly, it is bland methods of local treatmrent which have been suspected, in the case of breast fed infants. If a evolved over the last half mother is emotional and distressed, as she century. easily http://pmj.bmj.com/ Rarely an infant's eczema may be dependent may well be by the appearance and discomfort of upon offending substances applied to the skin, her suffering infant, this distress may be conveyed such as various types of soap, soda, the detergents to the baby at her breast. Some dermatologists used in laundering, the perfumes of cosmetic believe that this factor justifies the weaning of the powders or certain ingredients of dusting powders, child, but this should be done with considerable such as orris root, or even the metals which are reluctance after every other measure has been tried. present in the oxides used in powder bases. It is Once an infant is put on cow's milk or;a pro- certainly advisable to keep in mind the possibility prietary food one always wonders whether an on October 1, 2021 by guest. Protected of a contact allergen being responsible for an offending allergen is being introduced. It would eczematous eruption, but the matter should be seem that milk allergens are rarely important and readily established by patch tests and, if the the various preparations of dried milk specially specific allergen is avoided, the eczema should modified for allergic infants rarely produce clear up quickly. sufficient improvement to justify the expense of A smaller number of practitioners believe that their continued use. This is not to say that a few treatment on more general lines with particular weeks' experience with a different brand of milk, attention to consititutional and metabolic factors is or a modified milk, should not be given a thera- of major importance in the treatment of eczema, peutic trial, tut a mother should not be asked to while others put stress upon inherited qualities of bear the extra cost if the response is too indefinite hypersensitivity and believe that the psychological to be recognized. Probably the ordinary pooled adjustment of the individual to his or her malady milk as supplied to the public is as satisfactory as is of outstanding importance. It is probably fair any, and there is no particular merit in having T.T. comment to state that no school of thought has a milk, while Jersey milk is usually too rich and has monopoly of success in the treatment of this been known to be a factorin the eczema offat babies. Postgrad Med J: first published as 10.1136/pgmj.28.317.165 on 1 March 1952. Downloaded from March 1952 BRAIN: The Problem of Eczema in Infancy and Childhood 167 ''he milk for a days' feed should be lightly boiled histamine preparation has now been extensively for five minutes, then allowed to stand and the used with this hope but rarely with evidence of resu'ting film removed.