Chapter XXI · CUTANEOUS MANIFESTATIONS OF SUPER-ACIDITY

A surcharging of the blood with an abnormal amount of acidity leads generally to conditions which come under the domain of the physician. So-called rheumatism, gout and kindred ailments of all forms and varieties are every-day occurrences, and, being symptoms of systemic disturbances, should be treated by internal administration.

The podiatrist, however, in his daily treatment of foot troubles is called upon to treat locally certain forms of skin disturbances due to hyper-acidity which manifest themselves upon the surfaces of the foot.

Uric acid eczema is the general term employed to designate these annoying conditions and is synonymous with the older and now obsolete terms, lithemia and uric-acidema.

Definition. Uric acid eczema is a skin eruption due to a surcharge of uric acid in the blood and a precipitation of this acid in a certain part, so that the acid elements or urates are carried by the blood stream to the skin and there set up a dermatitis.

Characteristics. These manifestations may be found in all varieties and degrees from a mere dryness and hardness of the skin, in which the normal flexibility is gone, and in connection with which there is usually intense itching and burning, to the formation of deep fissures (usually found in the toe webs) and small ulcerative processes which may manifest themselves in any part of the foot and often present a stubborn resistance to all endeavors at healing. These symptoms may occur singly or, as in the most instances, in combination.

These conditions are usually met with in the spring of the year and no doubt are brought about by a series of changes in habits and diet which occur at this time.

Etiology. During the winter months the average person takes but little physical exercise as compared to his activities during the warmer weather. The foot, being at the base of a column of blood which must be forced back to the heart, against gravity, is coming constantly in contact with cold surfaces. This, together with a lack of exercise, tends to stagnate the blood circulation in the pedal extremities. Coupled with these two conditions, during the winter months, people are inclined to over-eat and over-drink, the waste materials from which excesses are but improperly eliminated, due also, to a great extent, to insufficient exercise. Here, then, we have a stagnation of the blood current in the pedal extremities, a surcharging of the blood in the feet with certain urates, and a precipitation of these solid constituents, due to the cold surfaces with which those members constantly come in contact.

This condition is present in the spring of the year when fresh vegetables and fruits begin to come into the market. A great many of these edibles, particularly strawberries and tomatoes, are markedly acid and when ingested tend to exaggerate the conditions in the blood already present. The result is generally a cutaneous eruption which may appear on any part of the body and which frequently occurs in the feet. (See chapter on Fissures and Burns.)

Fissures. Probably the most common condition met with from this cause is the cracking or fissuring of the toe web. This may be accompanied by itching and burning in varying degrees, but these latter complications are not always present. The skin between the digits is found to be blanched and macerated and often the superficial epidermic layers will become slightly thickened and exfoliated. The fissures occur in the web and are due to the skin losing its normal flexibility so that the tissues, as they expand in walking or in drying the parts with a heavy, rough towel, are not sufficiently extensible, and so they crack or fissure. These cracks may be merely superficial splits through the epidermic layers or they may become deep and ugly fissures which penetrate well into the corium. When they reach this latter stage, the parts are found to be exceedingly tender and the irritation to the tissues is severe. These fissures are prone to infective processes as their deep recesses present an excellent lodgment for invading bacteria.

The fissured area is usually confined to the web, but may be found extending around under the toe on either side or upon the plantar surface of the foot. When these conditions are of long standing, the edges of the fissure will be found to be thickened and calloused; it is found necessary to remove this growth before normal granulations may be expected.

Treatment. In cases where only pruritis is present and no distinct lesion manifests itself, tr. benzoes compositas will be found an efficient agent in reducing the itching and in aiding the general irritation to subside. In superficial fissures, tr. benzoin compound may also be used in many cases with good results. The parts should first be thoroughly cleansed with alcohol, 60%, dried, any loosened or exfoliated epidermis to be removed before the benzoin is applied. More or less smarting is to be expected from the application of the tincture, but as this is very transient, no great amount of pain is suffered by the patient. The tincture is applied by means of a sterile, cotton wound applicator, and is painted well down into the fissure itself, and over considerable of the surrounding integument. This tincture is very sticky and should be allowed to dry thoroughly before the hosiery is replaced. As compound tincture of benzoin forms a thin film or coating upon thoroughly drying, no gauze or cotton need be placed over the painted areas. This application may be renewed daily, the coating from the previous application being removed by alcohol and the parts cleansed and dried before the second application is made.

