Anti-Infectives

Since the cells in the lower layers of the skin are continuously growing and then dying as they get nearer the surface, it follows as a matter of course that they must be got rid of. Only the other day a patient of mine who had his leg out of a cast for the first time in a number of weeks was surprised to find how much powdery skin he could rub off.

This rubbing off of the scales of skin rarely seems to bother people much except when it occurs on the scalp. Then it is called dandruff and it is evident that many people find it a great nuisance. Modern dermatologists apparently do not consider it dignified enough for their consideration. In general man’s skin has not changed much in modern times, and so the book on diseases of the skin that I got in medical school forty odd years ago still serves me very well. It has several pages on dandruff. I have recently consulted two large up-to-date tomes on dermatology and they pay no attention to it except for those rare occasions when it is associated with severe infections. The original idea was that dandruff is an infection. I cannot find much evidence that infection here is really of much importance. My old book talks about seborrhea oleosa and seborrhea sicca. Apparently, all this means is that in some cases a greasy skin rubs off and in other cases a dry one.  I think the general public should be trusted to treat themselves accordingly.

Without a constant renewal of the dermis and a rubbing off of the epidermis, the skin would become pretty battle-scarred. It can have rough times, as we have seen, attacked from without or within. This often causes most uncomfortable disfigurement to its smooth pristine beauty. Yet the live cells of our dermis are usually able to repair the damage so that our snug-fitting garment can continue its important duties: to protect, to eliminate waste, and to regulate heat.

With all of these many activities of the skin, is it any wonder that Dr. Walter in his book on the vertebrates speaks of the skin as a jack-of-all-trades? It is the biggest organ in the body. I believe that in a good-sized man there is about twenty-five square feet of surface. It has about two and a half million sweat glands. Despite all its varied activities, we keep it reasonably young by continually renewing it. Perhaps many of you who are familiar with the country know that snakes periodically “slough” off their old skin, appearing in a new one. We also get rid of ours, but we do it continuously. The average man of three score years and ten has shed forty-five pounds of skin in his lifetime.

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SKIN CARE

Athlete’s foot

In contrast to this rather discouraging report about psoriasis, where medicine has not yet found the answer, it is a pleasure to tell of a disease which used to be decidedly bothersome but which in the modern city today (I have it on the word of the dean of our dermatologists) hardly ever causes a visit to the skin specialist’s office. This is athlete’s foot, or epidermophytosis, a fungous growth that thrives on moist, warm skin. Practically always growing on the skin are some mold-like organisms such as cause wheat flour to spoil. As they grow best in moist, warm areas, they are usually found between the toes or in the groins where they have the familiar but not very polite name of jock-strap itch. Not only the young athlete in the boy’s or girl’s school often caught this; but any hot city dweller seeking relief on a crowded beach was likely to pick it up. There are effective powders and salves, available at the drugstores, to relieve these symptoms. Best of all, preventive hygienic methods at swimming pools and beaches now protect our feet from infection so that the swimmer or sun-bather seldom needs to suffer from athlete’s foot.

Shingles

In considering diseases of the skin it must be remembered that the skin is an open book, spread before our eyes. What we see is, if the change of metaphor may be pardoned, merely the surface manifestation of what is happening in the depths. Take the ridiculously named shingles. When it is dignified by its Latin name of herpes zoster, we are more ready to consider the great suffering that accompanies it, particularly prolonged in elderly persons. Yet this classical name means merely a girdle of blisters.

It is agreed now that it is an inflammation in a ganglion, or knot of nerve cells, from which nerve fibers extend to the skin. The blisters always follow along the skin where the fibers end. The pain may appear before the skin lesions, thereby making diagnosis difficult at first. It never kills, but it may make its victims resigned to death.

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SKIN CARE

Another mysterious and one of the commonest of skin diseases is psoriasis. It is probably not well known to the general public as it usually persists throughout the patient’s life, so it is not brought forward as a subject of conversation. In fact, being rather disfiguring, it is kept secret as much as possible. It consists of scaly patches on the skin, the more common locations being the back of the arms, the front of the legs, and the body. Fortunately the face is frequently spared.

Psoriasis starts as minute spots which grow and merge into large areas, occasionally covering the whole back or even the whole body. Although the patient is usually symptom-free, being bothered only by the disfigurement and the untidiness of the scales flaking off, nevertheless severe cases may feel run down and even quite sick. Fortunately the scaling has a tendency to clear up at times, especially in warm weather, but it will break out again as cold temperatures return.

The cause is unknown. No evidence has been found of bacteria associated with the eruption, and the disease is not contagious. Some of the other ailments of the skin may be confused with psoriasis and the treatment proper for them would be bad for this condition. Therefore it is important that a competent skin specialist make the diagnosis. Probably sooner or later all such cases are seen by specialists, for even the most ignorant or indifferent will not forever accept with equanimity such unpleasantness.

There have been many methods of treatment, some of which give good results. Medicines taken into the system have in general amounted to little. It is fortunate if they do no harm. Vitamins, of course, have been tried. Massive doses have generally been considered necessary by their users, and in such amounts they are not at all innocuous. Experiments with diet may seem to help or to coincide with improvement. Apparently there are no good rules for this.

External applications give the best means of relief. They have to be handled with care and according to the state of the disease. It would be useless here to give a list of the drugs used. Self-medication is dangerous either with drugs or ultra-violet light from lamps or sunlight. And the relief is temporary. Almost always there are bound to be recurrences. X-ray has been used, but in a chronic recurring trouble like this one it should be seldom resorted to, for cancer is a distinct danger where these rays are repeatedly used on unhealthy skin.

All authorities agree that there is no definite cure or permanent alleviant. I do not believe that any good physician, having treated a case of psoriasis, ever assures the patient that he will no longer have the disease. In fact, I believe that he will tell him that he must expect to have it return later. It fluctuates so much, occasionally disappearing for a time that false hopes are bound to arise. Occasionally, but rarely, it has disappeared and not returned. Nobody knows why. Perhaps the period of remission has just happened to exceed the patient’s life span.

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SKIN CARE

Although the uninjured skin is germ-proof and it takes cutting instruments such as knives, needles and the boring tools of lice and itch mites, to penetrate it, still our minute enemies, bacteria and viruses, make many successful flank attacks on it. However they enter the body, they make plenty of trouble as they travel along, and in most cases the changes in the skin are the least important. Thus with spotted fever, as meningitis was formerly called, the infection of the brain is what raises havoc; and in scarlet fever, the effects on the heart and kidney can cause death. Fortunately, this disease has now become comparatively mild.

As the skin is wide open to observation, and nothing impresses us more than what we see, it is to be expected that a group of diseases with remarkable skin changes should be classified together. They were given the name exanthemata, a snappy word signifying “diseases blossoming out upon the skin.” These were of great importance long ago, their victims often being isolated in pest houses. In my medical school days patients with skin diseases of this type were often put in separate hospitals, although we no longer called them pest houses.

These diseases were all extremely contagious. I suppose that they are still just as contagious, but we know better now how to handle them. Smallpox is an example, once dreaded everywhere, now practically non-existent in the United States.
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SKIN CARE