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Jan. 18, 1964, vol. 90

S EBORRHEA capitis, or "cradle cap", is reported

to be the most common disorder of the scalp
encountered in infants,' and its incidence varies ABSTRACT
with geography and local nutritional customs.2 Forty-eight infants with seborrhea capitis
In the current view, the skin is a highly complex were treated with a preparation containing
zone with vital functions which serve to protect a polypeptide-fatty acid complex and
the person from potentially dangerous forces in the tyrotbricin in a propylene glycol vebicle,
environment.3 These functions include, among to determine if this material was non4oxic
others, homeostatic mechanisms, regulating the pH and if it was effective in the treatment of
of the skin surface, preventing excessive bacterial infantile seborrheic dermatitis. In this un-
and fungal growth, and forming oil-water emulsions controlled study, the preparation was effec-
which supply skin-softening and plasticizing effects. tive in 45 of 48 infants so treated; a
A disruption of the emulsifying mechanism, possible, mild sensitivity reaction was ob-
served in one infant.
through failure of the sebaceous glands to supply
lipids in proper amount, results in a dry, scaly,
itchy and often reddened skin, and may weaken
the skin's protective capability.
Though the etiology of seborrheic disorders re-
mains to be clarified, there is considerable evidence
that it is directly related to hormonal activity.
Except in early infancy, these disorders generally
do not make their appearance until puberty,4 and
there are marked changes in sebaceous activity
during the menstrual cycle.5 In the case of infants,
these disorders are attributed to hormonal factors
derived from the mother.2'4
The altered homeostasis of the seborrheic skin,
such as the alkaline pH and the changes in the
protective oil-water mantle, increases susceptibility
to transient pyogenic infections and sensitivity to
external irritants.4
In the light of current concepts, an effective
therapeutic regimen should include: removal of
skin surface crusts and scales, so as to deprive
fungi and bacteria of a culture medium; an anti-
infective agent to destroy existing pathological
organisms on the skin surface without develop-
ment of resistant strains or allergic reactions; a
means of restoring the normal acidity of the skin
surface; and a water-miscible agent for removal of
proteolipid material with gentle rinsing. Any thera-
peutic agent or agents encompassing these factors
should also be non-sensitizing and non-irritating,
since the seborrheic skin is highly sensitive.
Recent literature has reported the formulation
of a preparation which is said to embody the above
factors; this preparation has appeared to be useful
for the treatment of seborrhea capitis in several
clinical tests without irritation or other side
effects.6-8 The preparation contains a polypeptide-
From the Child Health Centre. Montreal Children's Hospital,
and Department of Pediatrics, McGill University.
*Assistant Physician, Montreal Children's Hospital, Montreal.
Canad. Med. Ass. J. 1.

