141

hmmorrhagic symptoms within two weeks of an attack ofrubella. These symptoms were confined to epistaxis,bleeding gums, spontaneous bruises, and purpura. In

previously reported cases hsematuria, melaena, and cerebralhaemorrhage have also occurred. In cases 1-3 fresh

hsmorrhagic lesions had ceased for up to a week beforethe platelet-count rose; and improved counts in cases 4and 5 were preceded by reduction in bruising and pur-pura and by lessening of the epistaxes (fig. 2). Similarobservations were made by Komrower and Watson (1954)and by Walker and Walker (1961) in their reviews ofacute idiopathic thrombocytopenia in children. Walker andWalker found that the mean duration of symptoms was

approximately three weeks shorter than the mean durationof thrombocytopenia. The duration of symptoms in thepresent cases varied from 2 days in case 1 to 58 days incase 4. In case 4 only was bleeding sufficient to warrantactive treatment.Besides hxmorrhage, physical findings were normal in

cases 2-5. Case 1 had a palpable spleen on one occasiononly. Splenomegaly has been an inconstant finding inother reported cases. At no stage in the illness did thechildren appear unwell. Ultimate recovery seems to bethe almost invariable outcome, and cases 1-4 are regardedas cured. Possibly, case 5 has not been observed for

sufficiently long to justify the same claim. In twenty-three of the previous twenty-five cases there was completerecovery. Of the other two cases, one reported by Steenand Torp (1956) had " slight thrombocytopenia

" seven

months after the onset of her illness, and the second diedat nine days from a cerebral haemorrhage (Ackroyd 1949).

It was impossible to arrange for serum-platelet agglutininsto be looked for, or for a direct antihuman-globulin test to bedone on any of our cases. Ferguson (1960) found serumagglutinins in one of his two cases, but they were absent in allsix cases reported by Tadzer (1958). There is no record of adirect antihuman-globulin test having been performed on apatient with thrombocytopenia following rubella.Spontaneous improvement in the platelet-count took place in

cases 1-3 and 5. Case 4 was treated with blood-transfusions,intravenous hydrocortisone, and oral prednisone because ofhis more dramatic symptoms. His platelet-count improvedafter 10 days of steroid therapy, but fell as the prednisone wasdiscontinued. A further improvement occurred spontaneously.Most of the earlier reported cases were untreated apart fromblood-transfusion when necessary, or were given vitamins Cand K with no obvious improvement.One of Steen and Torp’s (1956) cases was treated with corti-

sone with improvement, but relapsed when this was dis-continued. A further improvement was obtained with the

resumption of cortisone. The cause of thrombocytopeniacoming on after infections is not exactly known, but recent worksuggests that there is sensitisation of platelets and the subse-quent formation of platelet autoantibodies which may, or maynot, be freely circulating. If post-infective thrombocytopeniais a sensitivity reaction, steroids seem to be the logical treat-ment, although it is doubtful if any treatment is needed in a

self-limiting condition of relatively short duration.Carpenter (1959) suggested that steroids and splenectomy

should be withheld for 7 to 12 months after the onset inpost-infective cases, but Komrower and Wilson (1954) pointout that death from haemorrhage is most likely in the firstmonth of acute thrombocytopenia, and they suggest that treat-ment with steroids should be given in all cases for at least1 month, even if spontaneous remission is expected in mostpatients.

SummaryFive patients with thrombocytopenia arising within two

weeks of an attack of rubella are described.I am grateful to Dr. A. B. Lintott and Dr. J. D. Pryce for the

marrow-biopsy reports and their to technical staff for the many haema-tological investigations. I also wish to thank Dr. R. M. Mayon-White,under whose care the patients were admitted.

REFERENCES

Ackroyd, J. F. (1949) Quart. J. Med. 42, 299.Carpenter, A. F., Wintrobe, M. M., Fuller, E. A., Haut, A., Cartwright, G. E.

