1) Epidermis, The Outer Skin Layer.

The epidermis is stratified epithelium undergoing keratinization, it consists of the

following layers:
(1) germinative layer, or stratum basale, or stratum germinativum;
- innermost layer of the epidermis and borders directly upon the dermis, or true
skin.
- consists of a single layer of prismatic (columnar) cells arranged like a palisade;
between these cells there are slit-like spaces called intercellular bridges.
- Large round or Oval nuclei are seen mostly in the upper part of the cells. These
nuclei are rich in chromatin and stain deeply with main nuclear dyes and because of
that they seem darker than the nuclei of the cells of the overlying layers.
- 2 main functions:
1. main sprouting (cambium) elements of the epidermis - from which cells of all the
overlying epidermal layers form. The columnar cells arranged perpendicular to the
basement membrane divide by mitosis.
2. the protoplasm of the cells of the germinative layer contains a pigment,
melanin, in the form of brown granules of various size
(2) prickle-cell layer, or stratum spinosum;
- overlies the germinative layer and consists of five to ten rows of cells which are cuboid in
the deep parts of the layer but become flatter gradually as they approach the next layer, the
granular layer.
- like the cells of the germinative layer, are separated from each other by
intercellular bridges and come in contact by means of protoplasmic processes.
- cells are marked by the presence of specific tonofibrils in their cytoplasm. The
tonofibrils do not pass from cell to cell but terminate in the protoplasmic processes; in the
cytoplasm of the prismatic cells of the germinative laye
(3) granular layer, or stratum granulosum;
- contains one to two or four (on the palms and soles) rows of cells elongated parallel to
the epidermis; the nuclei of these cells gradually grow smaller and numerous granules
which take a deep stain with the main dyes appear in the protoplasm.
(4) stratum lucidum;
- overlies the granular layer and is composed of elongated cells containing a special
protein substance which refracts light strongly. This substance resembles drops of oil and is
called eleidin (Gr. elaia olive tree).
- also contains glycogen and fatty substances (lipoids, oleic acid) giving effect
impermeability of the epidermis to water and electrolytes
- consists of two layers, the upper one has an acid and the lower an alkaline reaction. There
fore, this stratum is a very complex epidermal layer.
(5) horny layer, or stratum corneum
- outermost layer of the epidermis,
- comes in direct contact with the external environment and is distinguished by resistance
to a variety of external factors.
- composed of fine, anuclear keratinized elongated cells. They are firmly attached to one
another and are filled with a horny substance (keratin).
2) Dermis, The True Skin
- located between the epidermis and the subcutaneous fat.
- Two layers are distinguished in it, the papillary (stratum papillare), or the
subepithelial layer and the reticular layer (stratum reticulare).
- The epidermis is molded into the dermis in the form of rounded strands between which
the papillae penetrate, which lends the boundary between the epidermis and the dermis
the appearance of an uneven wavy line; this ensures close joining of the epidermis and
the true skin.
- The presence of the papillae probably improves the conditions for the nutrition of the
epidermis because in this way the area of contact between it and the dermis is greatly
increased as a result of which the supply of nutrients to the epidermis from the papillary
capillaries is easier.
- The true skin is composed of a fibrous substance of collagen, elastic, and argyrophil
(precollagenous) fibres, and an astructural amorphous interstitial substance found between
the connective-tissue fibres. various cell elements: fibroblasts, histio-cytes, lymphocytes,
mast and plasma cells, and peculiar pigment cells (melanophages).
- Hairs, glands (epithelial appendages of the skin), muscles, vessels, nerves and nerve
endings are located in the dermis.

3) Blood & Lymphatic Systems Of The Skin

BLOOD SYSTEM OF THE SKIN

Large arterial vessels stretch from the fascia through the subcutaneous fat and give
of small branches to the fat lobules. On the boundary of the dermis and hypoderm,
they divide into branches which stretch horizontally and anastomose with one another. A
deep arterial plexus of the skin forms, which gives rise to branches supplying the coils of
the sweat glands, the hair follicles, and the fat lobules The small arterial branches orig-
inating from it supply the muscles, the sebaceous and the sweat glands, and the hair
follicles.
The venous capillaries stretching from the papillae, the sebaceous glands, the
draining ducts of the sweat glands, the hair follicles and muscles come together and form
the first superficial subpapillary venous plexus. In the area up to the boundary with the
subcutaneous fat, there are four venous plexuses. The veins arising from the fourth
plexus pass through the hypoderm and drain into the subcutaneous veins.
The epidermis is devoid of blood vessels.
The most powerful network of blood vessels is located in the skin of the face,
palms, soles, lips, genitals and in the skin around the anus.

LYMPHATIC SYSTEM OF THE SKIN.

The superficial lymphatic network arises in the papillary layer as blind rounded
dilated capillaries between which there are numerous anastomoses The second network of
lymph vessels is in the lower part of the dermis and already has valves. This is a network
of wide loops forming a lymphatic plexus which in deeper parts is continuous with lymph
trunks.
4) Neurorecepter Apparatus Of The Skin
The skin is richly supplied with nerve fibres and special nerve end apparatus or
nerve endings which form together a large receptor field of the skin as the result of which it
can accomplish the function of a sense organ. cerebrospinal and the vegetative
(sympathetic) nerves contribute to the innervation of the skin. The main nerve plexus is
in the deep parts of the subcutaneous fatty tissue. plexus of closely arranged nerve fibres is
located in the subpapillary layer, from which separate nerve branches penetrate the
papillae and epidermis. On approaching the epidermis, the fine nerve fibres lose their
myelin sheath and penetrate the intercellular bridges of the germinative and prickle-cell
layers as demyelinated axial cylinders.
The free nerve receptors are either dendriform or coil-shaped, sometimes with a
button-like or funnel-like thickening on the end of a very fine fibre. Nerve endings
(bodies, or corpuscles) are enclosed in a connective-tissue capsule.
The following encapsulated end apparatus are distinguished in the human skin:
laminated Vater-Pacini corpuscles, Golgi-Mazzoni bodies, Meissner's corpuscles, Krause's
bulbs, and Ruffini's bodies
Laminated Vater-Pacini corpuscles are the largest encapsulated receptors, which may
measure 3 mm and more. They are usually located in the subcutaneous fatty tissue and are
thought to be the receptors of the sense of deep pressure and proprioceptive sensations).
Blood and lymph capillaries are supplied to the capsule. The nerve fibre approaching the
corpuscle loses its sheaths and enters the centre of the capsul as a demyelinated axial
cylinder
Golgi-Mazzoni bodies are now considered to be a variety of laminated corpuscles
although they are much smaller than these corpuscles and are located not in the
hypoderm but in the dermis almost directly under and in the papillae.
Meissner's tactile corpuscles are situated in the papillae and have an elongated-
oval shape. Their outer connective-tissue capsule is tnin and special 'tactile cells' are
arranged inside it horizontally in relation to the long axisThe myelinated nerve fibre
approaches the lower pole of the capsule, loses its sheaths, and as a naked axial cylinder
penetrates the capsule in which it forms meniscus-like thickenings adjoining the tactile
cells
Krause's bulbs (the receptors for the sensation of cold) are situated in and under the
papillae. They are composed of a fine connective-tissue capsule and are oval. The nerve
fibre loses its sheaths, enters the capsule and forms a thick coil in it.
Ruffini’s bodies (receptors for the sensation of warmth) resemble Krause's bulbs in
structure but are located much deeper, in the deep parts of the dermis and in the upper
parts of the subcutaneous fat.
5) Function Of The Skin

