This feature is part of a year-long series of excerpts and special commentaries celebrating AFP's 50th year of publication. Excerpts from the two 1950 volumes of GP, AFP's predecessor, appear along with highlights of 50 years of family medicine.
This feature, “Practical Hints in Dermatology,” by Herman Goodman, M.D., is reproduced from the November 1950 issue of GP, with commentary by Karl E. Miller, M.D., assistant editor of AFP. Today's well-stocked drug stores, grocery and discount stores offer consumers and physicians a dizzying array of skin-care products and medications—all of them ready to go in small, medium and large sizes.
The physician in practice has for generations limited his capabilities in the field of dermatology. Training in dermatology at medical schools and hospitals has been incomplete. The physician entering practice remembers a few names and fewer titles for skin therapy. The longer he continues in practice, the fewer the names recalled, and the therapy diminishes to calamine lotion, Lassar's paste, sulphur ointment, and chrysarobin. Recently, the topical applications have included some few antihistaminics and antibiotics. A knowledge of the principles of treatment of the ailments of the skin is derived from a review of topical applications in phases of eczema and dermatitis.
Eczema and dermatitis comprise more than 30 percent of all skin diseases. The patient with reaction to insult of the skin common to eczema and dermatitis reaches the general practitioner usually after trying home remedies, drug store items, and advertised cures. The patient expects immediate relief…
The recognized skin features of immediate response to insult (acute) common to eczema and dermatitis include redness, swelling, loss of function, itching, oozing, and crusting. The first thought of the physician is to place the patient within a named group of reaction to insult. The full diagnosis is very important to facilitate removal of the cause, and to avoid future exposure. However, the patient must be treated at once. The general or local therapeutic bath is advised. The period of immersion is variable, depending upon the result. Addition of water softener helps reduce the possibility of further damage. The following is advised:
|Sodium hexa meta phosphate (Calgon)||1|
|Water, sufficient to make||100|
Directions to Pharmacist: Dissolve powder in distilled water.
Directions to Patient: Use as a wet dressing on gauze, or diluted in basin, or in bath water. Amount depends upon hardness of water. A good guide is the slippery feel of the modified water on addition of the solution.
Conventional soap may further irritate the skin in the immediate phase of reaction to insult common to eczema and dermatitis. A substitute:
|Sulfonated olive oil||20|
|Sulfonated coconut oil||4|
|Sulfonated castor oil||60|
|Mineral oil, low viscosity, sufficient to make||100|
Directions to Pharmacist: Mix the oils.
Directions to Patient: Dilute the mixture, one part to no less than four parts of water for cleansing the skin.
It may be difficult to procure all of the ingredients as soon as required. Any one of the easily available sulfonated oils may be utilized with the low viscosity mineral oil under these adverse conditions…
The skin in the immediate phase of reaction to insult common to eczema and dermatitis may itch. The physician is tempted to modify the lotion by the addition of carbolic acid. He writes:
|Calamine lotion, sufficient to make||100|
Many physicians recall another prescription for allaying itching.
|Calamine lotion, sufficient to make||100|
Directions to Pharmacist: Rub the menthol and phenol to form sludge, and incorporate into lotion. Affix shake label.
However, the physician might better forget calamine lotion, calamine, and zinc lotion with phenol or with menthol and phenol. Patients know the “Pink” lotion too well. The physician should avoid prescribing what is so easily available without prescription. Also, the phenol and menthol do not really alleviate the itching sensation. Calamine lotion is difficult to remove from an irritated area of skin. It is almost impossible to remove from an area of skin with short or long hairs…
Physicians also recall Lassar's paste with salicylic acid.
|Lassar's paste, sufficient to make||100|
The alleged purpose of the salicylic acid in this low concentration was explained by the late Paul Unna of Hamburg. Salicylic acid belongs to the group of chemical-reducing agencies (removal of available oxygen, etc.) according to Unna. Reducing agencies, according to Unna, act on the skin as keratoplastic agents spurring formation of keratin if in low concentration, under 6 percent. A modern viewpoint offers low concentration of chemical-reducing agencies as fostering emulsification and restoration of the normal skin emulsion. The objections to Lassar's paste are valid for Lassar's paste with salicylic acid. An improved paste:
Directions to Pharmacist: Rub starch in cold water until smooth. Heat with constant stirring until a translucent paste forms. Incorporate:
|Mineral oil, low viscosity||8|
|Lard, sufficient to make||50|
Moisten powder with mixture of fluids and lard. Mix all.
Directions to Patient: Apply to affected parts…
…The current practice is to prescribe one or another of a group of the available antihistaminics to patients with any and all forms of reaction to insult or injury appearing on the skin. Patients do not react the same from the same chemical group of antihistaminics, and the side-reactions vary with each patient and each chemical. At this time, the selection of the antihistaminic must depend upon the individual patient. Is it safe to prescribe a strong sedative-acting antihistaminic early in the morning for a man driving his car to work?
The logic of antihistaminic therapy depends upon the assumption that histamine is formed from histadine each and every time tissue, including the skin, is injured or insulted. The rationale is based on excellent experimental and clinical studies.—HERMAN GOODMAN, M.D.
In reviewing the article by Doctor Goodman, we find some interesting points; despite the advances in medicine, some things have not changed. The first similarity is the issue of education in dermatology. Dr. Goodman points out how limited medical school and postgraduate education were with regard to dermatology. He points out that the longer physicians are in practice, the more they forget basic treatment principles and become limited in their abilities to provide “state-of-the-art” care. These concerns about education in dermatology persist, and physicians continue to struggle with maintaining their understanding of current treatment options. That effort to continue to provide up-to-date treatment is why Dr. Goodman's article was published 50 years ago and why American Family Physician continues to provide its readers with the most recent clinical information.
The other aspect of Dr. Goodman's article that catches our attention is his comments about patients. He states that patients present to the “general practitioner” after trying home remedies, expecting immediate relief from their physician. We may consider our current time as the age of instant gratification, but patients in 1950 also expected immediate relief when faced with an illness.
The striking difference between Dr. Goodman's article and our current literature is the use of compounding. The physician of those days needed to understand which agents should be mixed into a compound and in what concentrations. The pharmacist who filled the prescription also had to know how to compound. When writing prescriptions, physicians had to include directions for both pharmacist and patient. Today, physicians write prescriptions for tubes of creams and lotions, and the pharmacist fills the prescription with a prepackaged product.
Finally, Dr. Goodman's article has another similarity to current publications. The author takes the reader through some basic understanding of the disease process. Then, in a logical fashion, he presents the reader with treatment options based on scientific observations. The article provides the busy “general practitioner” with practical information that would benefit his or her patients. Despite the passing of 50 years, some things do not change.— KARL E. MILLER, M.D.