Skin disease may arise from agents which attack it from outside or from within. These agents may take the form of damaging radiation (e.g. severe sunburn), irritants, or living organisms (e.g. the virus of warts or the mite of scabies). Agents arising from outside the body may nevertheless be spread via the bloodstream, the usual effect being involvement of a wide area of skin in a symmetrical pattern; examples are the rashes of secondary syphilis, measles and those of many drug eruptions.
Genetic and racial factors are important since many skin disorders are inherited. The climate, especially the degree of sun exposure and the humidity may bring on skin lesions or modify existing ones. Systemic disease such as diabetes mellitus or malignant disease can make the skin more liable to infection by bacteria, yeasts and fungi. Psychological upsets undoubtedly influence skin disease but only rarely are they the primary cause.
Patients with skin disease are often in considerable physical and mental discomfort, therefore the first task of the attendants, both nursing and medical, is to relieve discomfort and allay anxiety. The patient will be reassured by a calm confident approach and he should not be made to feel that his attendants are unwilling to come close.
The patient is usually most comfortable in a fairly cool environment. Rubber and plastic under-sheets are best removed. In the acute stages of skin disease itching may be a prominent feature and both daytime and night sedation with oral antihistamine or barbiturate drugs can be very helpful. Absolute bed rest is usually unnecessary and the patient can be allowed up for toilet purposes and for meals.
Baths. A morning bath daily or on alternate days often adds greatly to the patient's comfort provided it LY followed quickly by the appropriate topical therapv, Bathing removes remnants of the previous topical applica¬tions together with any accumulated skin debris such as scales and dried serum. The water should be warm rather than hot and five minutes in the bath should Ire sufficient. After the bath the patient pats (not rubs) himself thy with n soft towel.
Bath additives are helpful in many skin diseases. Emulsifying Ointment B.P. 100 it In a bath of water helps to lubricate the skin and prevent dryness. Emulsifying ointment baths are used for patients with chronic dry eczematous dermatitis or any condition where dryness of the skin is
troublesome. The emulsifying ointment is best dissolved in a small quantity (120 ml) of very hot water and added to the bath with stirring, otherwise it may remain as lumps floating on the surface. If the above material is found to be too greasy then a similar quantity of Aqueous Cream B.N.F, may be used.
Potassium permangate baths are used when bacterial infection is present. The correct concentration is achieved by adding 60 ml of potas¬sium permanganate solution (1 in 8,000) to a bath of water. The not uncommon practice of adding potassium permanganate crystals to the bath is hazardous since small skin burns may be produced if some of the crystals which do not have time to dissolve settle on the skin.
Coal tar baths are used almost as a routine in the treatment of psoriasis. Sixty ml of strong solution of coal tar is added to a bath of water and the plaques of psoriasis are rubbed gently to remove loose scales.
Ointments and creams. Topical corticosterod preparations have greatly improved the efficiency of treating many dermatoses, especially eczemas. The original preparation, hydrocortisone, although still useful in certain circumstances, has given way to more powerful steroids such as fluocino-lone (Synalar) and betamethasone (Betnovate). Usually 1 in 4 dilutions give a satisfactory result. Often an antiseptic such as chinoform (Vioform) is added to treat or prevent infection. Coal tar ointments and anti-fungal ointments are also in common use.
Application. A thin layer is applied to the affected area of the skin and rubbed in gently but well with the fingers. Applying ointment with gauze swabs is inefficient since the essential 'rubbing in' phase is omitted. Although the ointment can be applied with bare fingers it is now common practice for a pair of disposable polythene gloves to be worn. About 10 g of ointment is sufficient to cover the entire skin surface.
If the appearance of the skin has changed for the worse since the treat¬ment was prescribed, especially if pustules have appeared, then the doctor should be informed. If in doubt it is safer to omit a treatment rather than persevere with unsuitable therapy.
Dressings. The ideal covering for the skin after treatment is a single layer of stockinette gauze, since it is quickly applied, comfortable for the patient, and allows air to circulate freely. Corticosteroid ointments are sometimes used with polythene occlusion; an airtight layer of polythene over the treated skin is used to keep in moisture and aid penetration of the active constituents of the ointment to the deeper layers of the skin. For hands and feet polythene gloves and bags are employed; limbs and trunk may be wrap* in polythene sheeting. Unless otherwise ordered occlusion overnight only is employed.
Impregnated bandages are useful for wrapping affected limbs. The medicament contained in the bandage can be coal tar, ichthyol or a corticosteroid. An icht hyol paste bandage is especially useful for ulcerated legs. A common fault is to wrap the bandage too tightly, causing the patient much discomfort. If the bandage is cut across completely every 12 inches or so this problem will not arise. When the bandage has been thus applied in short strips it is held in place by a layer of stockinette gauze and a crepe bandage. If an ambulant patient with leg ulcers or gravitational
eczema is being treated in this way a firmer outside support is required and a stout elastic bandage is more effective than crêpe for this purpose.
Any supportive bandage should extend from the toes to the knee or higher, because if the foot is not included any tendency to oedema is aggravated.
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