(a) PROTECTIVE (BARRIER) FUNCTION OF THE SKIN

The skin is resistant to mechanical effects (blows, friction, compression, etc.) because of
the tightness of its epithelial covering and the presence of a large amount of resilient
elastic and collagen fibres and subcutaneous fat. The skin protects the organism from
the damaging effect of sun rays because it contains the pigment melanin which absorbs
ultraviolet rays. The skin surface is covered with an acid (pH 5.0-6.0) water-lipid
mantle, which attenuates or neutralizes the damaging effect of chemical substances and
prevents penetration of micro-organisms into the skin. Chemicals occurring on damaged
skin or those which are soluble in the epidermal lipoids penetrate the deeper skin
layers and from there may be disseminated in the body by way of the blood and lymph
vessels.
(b) SKIN AS AN ORGAN OF SENSE
Four types of skin sensitivity are distinguished: pain, tactile, heat, and cold. The
last two types are embraced under the common name of temperature, or thermal sense.
The sense of touch, pressure, and vibration are related to tactile sense.
Temperature and tactile sensitivity are aroused by definite specific stimuli acting
on the skin. The pain effect may be induced by various factors which, on reaching a
definite stimulation threshold, are perceived as the sense of pain. The sensation of itching
may also be considered a form of sensitivity.
Pain is a specific sensation with a pronounced emotional colouring. It is perceived
by free nerve endings in the epidermis and dermis. Because of the different emotional
colouring of pain sensitivity, acute and dull, stabbing, cutting and aching, dragging,
and other types of pain are distinguished. As the result of pain, a reflex act occurs which
is of a defensive or protective character and directed against the stimulus. The tactile
sensitivity of the skin is perceived by two types of receptor apparatuses: the nerve
plexuses around the hair follicles (hair sensitivity) and Meissner's corpuscles
(particularly in skin areas devoid of hair). The sense of touch is aroused when the skin
comes in contact with objects and when it is slightly compressed The sensation of
deep pressure is perceived by the laminated corpuscles.
Temperature sensitivity (the sensation of heat and cold) is very important in
the life of man because it makes it possible to regulate body temperature by
reflex. It is believed that Ruffini's bodies perceive heat stimuli and Krause's bulbs
cold stimuli. Dissociation (or splitting) of sensitivity is encountered in clini cal
practice, when one type of skin sensitivity is lost, while the others are preserved.
The conduction pathways of the skin sensory systems in the central nervous
system are distinguished according to the functional sign. The central, or cerebral
part of the skin temperature or tactile analyser, for instance, is the region of the
postcentral gyrus
(c) SKIN THERMOREGULATING FUNCTION
This is achieved by chemical and physical thermoregulation. The production of
heat, which forms in the body as the result of metabolism and the consequent release
of energy, belongs to chemical thermoregulation. This is heat production. An
opposite process is heat emission which is related to physical thermoregulation
and is accomplished by the skin through three mechanisms: heat radiation (heat is
radiated as radiant energy, namely infrared rays), heat conduction (heat is given off
into the external environment because of the difference in temperature between the
body and environment and because the environment conducts heat), and
evaporation of water from the skin surface When the environmental temperature is
low, the skin vessels are drastically constricted, circulation in them decreases (but
increases in the viscera) and as a result heat emission reduces.
Heat emission is regulated by reflex (on stimulation of the skin temperature
receptors) and by direct stimulation of the thermoregulation centres in the tuber
cinereum and lateral wall of the third ventricle (hypothalamic region). The skin
vascular reactions and the secretion of sweat, which are constituents of the process of
heat emission, are controlled by sympathetic nerves and fibres arising from the
sympathetic ganglia.
(d) SECRETORY AND EXCRETORY FUNCTIONS OF THE SKIN
The eccrine sweat glands produce sweat which has a weak acid reaction,
relative density of 1.004-1.008. It consists of 98-99 per cent of water and 1-2 per
cent of inorganic compounds such as phosphates, sulphates, sodium and potassium
chloride, calcium salts and organic substances (uric acid, urea, creatinine, creatine
ammonium, amino acids, carbohydrates) dissolved in it. Increased perspiration leads
at first to copious now of water from the tissues into the blood, after which the water
from the plasma is excreted by the sweat glands. The oral mucosa becomes dry and
there is a feeling of thirst. The apocrine sweat glands, whose function is linked with
the endocrine, especially the sex, glands contain in their secretions, be sides the
common components of sweat, glycogen, cholesterol and its ethers, and iron. Their
secretions have a neutral or weak alkaline reaction
The sebum, the secretion of the sebaceous glands, has a complex chemical
composition. Its main components are free lower and higher fatty acids, neutral fats,
nitrous and phosphorous compounds, carbohydrates, various stearins, steroid
hormones, and cholesterol compounds. On the surface, sebum mixes with the sweat
and forms a fine film of water-fat emulsion. The process of keratinization of the
epidermis with gradual conversion of the cell protein substance to keratohyalin,
eleidin, and keratin is now considered to be the secretory function of the epidermis.
(e) RESPIRATORY AND RESORPTION FUNCTIONS OF THE SKIN
The skin takes little part in respiration, i.e. the absorption of oxygen and
elimination of carbon dioxide children the diffusion of gases through the dilated
skin capillaries is more pronounced the skin discharges water vapours (up to 800
g daily, which is twice to three times the work performed in this respect by the
lungs
6) Function Of Skin
- formation of keratin (the horny substance), melanin, and vitamin D.
- active part in the metabolism of water, minerals (sodium, potassium, calcium, etc.),
fat, proteins, and carbohydrates in the body
- metabolism of hormones, enzymes, vitamins, and trace elements because, on the
one hand, it is a spacious depot and, on the other, some of these substances are
removed from the body with the secretions of the sebaceous and sweat glands.
- Protein metabolism in the skin occurs at the expense of collagen (98.8 per cent of
the total skin proteins), albumins, globulins, mucoid, elastin, keratin, and protein
metabolites (amino acids, urea, creatine, uric acid, ammonia, purine bases, and
pigments).
- Vitamin metabolism plays a very important part in the skin biochemical processes.
Vitamin C, for instance, contributes to the production of melanin and the conversion
of glucose to glycogen; vitamin A participates in the formation of the horny
substance; vitamins A, E, and D activate protein metabolism in the epidermis
and the assimilation of sulphur. Vitamins of the vitamin B complex, i.e. BL
(thiamine), B2 (riboflavine), B 5, B8, B12, and others participate in the oxidation-
reduction processes. Vitamin PP (nicotinic acid) improves various functions of the
liver and produces a vasodilative and photodesensitizing effects

7) Primary Infiltration Morphological Lesions

- A spot (macula) is a circumscribed alteration in the colour of the skin or mucous
membrane
Small inflammatory rose-coloured spots which may reach the size of the nail of the
little finger form a rash called roseola
Large vascular spots (the size of a child's palm and larger) are called erythema
- A papule is a solid, more or less hard lesion, elevated above the skin surface. It
resolves leaving neither a scar nor cicatricial atrophy, though a non-persisting trace,
pigmentation or depigmentation, may remain. Papules vary in size, from that of a
pin head to that of a coin or may be larger. Papules of the size of a millet seed
or the head of a pin are palled miliary (those in lichen planus or lichen scrofu-
losorum), of the size of a lentil or pea, lenticular (in psoriasis, secondary syphilis,
etc.), those of the size of a coin are called num-mular. Large (hypertrophied) papules
are mainly encountered in secondary recurrent syphilis (condyloma latum). Confluent
papules form plaques (to the size of a child's palm). Papules are usually strictly
circumscribed but they vary in shape (they may be spherical, oval, flat, polygonal,
pointed, navel-like, dome-shaped) and their surface is smooth or rough A
tubercle is an infiltrative solid skin elevation of a non-acute inflammatory
character. It often ulcerates and terminates by cicatrization or cicatricial atrophy
A nodule is a primary infiltrative morphological lesion without acute inflammation.
It is large (the size of a pea to that of a walnut or larger) and is situated in the
subcutaneous fat
8) Primary Exudative Morphological Lesions
- A vesicle is a primary morphological lesion of an exudative character; it has a
fluid-containing cavity and is slightly elevated. A cavity with serous, less
frequently serosanguineous contents, a covering, and floor are distinguished in a
vesicle. It can be distinguish as serous and hemorrhagic.
- A bulla is an exudative cavitary lesion the size of a hazel nut to that of a hen's
egg and larger. A bulla under the horny layer is called subcorneal, one in the
thickness of the prickle-cell layer intraepidermal, and bulla found between the epi-
dermis and dermis is called subepidermal
- A pustule is an exudative cavitary lesion containing pus
- A wheat is an exudative non-cavitary lesion which forms as a result of
circumscribed acute-inflammatory oedema of the papillary skin layer

9) Secondary Morphological Lesions

- Erosion is a superficial skin defect within the epidermis. Erosions appear after rupture of
vesicles, bullae and pustules and are of the same shape and size as the primary
morphological cavitary lesions in whose place they had formed.
- An ulcer (ulcus) is a skin defect with involvement of the epidermis, dermis, and
sometimes the deeper lying tissues.
- Crusts (crustae) form when a serous exudate, pus or blood, sometimes with an admixture
of the drugs applied, dries on the skin
- A scar (cicatrix) forms in place of deep defects in the skin which had been
replaced by coarse, fibrous connective tissue (collagen fibres)
- Lichenization, or lichenification is thickening and hardening of the skin marked
by exaggeration of its normal pattern, hyperpigmentation, dryness, roughness, and
shagreen-like appearance

10) Staphylococcal Pyodermas

The following staphylococcal pyodermas are distinguished: ostial folliculitis, sycosis,
deep folliculitis, furuncle, carbuncle, hidradenitis.
In these cases, the pathogenic staphylococci are mainly localized in the orifices of the
hair follicles and the sweat and sebaceous glands, which determines the clinical
features of staphylococcal pustules

