Atopic Dermatitis and Eczematous Disorders

Donald Rudikoff, Steven Cohen, Noah Scheinfeld, Donald Rudikoff, Steven Cohen, Noah Scheinfeld

• Publisher: CRC Press
• Year: 2014
• ISBN:
  9781000738063
• Edition: 1
• Topic: Medicina
• Subtopic: Dermatologia

It is estimated that around 15% of the population suffer from atopic dermatitis or eczematous disorders at some point in their lifetime, causing a significant percentage of visits to dermatologists, primary care physicians, and allergists. Despite much current research interest, the pathophysiology of these disorders and their optimum treatment rem

CHAPTER 1

THE HISTORY OF ECZEMA AND ATOPIC DERMATITIS

Douglas Altchek and Donald Rudikoff

There was a time when the word ‘eczema’ was going out of use in England, and it may be that it is coming into favour again because of the inevitable association of the word ‘dermatitis’ with workmen’s compensation (Vickers 1952).

Eczema has been called the keystone of dermatology yet no other disease in the field has provoked such fierce controversy and dissent (Bulkley 1881). Rudolph L. Baer (1955) said that it was a disease ‘about which a lively argument can be precipitated at the slightest provocation.’ Among nondermatologists, it is a disease often misinterpreted and, among physicians, to quote Sulzberger, it ‘serves as a trash basket into which nondescript itching odds and ends are often being thrown even by dermatologists who pride themselves on accuracy in other fields’ (Sulzberger and Goodman 1936). He added, ‘The subject of eczema is a morass in which many dermatologists are floundering about, and it is not astonishing that some allergists and immunologists who are beginning to attempt to enter here, have already begun to feel the insecurity of the ground beneath their feet.’

The word ‘eczema’ is used synonymously with ‘atopic dermatitis’ as well as many other types of dermatitis where nomenclature varies by medical specialty, geographic location, and time periods of history. With a bit of humor and a liberal use of quotes from the great masters of dermatology, this chapter provides the reader with historical sources from which the terms ‘eczema’ and ‘atopic dermatitis’ derive.

From the outset, the word eczema itself is confusing. Consider at least four different pronunciations: ek՛sema, ek՛zema, egze՛ma, eg՛zema. The term is derived from ancient Greek κ ξ ε μ α and literally means the result of (-ma) boiling (-ze) out or over (ec-). The word atopy, with which eczema is commonly associated, literally means no (a), place (top), ness (y). Sir Thomas More’s name for the ideally perfect place, utopia, literally means ‘no place’ as well, further adding to the confusion.

Despite efforts to expunge eczema from the dermatology lexicon, it has persisted among physicians and the public. Self-help books devoted to the subject invariably use the term ‘eczema’ in preference to ‘atopic dermatitis’, a term with its own problems. A search of historical newspaper databases over the past 150 years reveals thousands of classified and display advertisements for patent medicines that claim to be remedies for eczema. The word has even been mistaken for a woman’s name, as in the following excerpt from the 1898 New England Medical Monthly entitled ‘Abortion dangerous in England’ which reported:

A member of a distinguished family in England telegraphed to a no less distinguished dermatologist: ‘How can I abort eczema?’ The police, getting wind of such a dispatch and thinking ‘Eczema’ was a woman’s name, placed the gentleman under arrest. The tragedy itself was, however, aborted by a prompt explanation that ex-Emma and eczema were not the same (Anonymous 1898).

ECZEMA IN HISTORY AND LITERATURE

Atopic symptoms can be traced back to biblical times. The Hebrew word tzaárat was used in the book of Leviticus to describe a skin ailment, generally considered to be leprosy, but which may have been eczema, psoriasis, or other dermatoses. The term ‘lepra,’ derived from ancient Greek, refers to scaliness and, as Pye-Smith (1893) notes, ‘No doubt many other cutaneous affections, obstinate chronic eczema, syphilis, lupus, and perhaps psoriasis were confounded with leprosy in ancient times’.

In the ancient Chinese medical classics, eczema is referred to as jin yin chuang (suppurative ulcerative lesion) (Liang 1988). The six external evils are external causes and spleen dampness is its primary internal cause, an obvious reference to the ‘outside-in’ and ‘inside-out’ pathogenic mechanisms that are currently in vogue (Elias and Steinhoff 2008). Blood heat and wind heat are secondary causes in the Chinese view.

