Acne
Give a definition of acne.
Acne is an inflammatory, usually chronic, disease of the sebaceous glands, characterized by papules, tubercles, or pustules, or a mixture of these lesions, and seated usually about the face.
At what age does acne usually occur?
Between the ages of fifteen and thirty, at which time the glandular structures are naturally more or less active.
Describe the symptoms of acne.
Irregularly scattered over the face, and in some cases also over the neck, shoulders and upper part of the trunk, are to be seen several, fifty or more, pin-head- to pea-sized papules, tubercles or pustules; commonly the eruption is of a mixed type (acne vulgaris), the several kinds of lesions in all stages of evolution and subsidence presenting in the single case. Interspersed may generally be seen blackheads, or comedones. The lesions may be sluggish in character, or they may be markedly inflammatory, with hard and indurated bases. In the course of several days or weeks, the papules and tubercles tend gradually to disappear by absorption; or, and as commonly the case, they become pustular, discharge their contents, or dry and slowly or rapidly disappear, with or without leaving a permanent trace, new lesions arising, here and there, to take their place. In exceptional instances the eruption is limited to the back, and in these cases the eruption is usually extensive and persistent, and not infrequently leaves scars.
What do you understand by acne punctata, acne papulosa, acne pustulosa, acne indurata, acne atrophica, acne hypertrophica, and acne cachecticorum?
These several terms indicate that the lesions present are, for the most part, of one particular character or variety.
Describe the lesions giving rise to the names of these various types.
Blocking up of the outlet of the sebaceous gland (comedo), which is usually the beginning of an acne lesion, may cause a moderate degree of hyperæmia and inflammation, and a slight elevation, with a central yellowish or blackish point results—the lesion of acne punctata; if the inflammation is of a higher grade or progresses, the elevation is reddened and more prominent—acne papulosa; if the inflammatory action continues, the interior or central portion of the papule suppurates and a pustule results—acne pustulosa; the pustule, in some cases, may have a markedly inflammatory and hard base—acne indurata; and not infrequently the lesions in disappearing may leave a pit-like atrophy or depression—acne atrophica; or, on the contrary, connective-tissue new growth may follow their disappearance—acne hypertrophica; and, in strumous or cachectic individuals, the lesions may be more or less furuncular in type, often of the nature of dermic abscesses, usually of a cold or sluggish character, and of more general distribution—acne cachecticorum.
What is acne artificialis?
Acne artificialis is a term applied to an acne or acne-like eruption produced by the ingestion of certain drugs, as the bromides and iodides, and by the external use of tar; this is also called tar acne.
What course does acne pursue?
Essentially chronic. The individual lesions usually run their course in several days or one or two weeks, but new lesions continue to appear from time to time, and the disease thus persists, with more or less variation, for months or years. In many cases there is, toward the age of twenty-five or thirty, a tendency to spontaneous disappearance of the disease.
Is the eruption in acne usually abundant?
It varies in different cases and at different periods in the same case. In some instances, not more than five or ten papules and pustules are present at one time; in others they may be numerous. Not infrequently several lesions make their appearance, gradually run their course, and the face continues free for days or one or two weeks.
Does the eruption in acne disappear without leaving a trace?
In many instances no permanent trace remains, but in others slight or conspicuous scarring is left to mark the site of the lesions.
Are there any subjective symptoms in acne?
As a rule, not; but markedly inflammatory lesions are painful.
State the immediate or direct cause of an acne lesion.
Hypersecretion or retention of sebaceous matter. Recent investigations point to the possibility of a special bacillus being the exciting cause, in some instances at least. The pyogenic cocci are added factors in the pustular and furuncular cases.
Name the indirect or predisposing causes of acne.
Digestive disturbance, constipation, menstrual irregularities, chlorosis, general debility, lack of tone in the muscular fibres of the skin, scrofulosis; and medicinal substances such as the iodides and bromides internally, and tar externally.
