Definition. A chronic, inflammatory disease involving the sebaceous glands and the lanugo hair-follicles, characterized by papules, pustules and nodules.
Symptoms. Acne is one of the commonest diseases of the skin, occurring in over 7 per cent. of all cases. It is more noticeable in private practice because that class of patients are more apt to attend to their external appearance.
Acne simplex or simple acne is usually a blemish of youth, appearing from the twelfth to the eighteenth year and lasting from five to ten years if untreated. It is most often seen on the face, especially on the forehead, cheeks and chin, but it is quite common on the upper part of the shoulders and chest and may rarely be found elsewhere. The eruption is bilateral without symmetry and consists of comedones, papules and pustules from pin-head to split-pea in size, varying in number from one or two to hundreds. The papules may appear independently of comedones, but usually the latter will be noted in the center of the papules and later may be seen in the pustule. It is the rule to find all the lesions from the comedo, the bright to dusky red papule, to the yellowish- white pustule with its red areola in the same individual. Besides these the effects of previous lesions, such as stains which disappear gradually and scars which become less distinct in time, may also be found. Except a sore feeling when pressed upon and, occasionally, a slight burning or itching, there is generally little subjective sensation. Essentially a chronic disease acne, if untreated, may last from the advent of puberty to the time of full maturity, which is a somewhat variable period. It may then disappear spontaneously but some cases develop into the deeper-seated acne indurata while in a few cases the two forms coexist in youth.
Acne indurata may occur in the same localities as acne simplex but it is much more common on the back and neck than the former. It is even more chronic in its course, rarely or never disappearing without treatment. The lesions originate as deep-seated, round, avoid or flattish indurations or nodules, often better felt than seen at their onset. They may be few or many, isolated or aggregated, vary in size from a pea to a cherry, and as they enlarge, the covering skin becomes dark red in color. Most are indolent (blind boil), contain little pus and even if incised are apt to reform. Others suppurate quickly but if not opened there is little tendency to spontaneous rupture, and hence resolution is delayed for weeks. Nearby glands may be affected and the coalescence of several suppurating lesions will often lead to the formation of linear tumors or irregularly shaped nodules which need free incision and cause permanent scarring. These scars are a purplish or deep red and the color fades very slowly. Naturally, the lesions are tender and painful to the touch. Keloidal transformations and fibroid degeneration may follow and persist. Comedones may or may not be present, but when found do not bear the direct pathological relation to pustulation that they do in acne simplex.
Seborrheic diseases often complicate either form of acne, and may slightly alter the typical picture presented. A few conditions, many of which are unlike true acne, have been designated by the term acne and because of this confusing prefix or title, it is necessary to say a word of explanation.
Acne cachecticorum usually occurs in poorly nourished, strumous or scorbutic individuals and is probably partly or wholly tubercular in nature (see scrofuloderma). The lesions are chiefly located on the trunk and extremities and are pea to cherry-sized, flat, flaccid, vivid red formations containing a little seropurulent fluid.
Acne artificialis is a papulopustular eruption produced by the internal use of the iodids or bromids, or from external exposure to tar, paraffin or petroleum (see dermatitis medicamentosa).
Acne rosacea and acne erythematosa (see rosacea).
Acne decalvans (see folliculitis decalvans).
Acne keloid (see dermatitis papillaris capillitii).
Etiology and Pathology. This disease is common, its course is varied, and although a parasitic agent may be locally causative, it would appear that predisposing factors are necessary to make possible the proper surface conditions on which this parasite may develop. Hence it does not seem fair to view acne as either a purely local or purely systemic affection but rather as a combination of both. Concerning the local agents such external factors as a lack of cleanliness, dusty or dirty atmosphere and various drug and trade, or other external irritations, should be considered. Admitting the parasitic element, Sabouraud’s microbacillus of seborrhea is readily found in the comedones and causes the seborrhea while the staphylococcus albus butyricus is added for the acne. Unna and Gilchrist have also described a bacillus that they regard as causative. There is no doubt that staphylococci cause the suppurative lesions. In fact it is positive that a few cases are due to local agents or at least their activity is the chief element in causation.
Among the predisposing causes, the greatly increased activity of the sebaceous glands in and about the advent of puberty is the principal factor because the vast majority of cases occur between the ages of fifteen and twenty-five. Among other predisposing factors may be mentioned gastrointestinal, menstrual, genitourinary and catarrhal disturbances, sexual abnormalities, anemia, rapid growth with a weakened circulation, scrofula, tuberculosis and any debility from acute or chronic diseases. Besides the predisposing causes just mentioned which apply to acne in the young, acne in middle life may be due to sedentary living, gout, diabetes, respiratory, urinary, uterine and ovarian diseases, and intemperance of any sort or degree.