within four days. The three failures of therapy to the long-term effects of successful therapy. Be-
included a girl, aged 1 month, with a mild condi- cause of an apparently high incidence of recurrence
tion, whose parents discontinued medication after of some form of seborrhea in the same individuals
two days when no improvement was evident; a in infancy, adolescence and adulthood, the concept
boy, aged 2 months, whose parents similarly dis- of an "inborn diathesis", or the "seborrheic indi-
continued treatment after three days; and a girl, vidual", has had substantial medical acceptance
aged 2 months, who developed a marked erythem- for the past half-century.4 It is, however, far from
atous eruption of the scalp three hours after the universally accepted. The relationship between
initial application. This subsided spontaneously in "cradle cap" in infancy and the seborrheic disturb-
12 to 18 hours, and no further treatment was ance of later life, including the possible influence
carried out on this particular infant. on this later disturbance exerted by the elimina-
Though the figures are too small for definite con- hon of symptoms of the condition in infancy, thus
clusions, there is no significant difference in this remains to be clarffied.
study between the responses of male and female Irrespective of long-term consequences, there is
infants. As might be expected, however, cases of little uncertainty about the immediate value of
longer duration and of more severe involvement clearing up the "cradle cap", as regards both the
required, on an average, somewhat more lengthy removal of a possible focus for infection and
treatment than the milder cases, though all eight esthetic considerations.
cases with a duration of more than three months
responded successfully. The average duration of SUMMARY AND CoNclusIoNs
therapy in these eight cases was 4.4 days, as com- A polypeptide-fatty acid-antimicrobial prepara-
pared with an average of three days for all other tion designed to counteract the disturbed physio-
cases effectively treated. For the four severe chemical states observed in infantile seborrhea capitis
cases, the average duration of therapy was four was tested in an uncontrolled series of 48 infants
days, as compared with a 3.2-day average for the with "cradle cap". The medication cleared the condi-
"mild" and "moderate" cases. There was little hon entirely in from one to seven days in 41 of the
difference in duration of therapy between the latter 48 infants, and substantially cleared it in four others.
two categories. There were only three failures of treatment, one the
The one apparent "toxic.. reaction encountered result of an erythematous scalp eruption, which cleared
with cessation of medication. Aside from the one
in the study was the possible allergic reaction apparent sensitivity reaction mentioned, there were no
already noted. side effects and the medication was simple to ad-
The material used in this study was supplied by the
From this uncontrolled study, the polypeptide- Purdue Frederick Company (Canada) Limited, Toronto.
fatty acid-tyrothricin preparation appears to be
effective for the treatment of infant "cradle cap". It
appears also to avoid some of the unpleasant side 1. PASACHOF'F, H. D. AND MAFFIA, A. J.: New York J. Med.,
57: 265, 1957.
reactions such as conjunctival irritation and re- 2. Leading Article: Brit. Med. J., 2: 1462, 1958.
bound phenomena noted with other agents em- 4.
Derm., 81: 235. 1960.
INGRAM. J. T.: Brit. Med. ,T., 2: 1167, 1959.
ployed for this condition. 5.
WHEATLEY, V. R.: Practitioner, 180: 580, 1958.
BIALKIN, C.: Arch. Pediat., 76: 328, 1959.
Since the etiology of seborrhea is as yet obscure 7.
Russo, L.: Quart. Rev. Pediat., 15: 109, 1960.
SELDOWITE, M.: Amer. J. Dis. Child., 100: 875, 1960.
and its treatment is symptomatic, it is scarcely 9. GOODMAN, L. S. AND GILMAN, A.: The pharmacological
basis of therapeutics, 2nd ed., The Macmillan Com-
possible to draw definitive conclusions with regard pany, New York, 1955, p. 1409.

FEE SPLITTING means of his keen intellect and medical skill he has been
able to do this; and for this service he may receive the
"Are you for or against dichotomy?" By dichotomy is paltry sum of five or ten marks. The surgeon or specialist
meant a division of the fee between two doctors, one of who is called in undoubtedly helps to save this life, cer-
whom has, for some reason, given his patient into the tainly gets all the credit, and receives many times as great
care of the other. At this definition I hear all the doctors a sum as the poor practitioner who probably gets as much
crying with one voice: this practice is unworthy of our as the tip a thankful patient presents to the orderly on leav-
profession. And this I do not deny, for it is indeed an un- ing hospital. Now suppose the surgeon be a sensitive crea-
ethical procedure; but even with this dictum the subject hire who thinks of others and realizes the value of the
cannot be closed, for much more is involved in this ques- physician's art. He will say: it is unfair that I should re-
tion than first meets the eye. The fee-splitting may be the
result of a feeling of gratitude on the part of the surgeon ceive so much more remuneration than he. But the surgeon
for the assignment of the case; or from an idea that it is is perhaps also an ethical being. How then is he to repay
the fair thing to do. The general practitioner will probably the physician? And here lies the real problem of dichotomy.
recall many instances where he has made a correct diag- -Abstract of article from Muenchener MedizinL.che Woch-
nosis, advised operation and saved the patient's life. By erachrift, Canad. Med. Ass. J., 4: 71, 1914.