J. Amer. med. Ass. 171, 1911.Ferguson, A. W. (1960) Pediatrics, 25, 400.Komrower, G. M., Watson, G. H. (1954) Arch. Dis. Childh. 29, 502.Pitten, T. (1929) Arch. Kinderheilk. 86, 114.Steen, E., Torp, K. H. (1956) Arch. Dis. Childh. 31, 470.Tadzer, I. S. (1958) Acta med. iugoslav. 12, 233.Walker, J., Walker, W. (1961) Arch. Dis. Childh. 36, 649.

PHYSIOTHERAPY IN DERMATOLOGY

GUNTER HOLTIM.D. Leeds

LECTURER IN DERMATOLOGY

JOHN T. INGRAMM.D. Lond., F.R.C.P.

PROFESSOR OF DERMATOLOGY

UNIVERSITY OF DURHAM

FOR gravitational and other reasons, most skin dis-orders of the legs are associated ’with oedema which

impedes recovery. Resting, with the legs dependent, isharmful rather than helpful, and slight elevation of thelimb, as by raising the foot of the bed, is of limited value.On the other hand, in most affections, raising the limb toan angle of about 60° for thirty to sixty minutes with thetrunk in a horizontal position will effectively drain thelegs of oedema.

This can be followed immediately by the application ofa supporting bandage from toes to knee to prevent thereturn of oedema, and the patient can then resume hisnormal activities. An elastic bandage or stocking, or oneof the modern modifications of the Unna’s paste dressingmay be used for support and can be left undisturbed forweeks. An adhesive elastic bandage-used alone or

superimposed on an underlying ’Viscopaste’ type of

dressing-imparts elasticity and enables the leg-muscle tobe fully utilised in the return of fluid from the leg. Thedetails of bandage support are well known, but it shouldbe emphasised that the leg must first be effectivelydrained.To achieve comfort for the patient, and for ease of prac-

tice, a couch has been designed for use in busy outpatientdepartments and wards. The patient lies flat on the couchwhich is hinged at the centre, and when the lower end israised, the legs can be elevated from the hip to any requiredangle. At the other end, a second hinge allows a head-restto be raised to suit the patient’s comfort. This couch (seefigure) is made by New Equipment, Croxdale, Durham.The important features are the elevation of the limb from the

142

hip without bending of the knee, and the maintenance of this 1

position for a reasonable period-one hour. When properfacilities in dermatological outpatient departments become,available (as recommended by the Committee on Dermatology

i

of the Royal College of Physicians 1) postural-drainage couches I

should be provided as essential equipment.Nevertheless, a resourceful patient can improvise an effective

’

drainage unit in the home with planks or fracture-boards. This ’

treatment is of particular value for ulcers of leg, but it has manyother applications.

Occlusive Hydrocortisone BandagingHydrocortisone has revolutionised the treatment of

itching skin diseases, and has the great merit of causingneither primary irritation nor allergic sensitivity. Its onlydisadvantage at present is expense; but its effectiveness isenhanced and the cost of treatment is reduced if the hydro-cortisone cream, incorporated in a cotton bandage, is

applied as an occlusive bandage dressing which is leftundisturbed for one to six weeks or more.

This technique has been used in the skin department atNewcastle for more than a year with significant success.It is particularly applicable to chronic eczema, especiallyof the limbs, and it can completely transform the manage-ment of a child with persistent infantile eczema. Themethod is acceptable and welcome to the patient; itremoves the ritual of repeated and distressing replacementof dressings during the day, and has the advantage ofscreening the disease from the sight and from the inter-fering fingers of the patient and of those who care for him.We regard this advance in the treatment of an affectionthat can disrupt the whole life of a patient and his familyas of great importance.We have used hydrocortisone acetate in preference to

its analogues, and we believe that its insolubility prolongsits effectiveness and avoids the risk of absorption and ofconsequent systemic effects. The hydrocortisone acetateis incorporated in a conventional cream containing 10%silicone fluid because we believe that this may hold themedicament in the skin for longer periods. The creamcontains 1 % hydrocortisone acetate, and cotton bandageshave been impregnated with this by Smith & Nephew forour use. The bandages, after application, can be kept inplace by tube gauze and strapping, or by a light viscopasteor adhesive elastic bandage, according to the length of timethat it is intended to leave the bandage undisturbed.

