Skin is the largest organ of the body. Its main function is to protect the body from the environmental agents. These agents can act on the surface of the skin, or reach the skin via the bloodstream. Skin has a reasonable potential to protect itself from these agents but whenever that outside influence is more than what the body can deal with, the disease is produced. Several diseases however, recover even without any treatment because the body is a self-repairing machine. Notable examples of the skin diseases which tend to recover spontaneously, are herpetic infections which recover in 1-2 weeks, pityriasis rosea which recovers in 6 weeks, alopecia areata which recovers in 3 months, acne vulgaris which tends to disappear after the age of 25 years and pityriasis alba which recovers after puberty. A majority of the cases having infective dermatoses also tend to recover even if no treatment is given. Some skin diseases have a tendency for remissions and relapses which are related to specific aggravating factors. As an example, most cases having psoriasis and ichthyosis worsen during winter, and improve during summer, while patients having pyoderma, dermatophytosis and candidiasis tend to worsen during summer and improve with the onset of winter. Many other diseases also have remissions and relapses though the factors responsible for such relapses are not completely delineated. Thus, it is essential to know which diseases require treatment and which do not. This knowledge is particularly important because unscrupulous practitioners often attribute spontaneous recoveries/remissions to the effect of the drugs and the therapeutic procedures used by them.
Medical treatment however helps, (1) To ensure that the patient will recover from the disease when the chances of a spontaneous recovery are poor, (2) To induce an early recovery and thus reduce the morbidity and the suffering of the patient, and (3) To reduce the residual damage and sequelae of the disease.
With the progress made during the last few decades it has become possible to treat and cure most of the skin diseases provided the patient receives appropriate treatment.
Appropriate treatment includes appropriate drugs, correct dosages and adequate duration of therapy. Most of the failures in treatment are attributable to the tendency of some doctors/patients to use milder medicines, smaller doses or to stop the treatment earlier than necessary. This tendency stems 2from the fear of side effects. We consider that the side effects should be taken as a part of the treatment and ignored or tolerated if these are minor and insignificant because these are temporary and would disappear when the treatment is completed and the drugs are withdrawn. The side effects which cannot be ignored should be treated concomitantly with appropriate procedures and drugs. The only other option for the patient is to let the disease process have its normal course and face the consequences of the decision.
The treatment of skin diseases generally falls into four categories:
- A large number of skin diseases can be completely cured, and thus, completely eradicated if the patient receives correct treatment. These include diseases caused by infective agents, nutritional deficiencies, allergic disorders and several others such as lichen planus, alopecia, pemphigus, collagen vascular diseases and vitiligo, and other pigmentary disorders.
- Diseases caused by genetic factors like ichthyosiform dermatoses, and androgenetic alopecia can also be controlled with treatment and the patient will remain normal as long as the treatment is continued.
- Some diseases cannot be cured but their effects can be masked/camouflaged with appropriate agents. This group essentially included nevi, but now vascular and pigmented nevi can be treated with lasers while depigmented nevi can be treated with dermatosurgical procedures.
- There are very few diseases such as severe forms of epidermolysis bullosa and xeroderma pigmentosum, or malignancies with metastasis where almost nothing can be done, though efforts are being continued to find suitable remedies for these diseases as well.
A large majority of the skin diseases are merely a cosmetic problem and require treatment only because the pathology is visible on the skin surface. Leukoderma, diseases causing hyperpigmentation, various types of nevi, ichthyosiform dermatoses and various abnormalities of the hair and nails are evident examples. Most other skin diseases bring the patient for treatment, because these are associated with symptoms like severe itching. Otherwise the patient may not seek treatment.
It is usually much easier to treat a disease completely if the treatment is initiated at an early stage. Once the pathological process has established itself or when the complications have set in, the eradication of the disease process may be incomplete and the sequelae may be quite prominent. A dermatologist is often required to treat even the marks/scars left behind after the disease has been cured.
Most skin diseases can be treated in more than one way and all methods may be quite effective. For a particular patient, however, one should select a therapeutic regimen which is most appropriate for him. It is no use recommending a time-consuming regimen for a very busy patient or prescribing costly medicines for a poor patient. One must also take into account the response of the patient to the previously used therapeutic measures. Drugs which have previously been found to cause no improvement or those which 3have been seen to cause serious side effects in the patient should be avoided as far as possible.
The method of using a particular therapeutic modality is as important as the drug itself. Sufficient time should, therefore, be spent on explaining to the patient the method of using the prescribed drugs. The instructions should be written clearly on the prescription slip and preferably in a language which the patient can understand. It is unfortunate that some physicians continue to write prescriptions in an illegible hand-writing or use Latin or Greek symbols for instructions which make no sense to the patient. In cases where the general instructions are too long to be written on the prescription slip, as for the treatment of scabies, these instructions should be printed on small pamphlets which can be handed over to the patient for consultation at home.
The dermatologist should know and also inform the patient when to expect the results of the treatment given to the patient and ensure that the desired result has been achieved. If the expected result is not obtained, it will be necessary to look into the possible cause(s). The patient may not have understood the correct method of using the medicines, so it is important to discuss the method again. Unsolicited advice from the friends and relatives of the patient, who may not even be physicians, let alone the dermatologists, often discourages the patient from using certain drugs or the correct doses. Similarly, the misconcepts promoted by the manufacturers of various dermatological products through television and other advertisements and the comments of some chemists are likely to pollute the minds of the patients. This menace has to be guarded against.