Ostial Folliculitis, or Staphylococcal Impetigo (Impetigo

Staphylogenes)
The lesion in this disease is a follicular pustule the size of a millet grain or pin head,
found in the centre of the hair follicle and surrounded by a narrow hyperaemic band
of acute inflammation redness and some pain around the orifice of a follicle or
sebaceous gland. A semispherical or conic swelling forms soon with a pustule in the
centre; the top of the pustule is yellow because of the pus that accumulates under it.
lesions sometimes grow to the size of a large pea and are usually pierced by a fine
hair in the centre Treatment. The causes conducive to the origin of ostial folliculitis
are removed. Some of the pustules are opened and the pus removed, after which the
foci of affection are painted twice a day with 1-2 per cent alcohol solution of aniline
dyes (l%Sol. Gentianvioleti, seu Methyleni coerulei, seu Virides nitens) in 70 per
cent ethyl alcohol or with an aqueous solution of potassium permanganate (dark-
cherry coloured). The hair in the area of the lesions is cut, but not shaved, and for
preventive purposes the surrounding skin is wiped with 2 per cent salicylic or boric
acid or with a solution of camphor and alcohol (2.5 ml of camphor alcohol and 45
ml of 40 per cent rectified spirit). Powders containing 10 per cent sulphonamide
preparations may be used. Total-body ultraviolet irradiation with
suberythema doses (daily or every other day, a total of 6 to 10 sessions) is
recommended in recurrences of the disease or in copious eruption of the
impetiginous lesions. Hydrotherapy is forbidden during the disease.
Deep Folliculitis (Folliculitis Profunda)
Painful red nodules appear at first, which later transform into pustules pierced
with a fine hair Later, the follicle melts and dies and is replaced by connective
tissue.
Treatment. The lesions are painted with Castellani's paint, 1-2 per cent alcohol
solution of methylene blue or brilliant green. The healthy skin areas close to the
pustules are wiped with 2 per cent salicylic or camphor spirit to prevent
dissemination. A 'flat cake' of pure ichthammol may be applied to some of the areas
of deep folliculitis. Baths and showers are forbidden for some time.
Sycosis (Vulgaris, Simplex, Staphylogenes)
predominantly among males.
Areas of ostial folliculitis and folliculitis form usually on the scalp, in the region of
the moustache and beard, and less frequently on the inner surface of the wings of
the nose, on the eyebrows, in the axillae, on the eyelid margins, and on the
pubis. After the top of the pustules opens, the pus dries up into dirty-yellow crusts
which stick to the hairs
Treatment. The management of sycosis usually takes a very long time and calls for
patience on the part of both the physician and the patient. All identified exogenic
irritating factors should be removed (treatment of focal infection, improvement of
sanitary and hygienic conditions of work at enterprises with the removal of the
causes of injury to and soiling of the skin on the face, etc.). A general effect must be
exerted on the patient's organism when deviations in its activity are revealed; this
may be accomplished by prescribing hydrotherapy, sedatives, treatment at health
resorts, a change in the surroundings (in functional disorders of the nervous system),
autohaemotherapy, autovaccines (as non-specific and specific stim ulation therapy),
medication with preparations of iron, arsenic, sex hormones (e.g. methyl
testosterone in diminished sexual function), and vitamin B 12 (in anaemia). Broad
spectrum antibiotics (gentamicin, oletetrin, tetraolean, erythromycin) are prescribed.
External therapy includes disinfectant lotions (applied during exacerbation), 2-3 per
cent salicylic ointment is used in removing the crusts. Topical application of
synthomycin emulsion or sulphani-lamide liniment is indicated in good tolerance
(absence of allergic reaction). In the period of abatement daily painting with 2 per
cent solutions of aniline dyes (methylene blue, gentian violet, brilliant green, etc.) is
advisable or the prescription of ointment containing boric acid and tar. Ultraviolet
irradiation (erythema doses) is prescribed in marked infiltration in the foci of
affection.
11. Furuncle, carbuncle
- one of the common forms of pyoderma. It is acute staphylococcal pyonecrotic
inflammation of the hair follicle and the surrounding connective tissue.
- Aetiology. The causative agent of furuncle is Staphylococcus aureus and, less
frequently, Staphylococcus albus.
- Pathogenesis. A furuncle may form on previously healthy skin or may be a
complication of an already existing superficial or deep staphyloderma.
- Predisposing Factors: exogenic factors are mild mechanical injury inflicted to the
skin by particles of dust, coal or metal which create the site of entry for the
infection; rubbing with the clothing (on the neck, in the small of the back,
buttocks) which promotes repeatednodosum, erythema induratum, and scrofuloderma
(see the respective sections).
- Histopathology. The purulent inflammation involves the whole hair follicle, the sweat
gland, and the surrounding connective tissue (deep folliculitis with perifollicular
infiltrate). At first the histo-pathological picture is similar to that in ostial folliculitis but
later necrosis of the whole sebaceous-hair apparatus and the neighbouring tissues with
copious leucocytic infiltrate on the periphery is found. Very many dilated blood vessels and
marked swelling of the collagen are seen in the surrounding connective tissue. The elastic
and collagen fibres in the focus of affection are completely destroyed. A strong argentophil
network forms on the periphery of the necrotic foci. A thick ring of collagenous bundles
of fibres surround the focus of affection, making it difficult for the infection to escape
from the focus and be spread in the body (squeezing of the furuncle may lead to the
breaking of the infection through the protective ring).
- Treatment. The treatment of furuncle depends to a great measure on the type and spread
of the pathological process. In a case with a solitary furuncle and no complications, for
instance, only external therapy is prescribed (particularly when the patient applies for
medical advice early). In recurrent and complicated furuncles, in furuncles of hazardous
localization, and in furunculosis, especially in the chronic and disseminated forms,
external therapy is supplemented by general measures which act on the microbial flora,
stimulate the defence reactive forces of the body, and contribute to the removal of
intercurrent diseases revealed during examination of the patient.
Antibiotics are used extensively. Penicillin is given intramuscularly
Out-patients are treated with ecmonovocillin (a mixture of benzylpenicillin procaine
and ecmolin which is a triprotamine sulphate solution) and bicillins (benzathine penicillin)
which are longacting penicillin preparations.
broad spectrum agents, which have an antimicrobial effect, namely macrolids—
erythromycin and oleandomycin, and their combinations with tetracycline—oletetrin,
sigmamycin, and tetraolean.
Semisynthetic penicillins - methicillin (intramuscular injection of 1.0 g every four to six
hours), oxacillin (taken in tablets or capsules of 0.25-0.5 g every four to six hours for five
days or injected intramuscularly in a dose of 0.25-0.5 g two or four times a day).
Combination of antibiotics with oral antihistaminic agents is advisable.
Sulphonamides (sulphathiazole, sulphadimidine, sulphadimetho-xine,
sulphamethoxypyridazine) and other antimicrobial agents by a general action are used.
Nitrofuran derivatives: furazolidone, furazolin, furadonin (nitrofurantoin) and furagin
have been lately prescribed in staphylodermas resistant to antibiotics and sulphonamides.
 advisable to prescribe non-specific stimulation therapy (autohaemotherapy) and specific
immunotherapy with the staphylococcal vaccine (polyvalent or auto vaccine),
staphylococcus toxoid, and antiphagin. Gamma globulin is used in persistent furunculosis.
Treatment of obesity, diabetes, intestinal atony, diseases of the internal organs,
anaemia, etc. is a very important component in the complex management of patients
suffering from chronic furunculosis. The diet of such patients should contain food that is
easily assimilated and no piquant and spicy dishes are given. Alcoholic beverages are not
allowed. Vitamins A, C and the B complex as well as preparations of iron and
phosphorus (phytoferrolactol, one tablet given three times a day for 15 to 20 days) are
recommended.
The skin around the furuncle is disinfected with a solution of salicylic alcohol, camphor
spirit, ether, benzine or vodka. The hair is cut (but not shaved!) in the area of the furuncle
and in the area immediately surrounding it (to prevent the development of folliculitis and
new furuncles); this is done from the centre to the periphery. The hair is then removed from
the furuncle with sterile forceps, pure ichthammol (possessing bactericidal, keratoplastic,
local anaesthetic, and anti-inflammatory effects) is applied and covered with a thin layer of
sterile cotton. An 'ichthammol cake' is applied once or twice a day. The ichthammol that
was previoulsy applied is removed with warm water; no bandage is needed. Such
treatment of a solitary furuncle that has not opened sometimes prevents thеfurther
development of the pathological process. After the furuncle is opened, a dressing
with a hypertonic saline solution may be applied and the periphery of the ulcer
painted with pure ichthammol. A mercury plaster is sometimes applied to the
furuncle; after the furuncle opens the ulcer is treated with ointment dressings: 5
per cent camphor-ichthammol, Vishnevsky's (3 parts tar, 3 parts xerophorm, 94 parts
castor oil), 2 per cent ammoniated mercury, 10 per cent ichthammol, 1-2 per cent
yellow mercuric oxide, 5 per cent chlortetracycline or erythromycin, dibiomycin
ointment. Dry heat (heater, sollux, Minin's reflector) or exposure to the effect of
UHF electromagnetic field is advisable. Moist heat (wet compress) and water
procedures are not allowed during the disease. Surgery is recommended when the
furuncle develops into an abscess, as well as intensive antibiotic therapy combined
with immunotherapy (hyperimmune gamma globulin, hyperimmune
antistaphylococcal plasma, staphylococcus toxoid).
- Prognosis. In cases with solitary furuncles (except for those with furuncle on the
face) the prognosis is always favourable. The prognosis is grave in chronic
furunculosis (particularly in elderly individuals, in emaciated patients, and in those
with diabetes), in complicated furuncles, and in sepsis.

Carbuncle
A carbuncle is diffuse pyonecrotic inflammation of the deep layers of the dermis
and hypoderm with involvement of several neighbouring hair follicles into the
process. Unlike a furuncle, the pyonecrotic infiltrate in a carbuncle spreads over a
larger area and penetrates into the deeper layers of the dermis and hypoderm.
The lesion is called a carbuncle (L. carbo charcoal) because the large necrotic
areas formed during the pyonecrotic inflammation are dark and resemble
charcoal.
The back of the head, the back, and the loins are the favoured localization.
 The causative agent is Staphylococcus aureus and less frequently other
staphylococcal species.
Emaciation (resulting from chronic malnutrition or a severe systemic disease) and
metabolic disorders, impaired carbohydrate metabolism in particular (in diabetes
mellitus), contribute to the pathogenesis.
Clinical picture and course. A few individual hard nodules are found in the skin at
first, which coalesce into a single infiltrate. This infiltrate grows, sometimes to the
size of a child's palm. Its surface becomes semispherical, the skin is tense and
cyanotic in the centre. There is local tenderness. This is the first stage of the
development of the infiltrate, which takes 8 to 12 days. After that a few pustules
form in the area of the infiltrate the tops of which open and several openings form
giving the carbuncle the appearance of a sieve. Pus and green necrotic masses with
an admixture of blood are discharged from these openings. Larger and larger areas
in the centre of the carbuncle gradually undergo necrosis. With the rejection of
the masses an extensive defect in the tissues, an ulcer, forms sometimes down to
the muscles. The second stage, the stage of suppuration and necrosis, lasts 14 -to
20 days. After that, the ulcer is filled with granulation tissue and a course deep
scar fused with the underlying tissues forms as a rule. Large scars are also left
after surgery performed for a carbuncle.
Carbuncles usually occur as solitary lesions. Their development is attended with
high fever, excruciating pain of a tearing, pulling character, a chill, and indisposition.
A carbuncle may take a malignant course in old age, in emaciated patients suffering
from severe diabetes, and in neuropsychic overstrain. Such cases are marked by
neuralgic pain, delirium or deep prostration, and septic fever. Death may occur from
profuse bleeding from a large vessel or sepsis. Severe meningeal complications may
develop when the carbuncle is localized in the area of the nose or upper lip.
The diagnosis is not difficult. The anthrax carbuncle should be borne in mind, in
which tissue oedema is more pronounced; a black scab resembling anthracite (hence
the name) forms in the pustule and the specific causative agent, the aerobic Gram-
positive anthrax bacillus, is identified. A carbuncle is easily differentiated from a
furuncle by the clinical picture described above.
Histopathology. Deep necrosis of the lower parts of the dermis and hypoderm is
revealed. The necrosis spreads gradually to the periphery. These foci are seen in a
thick infiltrate of neutrophils.
Treatment. The treatment of carbuncles always includes general measures and does
not differ in principle from the treatment of furuncles. Antibiotics are given together
with sulphonamides in severe cases. Radiotherapy produces a favourable effect at the
onset of the disease. In rapid development of the carbuncle, a wide and deep cross-
like incision is indicated with excision of the necrotic areas; this is carried out by a
surgeon as a rule; antibiotic therapy is applied at the same time (500 000 U of
streptomycin is often injected twice a day simultaneously with injections of
penicillin in a daily dose of 1 000 000 U or injections of its analogues). The skin
around the carbuncle is disinfected with 2 per cent camphor spirit or salicylic acid
twice a day without fail and all scratches and excoriations are painted with
Castellani's paint or alcohol solution of iodine.
Prognosis. The prognosis depends on the patient's general condition.
 12. Hidradenitis, pyodermas in childhood