Mild vegetable astringents may also be employed in such cases. Principal among these are gallic and tannic acid. These drugs may be used in solution, ointment or dusting powder form and seem to be efficient in all. Dusting powders are usually preferred and the two most popular are bismuth subgallate (dermatol), a combination of bismuth and gallic acid, and tannoform, a powder containing 5 to 10% of tannic acid. These are applied after the parts have been made aseptic and thoroughly dried. Bismuth subnitrate may also be used with good results in this condition, as may thymol iodide (aristol). The latter has very little astringent action and, therefore, except for its antiseptic properties, cannot compare with the other powders mentioned. Pure ichthyol may also be used in the treatment of superficial fissures. The drug is dropped into the lesion and covered with gauze or cotton, as are the dusting powders. Another drug recommended in these cases is sodium bicarbonate. This agent is alkaline in its reaction and, coming in contact with the perspiration (acid) in these parts, serves to neutralize this excretion and so aids in returning the tissues to normal.

There are many other preparations, any of which may be used in the treatment of fissured toe webs. Among these are ichthyol ointments, 5 to 10%; balsam of Peru, scarlet red, and a 5% ointment of ammoniated mercury. Reports of cases treated by the above varying drugs show good results.

When the fissures are deep, and the discharge from their surfaces is considerable, slightly different measures must be adopted to hasten granulation. The edges of deep fissures are almost always found to be calloused and thickened and this condition, of course, must be eradicated before further treatment is administered. This is accomplished with a knife or shallow curette and the operation is usually painless to the patient and creates no hemorrhage. After the removal of this tissue, if the fissure be deep, silver nitrate, 5% solution, will be found efficient as an astringent to contract the parts and reduce exudation. After this application, a bland ointment is smeared over the area for the purpose of keeping the tissues soft, and this is covered by a sheet of gauze or cotton to hold it in place. Applications of the silver solution are made at frequent intervals until the desired result is obtained, when it may be discontinued and some dusting powder resorted to, to complete the healing process. Should proud flesh have developed in a lesion of this nature, through neglect, stronger solutions of silver nitrate or the fused stick must be resorted to for reduction of the superfluous granulations, followed by a wet dressing of liq. alum. acetate to aid in the reduction of the accompanying inflammatory symptoms. Lanolin and cocoanut oil have both been found efficient to massage into the parts in order to keep them soft and to prevent continued dryness and fissuring.

Blebs. Aside from the fissuring of the interdigital webs, super-acidity manifests itself upon the skin of the foot, and the whole body for that matter, in the formation of yellow or brownish blebs or vesicles. They are found to be a more or less circumscribed eruption and are met most frequently in the foot on the plantar surface in the hollow of the longitudinal arch. They range in size from a pinhead to a pea and, in most instances, are but slightly elevated above the surface of the surrounding epidermis. This is in all probability due to the involvement of the superficial parts of the true skin.

These lesions are usually uniform with a tendency to coalesce, and cases have been noted where patches of these eruptions covered a considerable area, in one instance, from the under surface of the foot, over its inner side, to the internal malleolus. Vesicular developments of this nature seldom occur singly but are often found in several groups on different parts of the integument, each group consisting of two, three or four distinct blebs.

Pruritis may or may not be present in connection with this dermatitis. When itching is present it is usually intense and the patient often breaks and tears the skin in an effort to relieve the irritation.

The areas of normal tissue adjacent to the eruptions may be found involved in a slight inflammatory process, although this is not common. These inflammatory symptoms usually subside rapidly under treatment.

Treatment. It is usually found advisable, if possible, to allow these blebs to remain intact, making no effort to puncture them but simply applying a dressing which will promote and hasten their absorption. Cases have been noticed where these lesions have been opened and have developed into angry, deep ulcerations which showed a marked tendency toward indolent granulation accompanied by profuse discharge.

However, when a bleb for any reason must be opened, it is best accomplished by use of a sharp pointed, sterile knife. The fluid contents are found to be a thin, syrupy, translucent, discolored serum, without any great odor, although resembling ichorous pus to some degree. There is a distinct loss of tissue as the ulcerations are often found to involve the upper parts of the derma. Upon evacuation of the fluid contents, the parts should be thoroughly sprayed with alcohol, 60%, and a moist, unguent or dusting powder dressing, as the operator desires, applied.

The solutions which may be used as moist applications are liq. aluminum acetate, or boric acid (saturated solution). Powerful germicides, such as mercury bichloride, are not necessary unless an infective process be present, and when used needlessly, they simply prevent or break down new granulations.

The dusting powders found useful in this connection are aristol (thymol iodide) and dermatol (bismuth subgallate). The parts should first be thoroughly dried before the powder is dusted on. If the discharge is found negative and the pruritis still persists, an ointment of ichthyol and sulphur, such as follows will prove efficient in reducing the itching and in stimulating healthy granulations:

Ichthyol 1.

Sulphur 1.

Menthol 1.

Vaseline 32.

This unguent is best held in place by a cocoon dressing and should be renewed until granulation is complete. Other unguents which may be used in this connection are sulphur, 10% (lanolin or vaseline base), balsam of Peru, 5%, and unguentine (a proprietary but useful combination of ichthyol, balsam of Peru and zinc oxide). These, however, do not tend to relieve the intense pruritis which usually accompanies these lesions as efficiently as the first mentioned combination.