The doses of various drugs and the expected duration of treatment should be explained to the patient who should be instructed to continue the treatment as long as the dermatologist considers necessary. The patient should also be informed about the other instructions and precautions necessary for recovery, but undue prohibitions should be avoided.
CARE OF THE SKIN AND HAIR
Most patients suffering from dermatological diseases should be encouraged to continue their daily activities. Regular baths are helpful in cleaning the skin by mechanically removing the bacteria, fungi, viruses and other similar micro-organisms and also some harmful chemicals present on the skin before these are able to take hold on the skin and cause disease. Baths should therefore, be prohibited only if the patient has high fever or if he is too sick/weak to take a bath. After the bath, however, the skin lesions should be dried with a clean towel and this should be followed by application of the medicines recommended for local use.
Soaps are necessary for a bath. Soaps emulsify the fats and oils on the skin and thus help the water to dislodge the microorganisms, scales, debris and whatever gets implanted onto the skin. Without a soap, it is generally 4not possible to clean the skin effectively. Soaps containing cream, milk and other similar agents promoted for preventing dryness, or soap substitutes are inefficient in cleaning the skin and thus promote dirtiness, these should be avoided. Similarly herbal and medicated soaps should also be avoided because the antiseptic as a rule gets washed off before it has adequate time to produce its effects. Moreover, unnecessary repeated exposures to the antiseptics can sometimes be harmful to the skin. This can lead to contact allergy to the antiseptic or growth of resistant bacteria.
The hair should preferably be cleaned with a shampoo because shampoos clean the hair better, and unlike soaps, these do not form curds with hard water. Like soaps mild shampoos are inefficient and medicated shampoos are risky. Shampoos leave the hair in a lustrous condition. The method of cleaning is equally important. While using soap or shampoo, it is important to massage the soap/shampoo on all parts of the skin and hair, because otherwise some areas are likely to be left out. The quantity of the soap or shampoo should be enough to produce adequate lather which should persist as long as the skin/hair are being massaged. Folds of the skin need extra care.
Other agents such as gram flour, curd, milk, milk cream, soapnuts, shikakai, etc. as cleaning agents are to be avoided as these are inferior cleaning agents and may even be contaminated with bacteria, fungi and soil pollutants such as DDT, and industrial pollutants. Each and every area of the skin diseases to be cleaned very thoroughly everyday and all days of life. The diseased areas need more cleaning. Use of edible materials for cleaning the skin and hair as often prescribed by unscrupulous beauticians must be avoided because it is unethical to waste eatable materials when there are scarcities all over. Contrary to the common belief, soaps and shampoos do not harm the skin or lead to the loss of hair. Ideally and as far as possible, the hair should be shampooed every day because the hair get as dirty as the rest of the skin and deserve to be cleaned every time the patient takes a bath.
Application of oil to the skin and hair makes the skin soft and prevents the hair from entangling. Mustard oil has weak antibacterial and antifungal activities. The belief that oils promote hair growth is erroneous, because users of oils are as bald as non-users. Oils on the other hand, interfere with cleaning of the skin and hair, aggravate acne vulgaris and sometimes lead to pigmentation of the skin. People who do not apply oils have as good hair and skin as those who use the oils. It is, therefore better to avoid wastage of precious edible oils on the skin and hair. In case the skin is dry, glycerine diluted with an equal volume of ordinary tap water, can be applied on the skin and even the hair, after the bath.
Cosmetics are used to beautify the skin, hair and nails and these are generally tested for their safety before being released into the market. Occasionally however, almost every cosmetic is likely to produce adverse reactions. Use of the cosmetics therefore should be restricted, as far as possible, more so if 5the patient is suspected to be having contact hypersensitivity to the cosmetic or pigmentation on the skin which is likely to have been caused by some such agent. In addition, oils or other greasy applications should not be allowed on acutely inflamed and exudative lesions, because these impede evaporation and lead to increased maceration. Talcum powders can absorb a small quantity of moisture or oil and thus have a drying effect. These also produce a cooling effect on inflamed skin, but these should be avoided on exudative lesions.
Dietary restrictions are necessary only if the patient has a confirmed allergy to some article of food. Unnecessary and unconfirmed prohibitions of dietary articles as a part of the treatment are unwarranted and only increase the suffering of the patient. Most patients, therefore can be allowed to drink or eat almost any article of food according to their taste and choice.
Rest in bed with elevation of the part is necessary if the patient has acutely inflamed and oedematous lesions. This elevation can be achieved either by placing a pillow or a sand bag under the part or raising the foot end of the bed if both the feet are to be elevated.
Hospitalization is necessary for acutely ill patients, or if the disease is likely to undergo a rapid change into a serious condition, or when the effect of the treatment needs careful reappraisal or adjustment of the dosage. Hospitalization is also necessary when the patient has to be removed from the environment or when he requires a specialized institutional therapy which cannot be undertaken at home. Sometimes, patients are also admitted when a large number of investigations or complicated tests are required to arrive at a diagnosis.
Isolation of a dermatological patient is generally not required. It is necessary only if the patient is suffering from a highly infectious disease, or if his own immunity has been compromised and he is prone to catch infection from other patients. Most skin diseases are not infectious and there is no need to wear gloves while examining skin lesions. A simple soap and water washing of the hands, however should be done after examining the patient particularly if the hand becomes smeared with the exudates from the skin lesion. Contrary to the common belief, a large proportion of even the leprosy patients are not likely to be infectious and most of the remaining patients also become rapidly non-infectious once they start taking appropriate treatment. Universal precautions however for the HIV infected patients are mandatory.