Hidradenitis (Gk. hidros sweat, aden gland) is purulent inflammation of the

apocrine sweat glands in the axillae (usually unilateral) or inguinal folds, less
frequently around the nipples and in the region of the large pudendal lips,
scrotum, and anus.
Aetiology. The most common causative agent is Staphylococcus aureus, which
enters the efferent duct of the apocrine gland through the orifice of the hair
follicle.
Pathogenesis. General weakening of the organism, increased sweating and sweat of
alkaline reaction in the axillae, inguinal folds and anus (especially in individuals
with faulty hygienic habits), macerations, microtraumas, cuts during shaving,
scratches on the skin consequent upon pruritic dermatoses in individuals with nerv-
ous and endocrine (diabetes, gonadal dysfunction) disorders, and diminished local
resistance are predisposing factors. The sweat apocrine glands develop only in the
period of puberty (earlier in girls than in boys). There are more of them in
females than in males. By old age the activity of these glands is extinguished and
hidradenitis therefore does not develop in the old. The disease is encountered more
often among females than among males.
Clinical picture and course. At the onset of the disease, solitary small hard
mound-like nodes are palpated in the thickness of the dermis or hypoderm. The
patient experiences mild itching or pain at this time. The nodes grow rapidly in size,
adhere to the skin, become pear-shaped and protrude like nipples and resemble
'bitch's udder'; the skin turns bluish-red, swelling of the tissues develops and the
painfulness increases considerably. The isolated nodes often coa lesce, soften,
and fluctuation appears after which they open spon taneously and thick pus with
an admixture of blood is discharged. No necrotic core forms. A diffuse hard disk-
like infiltrate resembling a phlegmon forms sometimes, in which case pain is felt
not only during movements but at rest too, and disables the patient. Matu ration
of the lesion is attended as a rule with indisposition, mod erately elevated
temperature, and marked painfulness. After the nodes open, the sensation of
stretching and pain subside and the ulcers heal in a few days (resolution of the
infiltrate takes longer). Recurrences are frequent, however, and lend the process
a protracted course. Axillary hidradenitis is usually unilateral, though bilateral
lesions are also encountered. The average duration of hidradenitis is 10 to 15 days,
but a protracted recurrent course is observed quite often (particularly .in obese
individuals, in patients with hyper-hidrosis, diabetes, and in persons who pay
little attention to skin hygiene).
Histopathology. The process is localized on the borderline of the dermis and
subcutaneous fat. The purulent infiltrate, consisting mainly of neutrophils in the
early stage and of lymphocytes and plasma cells later, embraces the apocrine
glands and the surrounding connective tissue. The infection then spreads along the
lymphatics to other apocrine glands and to the eccrine glands and leads to their
purulent melting and death.
Diagnosis. The diagnosis is made easily from the peculiar locali zation of the
process and the typical clinical picture. The absence of a necrotic core
distinguishes hidradenitis from furuncles. Tuberculosis colliquative is characterized
by a more protracted course, involvement of the lymph nodes at the very onset of
the process, no pain, the development of extensive ulcerative surfaces and many
fistules, and healing with the formation of bridge-like scars.
Treatment. To prevent the further development of the lesions in the early
stages, it is recommended to apply ultrasonics, UHF current, ultraviolet irradiation,
pure ichthammol ('cakes'), X-ray therapy in small doses (50-80 r, 1-2 mm Al filter,
30-40 cm skin-focus distance, 120 kV) repeated if necessary in three or four days. X-
ray therapy is also advisable when the disease tends to take a protracted course and
recur. Surgery is resorted to when agminated abscesses form. Injection of 0.5-1.0
procaine hydrochloride solution (8-10 ml) with penicillin (300 000-500 000 U) or
aqueous tetraolean solution around the lesions is advisable in marked infiltration
and pain. Such blockades are made every other day, treatment consisting of four or
five procedures. Vaccine therapy is a rational measure in persistent and recurrent
hidradenitis. In other respects hidradenitis is treated along the same principles as
furuncles. Prevention consists in proper hygienic habits (frequent washing of the
body with soap and sponge) and disinfection of the axillae with salicylic alcohol or
borocamphor spirit.

Pyodermas in childhood

vesiculopustulosis, multiple abscesses of infants, epidemic pemphigus of the

newborn, Ritter's exfoliative dermatitis, and impetigo neonatorum bullosa.

(Details refer to note PYODERMAS page 11-16)

13. Streptococcal pyodermas: impetigo bullosa, angulus infectiosus, perleche

Impetigo Bullosa
Impetigo bullosa is characterized by eruption of phlyctenae as large as a hazel-
nut or a dove's egg. The erosion forming after the bulla ruptures grows gradually
and remnants of the top of the bulla are left on its periphery. This form is localized
commonly on the dorsal surface of the hands and less frequently of the foot and
leg.

Angulus Infectiosus, Perleche

Angulus infectiosus, or angular stomatitis, or perleche is a condition marked by a
rapidly rupturing phlyctena in one or both angles of the mouth. Areas at the wings
of the nostrils and lateral mar gin of the palpebral fissure may also be involved in
the process. Flabby vesicles form at first in the angles of the mouth, which rup ture
and expose superficial linear slit-like fissures. The formed honey-yellow crusts drop
off because of maceration. The disease is attended with a sensation of itching,
salivation, and pain during eating. It takes a prolonged course in dental caries,
rhinitis, conjunctivitis, in persons who have a habit of licking the angles of the mouth
(that is why disease is encountered mostly in children), in elderly individuals with
dentures, and in persons whose diet lacks vitamins of the B complex.
nomena, changes in skin pH and water-lipid mantle are predispos ing factors.
Impetigo is particularly common in infants with improper hygienic care.
Clinical picture and course. The disease begins with the appearance of a small red
spot on whose surface a vesicle the size of a pin head to that of a lentile
(phlyctena) forms in a few hours. In some cases the phlyctena forms on visibly
normal skin. The tensed vesicles turn flabby within a very short time and their clear
secretions become purulent (cloudy) and sometimes haemorrhagic and then dry into a
thin grey crust which gradually falls off. The phlyctenae are usually separated one
from another by healthy skin, but they also may spread by peripheral growth and
coalesce to form annular lesions (impetigo circinata). The average duration of the
disease is three to four weeks. A transient bluish-pink spot is left after the crust falls
off. Neither scars nor atrophy of the skin are encountered. The favoured localization of
the process are the face and the sides of the trunk and limbs. The disease may spread
rapidly to all child contacts (hence the name impetigo contagiosa).
Impetigo bullosa, perleche, streptococcal cheilitis, pityriasis simplex, superficial
panaris, intertriginous streptoderma (intertrigo streptogenes), and posterosive
syphiloid (papular syphiloid impetigo) are clinical varieties of streptococcal
impetigo.

14. Pityriasis simplex, tourniole ( impetigo of the nail folds )

Pityriasis Simplex
Pityriasis simplex is considered to be a dry variety of impetigo streptogenes. It is
particularly common in children and is characterized by round or oval, strictly
circumscribed whitish or pink foci, which are abundantly covered with small scales.
The foci are especially conspicuous in individuals with pigmented skin. The disease
may be cured by exposure to sunrays, but the affected areas are tanned weakly so
that mottling of the skin surface occurs. The favoured localization is the skin around
the mouth, the cheeks, and the region of the lower jaw, sometimes the lesions
occur on the skin of the trunk and limbs.
The disease usually occurs in the spring or autumn. In children's collectives
pityriasis simplex may acquire the character of epidemics. There is sometimes a
sensation of mild itching.

Impetigo of the Nail Folds (Tourniole)

Tourniole (Fr. tourn circuit) is mostly encountered in adults. Phlyctenae form
around the fingernails, first with serous secretions, which later become cloudy-
purulent. The disease develops in wounding of the fingers and handnail, which create
conditions for the entry of streptococci. The affected phalange swells and is
painful.
After the phlyctena ruptures an erosion forms embracing the nail plate like a
horseshoe. The process may terminate in the loss of the nail plate. Lymphangitis, a
chill, indisposition, and fever are sometimes encountered.
15. Mixed strepto-staphilococcal pyodermas
This is a group of pyodermas in which staphylococci and streptococci act together
as the aetiological factor. A superficial form (impetigo vulgaris, or strepto-
staphylogenes) and atypical varieties of deep pyodermas (chronic ulcero-vegetative
pyoderma, pyoderma chancriforme and pyogenic granuloma—botryomycosis) are
distinguished.

