ACNE. BY GEORGE D. HOLSTEN, M.D., OF BROOKLYN, N. Y.J DERMATOLOGIST TO THE BROOKLYN E. D. HOSPITAL AND DISPENSARY ; PHYSICIAN, DEPARTMENT OF DERMATOLOGY, BROOKLYN THROAT HOSPITAL. FROM THE MEDICAL NEWS, November 18,1893. [Reprinted from The Medical News, November 18, 1893.] ACNE. By GEORGE D. HOLSTEN, M.D., OF BROOKLYN, N. Y.J DERMATOLOGIST TO THE BROOKLYN E. D. HOSPITAL AND DISPENSARY J PHYSICIAN, DEPARTMENT OF DERMATOLOGY, BROOKLYN THROAT HOSPITAL. The following definition of acne is taken from Jackson's Diseases of the Skin : "Acne is an inflammatory disease of the sebaceous glands and the hair-follicles, due to the retention of sebum ; it is characterized by an eruption of papules, pustules, or tubercles, upon the face, neck, shoulders, or chest; it usually begins at puberty and tends to run a chronic course." In considering the subject of acne, abetter under- standing of the disease will be obtained by first briefly reviewing the structure and functions of the portions of the skin affected. The sebaceous glands consist of two portions, the gland proper and the duct. The glandular por- tion is situated in the corium ; the glands are of the racemose variety; the various acini of which these are composed, from two to twenty in number, open into a common duct which empties into the hair- follicle. Each follicle has two or more glands at- tached. Embryologically, the sebaceous glands are to be 2 considered as adjuncts to the hair-follicle, even though at a later period in adult life they exceed the follicle in size. The sebaceous glands are divided by Sappey into three classes: First, those situated on the scalp, the bearded portion of the face, the axilla, and pubes, these being connected with hair-follicles that con- tain thick, coarse hairs, the hair-follicles predomi- nating over the glands; second, those of the fore- head, nose, cheeks, and chest, where the hairs are smaller-of the lanugo type-and the glands are large; and, third, those opening on the free surface of the body, not connected with hair-follicles, such as the glands situated around the corona glandis, the inner surface of the prepuce, the sur- face of the nipple, the vestibule, and the labia minora. Those of the second class are the most usually affected in acne. In structure, the glands have a membrana propria and are lined with cubical or cylindrical epithelial cells, of several layers in thickness, these cells being a direct continuation of the cells forming the rete. The cells of the innermost layer undergo a fatty de- generation, and this fat, mixed with fatty acids, cholesterin, fat-crystals, and the remains of the cell-bodies, forms a mass-the sebum-which, pass- ing out through the duct, is discharged into the hair-follicle, and serves to lubricate the hairs. There have been many terms employed to desig- nate the various grades of severity that acne may assume, but at the present time the disease is gen- erally divided into two varieties, acne simplex and acne indurata; the former being superficially seated 3 and papular or pustular in character, while the latter is deeply seated and pustular or tubercular. The first step in the development of acne is an excessive formation of sebum in the glands. This sebum, instead of being poured out on the surface of the skin, becomes inspissated, remains in the duct, the opening of which becomes more promi- nent as the sebum increases. Frequently the plug of sebum becomes tipped with black. This con- stitutes the condition of comedo, or, popularly, "black-heads." At the same time, an increase of horny epidermis takes place around the mouth of the gland, with an abnormally light, yet firm adhesion over the opening. The simplest form of acne, most frequently seen on the forehead and chin-papular or punctate acne-is then present. These papules are pin-head in size, of a white or pinkish color, and on their summits are seen the black tips of the plugs of sebum. Subjecting one of these comedones to lateral pressure, the plug of sebum can be squeezed out. The black-brown color of this comedo-tip was formerly supposed to be due to dirt. Unna considers it as produced by a normal pigment-constituent of the secretion of the skin, which he calls ultramarine, and which, under the influence of light, turns black; that such a pig- ment exists is denied by Krause. Kaposi, in his fourth edition, says he thinks that horny epidermis and fat, when they remain in contact with air for a long time, will become colored, and that atmos- pheric dirt is probably an accessory to this coloration. The papular form may remain as such or go on to another form. The plug of sebum acts as a for- 4 eign body, and excites an inflammation in the gland-tissue, and we then have the acne papule larger, of a more deeply red color, and frequently with a sur- rounding areola. The condition of the tissues now being favorable for the development of pus-cocci, some of these gain entrance into the duct, and pustular acne is then the result. At this time one's patient presents the acne lesions in their various stages of development-comedones, large and small papules, and pustules. All of these constitute simple acne. The disease may now remain in this condition, entirely limited to the superficial portion of the skin, and each lesion passing with more or less