The Local Treatment of Atopic Dermatitis part 3

Filed under: 4 - Atopic Dermatitis

My favorite preparations are as fol­lows :

Crude Coal Tar Undiluted.-This is not used enough; people have for­gotten about it, but it should be re­membered that when coal tar was first introduced in Switzerland and in France about 1910, it was always used in this way. Its incorporation into ointments came later. Undiluted tar is used on small thickened areas any­where on the body. It is painted on twice a day, and dusted over with tal­cum powder. It is very useful for the small cracks at the lobes of the ears, which are so common in atopic dermatitis.

Tar Pastes and Ointments.-These, of various strengths and made with various vehicles, are unrivalled in the local treatment of eczema in infants and children. Sensitization is un­usual. It is best not to use a tar preparation on a hairy area, or where there is any pustulation. Tar is photosensitive and should not be used on the face if there is to be exposure to bright sunlight or considerable irritation may result. The mother should be told of this. The more chronic and thickened the eczema is, the stronger the tar preparation should be. I have never seen any bad results from absorption, but have heard of them, and it should be re­membered that tar is a complex sub­stance, containing elements which are toxic if absorbed in large amounts. I have followed the rule not to use a tar preparation over a very large surface area, and have limited its use at one time to both legs, both arms and the face, or to the trunk.

My favorite preparations are the following:

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

This is about 5 per cent strength, and is the original tar paste used by Dr. Charles J. White, as he intro­duced it at the Massachusetts General Hospital in 1912. It is black and dirty.

(2)  Crude coal tar

Yellow wax aa 3 i ss Petroleum jelly Lanolin aa ad 3 ii

This is sometimes used on very thick chronic places (ankles or wrists), where there is no moisture, so a paste is not necessary, and it is desired to secure good penetration. It should not be simply spread on the skin, but well rubbed in. It is sometimes of advantage to add 10 grains of sali­cylic acid to the ounce. It is a strong-ointment-I use it only occasionally.

(3) “Daxalan”  ointment.*

This is similar in composition to No. 1, only a little weaker (3 per cent). It is a remarkably smooth and well-made preparation, and is pre­pared so much better than most druggists can make tar ointment that for a long time I have not used prescription No. 1, but have pre­scribed Daxalan instead. It is black and dirty.

(4)  Kolpix “A” and Kolpix “D.”

These ointments are also made by the Dome Chemical Company, and differ somewhat from the Daxalan ointment in that the tar has been treated in some way so that it is a medium gray color instead of black, and the base is not greasy but water-soluble. The strength of each is 2 per cent tar. Kolpix “A” is for acute, somewhat active eczema, Kol­pix “D” for chronic eruptions. Neither is very dirty. These are fine preparations-I use them a great deal.

(5) Tarquinor.t

This is another fine tar preparation, also in a water-soluble base, and not very dirty. Its strength is 1 per cent, and it has added to it 0.20 per cent of Quinolor, an antiseptic.

(6)  Tar and bentonite pastes.

At the Children’s Hospital about 1942, Mr. Donald Skauen, the hospital pharmacist at that time, in collabora­tion with friends at the Massachusetts College of Pharmacy, which is across the street, and with a few suggestions from me, developed a thick tar paste, which has proved very useful. It is made thick by bentonite, and smooth by adding a certain vanishing cream.

Fig. 35.-Ordinary atopic dermatitis. Local treatment: Daxalan ointment or Kolpix oint­ment A. It is a little too thick for hydro-cortisone ointment.

Pig. 36.-Deep papular form of atopic dermatitis. Local treatment: a 3 or 5 per cent tar paste. Hydrocortisone ointment does not do well for this type. (From New Eng­land J. Med., 1953.)

It can be made in various strengths, and we have called it Tar and Bentonite Paste Nos. 1, 2, and 3. The No. 1 is very weak, the tar in it being de­rived from liquor carbonis detergens (N.P.) ; the No. 2 contains 2 per cent of coal tar, the No. 3 contains 5 per cent. These pastes are much thicker than the other tar pastes and stay on the skin better. I use the No. 1 a great deal when I want a protective, rather mild, clean preparation for use on places that are not much thick­ened. There is too little tar in this preparation for it to be of any value in chronic, thickened eczema. It is not dirty. I use the No. 2 and No. 3 occasionally, but am more likely to use Daxalan or Kolpix.

Tar and Bentonite Paste No. 1

Bentonite    (TJ.S.P.)                                 7.50

Liquor carbonis detergens      (N.F.)           15.0

Water                                      15.0

Special vanishing cream or “Neo-
base” or Hydrophilic ointment
(U.S.P.)                                                   7.50

Paste zine oxide  (U.S.P.)                             45.0

For Paste No. 2, 2% of crude coal tar is used instead of the liquor carbonis detergens, and for Paste No. 3, 5% tar is used.

Special Vanishing Cream

Glyceryl monostearate                               8.0

Spermaceti                                                 7.0

Theobroma oil                                          5.0

Liquid petrolatum                                      8.0

Distilled water                                           67.0

Glycerin                                                    5.0

Methyl   parahydroxybenzoate                  0.0625

Propyl   parahydroxybenzoate                  0.0375

(7)  Hydrocortisone ointment  (1%, 2.5%)

This is a valuable addition to the armamentarium, although I am not quite so enthusiastic about it as some have been. I have treated, to date, about 120 infants and children with it. It is of most use for inflamed, rather superficial, slightly scaly areas. It does not do as well when there is no active inflammation and a good deal of thickening-for such places a tar preparation is better. It should be applied twice a day, and gently rubbed in.

The 1 per cent ointment in most cases works about as well as the 2.5 per cent and is much less ex­pensive. Hydrocortisone ointment is not a cure-it simply reduces inflam­mation, but it does this with remark­able efficiency. If it has worked well, and after a few days there is no more eczema, it is discontinued until the eczema returns, and then resumed. If after a while the 1 per cent oint­ment does no good, then the 2.5 per cent can be tried. If this does no good, go back to the older methods of treatment. Hydrocortisone oint­ment is by no means a cure-all for eczema, and there is still plenty of room left for the older preparations that have been successful for years in local treatment.

Some hydrocortisone ointments con­tain an antibiotic; some do not. It is best, if there is any question that the lesion being treated is infectious eczernatoid dermatitis, to use one of those that contains an antibiotic; several times I have seen such places develop gross infection after the use of the ointment without an antibiotic, and at least once when a hydrocorti­sone ointment containing neomycin was used. I think it best, if gross infection is present (pustulation), not to use hydrocortisone ointment either with or without added antibiotic, but to get rid of the infection by the means which have been previously described. So far as is known, no systemic effects are produced by hydrocortisone ointment.

---