Working in a dusty or dirty atmosphere is often influential, resulting in a blocking-up of the gland ducts. Workmen in paraffin oils or other petroleum products often present a furuncle-like acne.
The disease is more common in individuals of light complexion.
Is there any difficulty in the diagnosis of acne?
Not if it be remembered that acne eruption is limited to certain parts and is always follicular, and that the several stages, from the comedo to the matured lesion, are usually to be seen in the individual case.
In what respect does the pustular syphiloderm differ from acne?
By its general distribution, the longer duration of the individual lesions, the darker color, and the presence of concomitant symptoms of syphilis.
What is the pathology of acne?
Primarily, acne is a folliculitis, due to retention or decomposition of the sebaceous secretion or to the introduction of a micro-organism; subsequently, the tissue immediately surrounding becoming involved, with the possible destruction of the sebaceous follicle as a result. The degree of inflammatory action determines the character of the lesions.
State the prognosis of acne.
It is usually an obstinate disease, but curable. Some cases yield readily, others are exceedingly rebellious, especially acne of the back. Success depends in a great measure upon a recognition and removal of the predisposing condition. Treatment is ordinarily a matter of months.
What measures of treatment are usually demanded in acne?
Constitutional and local measures; the former when indicated, the latter always.
Upon what is the constitutional treatment based?
Upon indications. Diet and hygienic measures are important.
In dyspepsia and constipation, bitter tonics, alkalies, acids, pepsin, saline and vegetable laxatives, are variously prescribed. Special mention may be made of the following:—
℞ Ext. rhamni pursh. fl., ......................... fʒij-fʒiv
Tinct. nucis vom., .............................. fʒiij
Tinct. cardamomi comp., ................. q.s. ad. ℥iij. M.
SIG.—fʒ t.d.
Or Hunyadi Janos or Friedrichshall water may be employed for a laxative purpose.
In chlorotic and anæmic cases the ferruginous preparations are of advantage. Cod-liver oil is often a remedy of great value, and is especially useful in strumous and debilitated subjects. Calx sulphurata in pill form, one-tenth to one-fourth grain four or five times daily, is said, acts well in the pustular variety. In some instances, more particularly in sluggish papular acne, arsenic, especially the sulphide of arsenic, acts favorably. Upon the whole, the line of
treatment that keeps in view proper and healthy action of the gastro-intestinal canal is the most successful.
In inflammatory cases occurring in robust individuals the following is often of service:—
℞ Potassii acetat., ................................ ʒiv
Liq. potassæ, ................................... fʒij
Liq. ammonii acetat., ............ q.s. ad. ..... f℥iij. M.
SIG.—fʒj-fʒij t.d., largely diluted.
State the character of the local treatment in acne.
This must vary somewhat with the local conditions. Cases which are acute in character, in the sense that the lesions are markedly hyperæmic, tender and painful, require milder applications, and in exceptional instances soothing remedies are to be prescribed. As a rule, however, stimulating applications may be employed from the start.
The remedies are, for obvious reasons, most conveniently applied at bedtime.
What preliminary measures are to be advised in ordinary acne cases?
Washing the parts gently or vigorously, according to the irritability of the skin, with warm water and soap; subsequently rinsing, and sponging for several minutes with hot water, and rubbing dry with a soft towel; after which the remedial application is made. In sluggish and non-irritable cases sapo viridis or its tincture may often be advantageously used in place of the ordinary toilet soap.
The blackheads, so far as practicable, are to be removed by pressure with the fingers or with a suitable instrument (see Comedo), and the superficial pustules punctured and the contents pressed out. Scraping the affected parts with a blunt curette is a valuable measure, but is temporarily disfiguring. As a rule, however, cases do just as well without puncturing and scraping, and these methods sometimes leave behind scarring.
State the methods of external medication commonly employed.
By ointments and lotions. If an ointment is used, it is to be thoroughly rubbed in, in small quantity; if a lotion is employed, it is to be well shaken, the parts freely dabbed with it for several minutes and then allowed to dry on.
State the object in view in local medication.