rapidity through these different stages. The pus- tules rupture or dry up, and the lesions depending on the grade of inflammation and suppuration which has been present, leaving more or less scarring, though this is usually not strongly marked. After a variable length of time, if the disease is left untreated, it becomes more extensive and severe. The papules and pustules increase in number, and the individual lesions are larger, extend more deeply into the tissue, and the inflammatory symptoms be- come more severe; the tissues surrounding the glands are also involved, and the condition of acne indurata is then present. The disease is now char- acterized by lumps or tubercles, which are reddish or purplish in color, varying in size from that of a pea to that of a bean, and quite firm to the touch. Some- times these lumps are so deeply placed in the skin that but little is seen on the surface, and they can only be appreciated by the touch. At first but few 5 are present, and we have usually acne simplex, with here and there an indurated tubercle. After a time the tubercles become more and more numerous and prominent; several situated close to each other will apparently become matted together by the surround- ing inflammation, and rough, irregular, lumpy masses are then seen and felt, reddish or purplish in color, hard, ofttimes very painful, and at times small abscesses may be present. The skin of persons afflicted with acne is likely to be thick, coarse, and to have an oily or shiny appearance. In some, especially the young and robust, the skin is usually red and hyperemic, but generally the complexion is of a pasty-white color. In considering the etiology and pathology of acne, three processes must be borne in mind : the comedo-formation, the inflammation excited in the gland and surrounding tissues by this plug acting as a foreign body, and the invasion of the pyogenic cocci causing suppuration. The disease generally first appears at puberty and continues until full development is reached, say from the sixteenth or eighteenth year until the twenty- fifth or twenty-seventh, though it is frequently met with after this age. It is generally of more frequent occurrence and begins earlier in females. At the time of puberty there is a great developmental ac- tivity of the glands and hair-follicles. It is probable that in certain persons this activity of the glands is not only greater than it should be, but also that the product of such glands, which normally is a fatty or oily secretion, becomes perverted, and in addi- tion, that the normal extrusive power of the gland 6 is also deranged. At the same time, a parakeratosis of the surface and of the lining of the duct is taking place. Certain individuals are more predisposed to acne than others, such as those with a thick, pasty com- plexion, and in such cases the mouths of the follicles are prominent. So-called scrofulous persons, those whose health is not the best, and persons with seborrheal eczema also manifest a predisposition. The exciting causes are generally considered to reside in disturbances of the digestive, excretory, and sexual organs. Whether disturbances of the sexual organs per se will produce acne has been questioned. That such disturbances and acne are ofttimes found in the same person is true, but it has been claimed that a low- ered condition of the system generally and the in- fluence that sexual derangements have upon the digestive organs can more frequently be blamed for the acne. The statement is ofttimes made by female patients that their acne is worse at about the time of the men- strual period. A number of observations made by me during the past several years have shown that these patients were generally extremely costive and suffered from gastric disturbances; that when laxa- tives were administered and the diet carefully regu- lated as regards quality of food, especially avoiding the easily-fermentable foods, these exacerbations of acne did not occur. This fact would seem to dis- prove the statement made, unless it be argued that keeping the bowels clear reduced obstructive conges- tion of the pelvic viscera. On the other hand, a 7 brother practitioner, whose labors are principally in the field of gynecology, has lately informed me of three patients under his observation whose acne always improved with the advent of or during men- struation. It may be stated in broad terms that any cause that will lower the general health of a person will contribute to the development of acne. Over-eating, or the eating of improper food, as, e. g., the exces- sive use of sugars and starches, which easily undergo fermentation in the stomach; over-drinking of malt or spirituous liquors, or of tea; constipation ; exces- sive mental or physical work; the conditions of the system which give rise to gout, lithemia, oxaluria, uremia, or anemia; chronic malarial poisoning-all these are factors in the production of the comedone. Seborrheal eczema, and the condition of rosacea to which it leads, should also be recognized as im- portant factors in the production of acne. The frequency with which seborrheal eczema is met with in acne-patients leads me to regard the association as more than merely coincidental. I think that very many cases of acne have their starting-point in the seborrheal