Impetigo Vulgaris, seu Impetigo Strepto-Staphylogenes, seu Impetigo

Contagiosa

Pathogenesis. The conducive factors are preceding or concomitant pruritic skin

diseases (scabies, eczema, neurodermitis), trauma of the skin, soiling and
maceration of the skin with saliva and other excretions.
Clinical picture and course. The onset is acute and is marked by the formation of
streptococcal impetigo, phlyctenae on a hyperae-mic slightly oedematous skin.
Because of the attendant staphylococci the contents of the phlyctena turn cloudy
rapidly and become purulent. After that the secretions dry into a thick honey-
coloured or yellow crust. The lesions are usually localized around the mouth,
palpebral fissures, and nostrils (less frequently on the skin of the trunk and limbs),
and the disease prevails among children, girls and young women. The regional lymph
nodes are often enlarged.
The developmental cycle of a single lesion takes eight to 15 days after which
pigmentation of the skin remains for some time. It should be noted that the separate
pustules tend to fuse.
The diagnosis is based on the characteristic clinical picture, localization, and
course in children, girls and young women.
Treatment. The external agents are 1-2 per cent alcohol or aqueous solutions of
aniline dyes, and Hyoxisone, Lorinden C, Dermoso-lone, 1 per cent neomycin
sulphate, Decamine (Dequalinium), and 1-2 per cent boric acid-tar (on naphthalan)
ointments. The healthy skin areas are rubbed with 1-2 per cent boric-salicylic or
1-2 per cent salicylic-camphor alcohol.
Prevention. In order to prevent autoinoculation with streptococ ci and
staphylococci, washing and baths for older children are not recommended. Showers
and baths are not allowed for adults. Infants are given baths with a low-
concentration potassium permanganate solution (light pink colour) or solution of
bur-marigold, chamomile or 1:1000 ethoxydiaminoacridine lactate. Chocolate, ho-
ney, and other sweets are restricted. Any existing scabies, eczema, otitis, rhinitis,
conjunctivitis, and other pyodermas must be treated.
The prognosis is favourable.

Chronic Ulcerous and Ulcero-Vegetative Pyoderma (Pyodermia Chronica

Ulcerosa et Ulcero- Vegetans)
Pathogenesis. Diminished body resistance to pyococcal infection and weakened
pathogenic properties of the causative agent are important factors in the pathogenesis
of the disease. As a result the disease takes a protracted chronic course and there is
no vigorous body reaction to the entry of the pyococci. Disorders of the
functioning of the internal organs and the nervous and endocrine systems are
favouring factors. Local neuro-trophic disorders of the vascular system resulting
from impaired blood supply, injuries, overcool-ing, disturbed vascular
permeability and resistance as a consequence of hypovitaminosis or infection
suffered in the past are of no small importance. Chronic pyodermas are mostly
localized on the lower limbs, less frequently on the dorsal surface of the hand. The
diseases are prevalent among 40- to 60-year-old males.
Clinical picture and course. The disease begins with the formation of streptococcal
ecthyma, furuncle or a peculiar deep infiltrate, which undergoes necrosis rapidly with
the formation of an ulcer. The ulcer is large, with rounded, oval or scalloped
contours, thick infiltrated and eroded edges, and an uneven loose floor with poor
grey granulations and copious purulent or seropurulent discharge. Deep pustules
may form on the periphery of the main focus. Deep communi cating purulent cavities
are found in the depth of the infiltrates. The ulcerous process spreads along the
periphery under the crust and takes various contours and shapes; now it is shaped
like a circle or ring, now as garlands with scalloped edges. New phlyctenae or
pustules form continuously on the edges of the main foci and un dergo pyo-ulcerous
melting. The epidermis, dermis, hypoderm, muscles, and in some cases the bones
may be involved in the process at the same time. The process usually terminates
in the formation of scars. The disease is attended with somnolence, weakness, anae -
mia, and pain (mild as a rule) and follows a chronic course of many months or even
years.
Vegetations, wart-like tissue growths, may develop on the sur face of the
ulcerations or on the periphery of the ulcerous lesion. In some cases they gradually
cover the whole surface of the lesion (chronic ulcero-vegetative pyoderma). Occasional
or numerous fistulous channels form frequently from which a purulent secretion,
frequently with an admixture of blood, is discharged continuously. In some cases the
central area of the ulcerous surface heals, but spreading of the process on the
periphery is continued. This is the serpiginous form of chronic pyoderma.
The histopathological picture is that of inflammatory granuloma.
The diagnosis is difficult. The medical history and the results of histological
and bacteriological examination and of biological tests must be considered, in
addition to the clinical picture and course of the disease. The differential diagnosis is
made with verrucous, ulcerative, and ulcero-vegetative lesions occurring in
tuberculosis and tertiary syphilis, and with deep mycoses (actinomycosis, spo-
rotrichosis, deep blastomycosis).
Nodular-ulcerous syphilid is characterized by the formation of numerous small
nodules undergoing disintegration with the formation of ulcers the floor of which is
even and has a slight amount of discharge. The nodules erupt in bouts and are
found in various stages of development, that is why mosaic scars remain after them.
Other symptoms of tertiary syphilis and the findings of serological tests help in
making the diagnosis. Verrucous tuberculosis of the skin is marked by tubercles
with inflammation not acute in character which are attended with phenomena
typical of tuberculosis of the skin; in the ulcero-vegetative stage there is a very
small amount of discharge and no growth of new pyogenic lesions on the periphery.
Besides, the verrucous growths have a hyperkeratotic character and lesser
tendency for disintegration. Ulcers, which form on rupture of the scrofuloderma
lesions, have soft scrappy edges and an uneven floor with pale granulations and a
small amount of serous discharge. The presence of fistulous channels makes the
differential diagnosis difficult. The scrofuloderma lesions leave bridge-like papilli-
form verrucous scars. Verrucous tuberculosis of the skin and scrofuloderma may be
attended with positive tuberculin reactions. Actinomycosis is distinguished from
chronic ulcero-vegetative pyoderma by a woody firmness of the infiltrate and the
presenceof driisens of the fungus in the discharge. Sporotrichosis and deep blastomycosis are
differentiated on the basis of mycologic examination, including cultural examination of
discharge of the ulcer and of bioptic material.
Treatment. The resistance of chronic ulcerative and ulcero-vege-tative pyodermas to
treatment makes cure of the patient very difficult. The disease often recurs after the
disappearance of the clinical symptoms.
The sensitivity of the causative agent to antibiotics and the patient's immunological
reactivity must be taken into account in prescribing treatment. Semisynthetic antibiotics
and macrolides in a combination with immunotherapy (staphylococcus toxoid, gamma
globulim, autovaccine), non-specific stimulation therapy (pentoxyl, pyrogenal,
prodigiosan, autohaemotherapy, blood transfusion), polyvitamins, and physiotherapy
(UHF therapy, ultraviolet irradiation) are applied. Monomycin (250 000 U given four
times a day) may be combined with erythromycin (200 000 U given four times a day) or one
of these antibiotics may be combined with pentoxyl (0.2 g given three times a day) or
methyluracil (0.5 g given three times a day). The staphylococcal toxoid is injected
intracuta-neously in divided doses of 0.1 to 1.0 ml twice a week (a total of 15 to 20
injections). Staphylococcal gamma globulin is given by intramuscular injection (120 U)
every other day (5 to 10 injections). Preparations of iron and phosphorus (phytoferrolactol,
etc.), vitamins (A, E, Bx, B12, C), and cod-liver oil are prescribed to strengthen the patient's
organism.
Any abscesses that form are opened and the cavity is treated with a penicillin solution.
Dermatol, naphtha-naphthalan, and Vishnevsky's ointments are prescribed for topical
application. Mikulicz's ointment (see 'Ecthyma Vulgaris', Treatment) is prescribed in a
torpid course of the ulcerative process to stimulate the growth of granulations. In marked
vegetations, careful curettage (scraping with a sharp spon-scraper) of the whole affected
skin surface is recommended and subsequent painting of the wound surface with a silver
nitrate pencil and application of borated petrolatum dressing. Good results have been
gained with enzymatic agents (chymopsin, a preparation of chymotrypsin with trypsin, and
chymotrypsin which are used topically in the form of tampons) and with Henk's solution,
Eagle's medium (solution 199), Vulnazan and Dibunol ointments, and Solkoseril (jelly and
ointment). These agents promote the growth of granulations with subsequent cicatrization
and epithelization of the ulcerated skin defects. Moderate doses of corticosteroids given in
combination with antibiotics sometimes have a favourable effect in the serpiginous variant
of chronic pyoderma.
Prevention. In view of the fact that these forms of deep chronic pyodermas are usually
localized on the lower limbs, thrombophle bitis, vasculitis and trophic ulcers of the lower
limbs must be treated in good time.
 Prognosis. The life prognosis is favourable despite the long duration of the disease and
the development of recurrences.

