1347

ASCORBIC ACID FOR PRICKLY HEAT Singapore is 130 km. (80 miles) north of the equator.
T. C. HINDSON
M.A., M.B. Cantab., M.R.C.P., M.R.C.P.E,, D.T.M. & H.
DERMATOLOGIST, BRITISH MILITARY HOSPITAL, SINGAPORE
A chance observation led to the use of
Sum ary ascorbic acid, 15 mg. per kg., in a double-
blind trial in 30 children who had had repeated attacks of
prickly heat. Of 15 children given ascorbic acid for two
weeks, 14 improved or were free from lesions compared
with 4 out of 15 given placebo. All 30 were then given
ascorbic acid: no further lesions were seen after one and
two months. Only a few patients reported lesions during
that time. No unwanted side-effects have been seen.
The climate is hot and humid and there is little seasonal
variation with temperatures around 80°F (26°C) and
humidity 84—85%. The average annual rainfall is 88 in.
(220 cm.). The effective temperature (Stephenson 1963)
calculated by taking into account humidity, dry bulb
temperature, and wind speed, exceeds 78 °F (25 °C), the
accepted comfort zone, for much of April and May.
The work of Griffin et al. (1967) suggests that the primary
event in the genesis of prickly heat is cessation of sweat-
gland activity which they termed " sweat gland fatigue ",
and they were able to demonstrate, in individuals in
whom prickly heat was artificially induced by occlusion
with polyethylene, that areas of sweat-gland fatigue ex-

Introduction
My attention was first drawn to the
efficacy of high
doses of ascorbic acid in the treatment of prickly heat
after interviewing an Australian Air Force officer who
had an acute intertriginous dermatitis (see figure). This
rash is very common in the tropics and Monilia can be
isolated from it on microscopy and culture. However, it
does not respond satisfactorily to local nystatin and it is
suspected that it is a manifestation of prickly heat second-
arily infected with Monilia.
This patient said that he had had the rash for one year
previously and that it had resisted all topical therapy, but
that it suddenly cleared in the course of a week when he
’
was taking ascorbic acid 1 g. daily (’ Redoxon Effervescent ’
Roche Products) because he believed it beneficial for a
Typical groin lesion of prickly heat in the tropics
cold which he had at that time. I put him on ascorbic
acid 1 g. daily as the sole treatment, and when re-examined
ten days later his groin was normal. Ascorbic acid was
tended considerably beyond areas of prickly heat apparent
on examination. This would explain the prevalence of
then tried in the treatment of five children who had
recurrent severe prickly heat. They were given a dose prickly heat in Singapore where, because of the climate,
sweat glands are always active.
proportional to their weight, and no further attacks of
prickly heat presented while they were taking it. Sub- Patients and Methods
sequently I carried out a double-blind trial of ascorbic acid 100 mothers, who had been in Singapore longer than six
in the treatment of 30 cases of prickly heat. months, were interviewed consecutively they came through
as
the cash desk of the main service grocery store (N.A.A.F.I.).
73 described rashes developing intermittently in their children,
which corresponded to a clinical picture of prickly heat: 52
Abele, D. C., Tobie, J. E., Hill, G. J., Contacos, P. G., Evans, C. B. (1965)
Am. J. trop. Med. Hyg. 14, 191. had sought medical advice because of it on one occasion and 17
Burkitt, D. P., Wright, D. H. (1966) Br. med. J. i, 569. on more than one occasion.
Cohen, S., McGregor, A. I. (1964) in Immunity to Protozoa (edited by 30 cases were selected; the criterion being that all patients
P. C. C. Garnham, A. E. Pierce, and I. Roitt); p. 123. Oxford.
Coons, A. H., Kaplan, M. H. (1950) J. exp. Med. 91, 1. should have suffered continuously from prickly heat for a
Curtain, C. C., Baumgarten, A., Kidson, C., Gajdusek, D. C., Gorman, period of eight weeks, immediately before the date of initial
J. G., Rodrique, R., Champness, L. (1965) Br.J. Hœmat. 11, 471. interview. Ages ranged from four months to eight years.
Kidson, C., Gorman, J. G., Parkinson, D. (1965) Trans. R. Soc.
—

