Lesions on the Body.-For lesions on the body, crude coal tar paste, am-moniated mercury, salicylic acid and sulfur, Pragmatar, or Vioform oint­ments are excellent.

*(1)  Crude  coal  tar  3 i Zinc oxide 3 ii Starch 3 iv Petroleum jelly ad % ii

(2)  Ammoniated mercury ointment U.S.P. 3%

(3) Ac.   salicylic,

Precipitated sulfur aa gr. xx Petroleum jelly § ii

(4) Pragmatar  ointment

(5) Vioform 2% in petroleum jelly or in Lassar’s paste, or Vioform cream 3%t

Feeding.-The diet is important. The milk formula should be low in fat and sugar, and high in casein, about as follows:

Pour off the top 4 oz. from a quart of milk and use it for something else. The formula is

28 oz. milk 6 oz.  water 2 level tablespoonfuls of Karo  syrup  or

Dextri-Maltosei 4 level tablespoonfuls of  Casec.t

Cook in a double boiler for !/2 hour to make a smooth gruel and add enough water to replace what has boiled away.

Soybean foods, which are used now by so many pediatricians for prac­tically every baby who has any skin rash whatsoever, are not indicated.

It is probably a good plan to give multiple vitamin B₁₂§ drops, and finely ground liver. I am not sure whether or not these really do any good but they can do no harm, and have been highly recommended by some.

The results of treatment in sebor-rheic dermatitis, provided there is no allergy along with it, are usually very satisfactory.

*For other tar ointments, see section on atopic dermatitis.

t Ciba Pharmaceutical Products, Inc., Sum­mit, N. J.

J Mead Johnson & Company, Evansville, Ind.

§ Multi-Beta B_K drops, White Laboratories, Kenilworth, N. J.

Intertrigo.-For intertrigo, salves are of no value except possibly hydro-cortisone ointment, and often do more harm than good. Lotions are better.

My favorites are:

(1) Burow’s solution 3iv Zinc  oxide Talc aa 5 i Glycerin 3 vi Lime water ad 3 iv

(2)  Aqueous   solution   of   gentian   violet 1%

(3)  Silver nitrate solution 0.25%

It is also desirable, if possible, to prevent the skin surfaces of the creases from coming together, and little rolls of absorbent cotton can usually be kept on pretty well in the groins, and in the creases of the neck.

The Scalp.-If local treatment is to do any good, the hair must be cut as short as possible.

A. The Dry Type With Small Scales: First thickly apply the follow­ing salve for three days. Rub it in well, and cover the head with a cheap cotton cap.

Ac. salicylic gr. xx Petroleum jelly J iv

On the fourth day scrape out with a fine comb as much of the scale as pos­sible. Shampoo with pHisoHex or a mild soap. Then apply Pragmatar ointment.* This consists of coal tar, sulfur, and salicylic acid. It is a fairly strong ointment, but most scalps tol­erate it. Use this for three days, shampoo again, then leave the scalp alone for three days. Repeat the treat­ment, and keep up this schedule as long as necessary.

B. Crusted Type: Here there is a foul, piled-up accumulation of yellow crusts and scales, with the hair matted down in it, and underneath all this an inflamed scalp. It is necessary to do away with this corruption and get down to bedrock before any good can be done. It is not possible to do a good job of hair cutting until the whole mess has been softened up. The best way to do it is with continual dressings of thick gauze packs wet with normal saline solution, kept on by a tightly fitting cap. After about two days of this treatment the hair can be cut, and the scalp gently scraped and washed with pHisoHex.

Fig.  5.-Seborrheic   dermatitis.      Local   treatment:     tar   paste   or   sulfur   and   salicylic   acid  ointment.

This usually leaves a pretty much reddened, inflamed sur­face. If there are oozy places the oozing must be stopped. If there are not many and they are small, wet dressings of 14 per cent silver nitrate solution can be used. If the whole head is involved it is best to use Burow’s solution (1 tablespoonful to 1 glass of water). Then boric or zinc oxide ointment is applied for a few days, and when the inflammation has calmed down somewhat, proceed with the Pragmatar ointment as in the dry type. If there is pustulation, neomycin, bacitracin, or erythromycin ointment should be used, plus an anti­biotic internally.

Seborrheic dermatitis is more common in babies under 4 months of age than it is in older children. It is most frequently seen in fat babies, and in looking over the records from my office files of twenty-six babies in whom I had made this diagnosis, on sixteen of the records I had put down a special note that the baby was thriv­ing and very fat. In another consecu­tive series of 100 eczematous babies under 2 years of age, the diagnosis of seborrheic dermatitis had been made in eighteen.

Seborrheic dermatitis often begins with cradle cap, a superficial scaly eruption on the cheeks and intertrigo of the axillae, groins, and neck, and sometimes around the umbilicus. In many patients the trouble goes no further than this. In some, lesions develop on the trunk-the arms and legs are not likely to be involved. Seborrheic dermatitis is essentially a disease of scaling on an inflammatory base; vesiculation is not present, nor is oozing, unless there has been a good deal of rubbing. The lesions on the trunk begin as small, light pink spots, which are covered with yellowish scales. The scales may or may not be greasy. These spots enlarge and coalesce to form still larger areas, which may sometimes be sheetlike in character. There is often clearing in the center, and the margins are sharp. In some cases there may be a more severe degree of inflammatory reac­tion, and the entire skin surface may be covered with large plaquelike scales; seborrheic dermatitis has taken on the characteristics of Leiner’s disease (see below).

In older children intertrigo and cradle cap are not so prominent as in babies, and Leiner’s disease does not occur. As a rule, seborrheic dermati­tis itches but little, there is no eosinophilia, skin tests are negative, and un­less complicated by atopic dermatitis it is not associated with asthma or hay fever. It does, however, in infancy bear some poorly understood relation­ship to atopic dermatitis, and often precedes it. Some babies who have seborrheic dermatitis at the third or fourth month are cured of it with proper treatment-there is no recur­rence and they develop no atopic dermatitis, hay fever, or asthma. In others, characteristic atopic dermatitis, with vesiculation, severe itching, and positive skin tests gradually develop, so seborrheic dermatitis, although not primarily an allergic disease, can and does occur in allergic infants.

Fig. 1.–Seborrheic dermatitis. The lesions are “nummular” in shape, but very different in color and appearance from those seen in nummular eczema. Note piling up of scales and clearing in centers of some lesions.

Fig.   2.-Seborrheic   dermatitis. Fig.  3.-Same    patient    as    in after   treatment.

The cause of seborrheic dermatitis is not well understood. Some have thought that it is due to infection with a yeastlike organism (pityrosporon of Malassez), others that it is from over-activity of the sebaceous glands, others that it has nothing to do with the se­baceous glands, but that it is caused by a deposition of too much fat in the skin from eating too much fat, still others that the cause is lack of a spe­cial dietary factor which is contained in liver, casein, and some vegetables, particularly carrots. It seems possible that all these factors may be opera­tive. The sharply margined lesions certainly suggest infection with a yeastlike fungus, and they respond well to ammoniated mercury or sulfur ointment; in adults seborrheic derma­titis often occurs in places where there are abundant sebaceous glands (the sides of the nose and front of the chest), and in infancy it is undoubt­edly most likely to occur in fat babies who are overfed with milk fat, and a diet low in fat and high in casein is efficient therapeutically.

Treatment is efficient: it is com­bined local and dietetic.