Chancriform Pyoderma (Pyodermia Chancriforme)

Aetiology. The disease is usually caused by Staphylococcus aureus, but streptococcus may
also be the causative agent that is why the condition is related to the group of mixed
pyodermas.
Pathogenesis. Factors conducive to the disease are: poor hygienic habits, narrowing of
the preputial orifice, or phimosis, in which the accumulating smegma irritates the skin on
the glans penis and the prepuce, causes inflammation, and facilitates the formation of
erosions and ulcers.
Clinical picture and course. The appearance of an erosive, most frequently ulcerative,
lesion with regular rounded or oval contours, hard, swollen elevated edges and an infiltrated
floor, which has a red-meat colour and is sometimes covered with purulent secretions or
gangrenous decay, is a characteristic symptom. There are usually solitary, rarely
multiple ulcers, localized on the genitals as a rule, though they may also be found on
the face, lips, eyelids, and tongue. The similarity to the syphilitic hard chancre is greater
because of the more or less marked thickening in the base of the ulcer, mild tenderness of
the ulcer, and moderate hardness and enlargement of the regional lymph nodes to the size
of a cherry or hazel-nut. The course of chancriform pyoderma may drag out for two or three
months and terminate by the formation of a scar. Some authors do not consider
chancriform pyoderma to be a separate nosological form but claim it to be ecthyma
vulgaris of the genitals.
Differential diagnosis with hard chancre may be very difficult because the absence of
Treponema pallidum in the serum still does not rule out the diagnosis of hard chancre. The
medical history and the results of serological tests help in making the diagnosis. Besides,
it should be borne in mind that the hard infiltrate in the base of the hard chancre is found
only within the boundaries of the erosion or ulcer, whereas the infiltrate on the floor of the
ulcer in chancriform pyoderma extends beyond its boundaries.
The final diagnosis in some cases is made only after a long period of observation over
the patient and repeated serological tests.
Treatment. Penicillin and other antibiotics are prescribed only after the final diagnosis
has been made. External treatment consists of baths (when the ulcers form on the genitals)
of a weak-concentration potassium permanganate solution and the application of dia-
chylon or xeroform ointment and 5 or 10 per cent emulsion of sulpho namides.

16. Mycoses: classification

All human dermatological mycoses are divided into four large groups:
(1) keratomycoses (pityria-sis versicolor and, very conditionally, erythrasma,
trichosporosis nodosa [piedra], trichomycosis axillaris);
(2) dermatomycoses (epi-dermophytosis, rubromycosis, trichophytosis, microsporosis
and fa-vus), which form the most representative group of fungus skin diseases of highest
social and epidemiological significance;
(3) candidiases (of the skin, mucous membranes, and viscera);
(4) deep (systemic) mycoses forming large but relatively rare group of fungus diseases.
17. Keratomycoses: pityriasis versicolor
Aetiology and pathogenesis. The causative agent Pityrosporum orbiculare, or
Malassezia fair fur is found in the homy layer of the epidermis and the ostia of the
follicles. When the diseased scales are examined with the microscope, the fungus is seen
as short, rather thick twisted threads of mycelium and clumps of round spores with a
double-contour capsule arranged as bunches of grapes. The disease is prevalent among
young men and women. In children, particularly in those under 7 years of age, it is a rare
occurrence. It may develop in weak children, in those with diabetes mellitus, tubercu-
losis, vegetoneurosis with increased sweating and in the prepuber-tal and pubertal
periods.
Pityriasis versicolor is marked by low contagiosity. Clinical picture and course.
Yellowish-brownish-pink spots with no inflammatory phenomena form on the skin, at
the ostia of the hair follicles and gradually grow in size. They then coalesce and cover
large skin areas and have microscalloped edges. The colour of the spots gradually turns
dark-brown, sometimes cafe au lait. This colour range served as the basis for the name of
the disease (versicolor). The spots are not elevated above the skin surface, cause no
subjective complaints (sometimes there is a mild itching) and are attended with bran-like
scaling (hence the name pityriasis furfu-raceous) which is easily detected by scratching
of the skin (Besnier-Meshchersky's sign).
There is usually no symmetry in the arrangement of the spots in pityriasis
versicolor. The chest and the back are the favoured sites, less frequently the spots are
found on the neck, abdomen, the sides of the trunk, and the lateral surfaces of the arms.
Lately, with the use of a mercury vapour lamp supplied with Wood's glass (see below) in
the diagnosis of the disease, the spots of pityriasis versicolor are quite often detected
(especially in a diffuse process) on the scalp but with no involvement of the hair. This
may possibly be among the causes of the frequent recurrences of the disease, despite the
seemingly successful therapy. Pityriasis in children of pre-school age or in adolescents of
the pubertal period is characterized by the involvement of extensive skin areas on the
neck, chest, in the axillae, on the abdomen, back, the upper and lower limbs, and the
scalp. The disease is of a long duration (months and years). Recurrences are frequent
after clinical cure. It should be borne in mind that patients may be cured rapidly by
sunrays and in such cases the skin in places of previous eruptions does not become tan-
ned and white spots form (pseudoleucoderma).
Histopathology. In the absence of inflammatory phenomena, there is looseness of
the horny layer, in which threads of mycelium and spores of the fungus are found.
The diagnosis presents no difficulties and is often made on the basis of the
characteristic clinical picture. In difficult cases, auxiliary diagnostic methods are used.
Baltser's iodine test is one of them: when the skin is painted with a 5 per cent iodine
tincture, the affected areas with the loosened horny layer are stained more intensively
than the healthy skin areas. Solutions (1-2 per cent) of aniline dyes are sometimes used
instead of iodine. Besnier-Mesh-chersky's sign may be tested: when the spots are
scratched desqua-mative lamella are produced because the horny layer is loose. Clinically
latent foci of affection are detected by means of mercury vapour lamp whose rays are
passed through a glass impregnated with nickel oxide (Wood's glass). The examination is
conducted in a dark room in which the spots of pityriasis versicolor produce dark-brown
or reddish-yellow fluorescence. With the detection of the clinically asymptomatic lesions,
including those on the scalp, a more rational treatment will be prescribed and recurrences
prevented in some of the patients. The diagnosis may also be verified by the detection of
fungus components in microscopy of scales treated with 20-30 per cent potassium or
sodium hydroxide solution.
Pityriasis versicolor sometimes has to be differentiated from syphilitic roseola (in
which the lesions are rose-coloured and disappear from pressure and there is no scaling;
other symptoms of syphilis and positive serological tests are taken into account) and
Gibert's pityriasis (rose-coloured spots arranged on Langer's lines of skin tension; they
are rhomboid or slightly elongated with peculiar scaling in the centre resembling
cigarette paper and are called medallions). Secondary, or false leucoderma, which forms
after treatment of pityriasis versicolor, is differentiated with true syphilitic leucoderma. In
the latter disease, coalescent hyperpigmented spots do not form, the lesion has the
character of a lace net and is mostly located on the neck, in the axillae, and the sides of
the trunk; blood serological tests are positive, and there are other manifestations of
secondary recurrent syphilis.
Treatment. Keratolytic and fungicidal agents are rubbed into the affected skin areas.
Salicylic (5 per cent) or resorcinol (3-5 per cent) alcohol and sulphuric (10-20 per cent)
or salicylic (3-5 per cent) ointment may be prescribed. Favourable results have been
obtained with Andriasyan's solution (Urotropini 10.Q, Glycerin! 20.0, Sol. Ac. acetici8%
70) which does not stain the skin and has no irritating properties. The solutions and
ointments are rubbed into the skin for four to six days after which the patient takes a bath
with tar soap and changes his underwear. Ultraviolet irradiation has a beneficial effect.
Diffuse forms are treated by Demyanovich Ts method, i.e. with 60 per cent sodium
thiosulphate solution and 6 per cent hydrochloric acid as in the management of scabies.
In treating children, the percentage of the agents used is lowered to 40 and 4,
respectively.
For the prevention of recurrences, the affected skin areas are rubbed with 1-2 per
cent salicylic or 2 per cent boric acid-salicylic alcohol once a day for several weeks after
the treatment has been completed or treatment is repeated in one or two months.
Prevention. Increased sweating is treated and body-hardening measures are
prescribed. Patients should avoid overheating. Skin hygiene should be strictly observed.
As a preventive measure, rubbing of the skin with vodka or 8 per cent vinegar once or
twice a week is prescribed after recovery*