eczema. Patients having the two diseases after being cured of them so far as the face is con- cerned, but failing to properly carry on treatment for the seborrheal eczema still remaining in the scalp will have a return of the acne with the next exacerbation of the seborrheal down on the face, and especially is this the case in patients past forty years of age. Seborrheal eczema we find existing as slightly yellowish, or yellowish-gray, or slightly reddish, 8 circumscribed, scaly patches occupying the fore- head, temples, or neck, at the edges of the hair, on the cheek, or in the naso-labial fold, or more fre- quently, as a congested condition of the forehead, nose, cheeks, immediately beside the nose, and on the chin, associated with slight scaling or with papules from the size of a mustard-seed to that of a pea, sometimes smooth, at other times covered with yellowish, fatty scales; with this condition of the face there will always be more or less dandruff of the scalp. Bearing in mind then the conditions that predis- pose to acne, the exciting causes and the pathologic changes that occur, we have an index to the meas- ures to be pursued for its relief. The regulation of the various functions of the body are familiar to all, and must be followed on the general principles that govern the treatment of these conditions. I shall, therefore, not speak of them, but consider the means directed against the disease itself. As the comedones are the first exciting cause of the inflammation in the gland, they should be re- moved as soon as possible. For this purpose their mechanical expression by means of a comedo- extractor will be found of advantage. For the exces- sive formation of horny epidermis over and around the mouth of the follicle, mechanical or chemic means are necessary. Of the former, scraping with a curet, frictions with some coarse substance, such as finely powdered marble-dust, corn-meal, or pumice-stone, will effect the necessary change. As these means are not always agreeable to patients 9 in private practice it may be better to try the chemic agents, such as salicylic or acetic acid, or the alkalies, such as potash-soap, spirit of green soap, liquor potassii, made up into ointments or pastes or lotions; or reducing agents, such as resorcin, sulfur, or the mercurial salts. For the inflammatory reaction likely to be excited by the curetting or the energetic action of chemic agents, zinc oxid, carbonate of magnesia, corn- starch, ichthyol, will be found useful. As antisep- tics, corrosive sublimate, boric acid, resorcin, and sulfur are among the best, and to restrain the excessive glandular activity and stimulate the skin to healthy action nothing is superior to sulfur. To understand better the use of these various remedies in the different stages of acne let us sup- ose a case of indurated acne with large, red, pain- ful tubercles and pustules, and consider its treat- ment. Having given all necessary attention and direction as regards the system generally and cor- rected all derangements, we will, if the patient per- mits, with a dermal curet scrape off the tops of the pustules and express their contents; with a dermal lancet or a small scalpel incise the tubercles and let out the pus found in them, and with the comedone- extractor press out comedones. Bleeding should be encouraged for a short time by compresses dipped in a warm saturated solution of boric acid, the bleeding lessening the congestion and the boric acid at the same time acting as an anti- septic. Then to soothe the inflamed painful face zinc oxid and magnesium carbonate, with or without ichthyol, in lotion or in Bassorin paste, may be 10 applied several times daily. After the reactionary inflammation has subsided a lotion containing mercuric chlorid is applied during the day and a resorcin-paste at night. The bichlorid acts as an antiseptic to prevent the formation of new pustules and also stimulates the glands to more healthy action, while the resorcin acts in very much the same way as does sulfur. If the horny epidermis is abundant, salicylic acid may be added to the paste. All of the pustules, tubercles, and come- dones cannot, of course, be treated at the first con- sultation; therefore this mechanical treatment will have to be repeated until the face is in a fairly good condition. The face should be washed daily with warm water and soap, and if the skin be thick, a potash-soap will be useful, while upon thin, sensitive, inflamed skins an ichthyol-soap will be of service. In either case the lather should be permitted to remain on the face for several minutes-from five to fifteen-rinsed off with cool water, the face dried, and whatever remedy is employed, then applied. When the acute stage of pustulation has subsided, stimulating remedies will come into service, and of these sulfur in some form is the best. The sulfur may be employed as an ointment ; in the " lotio alba," made by mixing together solutions of sulfur- etted potassium and zinc sulfate, to which some sulfur is then added, or it may be suspended in Bassorin paste, which has the advantage over oint- ments of drying in a short time, making a smooth, even dressing on the skin, keeping the remedy in 11 close contact for a length of time, and of being easily removed with warm water. In this