Historical figures that may have had eczema include the Roman emperor Augustus, the eighteenth-century French physician Jean Paul Marat, Adolf Hitler, and Joseph Stalin (Mier 1975, Dotz and Jean Paul 1979, Montefiore 2005, Kershaw 2008). Mier (1975) quotes the Roman historian Suetonius (ad 69–140) in his description of Augustus: ‘His body is said to have been marred by … a number of hard, dry patches suggesting ringworm, caused by an itching of his skin and a too vigorous use of the scraper at the baths.’ Suetonius notes that Augustus was subject to ‘certain seasonal disorders: in early spring a tightness of the diaphragm; and when the sirocco blew, catarrh.’

Jean Paul Marat practiced medicine in London before he became a radical voice of the French revolution. He was murdered in 1793 by Charlotte Corday while sitting in his medicinal bath writing down the names of the deputies from Caen whom he intended to send to the guillotine (Mysticus 1920). According to Mysticus (1920), ‘Throughout the last year of his life Marat had been suffering from a severe skin disease, une maladie dartreuse, which he had contracted during his concealment in the cellars and sewers of Paris. Hints have so often been made that his complaint was of an unspeakably loathsome nature that the truth should be plainly stated, that he was afflicted with eczema and prurigo.’ This retrospective diagnosis is considered to be highly speculative (Dotz and Jean Paul 1979).

The ‘summoner’ in Chaucer’s Canterbury Tales is also afflicted with eczema (Chaucer [about 1370] 2006).

A summoner was with us in that place,

Who had a fiery red cherubic face,

For eczema he had; his eyes were narrow,

As hot he was, and lecherous, as a sparrow.

In fourteenth-century England, a summoner was a religious court employee who summoned those suspected of offenses against church law.

Another controversial personage who may have suffered from eczema rubrum was the charlatan and pretender to the throne of France, Eleazar Williams. Williams served as an Episcopal minister to the Oneida and Mohawk Indians in upper New York State.

Alfred Hardy, physician of the Hôpital Saint-Louis in Paris and champion of the diathetic basis of disease, asserted a predisposition to eczema among Jews since biblical times:

It is very frequent among the Jews; and generally of great gravity … This predisposition seems to me to be inherent in the race, and it is probably for this reason that Moses, that great hygienist, forbade to Israelites the use of pork, which especially favors cutaneous eruptions. (Dickinson 1891).

Even stranger are the bizarre treatments advocated for eczema. Perhaps the strangest example involves a Swedish fisherman who suffered an unbearable itch from eczema. Upon the recommendation of a friend, he smeared fresh pig dung all over his body and, as if that were not enough, the fisherman became so aroused by seeing a sow in heat that his subsequent actions almost landed him in jail for taking animal husbandry a little too far (Rydström 2003).

EVOLUTION OF THE TERM ‘ECZEMA’

The word eczema was first used by Aetius of Amila (AD 543) to denote ‘hot and painful phlyctenae which do not ulcerate’ (Wigley 1953). Phlyctenae are small blisters or pustules but as used by Aetius were probably furuncles (Unna 1903, Agnes 2006). The term ‘eczema’ is nowhere to be found in Daniel Turner’s De Morbis Cutaneis (1731) or Seguin Henry Jackson’s Dermato-pathologia published in 1792, and remains absent from the medical literature until Willan’s text published in 1797 (Turner 1731, Jackson 1792, Unna 1903). Robert Willan (1757–1812) (Fig 1.1) developed a classification of skin disease drawn from a treatise by the Viennese physician Joseph Plenck (Patalay et al. 2008). Establishing eight orders of cutaneous disease, the fourth order included seven vesicular (or bullous) genera – varicella, vaccinia, herpes, rupia, miliaria, eczema, and apthae. Willan’s ideas were introduced to the French by Laurent-Theodore Biett (1781–1840), who had visited with Willan’s student, Thomas Bateman (1778–1821) at the Public Dispensary in London (Beeson and Pierre 1930, Tilles and Wallach 1999). Except for Alibert, who remained hostile to Willan’s ideas, the majority of nineteenth- and twentieth-century French dermatologists embraced his classification. The groundbreaking system of Willan and Bateman, based on primary lesions, rather than symptomatology or clinical course, remains a cornerstone of modern dermatological diagnosis.

Fig 1.1 Robert Willan: the British physician created a classification of cutaneous disease that formed the basis for diagnosis based on primary lesions. (Reprinted from Crissey and Parish 1998. © 1998 with permission from Elsevier.)

Willan and Bateman defined eczema as ‘an eruption of minute vesicles, non-contagious, crowded together; and which from the absorption of the fluid they contain form into thin flakes or crusts … the effect of irritation, whether internally or externally applied’ (Bateman 1836). Lesions had an affinity for the inner thighs, axillae, inframammary area, and anus, lacked surrounding inflammation, and smarted rather than itched.