Ultraviolet-ray Treatment of ChilblainsIn the cold, damp climate that favours the appearance

of chilblains a summer holiday in sunshine with adequatesunburning and tanning of the extremities is known torelieve chilblains during the following winter. The chil-blain circulation is marked by persistent spasm of thesmaller arterioles in the skin from cold. It has been shown 2

that injury of the skin, and especially injury by intenseultraviolet irradiation, is followed by diminished ability ofthe minute vessels of the skin, including the arterioles, tocontract, and that this persists for several months. Wehave utilised this knowledge in the treatment of patientswith chilblains by subjecting them to a strong erythemadose of irradiation from an ultra-violet lamp once a weekfor three successive weeks in September and October.

This is particularly valuable in the treatment of perniosisof the legs in young girls and women who cannot be

weaned from modern fashions in dress, and who suffer theindignity and discomfort of ugly, blue, swollen and

1. Royal College of Physicians of London: Report of Committee onDermatology, 1960.

2. Holti, G. Clin. Sci. 1955, 14, 143.

thickened legs and ankles that result from the disability.The treatment is also useful in patients with paralysis frompoliomyelitis whose limbs are cold and blue. There areother troublesome and persistent skin manifestations ofimpaired peripheral circulation such as perionychia andchronic discoid lupus erythematosus, in which treatmentof the underlying perniosis with ultraviolet irradiation maybe helpful..We have used the Q.600 ’ Hanau ’ lamp (J. C. Peacock, Son

Ltd., Newcastle upon Tyne) which will cause severe erythemain four to six minutes in the average subject at a distance of50 cm., and the dose must be increased by about 30% each timeto produce an erythema reaction on the second and third treat-ments. It is wise to test a small area of the patient’s skin toexposures of four, five and six minutes at 50 cm. first, todetermine the necessary dose in each patient. A brisk erythemaappears in eight to twenty-four hours and subsides within twoto three days. The irradiation required for this purpose isabout three or four times the minimal erythema dose. An

inadvertently severe reaction can be relieved by the applicationof hydrocortisone cream or lotion. The effects of treatment arelong-lasting, and three effective irraditions in September willnormally protect a patient throughout the winter months.

These three techniques have much in common and areoften combined in treatment. They save time and expense.They have a useful psychological effect not only because ofthe relief and comfort they provide, but because theyremove the disease from a central place in the affairs of thepatient and of the family. The harmful ritual of treatmentsessions in the home is abolished and, most important,recovery is expedited. The treatment need not interferewith, indeed it may facilitate, the pursuit of his normalroutine by the patient, and attendances at surgery andhospital are reduced.The value of occlusive dressings has received only

limited recognition in the past, and their use could

probably be extended widely with advantage. Apart fromwhat has been mentioned, the fact that injured tissues arekept at rest under constant environmental conditions oftemperature and humidity is likely to favour recovery.

Iontophoresis for Chronic Perionychiaand Morphoea

Chronic perionychia is often intractable and maydepend upon a poor peripheral circulation which willrespond to ultraviolet irradiation. The infective agents-usually Candida albicans, Pseudomonas pyocyanea, andpyogenic cocci-are not readily accessible to local applica-tions or systemic treatment. An effective treatment isionisation with 1 % copper sulphate, twice weekly for fourweeks and then monthly for four months, to cover theperiod of nail growth. Hydrargaphen (’ Penotrane’)lotion is prescribed for routine daily application to the nailsac with a pointed orange stick or a fine brush. Dry heatis another useful therapeutic measure for this affection.There is no consistently effective treatment for mor-

phoea (localised plaques of scleroderma). In the course oftime these will commonly clear spontaneously in patientsunder middle age, but they may cause pain and disabilitywhen they are situated over a joint. A steady softening andincreased flexibility may follow iontophoresis with hyalur-onidase at weekly intervals for eight or ten weeks usingthe technique described by Wilson 3 for the treatment ofleg ulcers.

If a physiotherapy unit is not available, these tech-niques can be practised in a suitably equipped dermato-logical department.

3. Wilson, E. R. J. Physiother. 1955, 41, 78.