18. Erythrasma
Aetiology and pathogenesis. Erythrasma is considered by tradition in the group of
keratomycoses though it is now established that Corynebacterium minutissimum, the
causative agent of the disease, is not related to fungi, while the disease itself is a
pseudomycosis. The Corynebacterium organisms are found only in the horny layer of the
epidermis and do not affect the hair or nails. Microscopy of scales removed from the
diseased skin areas reveals fine twisted threads of various length resembling mycelium
and cocci-like cells (as clusters or chains of round spores). The individual properties of
the body, increased sweating, dampness and high temperature of the air, changes in skin
pH in the alkaline direction, maceration, and rubbing are important factors in the
pathogenesis of the disease. The micro-organism is a saprophyte, possesses low virulence
and is therefore also found on healthy skin of individuals under ordinary conditions.
Infection may be transmitted through bedclothes and underwear and bath and during
sexual intercourse.
Clinical picture and course. Light-brown or brick-red patches appear and then
coalesce to form large foci with clearly demarcated, sometimes scalloped or arch-like
outlines. There are no inflammatory phenomena. The surface of the patches is either
smooth or is covered with fine furfuraceous scales. A slight elevation is sometimes seen
on the edges of the focus and the centre of the focus is either pale or brownish
pigmentation forms. There are no subjective disorders as a rule though sometimes the
disease is attended with mild itching. The itching may occur in the summer when
inflammation develops on the surface of the lesions because of increased sweating and
poor hygienic habits. Erythrasma is localized in the large skin folds. The inguinofemoral-
scrotal region is the most common site in males and the axillae and the folds under the
mammary glands and around the umbilicus in females. Erythrasma is very rare ia
children. The disease follows a chronic course with frequent recurrences, especially in
sweating, obese, and untidy individuals. Since there are no subjective disorders, the
disease is often not recognized and is discovered only during examination by a physician.
The histopathological changes are the same as those in pityriasis versicolor.
The diagnosis is based on the characteristic localization of the patches and their
brownish-reddish colour and scalloped outlines. Bacterioscopy is rarely undertaken.
Luminescence diagnosis is used extensively. It consists in irradiation with a mercury
vapour lamp fitted with. Wood's glass; in its rays the foci produce a coral-red or brick-red
fluorescence because the causative agent of erythrasma secretes water-soluble porphyrins
in the process of vital activity. Inguinal epidermophytosis is marked by elevated edges, a
border of macerated epidermis on the periphery of the foci, vesicles, inflammatory
phenomena, and itching. The continuous edge of the focus distinguishes erythrasma from
rubromycosis of the inguinofemoral folds, in which the foci have an irregular
inflammatory swelling of the edges, the skin of the feet and the nails is involved as a rule,
and there is itching of various intensity. Erythrasma is distinguished from pityriasis
versicolor by the localization and colour of the foci and the character of fluorescence
produced on irradiation with a luminescent lamp. Intertrigo is marked by acute
inflammatory manifestations and clearly demarcated foci.
Treatment. The same agents as in pityriasis versicolor are applied in the treatment
but in lower concentration because the erythrasma lesions are localized in more delicate
skin folds. The application of 5 per cent erythromycin ointment is particularly
recommended because in erythrasma, as distinct from fungus skin lesions, it produces a
marked therapeutic effect. The ointment is rubbed into the skin for 12 to 18 days. In a
diffuse process, 1.0 g of erythromycin is given daily per os.
Prevention. The skin is wiped with 2 per cent boric acid-salicylic alcohol and
powdered with an acid powder (5-10 per cent boric acid).
19. Epidermophytosis inguinalis
Aetiology. The causative agent is the fungus Epidermophyton inguinale Sabouraud
(E. floccosum).
Epidemiology. Contamination occurs in public baths and from using a common bath
and sponges. The causative agent may be conveyed to humans by means of bed-clothes,
oil-cloth, bed-pans, thermometers, towels and sponges shared with a sick individual.
Pathogenesis. Increased sweating in the inguinofemoral folds and axillae,
particularly in obese individuals and in those with diabetes me 11 it us, moistening of the
skin with compresses are factors which facilitate the development of the disease. The
disease is encountered most frequently among men; children and adolescents rarely nave
it.
Clinical picture and course. The lesions are localized in the femo-roscrotal folds, on
the medial surface of the thighs, on the pub is, and in the axillae. In some cases the
pathological process may spread to the skin on the chest, abdomen (between the skin folds
in obese individuals), under the mammary glands in females, etc. Red inflammatory,
scaling spots the size of a lentil appear first. As the result of peripheral growth they give
rise to large oval foci with a hyperaemic, macerated surface and an elevated oedematous
edge, which is sometimes covered with vesicles, crusts, and scales. Later the foci may
coalesce and form extensive areas of affection the size of a palm with geographic outlines.
The centre of the foci pales gradually and becomes slightly depressed. There is a border of
desquamating macerated epidermis on the edges. The patients are troubled by mild itching
which increases during exacerbations. The disease has a sudden onset as a rule, but then it
takes a chronic course and may continue for months and years with periodical
exacerbations (particularly in the hot season and in excessive sweating). In view of the
similarity of the clinical picture with that in eczema, old authors called the disease eczema
marginatum.
The diagnosis is made on the basis of the typical clinical picture, localization of the
process, acute onset, chronic course, and the detection of threads of septate mycelium on
microscopy of scrapings from the surface of the lesions (the best material for examination
is the desquamating epidermis taken from the periphery of the lesion). The disease is
distinguished from erythrasma by the difference in the clinical picture and course. Chronic
trichoptiytosis of the smooth skin is usually not localized in the folds. Superficial yeast
lesions with a similar clinical picture are differentiated by the findings of microscopy of
scrapings from the surface of the foci. Rubromycosis is differentiated by the results of
cultural examination
Treatment. In the acute period, when there are signs of «czema-tization, cold lotions
with a 3 per cent boric acid solution or 0.25 per cent silver nitrate solution are applied
externally. If there is no eczematization, painting the foci with 1-2 per cent iodine tincture
for several days, even in the acute period, is recommended, after which 3-5 per cent
sulphur-tar or boric acid-tar ointment is prescribed for two or three weeks. It is advisable
to apply fungicidal agents: Nitrofungin, Mycoseptin, Amycazole, Undecin and Zincundan
ointments, 2-5 per cent Castellani's paint, Wilkinson's ointment half-and-half with
naphthalan, and Octathione ointment. In the acute period, hyposensitization therapy
should also be conducted (oral medication with 10 per cent calcium chloride solution, 0.5
g of sodium thiosulphate given three times a day, etc.).
 For the prevention of recurrences after the achievement of a clinical cure, the skin
in the region of the cured lesions is painted with 2 per cent iodine tincture daily or every
other day.

20. Epidermophytosis of the feet, hands, nail plates

Epidermophytosis of the Feet, or Tinea Pedis (Epidermophytosis Pedum)

Tinea pedis is a widespread disease encountered in all countries of the world. Its
incidence among some population groups (swimmers, workers of public baths and
showers, athletes, workers at hot shops, coal mines, etc.) is high and, according to
different authors, reaches 60 to 80 per cent. The rural population acquires the disease less
frequently than does the urban population. The disease is relatively rare in children (in
3.9 per cent of examined children under the age of 15 years). At the age of 16 to 18,
however, its incidence is already 17.3 per cent.
Aetiology. The causative agent is the fungus Trichophyton men-tagrophytes, a
variant of T. interdigitale, which was previously called Epidermophyton Kaufmann-
Wolf. Only by tradition is the foot disease caused by T. interdigitale called
epidermophytosis of the feet. In distinction from Epidermophyton inguinale, this fungus
affects the hair in a test tube.
Epidemiology. The disease is contagious and is transmitted by sick individuals to
healthy persons in public baths, swimming pools, showers, and on the beach through
infected mats, spreads, flooring, wash basins, and benches. Footwear, socks, and
stockings worn by an individual with the disease are contagious, and sharing footwear is
therefore dangerous. The threads of the mycelium and the spores of the fungus are
contained in great amounts in the scales of the epidermal horny layer, which the sick
person 'loses' in abundance as a result of which an unfavourable epidemiological situa-
tion is created.
Pathogenesis. The conversion of the fungus from a saprophytic to a pathogenic
state is promoted by increased sweating of the feet, flat foot, tight interdigital spaces,
improperly fitted footwear (this is one of the causes of outbreaks of the disease among
recruits), sores, intertrigo, anatomico-physiological properties of the skin typical of each
definite age, chemism of the sweat, and alkaline shift in sweat pH. Disturbed function of
the central and peripheral nervous and endocrine systems, angiopathies, acrocyanosis
and other disorders of the lower limb vascular apparatus, ichthyo-tic skin lesions, and
hypovitaminosis are the endogenic factors, which are favourable for the development of
tinea pedis. Mechanical and chemical traumas of the skin on the feet, unfavourable
meteorological conditions, and a high environmental temperature are also significant.
The degree of the virulence and pathogenicity of the fungal strain should also be taken
into account.
Clinical picture and course. The following clinical varieties of tinea pedis are
distinguished: squamous, intertriginous, dyshidrot-ic and unguium. Epidermophytids are
distinguished as a manifestation of an allergic reaction. Some mycologists of today do
not acknowledge the existence of a subclinical form of epidermophytosis and consider
the condition to be either a carrier state (if the causative agent is detected but there are no
clinical symptoms of the disease) or a squamous form without obvious symptoms. The
separation of epidermophytosis of the feet into forms is conventional because a
combination of several clinical variants is often encountered or one form may change to
another.
The squamous form. Moderate scaling on a slightly hyperaemie skin is found on
the arches of the feet. The scaling may be restricted to small areas or may extend over
large surfaces. Some patients complain of slight itching felt now and again. Quite often
the disease remains unnoticed by the person and because of this it is particularly
dangerous epidemiologically. In exacerbation of the process, the squamous form may
change to the dyshidrotic form and, vice versa, the dyshidrotic form may terminate by
the squamous form. At the onset of the disease, the process is always unilateral but later
the other foot may also become involved.
The intertriginous form may occur independently but more frequently it develops
when there is a mildly pronounced squamous form. The process begins in the interdigital
folds, usually between the fourth and the little, less frequently between the third and
fourth toes. In some cases the disease spreads to the other interdigital folds and then to
the flexor surface of the toes and the dorsal surface of the foot. Cracks surrounded on the
periphery by a whitish separating horny layer of the epidermis form in the interdigital
folds. Weeping surfaces, itching of various intensity, and sometimes (when there are
erosions) pain appear.
Very often the process persists for a long time, with remissions in the winter and
exacerbations in the warm seasons. The formation of cracks and the looseness of the
horny layer in the intertriginous form are conducive to the entry of streptococcal infection
and the development of chronic recurrent erysipelas of the legs and thrombophlebitis.
The dyshidrotic form is characterized by the formation of a group of vesicles on
the arch of the foot. The vesicles resemble soft-boiled sago grains, they have a hard top
and their size ranges from the size of a pin head to that of a small pea. The vesicles
coalesce and form multilocular bullae in whose place eroded surfaces with a ridge of
macerated epidermis on the periphery form. The process may extend to the lateral and
medial surfaces of the foot and thus forms a single pathological focus with the
intertriginous form. The subjective symptoms are itching and pain. With the occurrence
of secondary infection the contents of the vesicles turn cloudy, pus is discharged when
the vesicles open, and lymphangitis and lymphadenitis may develop. As the
inflammatory reaction gradually subsides, the excoriations undergo epithelization, new
vesicles do not form, and the focus of affection acquires a squamous character. In severe
cases with secondary infection, the patients have to be hospitalized. A characteristic
feature is unilateral localization of the process. This form is distinguished by a protracted
torpid course, recurrences and exacerbations mainly developing in the spring and
summer.
Podvysotskaya described for the first time exacerbation of a dyshidrotic (less
frequently intertriginous) variant of the disease complicated by secondary pyogenic
infection (acute epidermophytosis). It is characterized by an eruption of a great number
of vesiculo-bul-lous lesions on the soles and toes; the skin of the toes is oedematous and
swollen. Acute epidermophytosis is attended with a feeling of indisposition, headache, a
temperature reaction, inguinal lymphadenitis, and the eruption of epidermophytids, i.e.
secondary generalized allergic lesions. The disease lasts about one or two months and
responds to treatment rather easily, though recurrences are possible.
Epidermophytosis, or ringworm of the nails (Tinea unguium)

