Part 9
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:--
[Rx] Ext. rhamni pursh. fl., .............. f[dram]ij-f[dram]iv Tinct. nucis vom., ................... f[dram]iij Tinct. cardamomi comp., .......q.s. ad [Oz]iij. M.
SIG.--f[dram]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:--
[Rx] Potassii acetat., .................... [dram]iv Liq. potassæ, ........................ f[dram]ij Liq. ammonii acetat., .... q.s. ad ... f[Oz]iij. M.
SIG.--f[dram]j-f[dram]ij 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:--
[Rx] Sulphur, præcip., .................... [dram]ss-[dram]j Adipis benz. Lanolin, ............ [=a][=a] ....... [dram]ij.
Or it may be used as a lotion, as in the annexed formula:--
[Rx] Sulphur, præcip., .................... [dram]iss Pulv. tragacanthæ, ................... gr. x1 Pulv. camphoræ, ...................... gr. xx Liq. calcis, ........ q.s. ad ........ f[Oz]iv. M.
Another lotion, especially useful in those cases in which an oily condition of the skin is present, is the following:--
[Rx] Sulphur, præcip., .................... [dram]iss Etheris, ............................. f[dram]iv Alcoholis, ........................... f[Oz]iijss. M.
A compound lotion containing sulphur in one of its combinations is also valuable in many cases:--
[Rx] Zinci sulphatis, Potassii sulphureti, .... [=a][=a] ... [dram]ss-[dram]iv Aquæ, ................................ [Oz]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:--
[Rx] Ichthyol, ............................ [dram]ss-[dram]j Cerat. simp., ........................ [dram]iv. 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:--
[Rx] Hydrarg. chlorid. corros., ........... gr. ii-viij Zinci sulphatis, ..................... gr. x-xx Tinct. benzoini, ..................... f[dram]ij Aquæ, ............ q.s. ad ........... f[Oz]iv.
In extremely sluggish cases the following, used cautiously, is of value:--
[Rx] Ichthyol, Saponis viridis, Sulphur, præcip., Lanolin, ............. [=a][=a] ...... [dram]j.
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.
#Acne Rosacea.#
#Give a descriptive definition of acne rosacea.#
Acne rosacea is a chronic, hyperæmic or inflammatory disease, limited to the face, especially to the nose and cheeks, characterized by redness, dilatation and enlargement of the bloodvessels, more or less acne and hypertrophy.
#Describe the symptoms of acne rosacea.#
The disease may be slight or well-marked. Redness, capillary dilatation, and acne lesions seated on the nose and cheeks, and sometimes on chin and forehead also, constitute in most cases the entire symptomatology.
A mild variety consists in simple redness or hyperæmia, involving the nose chiefly and often exclusively, and is to be looked upon as a passive congestion; this is not uncommon in young adults and is often associated with an oily seborrh[oe]a of the same parts. In many cases the condition does not progress beyond this stage. In other cases, however, sooner or later the dilated capillaries become permanently enlarged (_telangiectasis_) and acne lesions are often present--constituting the middle stage or grade of the disease; this is the type most frequently met with. In exceptional instances, still further hypertrophy of the bloodvessels ensues, the glands are enlarged, and a variable degree of connective-tissue new growth is added; this latter is usually slight, but may be excessive, the nose presenting an enlarged and lobulated appearance (_rhinophyma_).
#Are there any subjective symptoms in acne rosacea?#
As a rule, no. Some of the acne lesions may be tender and painful, and at times there is a feeling of heat and burning.
#What do you know in regard to the etiology?#
In many cases the causes are obscure. Chronic digestive and intestinal disorders, anæmia, chlorosis, continued exposure to heat or cold, menstrual and uterine irregularities, and the too free use of spirituous liquors, tea, etc. are often responsible factors.
It is essentially a disease of adult life, common about middle age, occurring in both sexes, but rarely reaching the same degree of development in women as observed at times in men.
#Is acne rosacea easily recognized?#
Yes. The redness, acne lesions, dilated capillaries, and, at times, the glandular and connective-tissue hypertrophy; the limitation of the eruption to the face, especially the region of the nose; the evident involvement of the sebaceous glands, the absence of ulceration, taken with the history of the case, are characteristic.
It is to be distinguished from the tubercular syphiloderm and lupus vulgaris, diseases to which it may bear rough resemblance.
