# Skin Diseases of Children/Ringworm and Favus

PLATE: II
TRICHOPHYTOSIS CAPITIS.
From the collection of photographs of
Dr. GEORGE HENRY FOX.
RINGWORM AND FAVUS.
There are few if any cutaneous affections so ineffectually and unsuccessfully treated by the physician in general practice as are ringworm and favus. The family physician who assumes to understand and undertakes to treat (as every family physician should do) the common affections of the skin is often guilty of serious malpractice in the management of these parasitic affections. The diagnosis is generally made without difficulty, although mistakes will sometimes occur in the best-regulated practice. But, granting that the diagnosis is speedily and correctly made, the treatment commonly employed is so poorly adapted to the requirements of the case and so imperfectly carried on, that many incipient cases, which ought to be cured by a few weeks of vigorous treatment, are allowed to persist for months or years, it may be, and to become so chronic and intractable that even the most skilful treatment must then require a long period of time and much patience to effect a cure. Nor is this the only baneful effect of this feebleness of therapeutic efforts. Other children in the family, the school, or the vicinage are permitted to contract the disease, while the physician treating the original case remains blissfully ignorant of the ever-increasing debt of suffering which is his just due. Therapeutic incompetence may appear less criminal than wilful neglect, but the results are equally unfortunate, and in the treatment of these common parasitic affections the physician ought not to be guilty of either charge.
There are three common affections of the skin due to the presence of a vegetable parasite—viz., favus, trichophytosis (ringworm), and chromophytosis (tinea versicolor). As the latter is rarely if ever met with in childhood, it may be left out of consideration at present; and since the remaining two, though distinct in origin and clinical features, are allied in nature and call for similar methods of treatment, it will be convenient to consider them together. ​Upon non-hairy parts, such as the face, neck, hands, and trunk, ringworm begins as a minute, slightly reddened, scaly disc, which gradually enlarges. When it has reached the size of a ten-cent piece the advancing border appears elevated while the centre tends to become smoother, and the lesion presents an oval, circinate. or "ring"-like appearance (Fig. 5). In rare cases a circle of fine vesicles can be detected at the periphery. One or more rings may be present, and the coalescence of two
Fig. 5.—Trichophytosis corporis.
or more may produce an irregular patch like a figure of eight or a trefoil. Occasionally when the ring has attained considerable size red papules or new foci of disease may appear in the smooth and perhaps slightly pigmented centre, and by gradual development may produce two or even more concentric rings.
Favus developing upon non-hairy parts produces scaly discs which at first are not readily distinguishable from the lesions of ringworm; but soon upon the branny surface a minute yel​low, cup-shaped crust of the size of a pin's head will develop, which at once settles the question of diagnosis. These bright-yellow, pin-head cups multiply and by coalescence form a sulphur-colored crust which is quite characteristic (Fig. 6).
Ringworm and favus of non-hairy parts cannot be considered as serious affections, but when the parasitic fungus of either finds its way into the hair follicles upon the scalp, as often happens with children, the case is quite different. The unfor-
Fig. 6.—Favus corporis.
tunate child is now the victim of an extremely obstinate disease, and, unless judicious measures are adopted without delay, is doomed to months or perhaps years of annoyance, if not of actual suffering. Upon the scalp these affections are always obstinate, and when this fact is not appreciated by the physician in charge of the case, and inefficient measures are adopted, the case usually goes from bad to worse until a cure seems nearly hopeless.
The first indication of ringworm of the scalp is commonly a ​small scaly disc, which appears almost bald from the breaking of the hairs close to the surface (Fig. 7). This dry, roughened patch, with its characteristic growth of short, broken hairs, tends to enlarge if allowed to go untreated (see plate), and other discs are apt to develop in the vicinity or upon other portions of the scalp. Frequently a large number of scaly points or small discs may be found involving the greater portion of the scalp and constituting what is known as disseminated ring-
Fig. 7.—Trichophytosis capitis.
worm (Fig. 8). Neglect in such a case is usually followed by a coalescence of the patches and disease of nearly the whole scalp. Not infrequently an eczema complicates the ringworm and obscures the diagnosis.
In rare cases the ringworm fungus, instead of producing scaly discs, sets up a deep-seated inflammation of the hair follicles, and a bald, fluctuating tumor or a cluster of boggy, rounded elevations forms upon the surface of the scalp. This condition is generally painful, and is known as kerion or the ​kerionic form of ringworm. The suppuration often loosens the hair, and in these cases complete baldness is more frequently found than the stubble-like growth of hair which characterizes the ordinary form of the disease. According to recent observations, this form of ringworm is due to a special fungus which also affects the lower animals.
In favus of the scalp there are no broken hairs found as upon the discs of ringworm, and the diagnosis is usually based upon
Fig. 8.—Trichophytosis disseminata.
the presence of the minute yellow, cup-shaped crusts which develop at the orifices of the hair follicles. When these are allowed to multiply, a thick, pale-yellow, friable crust forms, as is seen in the well-marked case (Fig. 9) which was originally published in the author's "Photographic Illustrations of Skin Diseases." Much has been said about the peculiar odor of favus as a basis of diagnosis. While it is true that in a neglected case, where the crusts have accumulated, a keen scent combined with a vivid imagination may perceive a fragrance which is ​quite suggestive of "mice," "putrid urine," or "an ill-kept menagerie," the diagnosis can be far more readily made from the characteristic appearances. In doubtful cases, moreover, in which there are no characteristic crusts, the peculiar favic odor is not likely to be perceived by ordinary olfactories. While typical cases of ringworm and favus are totally unlike in their clinical appearance, treatment often obscures the characteristic features, and hence, in cases where the crusts have
Fig. 9.—Favus capitis.
been removed, the differential diagnosis may sometimes be attended with difficulty. In ringworm, however extensive and chronic the case may be, the hair is not apt to be permanently destroyed; while in favus the pressure of the crusts which develop in the epidermic layer around the orifices of the follicles tends to produce atrophy of the hair bulbs, and in all cases of long standing a few bald, depressed, and cicatricial areas are generally observed, and upon these the hair will never grow. In chronic cases, even after the disease has been cured, a num​ber of wiry, twisted, or deformed hairs are usually seen growing around or among these cicatricial patches.
