unanswered questions and disputes about the nature and clinical identity
or identity of diffuse neurodermatitis, Besnier’s pruritus and atopic
dermatitis and their similarities with eczema and other ” pruriginous
” processes. Currently, the prevailing opinion is that diffuse
neurodermatitis, Besnier’s pruritus and atopic dermatitis of American authors
are identical diseases. Unclearness exists in particular regarding the
connection between them and true infantile eczema. Many authors also call the
latter constitutional or atopic eczema; at the same time, it is noted that
children’s eczema at an older age “turns” into Besnier’s pruritus ,
diffuse neurodermatitis or atopic dermatitis.
We do not share this opinion about childhood eczema. In our opinion, there is a true childhood eczema, already described above, which usually disappears without a trace by the end of the second year. In addition, there is a kind of eczema in older infants and in young children, which is the first expression of diffuse neurodermatitis or Besnier’s diathetic pruritus or atopic dermatitis. It does not go away by the end of the second year of life, but continues after that, sometimes throughout life: it is characterized by a number of morphological, evolutionary and general symptoms that individualize it.
Beignet describes how prurigo diathesique is a chronic disease characterized by severe itching, with polymorphic changes in the skin. It usually begins in the first months of life. Morphological changes in the skin at this stage of development resemble dry subacute eczema processes, in connection with which German dermatologists ranked this disease among the group of chronic eczemas, where it appeared for a long time. Usually, these eczema inflammations were preceded by severe itching, easily leading to skin lichenification , which made it impossible at this stage to differentiate this disease from diffuse neurodermatitis. A special evolution of the disease that begins in infancy and early childhood, a special localization of changes, a combination or alternation with a number of other allergic manifestations (asthma, asthmatic bronchitis, hay fever, strophulus , swelling of the lymph nodes and, in general, the presence of more pronounced symptoms of a general disorder of the whole organism) , make up the hallmarks of Besnier’s diathesis pruritus .
Under the name of neurodermatitis, a group of pathological processes of the skin was described (Brock), in the first place – one limited and one diffuse form characterized by severe itching, lichenoid papules and typical lichenification . As with limited, so, especially with diffuse forms, the rash resembles subacute and chronic eczema processes; therefore, some authors have attributed neurodermatitis to chronic eczema. In its development, general symptoms and pathogenesis, neurodermatitis in infants and young children, especially its diffuse forms, does not differ from Besnier’s pruritus . Therefore, regardless of the dispute about whether diffuse neurodermatitis in adults should be identified with Besnier’s pruritus , we believe that in infancy and childhood these are identical diseases.
The name “atopic dermatitis” introduced by American authors does not give anything new for the morphology, evolution and nosology of the described dermatoses, but. is just a new name for neurodermatitis, Besnier’s pruritus and similar processes. When creating this name, we proceeded from the assumption that Coca’s atopic diathesis (A. Coca ) is involved in the pathogenesis of these processes. The extension of this concept to the clinic, as L.P. Mashkilleyson says , is not necessary. It only burdens the already complex dermatological terminology. We disagree in particular with the complete identification of childhood eczema with atopic dermatitis.
The essence of diffuse neurodermatitis ( prurigo Besnier ) in infancy and childhood. For a long time, the authors noticed, and still notice, various features in some cases of childhood eczema. The combination of these features is characteristic of the third type (after seboroid dermatitis and true childhood eczema) of eczema reaction in infancy and childhood – neurodermatitis or Besnier’s pruritus .
The onset of the disease
Neurodermatitis also occurs in the first months of life, but generally
later than true childhood eczema. In some cases, children 4-5 years old can
also get sick. In a word, each eczema that began after the 4-5th month of life
in infancy and childhood can raise suspicion of neurodermatitis.
Morphology and localization. The histopathological picture of neurodermatitis corresponds to the picture of subacute and chronic eczema with more pronounced acanthosis and almost complete absence of intraepidermal vesicles. At the beginning of its development in infancy, with relapses and exacerbations of neurodermatitis, the lesion in children can be erythema -edematous and get wet, completely resembling true childhood eczema. However, with careful observation, it can be found that with neurodermatitis, the affected skin is drier, more prone to lichenification , less weeping and wetting is shorter.
In later and more typical cases, the eruptive element is a lichenoid nodule, and simultaneously with eczema -like plaques, separate papulo-urticarial or papulo-vesicular elements appear, resembling a rash with strofulus . Also in the later stages, the skin on the affected areas begins to infiltrate, thicken, become covered with abrasions, crusts, lichenify and darken.