URIC ACID AND THE NAILS

The toe nails also manifest conditions of super-acidity. They may be affected as to color or texture, and sometimes in advanced or neglected cases, as to size and shape.

Discoloration. The nails, due to functional derangements in the matrix, become loosened and discolored from the presence of an abnormal amount of uric acid. They may be whitish, yellowish or brown, and in some cases are found almost entirely black, as if bruised. The nails in these instances are usually entirely loosened, or at least in part, from the bed, and sometimes fall off, practically of their own accord.

Treatment. Nothing much can be done locally for these conditions, and the main concern of the podiatrist is to see that the edges of the loosened nail are not allowed to irritate the softer tissues adjacent. This is best accomplished by packing cotton or gauze under these edges so that the nail, if movable, will rub upon this packing and not upon the skin. It may be found advisable to first clean out (from under and around the nail) any excrementitious matter which is always present to a greater or lesser degree. However, too much “digging” about these parts should never be indulged in, as the operator is liable not only to cause a lesion, but to loosen the nail to such a degree that its removal is imperative. If possible, this is to be generally avoided, for it has been found advantageous to allow the older nail to remain in place as long as possible in order to protect the new-forming nail beneath. Alcohol, 60%, sprayed over the part after removing the disintegrated material, will serve as a cleansing agent and will insure asepsis to the parts.

Texture Changes. Under the influence of uric acid precipitation in the pedal extremities, the texture of the nail is often found changed to a marked degree. The nail becomes exceedingly hard, dry and brittle so that it powders, chips off and breaks away under any sort of pressure. The nails are often found ridged, and in some instances these longitudinal ridges have become decided and permanent cracks in the nail body.

Treatment. In clipping nails of this nature, care should be taken that too much does not chip off or break away from the pressure of the clipper blades. It will be found advisable to cut but a small portion of the nail at a time, and that very carefully. The waste material found around or under the nail body should be carefully removed and, if necessary, the nail itself should be thinned out by the use of a rotary file. The parts should be thoroughly cleansed, and the grooves and free edge should be packed with gauze or cotton to prevent the nail from moving during the movements of the toe and thereby developing trouble.

Changes in Size and Shape. The so-called “club” nail is found in many cases where the patient is a sufferer from a uric acid diathesis. This does not occur as frequently in cases of acute dermatitis as in cases of chronic rheumatism and gout. These are cases where there is functional derangement of the matrix which causes the nail’s longitudinal growth to be arrested, followed by an increased vertical development.

The nail is generally found to be about one-half its normal length and may be from one-sixteenth to one inch or more in thickness. Cases have occurred where the nail in appearance and structure closely resembled a cow’s horn.

Club nails of this variety do not, as a rule, cause a great amount of discomfort and then only when they develop to such thickness as to receive and transmit direct pressure from the shoe.

Treatment. Club nails are not curable and the treatment is merely cosmetic. It consists in grinding and filing the nail down to what would be its normal thickness, or as nearly that as possible. This, of course, is best accomplished by means of a rotary file. As much of the nail is clipped away as is possible, when the rotary file with a coarse-grained “barrel” bur is used. Considerable pressure should be brought to bear unless the patient complains of heat due to the friction. When the greater portion of the nail is thus removed a “finishing” bur is substituted and the roughened surfaces are smoothed off. The clippers should then again be used to give the nail a fairly normal shape and the parts under the nail are to be then cleansed out as much as is advisable.

In using a rough cutting bur the operator must exercise great care that the skin covering the posterior or the lateral folds is not broken. If the handpiece of the file is grasped firmly in the palm of the hand and directed by the index finger while the thumb is rested on the toe and the bur is directed to it (the thumb), the operator will always have complete control of the instrument, and this danger is minimized. It will be found advisable, after cleaning under and around the nail, to spray the parts with some antiseptic solution or to paint the parts with tincture of iodine. This is done to insure complete asepsis. Should the skin be broken during the filing or cleaning, the parts should be first made thoroughly aseptic and a dressing to prevent contamination should be applied.

Prognosis. It must always be remembered that these lesions are merely local manifestations of a systemic derangement and although the painful or annoying characteristics may be alleviated or cured, the cause of the trouble must be reached, through internal channels.

Diet is the principal means of removing this surcharged acid condition of the blood and, although some medicines or waters may be and are ordered by the physician as eliminants, proper care as to dietetics is essential to the patient’s well-being. Systemic treatment by the physician, combined with local applications by the podiatrist, are usually conducive to beneficent and lasting results. In cases of manifestations of a uric acid diathesis in the nails, nothing much can be done except through the channels just described; and in cases of club nails due to a like etiology, nothing can be done to cure them. Removal of the nail does not, as is sometimes supposed, effect a cure, and in many instances serves but to make the new nail even worse than its predecessor.