Acne is an inflmmatory condition involving the sebaceous ducts and attacking the lanugo hair-follicles, frequently extending to suppuration and destruction of the follicles. It consists briefly in a stoppage of the gland outlet from some extraneous material or comedo formation as a result of hyperkeratosis. Besides this mechanical factor there must be present an agent, unknown as yet, whether it be a microorganism, a chemical or irritating change in the secretion, or some substance eliminated by the glands, to complete the pathological picture. Seborrhea probably occupies the chief place among the local factors that prepare the soil for parasitic invasion.
Diagnosis. The characteristic location of acne, its course, type of lesions, frequency of occurrence, origin at puberty and association with comedones, especially in the simple variety, should make an easy differentiation from the following:
Rosacea usually occurs in mature life, begins with temporary hyperemia, gradually followed by more permanent redness of the skin of the face and dilation of the superficial blood vessels. Acnoid lesions are secondary in occurrence.
Papulopustular eczema has smaller lesions forming in patches with exudation, crusting and itching, unconnected with comedones.
The pustular syphilid occurs in groups and underneath the crusts will be found small ulcers. Besides, there is a history of other syphilitic manifestations and a much wider distribution than is found in acne. The tubercular or gummatous syphilid of the skin occurs in groups and degenerates into ulcers which often spread by one=sided extension. Although this form may resemble acne when the nose only is affected, other evidences of syphilis, together with the effects of treatment, should establish its nature.
Variola presents constitutional symptoms, with an acute course and a typically progressive eruption.
Sycosis is found in adult males, is limited to the bearded area and the center of the lesion is occupied by a hair instead of a comedo as in acne.
Prognosis. A cure may be expected if the proper treatment can be followed systematically and persistently. The duration of treatment depends upon the underlying factors and the ability of the patient to follow directions, even if they embrace continued self-denial. Scarring may be expected in cases of a deep, indurated or long standing nature.
Treatment. This is both constitutional and local and the latter may be all that is necessary in very mild cases, or in those approaching maturity with the well known tendency to spontaneous cure at that time. But ordinarily, systemic treatment is all important if permanent relief is to be expected.
External treatment is employed to insure absolute cleanliness and for stimulation, counterirritation and the destruction of pus. The simpler the local treatment, the better, because the aim is to produce a healthy state of the tissues with as little scarring as possible. Powders, ointments and lotions are employed. The first are best avoided; the second do well as intercurrent remedies; while the lotions should be used as a regular procedure.
Cleanliness is obtained by the use of simple soap and hot water or, rather more often, a salicylic acid, resorcin or ichthyol soap having solvent qualities may be indicated. Occasionally, hot boric acid lotion, or the same diluted with equal parts of alcohol, applied cold, may accomplish the purpose more successfully. When more stimulation is needed, hot and cold water compresses may be applied in alternation, or tincture of green soap may be applied with hot water, but it should not be continued indefinitely or applied too thoroughly, because the congestion desired must be temporary or it will defeat rather than aid the cure. These cleansing applications should be applied at night before retiring so that the irritation may subside before morning.
Rarely mild agents, like boric acid 20 to 40 grains or slaicylic acid or resorcin 5 to 20 grains to the ounce of cold cream, may be employed after a washing. In a few cases dusting powders of boric acid, calendula, bismuth, calomel, ichthyol or aristol in strengths of 1 to 8 parts to 15 of powdered starch or stearate of zinc may be preferred. Ordinarily the use of powder or grease in any form, no matter how simple, is to be avoided. In this connection I might say it is my routine practice to insist, after local cleanliness is established, that toilet powders, soaps, creams and hot water must never be used. Cold water applied frequently in the form of compresses with or without the necessary “elbow grease” to remove the dirt, is the safest course for most acne patients to pursue.
Comedones should always be removed, not hurriedly, but gradually with thoroughness in the manner heretofore described. While it is not essential to open the smaller pustules, because these and some of the larger ones as well, care for themselves, it assists in the treatment to incise such lesions and gently express the contents. After puncture the cavity and surrounding surface should be cleansed with a solution of alcohol, carbolic acid, hydrogen peroxide or thymol. The same object will be achieved and in some instances more satisfactorily by the application of Bier’s suction or exhaustion cups. In any case the patient should not be allowed to open the pustules or remove blackheads with his finger nails or with some home implement, such as a watch key.