Changes, especially at the beginning, are localized mainly on the face, and along with the cheeks, the forehead is more often affected. At the same time, changes gradually appear on the back of the head, in the elbow and popliteal folds, around the mouth, on the hands, in the genital area, on the inner surfaces of the thighs, on the outer surfaces of the limbs and on other areas of the skin. In general, disseminated and lichenified eczema in infancy and childhood is more often not true childhood eczema, but neurodermatitis.
Evolution and symptoms
While true childhood zkzema usually disappears without a trace around
the end of the second year of life, Besnier’s pruritus, for the most part with
remissions of various durations, can last until puberty, and sometimes does not
go away until the end of life. The disease develops in attacks that often occur
seasonally (mainly in winter and spring).
Before and during each attack there is a very intense itching. Itching makes infants and young children who suffer from diffuse neurodermatitis extremely restless; they do not sleep well, are pale, whiny, capricious, thin. At the slightest irritation, they have an attack of itching and the children begin to itch uncontrollably. Over time, there comes a “cold” swelling of the inguinal, femoral and other lymph nodes.
Simultaneously with skin phenomena, in most children with Besnier’s pruritus , allergic rhinitis, asthmatic bronchitis, and later bronchial asthma are observed. These phenomena accompany skin attacks or alternate with them.
Etiology and pathogenesis. Currently, the prevailing opinion is that diffuse neurodermatitis is caused by a special, congenital or acquired state of hypersensitivity to various exogenous and endogenous stimuli of an antigenic and non- antigenic nature. Skin tests with various allergies are very often positive; this applies in particular to inhaled allergens (dust, hair, animal origin, plant products and pollen). Antibodies are often detected (passive transfer method). There are also positive complement-fixing reactions, colloidoclasia phenomena ( positive Zogan index ). However, all attempts to establish a specific allergic hypersensitivity were unsuccessful. Removal of allergens for which positive skin tests were obtained did not lead to a cure. Their introduction is not always associated with subsequent deterioration. Reactions to various therapeutic agents are unexpected and inadequate: highly irritating agents may be well tolerated by the skin, while seemingly indifferent agents may cause skin irritation. Hill ( Hill ) admits that with neurodermatitis there is a special local X-factor that causes a tendency to white dermographism, vasoconstriction and hypersensitivity of the skin to various irritants. The tendency to spasm of small blood vessels of the skin in neurodermatitis is considered to a certain extent similar to bronchospasm in bronchial asthma that accompanies this disease.
This disease can often be familial, with parents having asthma or hay fever in the south , and Besnier’s pruritus in children . In children suffering from Besnier’s pruritus , at a later age, skin phenomena may disappear, or asthma, hay fever may remain or develop. All this gives grounds for the adoption of a special, congenital, family diathesis ( Coca ‘s atopy ).
The role of status was discussed thymicolymphaticus , pluriglandular endocrine dysfunction, helminthiasis , and torpid tuberculous intention, but no specific evidence was presented.
Based on family questionnaires, it was possible to establish that neurodermatitis develops mainly with careless, rude, insufficiently caring care for children.
With regard to diffuse neurodermatitis, it has been found especially necessary that it is susceptible to the influence of changes in the environment, and improves, in particular, when staying at sea or at an altitude of more than 1200 m above sea level. It is believed that in these conditions, along with the elimination of irritating allergens, climatic factors (atmospheric pressure, humidity, temperature, winds, etc.) also influence.
From the foregoing, it can be seen that the etiology and pathogenesis of neurodermatitis still remain unclear. Along with the role of some trophallergens and dust-like allergens, when discussing pathogenesis, the assumption that neurodermatitis is a kind of trophic neurosis that develops in people with functional insufficiency of the central nervous system (S. T. Pavlov) is increasingly making its way. In support of this assumption, along with the data presented above in the section on the pathogenesis of eczema, the following can be cited. Even Brock, giving the name to this disease, on the basis of clinical observation, connected its occurrence and development with the state of the nervous system. At present, it is also known that the best results in the treatment of neurodermatitis are obtained with the use of agents that act on the central and autonomic nerves, the system. Clinical improvement of neurodermatitis in high-altitude summer, according to our observations, is accompanied primarily by the normalization of the tone of the autonomic nervous system and the processes of excitation and inhibition of the central nervous system. The role of the autonomic nervous system in the pathogenesis of neurodermatitis is also indicated by the studies of A. V. Loginov and O. K. Shaposhnikov, who found in the skin of patients with neurodermatitis the presence of a substance similar to adrenaline and a decrease in the permeability of skin vessels. As the immediate causes of neurodermatitis, various exogenous and endogenous intoxications are indicated.