In a lecture to the Dermatological Society of Great Britain and Ireland in 1902, esteemed German dermatologist Paul Gerson Unna (1850–1929) summarized the history of eczema in the nineteenth century. Unna asserted that Willan’s conception of eczema was limited to vesicular sunburn reactions, mercurial dermatitis and eczema impetiginoides, bearing little resemblance to the eczema of his European contemporaries at the turn of the twentieth century (Unna 1903). It was emphasized that Willan used ‘internally’ to describe the internal administration of mercury; and, areas of predisposition, especially the inner thighs and perianal area, were characteristic of mercurial dermatitis. As Willan stressed the absence of surrounding erythema and smarting rather than itching, Unna concluded that the great British master was not describing the eczema known to European practitioners of 1902. The presence or absence of vesicles was to become a fertile topic of debate in dermatology.

Unna (1903) credited the French physician Pierre Rayer (1793–1867) with the prevailing view of eczema. Born into tempestuous times, Rayer gained renown not only for his prowess in the field of dermatology but also for his work in kidney disease, eventually becoming physician to the king. He lived modestly. When an arrogant financier asked of Rayer, ‘Is it true, Doctor, that the Roman physicians were all freed slaves?’, he replied, ‘Yes, but that was the time when Mercury was the god of bankers and thieves’ (Beeson and Pierre 1930). Rayer (1833) wrote, ‘Chronic eczema is always dependent on a peculiar organic disposition, which some pathologists suppose to be an alteration of the humors. This disease may continue for some months or several years’ (Rayer 1833). Unna’s main criticism of Rayer was the inclusion of Willan’s mercurial and solar eczema under the banner of eczema.

With regard to other authors, Unna held Jonathan Green in high regard for building on the work of Rayer, with the addition of a proper or constitutional eczema (Unna 1903). He credits Devergie with ‘having the courage to say, what all dermatologists … knew … that Rayer’s eczema by no means always commenced with Willan’s clear, clustered vesicles on noninflamed bases and … often did not show vesicles in its whole course.’

If Unna was correct, it would seem ironic that the varieties of eczema discussed nowadays bear little relation to the eczemas of Willan and Bateman, namely mercurial dermatitis, vesicular eruption associated with sunburn, and eczema impetiginoides. In defense of Willan and Bateman, the conditions that we now consider to be eczema/atopic dermatitis were definitely included in their works but in different categories. As for eczema rubrum (darte squameuse humide of Alibert), Bateman clearly states: ‘it is often associated with gastrointestinal inflammation, without any mercurial preparation having been taken’ (Bateman 1836).

In 1933, the well-known British dermatologist Horatio George Adamson (1866–1955) defended the reputation of the great British masters. Although he thought that Willan’s definition of eczema best fit ‘dermatitis traumatica v. venenata (contact dermatitis),’ Adamson decried the assertion that Willan and Bateman had not recognized what came to be accepted as eczema. According to Adamson, Willan and Bateman used the term ‘impetigo’ as a surrogate for eczema. Had impetigo not been appropriated for bacterial impetigo we would now be calling eczema by Willan’s designation of impetigo and contact dermatitis would have retained the name eczema.

Willan and Bateman’s impetigo was classified within ‘humid or running tetters,’ comprising several forms. At the time, a tetter was defined as a skin disease in humans or animals causing itchy or pustular patches, such as eczema or ringworm. Impetigo figurata corresponded to patchy eczema of the limbs (nummular eczema); impetigo sparsa was dispersed on the extremities, neck, shoulders, and even on the face, ears, and scalp. This form, they noted, ‘in young subjects fixes itself in the flexures of the larger joints and … is accompanied by intense itching … .’ Bateman described impetigo sparsa as ‘not unfrequent in young children in whom it appears to be the sequela of porrigo larvalis, if indeed it be not the same disease … . It occasionally supervenes to lichen’ (Bateman 1836). Thus Bateman alluded to infantile eczema of the face and scalp, as well as its evolution into childhood eczema. Porrigo was a designation of skin diseases of the scalp and larvalis means mask-like.

INFANTILE ECZEMA

Although dermatologists clearly recognized the presence of oozing, crusted eruptions on the face and scalp of infants, they were not categorized as eczema according to Willan and Bateman’s classification. Terms such as ‘crusta lactea,’ ‘porrigo larvalis,’ ‘tinea granulata’ (Alibert), and ‘strophulus’ were used to denote these eruptions. Sir Erasmus Wilson (1809–1884), the revered British dermatologist, Egyptologist, and President of the Biblical Archeology Society, perhaps best remembered for bringing the Egyptian obelisk Cleopatra’s Needle to London, publish...