trop. Med. Hyg. 59, 415. There were 18 boys and 12 girls. The sites affected were as
Dalldorf, G., Linsell, C. A., Barnhart, F. E., Martyn, R. (1964) Perspect. follows:
Biol. Med. 7, 435.
Gilles, H. M., Hendrickse, R. G. (1963) Br. med. J. ii, 27.
Houba, V., Allison, A. C. (1966) Lancet, i, 848.
Kaplan, M. H., Meyserian, M., Kushner, I. (1961) J. exp. Med. 113, 17.
Kibukamusoke, J. W., Hutt, M. S. R., Wilks, N. E. (1967) Q. Jl Med. 36,
393.
Marsden, P. D., Connor, D. H., Voller, A., Kelly, A., Schofield, F. D.,
Hutt, M. S. R. (1967) Bull. Wld. Hlth Org. 36, 901.
Richards, A. I. (1954) Economic Development and Tribal Change: a
Study of Immigrant Labour in Buganda. Cambridge.
Rowe, D. S., McGregor, I. A., Smith, S. J., Hall, P., Williams, K. (1968)
Clin. exp. Immun. 3, 63.
Shaper, A. G. (1968) Trans. R. Soc. trop. Med. Hyg. (in the press).
—

Coles, R. M. (1965) Br. Heart J. 27, 121.