To hasten the maturation and disappearance of the existing lesions, and to stimulate the skin and glands to healthy action.
If slight irritation or scaliness results, the application is to be intermitted one or two nights; in the meantime nothing except the hot-water sponging, with or without the application of a mild soothing ointment, is to be employed.
Is it usually necessary to change from one external remedy to another in the course of treatment?
Yes. After a certain time one remedy, as a rule, loses its effect, and a change from lotion to ointment or the reverse, and from one lotion or ointment to another, will often be found necessary in order to bring about continuous improvement.
Name the various important remedies and combinations employed in the external treatment of acne.
Sulphur is the most valuable. It may often be applied with benefit as a simple ointment:—
℞ Sulphur, præcip., ................................ ʒss-ʒj
Adipis benz.
Lanolin, .....................āā.................. ʒij.
Or it may be used as a lotion, as in the annexed formula:—
℞ Sulphur, præcip., ................................ ʒiss
Pulv. tragacanthæ, ............................... gr. x1
Pulv. camphoræ, .................................. gr. xx
Liq. calcis,........ q.s. ad. ................... f℥iv. M.
Another lotion, especially useful in those cases in which an oily condition of the skin is present, is the following:—
℞ Sulphur, præcip., ................................ ʒiss
Etheris, ........................................ fʒiv
Alcoholis, ...................................... f℥iijss. M.
A compound lotion containing sulphur in one of its combinations is also valuable in many cases:—
℞ Zinci sulphatis,
Potassii sulphureti, ................āā........... ʒss-ʒiv
Aquæ, ............................................ ℥iv. M.
(The salts should be dissolved separately and then mixed; reaction takes place and the resulting lotion, when shaken, is milky in appearance, and free from odor; allowed to stand the particles settle, the sediment constituting about one-fourth to three-fourths of the whole bulk).
At times the addition to this formula of several drachms of alcohol and of five to ten minims of glycerin is of advantage.
An external remedy, often valuable, is ichthyol. It is thus prescribed:—
℞ Ichthyol, ........................................ ʒss-ʒj
Cerat. simp., .................................... ʒiv. M.
The various mercurial ointments, especially one of white precipitate, five to fifteen per cent. strength, are sometimes beneficial.
A compound lotion, containing mercury, which frequently proves serviceable, is:—
℞ Hydrarg. chlorid. corros., ....................... gr. ii-viij
Zinci sulphatis, ................................. gr. x-xx
Tinct. benzoini, ................................ fʒij
Aquæ, ................... q.s. ad. .............. f℥iv.
In extremely sluggish cases the following, used cautiously, is of value:—
℞ Ichthyol,
Saponis viridis,
Sulphur, præcip.,
Lanolin, .......................āā................ ʒj.
In such instances the application of a strong alcoholic resorcin lotion, ten to twenty-five per cent. strength, repeated several times daily till marked irritation and exfoliation occur (a matter usually of one to three days), will sometimes be followed by marked improvement. Acne of the back is treated with the same applications, but usually stronger; in this region applications of Vleminckx's solution and formaldehyde solution, weakened considerably, at first at least, prove of value.
Obstinate and indurated lesions may be incised, the contents pressed out, and the interior touched with carbolic acid by means of a pointed stick. The x-ray has proved a most valuable addition to our resources in the treatment of acne, and is especially serviceable in extensive and obstinate cases. An exposure should be made about twice weekly, at a distance of five to ten inches and for from three to ten minutes, and a tube of medium vacuum used. It must be used with great caution and never beyond the production of the mildest erythema. The hair, eyes, and lips should be protected. The x-ray treatment is best reserved for obstinate cases, and then used mildly, and rather as an adjuvant to the ordinary methods than as the sole measure.
What precaution is to be taken in advising a change from a sulphur to a mercurial preparation or the reverse?
Several days should be allowed to intervene, otherwise a disagreeable, although temporary, staining or darkening of the skin results—from the formation of the black sulphuret of mercury.