The initial changes form on the free margin of the nail plate as yellow spots and
bands. The whole plate then thickens and turns yellow or ochre-yellow, crumbles and
breaks easily, and horny material accumulates under it (subungual hyperkeratosis). In
some cases the plate becomes thin and is separated from the nail bed (onycholysis). The
nail plates of the big and little toes are affected most frequently. The finger nails are
never involved in the process. It is claimed that the nail plates are affected in
approximately 20 to 30 per cent of patients with epidermophytosis.
Histopathology. In dyshidrotic epidermophytosis, small foci of spongiosis and
vacuolization of the cells of the prickle-cell layer are found in the epidermis, which leads
to separation of the cells and the formation of loculi. The vesicles merge and form large
bullae some of which rupture while others transform to a structureless homogeneous
mass. Mild inflammatory reactions are often encountered in the papillary layer of the
dermis. Threads of the fungal mycelium may be found in the horny layer.
Diagnosis. With a characteristic clinical picture and threads of the fungal mycelium
found by microscopy the diagnosis is easily made. Hyperdiagnosis is quite frequent,
when the bullous lesions on the feet and the maceration (in dyshidrosis, eczema of the
feet, candidiasis of the interdigital folds, intertrigo, etc.) are mistaken for intertriginous or
dyshidrotic epidennophytosis, while psoriat-ic lesions, eczema tiloticum, various mildly
pronounced hyper-keratoses, etc. are erroneously diagnosed as the squamous form of
tinea pedis.
Dyshidrosis lamellosa sicca is distinguished from squamous epidermophytosis by
the symmetrical arrangement of the lesions, the absence of inflammatory phenomena, and
no threads of fungal mycelium in the scales. The psoriatic papules and patches are greatly
infiltrated and are characterized by sharply circumscribed foci of affection and
macrolamellar scaling, and there are psoriatic lesions on other parts of the body. The
papules of the secondary period of syphilis in the stage of resolution may resemble
squamous epidermophytosis, but they are either arranged separately or form figures
(rings, garlands), have a dense-elastic consistence, and are attended with other
manifestations of infection (alopecia, leucoderma, papu-loroseolous lesions on the trunk,
limbs, oral cavity, and genitals, polyadenitis, and positive results of serological tests).
Intertriginous eczema and intertriginous candidiasis in distinction from
intertriginous epidermophytosis are marked by considerable prevalence of vesiculation,
weeping, maceration, and positive results of microscopy for Candida albicans in
candidiasis.
Dyshidrotic eczema is distinguished from dyshidrotic epidermophytosis by a
bilateral affection and extension of the inflammatory phenomena to the sides and dorsal
surface of the foot.
Epidermophytosis of the nails is characterized by asymmetrical localization,
affection of the nail plates of only the big and little toes, and no changes of the finger
nails. Rubromycosis of the nails is characterized by involvement of almost all the toe and
finger nails, while trophic changes are marked by symmetry and drastic dystrophic
changes of all nail plates with pronounced deformities.
In epidennophytosis, skin tests with intracutaneous injection of epidermophytin are
positive.
 Microscopic diagnosis. It is advisable to collect the macerated separating epidermis
on the periphery of the lesions for examination in dyshidrotic and intertriginous
epidermophytosis of the large folds. If there are vesicles and bullae, their tops are cut off
with a pair of sterile scissors and examined. In the squamous form, scales are scraped off
the lesions and examined. The horny material is scraped off the nail plates with a scalpel,
or cut off with a pair of scissors along the free edge of the nail plate, or collected on a
glass slide after treatment with a drill. The pathological material is soaked in 20 to 30 per
cent caustic alkali solution (KOH or NaOH) and examined with a 'dry system'
microscope under high magnification. The components of the fungus are seen as double-
contour threads of mycelium of various size and round or square spores (arthrospores).
The mycelium of a pathogenic fungus in the scales should be differentiated from the
mosaic fungus (which is believed to be a product of cholesterol disintegration) found on
the margins of the epithelial cells in the form of loops; it consists of uneven segments
(pleomorphism of segments) which dissolve gradually in the alkali (whereas the
components of the fungus are seen better with time). Microscopy makes it possible to
distinguish epidermophytosis from candidiasis, which is characterized by the presence of
budding yeast cells in the preparation. However, the microscopic picture of the threads of
the fungal mycelium in epidermophytosis, rubromycosis, and trichophytosis is similar
and they are differentiated by cultural diagnosis (growth of cultures on nutrient media) in
special bacteriological laboratories.
Epidermophytids are secondary allergic eruptions occurring because the fungus
Trichophyton mentagrophytes, a variant of T. in-terdigitale, possesses potent toxico-
allergenic properties and sensitizes the patient's organism imperceptibly for a long time.
In acute forms of epidermophytosis, sensitization occurs not only because of increased
absorption of the products of vital activity of the fungus but also as a consequence of the
sensitizing effect of the products of the patient's own changed protein. In view of this, in
60 per cent of cases epidermophytids occur in patients with dyshidrotic epider-
mophytosis, though they are also sometimes encountered in the intertriginous and even
the squamous forms. Epidermophytids occur close to the foci of epidermophytosis
(regional), but may be generalized. They are mostly localized on the palms and fingers.
The morphological character of the epidermophytids may be diverse: erythemato-
squamous, urticario-exudative, dyshidrotic (vesicular), pustular or eczematous. Vesicular
and squamous epidermophytids occur mostly on the palms, the urticario-exudative and
erythemato-squamous on the face, trunk and limbs. Generalized epidermophytids are
often attended with general symptoms: temperature reaction, chill, indisposition, and
sometimes severe itching. Eczematous and dyshidrotic epidermophytids may take a
protracted course and in inadequate treatment, transform to eczema.
Treatment. The treatment varies depending on the clinical form of tinea pedis, but
the condition common for all forms is as follows: the more acute the process, the lower
must be the concentration of the fungicidal and disinfectant agents. Treatment of acute
epidermophytosis is conducted on the same principles as treatment of acute eczema:
hyposensitization therapy (calcium preparations, antihis-taminics, vitamins,
autohaemotherapy) and topical anti-inflammatory treatment (cooling lotions or warm
foot baths with potassium permanganate); the lesions are previously treated (the bullae
and vesicles are opened, the tops are removed, the separating epidermis is cut off, etc.).
Acute dyshidrotic epidermophytosis attended with epidermophytids is managed by a
complex of hyposensitization therapy (calcium chloride orally or intravenously,
intravenous infusion of sodium hyposulphate, injections of vitamins B x and B6,
autohaemotherapy, diphenylhydramine hydrochloride, diazoline, di-prazine, etc.) and
corticosteroid hormones (prednisolone, triamcinolone or dexamethasone) prescribed in
small doses. Sulphonamides are given for five to seven days when a pyogenic infection
develops (purulent content of the vesicles and bullae). The prescription of antibiotics in
such cases is undesirable because they may lead to exacerbation of epidermophytosis
and the development of epidermophytids.
With gradual abatement of the inflammation (in the dyshidrotic and intertriginous
forms of epidermophytosis) treatment with des-quamative and fungicidal agents is
applied, increasing gradually their concentration: 3-5 per cent sulphur-tar or salicylic-tar
pastes, beta-naphthalan ointment, Zincundan, Undezin or Afungil ointments.
Ointments which cause separation of the horny layer are prescribed in squamous
epidermophytosis: Whitfield's ointment (Ac. benzoici 1.0-2.0, Ac. salicylici 2.0-3.0,
Vaselini 30.0) or Arie-vich's ointment (Ac. lactici 6.0, Ac. salicylici 12.0, Vaselini ad
100.0). After the horny material is rejected, Andriasyan's solution (Urotropini 10.0
Glycerini 20.0, Sol. ac. acetici 8% 70.0) or Castel-lani's paint (Fuscini basici spirituose
concentrati 20.0, Sol. ac. car-bolici 5% 190.0, Ac. borici 2.0, Acetoni puri 10.0, Resorcini
20.0), nitrofungin, and fungicidal ointments (0.05-1.0 per cent nitrofuri-len, sulphur-
salicylic-tar, octathione, Undezin, Zincundan, etc.) are applied. After the use of
fungicidal solutions and ointments in intertriginous epidermophytosis, various powders
are applied (di-mazole, dequalinium or the following prescription: Sulfur pp., Ac.
salicylici aa 1.5, Ac. borici 5.0, Zinci oxydati, Talci pulv. aa 25.0). The treatment of tinea
unguium is discussed in the section dealing with the treatment of onychomycoses in
rubromycosis. Instead of radical removal of the few nail plates infected with the fungus
Epidermophyton, painting with iodine tincture is prescribed to prevent the spread of the
fungus.