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Kaplan, M. H., Foster, W. D., Macintosh, D. M., Wilks, N. E. (1967) The 30 patients were divided into two equal groups. Half
Lancet, i, 598. were given ascorbic acid and half a placebo. Patients were
Soothill, J. F., Hendrickse, R. G. (1967) ibid. ii, 629. allotted to each group by the pharmacist without my know-
Stiehm, E. R., Fudenberg, H. H. (1966) Pediatrics, Springfield, 37, 715.
Uriel, J. (1958) Clin. Chimica. Acta, 3, 234. ledge. The dosage of ascorbic acid was based on the obser-
van der Geld, H., Peetom, F., Somers, K., Kanyerezi, B. R. (1966) Lancet, vation of the original patient, who weighed 154 lb. (70 kg.) and
ii, 1210. was taking 1 g. daily. It was assumed therefore that 1 g. was
van Tongeren, J. M. (1966) ibid. i, 1266.
Voller, A., Bray, R. S. (1962) Proc. Soc. exp. Biol. 110, 907. necessary for a patient of 150 lb. weight and the dosage for the
Webster, D. (1962) Clin. Chimica. Acta, 7, 277. children was calculated to the nearest 25 mg., on a dose-for-
 1348
weight basis. Where a child was too young to take tablets
parents were instructed to administer them crushed with food.
Results
The table shows the results after two weeks.
The 11 patients from the placebo group whose lesions
had either not improved or had worsened were given
ascorbic acid; after a further two-week interval 6 had no
lesions and 5 had improved. None were recorded as
unchanged or worse. All 30 patients were then given
RESULTS AFTER TWO WEEKS
ascorbic-acid therapy and re-examined after a further one
and two months.
At neither examination were lesions visible on any of
the 30 patients. After one month 5, and after two months
4 reported that they had had occasional lesions during the
period.
Thus it seems that ascorbic acid, when given in high
doses, is effective in the treatment and prevention of
prickly heat. No unwanted side-effects have been recorded
from such doses to date.
The exact mechanism of action of ascorbic acid in pre-
vention of prickly heat is not yet established, although I
have found that it reduces the area of experimentally
induced sweat-gland fatigue and its subsequent duration.
Ascorbic acid is known to act as a hydrogen-ion carrier
for the intracellular redox enzyme systems (Mapson 1954)
and Shamin Ara and Pakis (1953) postulated that in con-
ditions of profuse sweating significant amounts of ascorbic
acid might be lost by this route, but Sargent et al. (1944)
doubted whether any loss of the vitamin in this way would
be significant. Ascorbic-acid levels in sweat collected from
individuals on high ascorbic-acid intake have not yet been
carried out.
That sweat glands, hyperactive in a tropical atmosphere,
might selectively become short of this vitamin, or that the
vitamin in large doses might take over the action of, or
replenish some essential, but fatigued enzyme system such
as the succinic-dehydrogenase system-which Dobson
at el. (1958) showed was the first to disappear on excess
sweating-is an attractive hypothesis which needs further
investigation.
I thank Lieut.-Colonel H. S. Moore, Prof. C. D. Calnan, Colonel
W. J. Irwin, and Lieut.-Colonel S. E. M. Jarvis for their help and
encouragement, the R.A.F. Metereology Section, Changi, for climate
data, and Dr. A. J. F. Eberle and the staff of Roche Pharmaceuticals
Ltd. for professional and financial assistance.
Requests for reprints should be addressed to T. C. H., R.A.M.C.,
British Military Hospital, c/o G.P.O. Singapore
REFERENCES
Dobson, R. L., Foronisano, V., Lotitz, W. C. (1958) J. invest. Derm. 31,
147.
Griffin, T. B., Maiback, H. I., Sulzberger, M. B. (1967) ibid. 49, 379.
Mapson, M. A., (1954) The Vitamins, Chemistry, Physiology and Pathology,
New York.
Sargent, F., Robinson, P., Johnson, R. E. (1944) J. biol. Chem. 158,
285.
Shamin Ara, Pakis, J. (1953) Sci. res. 5, 61.
Stephenson, P. M. (1963) Meteorol. Mag. 92, 338.
GRANULOMATOUS HEPATITIS
ACCOMPANYING A SELF-LIMITED
FEBRILE DISEASE
M. ELIAKIM S. EISENBERG
M.D. Jerusalem M.D. Jerusalem
I. S. LEVIJ T. G. SACKS
M.D. Utrecht M.B. Pretoria, M.Med.(Path.)
Cape Town, M.C.Path.
From the Departments of Internal Medicine B, Pathology, and
Microbiology, Hadassah University Hospital and Hadassah
Medical School, Jerusalem, Israel
Five patients with a self-limited febrile
Summary disease
resembling infectious mononu-
cleosis are described. The main manifestations of the
disease included fever, cough, a slight enlargement of
the spleen, and peripheral lymphocytosis. Gross lympha-
denopathy was absent, abnormal lymphocytes were not
found, and the Paul-Bunnell test was negative in all
cases. Hepatocellular function tests were slightly
impaired but jaundice was absent. Liver-biopsy speci-
mens which were performed in three of the cases,
revealed lesions resembling granulomas. The course of
the disease was not influenced by antibiotics, and com-
plete recovery ensued within 3 to 4 weeks. Subsequent
biopsy specimens showed no abnormalities. The cause
of the disease remained obscure in spite of an extensive
search for ætiological factors.
Introduction
DURING the spring of 1966 we saw five patients with a
disease resembling infectious mononucleosis but lacking
some of its typical features. An extensive search for
aetiological factors was fruitless. The cases represented
a diagnostic challenge, and there were several interesting
features, notably evidence of liver involvement.
Case-reports
FIRST CASE
30-year-old civil-servant was admitted to the hospital in
A
May, 1966, because of malaise, fever, severe headache, and
non-productive cough of 6 day’s duration. The temperature
was intermittent and rose to 39°C (1024°F) in the evenings,
without chills.
He was in excellent general state, temperature 38°C
(1006°F), pulse-rate 100 per minute, blood-pressure 130/70
mm.Hg. No jaundice. The pharynx showed slight conges-
tion. A soft, grade-2, blowing. systolic murmur (known to
exist since childhood) was heard at the 4th left intercostal
space. Liver was neither tender nor palpable; spleen pal-
pable 2-3 cm. below the costal margin; no lymphadenopathy.
Laboratory data
Erythrocyte-sedimentation rate (Westergren) 10 mm. in
lst hour, 22 mm. in 2nd hour; Hb 16-3 g. per 100 ml. White
blood-cells 7100-11,500 per c.mm. The differential count
revealed 55-65% lymphocytes, 8-10% monocytes, and 32-46°.
segmented cells (five counts). Urinalysis normal. Multiple
blood and urine cultures sterile. Sputum grew Hœmophilus
influenzœ. Thick blood preparations revealed no malaria
parasites or Borrelia. Serological tests for Salmonella infec-
tions, typhus fever, brucellosis, infectious mononucleosis,
and Q fever all negative. Wassermann reaction was negative;
no L.E. cells. Many stool examinations revealed no ova or
parasites. Liver-function tests are listed in table I. X-ray of
the chest showed slight enlargement of the left atrium and
ventricle; lungs normal.
The temperature remained elevated for 18 days after
admission and was not affected by the oral administration of