If we take into account the listed features of morphology, evolution,
localization and general symptoms, then it is relatively easy to make a
diagnosis of Besnier’s pruritus . In infancy and early childhood, it must be
differentiated mainly from true childhood eczema and seboroid dermatitis; this differential
diagnosis was discussed above. Papulo-urticarial diseases accompanying
childhood neurodermatitis are of particular diagnostic importance . rashes and
urticarial nature of skin reactions in relation to various allergens. In older
children, besnier ‘s prurigo must be differentiated from prurigo. Hebrae ,
other pruriginous processes, some contact-allergic dermatitis, lichen planus,
psoriasis, scrofulous lichen, which are discussed in the relevant sections.
Forecast of prurigo besnier quo ad sanationem is always serious. As has been said, a disease with more or less prolonged remissions can last until puberty and beyond. In connection with the prognosis, the following complications and features of the development of some cases of diffuse neurodermatitis should be taken into account.
With diffuse neurodermatitis in children, secondary infections are observed, but they are much weaker and less common, despite very severe itching and scratching. In some cases of diffuse neurodermatitis, the so-called atopic erythroderma develops. It may precede or accompany the underlying disease and remain after the latter has recovered. In this condition, the skin of the whole body is light red in color, reminiscent of a goose; it is thickened and has no particular tendency to vesiculate and ooze . There is a pronounced desquamation, general enlargement of the lymph nodes, very severe itching. With this form, hypersensitivity to various antigenic stimuli is very noticeable and a tendency to secondary infection is more pronounced. The expressed eosinophilia is found in the blood ; the number of white blood cells is significantly increased without signs of blood disease.
In a small number of cases with Besnier’s pruritus between the ages of 16 and 35, cataract development is observed [ Roxburg ( Rox – rurgh ), Brunsting )]
Long-term follow-up of the fate of children with Besnier’s pruritus , ” proved the following: out of 84 still in infancy from a secondary infection 6 died (mortality is higher than in the control group); in 55% of patients , eczema continued until the age of 13, and in many individuals up to 20 years; 27% of children recovered during the first three years of life; asthma, chronic bronchitis and seasonal rhinitis was found in 73% of patients (in the control group – 5-7%); asthma was most often observed; 22% of children had pneumonia one or more times in the control group – 2%); 23% of patients had headache and frequent vomiting , and 17% had urticaria (in the control group, a significantly lower number of such disorders – up to 0%). In children whose parents had eczema, the duration of the disease was longer. In general, diffuse neurodermatitis in infants and small children children is considered a serious disease that significantly impairs and endangers the health and further development of children.
Of the three types of eczema reactions described in children,
neurodermatitis is the most difficult to treat. All therapeutic considerations,
methods and means, discussed in detail in the treatment of true childhood
eczema, are fully applicable to neurodermatitis. Since this disease is
associated with functional disorders of the central nervous system and is
particularly sensitive to various exogenous and endogenous stimuli, treatment
aims to reduce such disorders and eliminate all possible irritations. The main
goal of treatment is to soothe itching and remove the causes that support it.
All common local antipruritics (bromine, calcium, antihistamines,
glycocorticoid hormones, neuroplegic drugs, etc.), psychotherapy are used.
The priority in the description of cataracts in neurodermatitis belongs to N.I. Andogsky (1913) – Ed.
Along with the elimination of all foodborne irritants (see the section on eczema), with neurodermatitis it is very important to remove various irritants of animal and vegetable origin (wool, hair, dust, pollen, fur, fluff), which are often found in the immediate environment of the child (blanket, mattress, linen, clothes, toys, furniture, etc.). Sometimes for this purpose a change of place of residence is required, and for older children, a direction to a highland area.
External treatment is carried out as with true childhood eczema. Children with besnier pruritus tolerate tar well . Well-washed pine tar is often used, pure or in combination.
In particularly severe cases that are not amenable to other treatment, with more significant infiltration of the skin, one can keep in mind and carefully apply X-ray therapy or boundary rays, and in all cases – general irradiation with a mercury-quartz lamp and antipruritic baths.