way the disease will soon be brought under control. Then should come a period of after- treatment, the object of which is the prevention of relapses. Here the most service will be secured from the long-continued use of a feeble resorcin, or resorcin-sulfur, or resorcin-sublimate lotion. Internally arsenic has long been held in great esteem. It will not be of service used alone, or during the acutely inflamed stage, but at later periods or when a condition of parakeratosis, exists, then, in conjunction with external remedies, it will do good. Ergot has also been extolled, but my results with it have been disappointing, except that it is useful at times to lessen the vascularity of the face ; but it has seemed to me that this could be better obtained by the use of local sedative and antiseptic remedies in a much shorter time. When patients will not permit such surgical measures as I have mentioned, a slower course of treatment will have to be adopted. Antiseptic ap- plications must be employed until suppuration ceases, combined with remedies to reduce excessive horny formation and to alter the action of the sebaceous glands. The frequent and intimate association of sebor- rheal eczema with acne should direct attention to this condition, and especially after the acne has been cured should treatment be continued against the still existing dandruff. The remedies that will prove of most service will be resorcin, sulfur, boric 12 acid, salicylic acid, chrysarobin-in fact all of those belonging to the class of reducing agents. In the discussion of Dr. Holsten's paper, Dr. James McF. Winfield said : The thorough manner in which Dr. Holsten has gone into the subject and the treatment of acne, leaves but very little for me to add, except per- haps a word as to the part genital reflexes play in the production of acne. In writing on acne great stress is put upon disturbances of the gastro- intestinal tract, as the great exciter of this common and exceedingly annoying cutaneous disorder. While the genital organs with their reflexes are to a greater or less extent ignored, I am inclined to the belief that the sexual tract is more likely to reflect its hyperemia on the face than upon any other organ or tract of the body. It is a fact that the simple form of this disease is observed during youth-a time of life when the sexual organs are in a state of unstable equilibrium; and furthermore, rosacea is more frequently observed late in life when the sexual and procreative powers are on the decline. We have all seen an active outbreak of acne on the face of a young woman about the menstrual period, while during the interim she is perfectly free from it. The gynecologists teach us that both acne and rosacea are common accompaniments of various dis- eases of the female genital organs, and, also, that after the cure of these diseases the acne disappears. American authors have paid more attention to the treatment of acne by remedies directed to the relief of genital irritation than foreign writers. Piffard, 13 Dunslow, and Sherwell have written the most on this line of treatment. Dr. Piffard, in his work on The Materia Medica and Therapeutics of the Skin, published in 1881, recommends that strict search be made for sexual causes of acne and the proper therapeutic measures applied. In about the same year Drs. Dunslow and Hyde published their papers on the ergot-treatment of acne. They, however, thought this drug produced its good effect by its tonic action on the non-striated muscles sur- rounding the sebaceous glands. I have not seen much marked benefit from ergot upon acne in the male subject; but its good effects cannot be denied in certain cases in females when the menstrual func- tions are irregular; but in these cases the result seems to come from its oxytocic power rather than from any tonic effect on the involuntary cutaneous muscles. I have found it well to give ergot in doses of from fif- teen to twenty drops, t. i. d., beginning four days be- fore the expected period. This is given as a supple- ment to hot vaginal douches.1 In 1884, Dr. Sherwell read a paper before the American Dermatological As- sociation on " The Treatment of Acne in the Male Subject by the Passage of the Cold Sound." This paper was followed the next year by one by Dr. Dunslow entitled " Urethral Irritation in the Male the Cause of Certain Neuroses, and also of Acne." All of Dr. Sherwell's cases had hypersensitive urethras, while Dr. Dunslow goes a step further and reports cures following the relief of urethral stric- tures. 1 See paper published in Journal of Cutaneous and Genito- urinary Diseases, March, 1891. 14 I am able to indorse Dr. Sherwell's method, or in fact any other method or treatment that will relieve the genital irritation which is so common in the disease under discussion. I have had excellent results from the cold sound in the male cases, and also from the hot vaginal douche in the female.1 And I think it would be well to add to the treat- ment of acne some means directed to the relief of genital irritation. i Ibid. The Medical News. Established in 1843. A WEEKL YMEDICAL NEWSPAPER. Szibscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHL Y MEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTA TION RA TE, £750 PER ANNUM. LEA BROTHERS CO. PHILADELPHIA.