The disease pursues a variable course. It may last for years, with exacerbations, or outbreaks may occur from time to time. Treatment is, as a rule, unsatisfactory. For external treatment applications of a bland or soothing character afford the most relief. Vaseline, cold cream, and oily substances are generally of most service. Stimulating applications seldom prove useful—in fact, will in most cases give rise to discomfort and positive aggravation. In regard to constitutional remedies general indications are to be followed. There is no drug that seems to exert a specific influence.
Dermatitis Exfoliativa.
This term is employed to designate certain cases in which more or less exfoliation is the prominent characteristic, and which cannot be classified under the head of any of the other diseases in which this symptom is noted. These cases have been variously described under the names of general exfoliative dermatitis, recurring exfoliative dermatitis, desquamative scarlatiniform erythema, recurrent acute eczema, acute general dermatitis, and recurrent exfoliative erythema. The affection is characterized by an erythematous inflammation, rarely vesicular or bullous, acute in type, with desquamation or exfoliation of the epidermis accompanying or following its development. There is also usually more or less marked constitutional disturbance, in some instances of a serious nature, and a tendency to relapse and recurrence. It is possible that in some instances the disease could be properly classified under the head of eczema, psoriasis, pityriasis rubra or pemphigus foliaceus.
Lichen Ruber.
Lichen ruber is an inflammatory disease, characterized by small flat and angular or acuminated, smooth and shining or scaly, discrete or confluent red papules, having a distinctly papular or papulo-squamous course, attended with a variable degree of itching. Two varieties are met with—the plane (lichen ruber planus) and the acuminate (lichen ruber acuminatus), the first of which occurs much the more frequently in this country. The acuminate variety is met with chiefly in Austria, where it was first described by Hebra: it is very rare in the United States, only a few authentic cases being on record. In lichen ruber planus the papules vary in size from a pinhead to a pea, and are peculiar in that they are not rounded, but are quadrangular or polygonal in shape. In their early stage they have a smooth, glazed surface, and are free of scales, but later they become papulo-squamous. They are more or less flattened on their summits, and show slight umbilication with whitish puncta. They are of a dull pinkish, reddish or violaceous color, the hue varying with the individual, age, and locality. As a rule, they are numerous, and occur in variously-sized aggregations, the distribution scarcely amounting to grouping. They tend to coalesce and form patches, which are slightly elevated, flattened, and uneven, the lesions when crowded together having a mosaic pattern. In lichen ruber acuminatus the papules are smaller, pointed, scaly, and disseminated, showing no disposition to group. This variety of the disease spreads rapidly, pursues a chronic course, and is a more serious affection, sometimes terminating fatally.
Lichen ruber planus usually presents itself upon the extremities, especially upon the flexor surfaces, the forearms and wrists and backs of the feet being favorite localities. Not infrequently it appears in the form of short or long narrow bands, following the natural lines of the skin, and sometimes nerve-tracts. The course of the disease is generally slow, extending over months. Occasionally, however, especially where the lesions are acute and very numerous, it is comparatively rapid. New papules continue to show themselves from to time, the older ones disappearing by absorption, leaving persistent marked reddish or brownish pigmentation, which is to be regarded as a characteristic symptom.
The etiology of the disease is at times obscure, although, according to our experience, patients usually show signs of impaired nutrition or nervous depression, arising from varied causes, as, for example, overwork or shock. It occurs at all periods of life, but is usually met with at middle age, and is more common in women than in men. Pathologically, the process is considered an inflammation of a chronic character, accompanied by more or less alterative changes in the structure of the skin, involving the several layers as well as the follicles. The lesion is always of a papular type. Later investigations (Robinson) into the anatomy of the lesions of lichen ruber acuminatus and lichen ruber planus are apparently indicative of the distinct nature of the two varieties, the former being considered a paratypical keratosis, leading to retrograde changes and atrophy, and the latter an inflammatory process occurring in and about the papillæ and upper part of the corium.
In the diagnosis of lichen ruber the papular syphiloderm, lichen scrofulosus, psoriasis, and papular eczema are to be excluded. The irregular and angular outlines of the lesions of the plane variety, taken with their flattened, slightly umbilicated, smooth, or scaly summits and the dull-red or violaceous hue, are sufficiently characteristic. The evolution of a patch of psoriasis is entirely different from that of this disease, the former appearing as small spots and enlarging by peripheral growth, the patches of the latter resulting from aggregations of lesions. In papular eczema the papules are rounded, bright-red in color, intensely itchy, and have a different history and course. The prognosis of lichen ruber planus is generally favorable, although some cases are exceedingly rebellious. According to Hebra, in the severe forms of lichen ruber acuminatus, if neglected or improperly treated, a fatal result may ensue.
A general tonic plan of treatment is almost always indicated, such remedies as iron, quinia, strychnia, and the mineral acids proving of benefit. Arsenic exercises in many cases a specific influence. When the general health is much reduced arsenic fails, as a rule, to benefit until the patient's condition is brought back to its normal tone. The remedy should be given in tolerably large doses, and continued until the lesions have entirely disappeared. On account of the itching and discomfort experienced, external applications are demanded. The various antipruritic remedies mentioned in the treatment of eczema may be employed. Alkaline baths are useful. Unna has reported a few instances of cure of well-developed cases of the disease by the use of an ointment composed of two ounces of oxide-of-zinc ointment, forty grains of carbolic acid, and from one to two grains of corrosive sublimate. Tarry applications, especially in the form of lotions, often prove of service, the liquor picis alkalinus and the liquor carbonis detergens being the preparations commonly employed.