Trichophytosis capitis is a disease of youth, and even when allowed to go untreated it will tend to a spontaneous cure as the patient matures. Though ringworm of the beard is very common in men, for some inexplicable reason ringworm of the scalp is never met with in adult life in either male or female. Favus, on the other hand, occurs at all ages. Developing in youth, it may persist indefinitely, although it is far more frequent in childhood than in adult life.
The cause of ringworm and favus is the presence in the epidermis and hair follicles of a micro-organism, the growth of which gives rise to more or less inflammation and the characteristic clinical appearances already described. The parasitic fungus causing ringworm is the trichophyton. Several varieties have recently been described, but it is not as yet satisfactorily proven that these varieties of the fungus are the cause of all clinical variations noted in the course of the disease. The etiological factor in favus is the achorion. This fungus does not penetrate the shaft of the hair as readily as does the trichophyton, and hence the absence in favus of the broken hairs which are so characteristic of ringworm. Children in perfect health are liable to contract either disease from some child already affected, or possibly from some pet animal. No particular condition of the skin is necessary to furnish a congenial soil for the development of the parasite, although it is true that in weak, poorly nourished children whose heads are often moist the disease is more likely to thrive and the inflammatory symptoms to be more marked. Age, however, seems to modify the character of the soil in a notable degree, and it is well to remember the clinical fact, already mentioned, that ringworm of the scalp, so common in childhood, is never seen in adult life.
In like manner ringworm of the beard, so frequently seen in middle life, is quite exceptional among old men. In the treatment of ringworm and favus a host of local applications are recommended by dermatological writers, which only proves that the majority of them are of very little value. Moreover, an admirable prescription may be written, but if the nurse or person in charge of the patient is not given full and explicit directions as to how the treatment should be carried out, the result is certain to be unsatisfactory. The local remedy employed is often of far less importance than the exact method of its use, and attention to minute details which may seem ​unimportant to the inexperienced is always the key to success. In no other affections of the skin are intelligence and persistence so essential, and for the exercise of these in the daily care of the patient the physician should hold himself responsible.
On non-hairy parts ringworm and favus can be readily cured by almost any parasiticide. A ten per cent ointment of salicylic acid is an effective application, or, if the skin is very delicate, it may be better to simply moisten the patches frequently with a saturated solution of sodium hyposulphite in rosewater. But when the scalp is affected the cure is always a difficult one, and the first step is to impress upon whoever is in charge of the case the important fact that half-way measures will do little or no good. It is always advisable to shampoo the scalp thoroughly once a day, especially if the hair is short, as this gives the parasiticide application a much better chance to penetrate the hair follicles. The neglect of frequent and thorough washing of the scalp is the chief cause of the frequent therapeutic failures. When this is carefully attended to, the thorough inunction twice daily of sulphur ointment, oleate of mercury, or chrysarobin ointment (ten per cent) is certain to do good. If a cap is worn by the patient, as is advisable, it should be fastened to the head by a ribbon or strip of bandage, and not by a rubber band, on account of the serious results which might ensue from a prolonged stoppage of the circulation.
There is one remedy which is indispensable in chronic cases and of the greatest value in any case. It is epilation. It must be admitted that this is always troublesome to the physician or nurse who undertakes to carry it out, and more or less painful to the patient. But it saves time and trouble in the end. With a well-made pair of epilating forceps, which should be light and broad at the end of the blades, the short hairs can be firmly caught and quickly pulled out. It is advisable to epilate first the long hairs around the margin of a patch until a narrow white ring of healthy scalp appears. This will prevent any increase in size of the patch, and the short hairs upon the reddened, scaly surface of the patches can be pulled at leisure. As many of these will break in the process of epilation, the operation must be repeated until the patch is quite bald and begins to assume a comparatively healthy appearance. The epilation and the application of parasiticides can be carried on at the same time. When the inflammation has subsided and the scaling disappeared, and all the patches have assumed a comparatively healthy appearance, the hair may be allowed to ​grow and all treatment suspended save the daily use of a five per cent salicylated oil. If, however, at any time a slight scaliness or dry, brittle appearance of the hair is noted at any point, it is advisable to epilate again and convert the suspicious spot into a small bald disc. This plan of treatment is best calculated to effect a certain if not a speedy cure, but often it will require months of patient and persistent treatment, and perhaps a year or more in exceptionally extensive and chronic cases.
The parents or guardians of the patient should always be apprised at the outset of the obstinacy of the disease and its unfavorable prognosis as regards a speedy and pleasant cure, in order to avert the discouragement and dissatisfaction with the method of treatment which otherwise would naturally ensue.
It seems hardly necessary to add that no child with ringworm should be allowed to attend school. If our city Board of Health could make provision for a periodical inspection of the public-school children, with a view to checking the spread of ringworm and other contagious diseases, a considerable amount of suffering and expense could be saved to a certain number of scholars and their parents. Furthermore, if some careless physician were sued for malpractice for allowing an uncured case of ringworm or favus to attend school, simply because upon a hasty inspection, without the use of a microscope, he thought the child was all right, it might be unfortunate for the physician, but by no means a bad thing for the profession.