Many liquid preparations have been suggested for acne and among the best are those containing sulphur or its compounds. Ichthyol, resorcin and mercuric chlorid have also been successfully used, and the following stimulating prescriptions will present a fair variety of these formulas:
Rx Sulphuris precipitati,
M. To be boiled down to six ounces and filtered. Dilute one part to ten. (Velminckx).
Rx Zinci sulphat.,
q.s. ad z3iv;
Spts. vin. rect.,
Rx Sulph. praecip.,
Rx Hydrarg. bichlorid.,
Spr. vini rect.,
q.s. ad z3iv;
Ointments may be needed if lotions are not tolerated, either because they seem to have lost their efficacy or because the skin is naturally dry. I invariably apply them at night and even in cases that seem to thrive under their use, a lotion is dabbed on two or three times during the day. Among the ointments that may be used for decided pathogenic effects are the following:
Rx Sulphuris precipitati,
Lassar’s paste: Amyli,
Rx Hydrarg. ammoniat.,
Ung. zinci oxidi.
q.s. ad 3j;
Rx Sulphuris precipitati,
Rx Hydrarg. bichlorid.,
Emuls. amygdal. amar.
Tinct. benzoin. comp.,
Acne of the back or trunk is treated with the same preparations, especially the stronger ones, applied more energetically. My custom is to thoroughly wash the part affected with tincture of green soap and hot water, immediately followed by the application of dilute ether, which in turn is followed by a dusting powder of boric acid, with or without salicylic acid. A strong solution of resorcin, 1 dram to the ounce of equal parts of water and alcohol, or better yet, formalin, pure or diluted, may be used in place of the other applications.
Rather than use the stronger ointments or lotions, recourse may be had to physical therapy. In this repeat I believe the routine application of the high- frequency currents is most beneficial in all mild cases, if applied once or twice a week for about five minutes. The particular variety of these currents must depend upon the exact nature of the case, but the resonant form (Oudin) with a glass electrode is usually indicated. High-frequency sparking or mild fulguration may benefit individual cases and these varieties, together with the other forms of high-frequency currents, have entirely supplanted faradic and galvanic energy. While the X-rays are not as generally successful as formerly thought, because they do not prevent recurrence, they are a valuable asset in chronic, persistent, indurated, deep-seated and pustular acne. It is not necessary to carry the treatment beyond a point where a mild erythema develops, and the eyes, eyebrows and scalp should be carefully protected. Exposures are from three to ten minutes’ duration, at a distance of from eight to fifteen inches, using a soft to medium tube and repeating the treatment every three to five days. The disadvantage of this treatment is that it must be vigorous to insure a cure and hence may leave pigmentation, wrinkling and telangiectasis. In any case, I believe it should only be used for obstinate cases, or as an auxiliary to other measures. Even the massive dose X-raying which presents many advantages over the fractional method just described, offers no better prognosis. In a few instances I have applied solidified carbon dioxide for from five to fifteen seconds, using very slight pressure, to persistent acnoid lesions with the best results possible.
Vaccine treatment has been warmly extolled for acne, but it should be reserved for obstinate cases and, if used, an autogenous vaccine is preferable to the stock variety. If the latter must be employed, a mixed vaccine of staphylococci and acne bacilli is preferable, because the acne pustule in most cases contains both germs. I have given this method of treatment a thorough trial and, to describe it mildly, am not enthusiastic about it for the average case.
The constitutional treatment of acne embraces the relief of all abnormalities, no matter how trivial. In this respect diet is most important, as digestive disturbances and constipation are the common predisposing agents. The substitution of vegetable for animal food is often indicated, especially in the plethoric while in the anemic the opposite may be true. But idiosyncrasy plays an important part because simple foods may often cause an irritation of the face, although not so commonly as shell fish, excessive sweets and highly seasoned foods. Water between meals, and not with meals, is a useful agent because excretion must be attained as well as secretion. Exercise is most important and, if the genuine article is not possible, passive exercise in the shape of massage or general applications of the static, galvanic and high- frequency currents may be employed. All sources of irritation in the alimentary or genitourinary sphere should be treated, when found, because from them moral perversions may develop and lead to more than local diseases. In this connection physical weariness is of value as an auxiliary corrective treatment, although pride and the fear of exaggerated consequences will help.
An indicated homeopathy medicine for acne often benefits with the acid of the simplest local treatment. Unfortunately a goodly number of these cases show a marked lack of subjective and constitutional symptoms, so that it is necessary to prescribe on a basis of objective lesions only. Almost any drug might be indicated, but the following have repeatedly give relief: Agaricus, Alumina, Aloes, Am. carb., Antim crud., A. tart., Argentum nit., Arnica, Aurum mur., Arsenicum, A. brom., A. iod., Baryta act., B. carb., Berberis, Belladonna, Borax., Bovista, Calcarea phos., C. sulph., Chelidonium, Colchicum, Crotal., Cocculus indicus, Cycla., Digitalis, Graphites, Hepar, Jugl. reg., Kali brom., K. bich., K. iod., K. mur., Lyco., Nit. acid, Nux. mosch., N. vom., Pet., Phosphorus acid, Pulsatilla, Rhodod., Sabina, Sarsap., Selenium., Sepia, Silicea, Sul., Thuja and Zincum met.