#State the prognosis of acne rosacea.#
All cases may be favorably influenced by treatment; the mild and moderately-developed types are, as a rule, curable, but usually obstinate. It is a persistent disease, showing little, if any, tendency to disappear spontaneously.
#What is the method of treatment?#
Both constitutional and local measures are demanded in most cases.
#Upon what is the constitutional treatment to be based?#
The constitutional treatment, beyond a regulation of the diet, is to be based upon a correct appreciation of the etiological factors in the individual case. There are no special remedies. Iron, cod-liver oil, tonics, ergot, alkalies, saline laxatives, and similar drugs are to be variously prescribed.
#What is the external treatment?#
In many respects, both as to the preliminary measures and remedies, essentially the same as that employed in the treatment of simple acne (_q. v._). The _x_-ray treatment is not so efficient in this disease, however, as in acne. In addition to the treatment there found, several other applications deserve mention:--
In many cases _Vleminckx's solution_[C] is valuable, applied diluted with one to ten parts of water. Also, a mucilaginous paste containing sulphur:--
[Rx] Mucilag. acaciæ, ..................... f[dram]iij Glycerinæ, ........................... f[dram]ij Sulphur, præcip., .................... [dram]iij. M.
[Footnote C: [Rx] Calcis, .............................. [Oz]ss Sulph. sublimat., .................... [Oz]j Aquæ, ................................ [Oz]x.
To be boiled down to [Oz]vj and filtered.]
Or a similar paste with the glycerine in the foregoing replaced with ichthyol may be used.
#In what manner are the dilated bloodvessels and connective-tissue hypertrophy to be treated?#
The enlarged capillaries are to be destroyed by incision or by electrolysis. Properly managed the vessels may be thus destroyed, but unless the predisposing causes have disappeared or have been remedied, a new growth may take place.
If the knife is employed, the vessels are either slit in their length or cut transversely at several points. The method by electrolysis is the same as used in the removal of superfluous hair (_q. v._).; the needle may, if the vessel is short, be inserted along its calibre, or if long, may be inserted at several points in its length.
Excessive connective-tissue growth, exceptionally met with, is to be treated by ablation with the scissors or knife.
#Acne Varioliformis.# (_Synonyms:_ Acne Frontalis; Acne Rodens; Acne Necrotica; Lupoid Acne; Necrotic Granuloma.)
#Describe acne varioliformis.#
Acne varioliformis is characterized by lesions of a moderately superficial papulo-pustular type, which in disappearing leave slight or pit-like scars. The forehead and scalp are the favorite sites, but they may also occur elsewhere. The eruption is rather scanty as a rule, consisting usually of ten to thirty lesions. They begin as small maculo-papules, as papules, or as minute nodules in or on the skin, and gradually become small pea-sized, with a tendency to slight vesiculation or pustulation at the central part. The lesion is sluggish in its course, drying to a thin crust, which finally falls off, leaving a depressed variola-like scar. New lesions arise from time to time, and the disease thus continues almost indefinitely. There may or may not be itching. In what appears to be a variety of this disease, known usually as _acne urticata_, there is considerable itching just at the time the lesion is appearing. The malady is not frequent, but occurs in both sexes, usually in those between the ages of twenty and fifty. It seems probable that the eruption is parasitic in origin.
The maladies variously known as hydradenitis suppurativa, acnitis, spiradenitis, folliclis, granuloma necroticum, etc., in which the lesions, primarily at least, are somewhat deeper seated, sluggish in their course, and followed by scarring, could be also included under this head.
#Give the prognosis and treatment.#
The disease is rebellious and tends to recur. The most efficient applications are those of sulphur and resorcin, the same as prescribed in ordinary acne.
#Sycosis.# (_Synonyms:_ Sycosis Vulgaris; Sycosis Non-parasitica; Folliculitis Barbæ; Sycosis Coccogenica.)
#What do you understand by sycosis?#
Sycosis is a chronic, inflammatory affection involving the hair-follicles, usually of the moustache and bearded regions only, and characterized by papules, tubercles, and pustules perforated by hairs.
#Describe the symptoms of sycosis.#
Sycosis begins by the formation of papules and pustules about the hair-follicles; the lesions occur in numbers, in close proximity, and together with the accompanying inflammation, make up a small or large area. The pustules are small, rounded, flat or acuminated, discrete, and yellowish in color; they are perforated by hairs, show no tendency to rupture, and are apt to occur in crops, drying to thin yellowish or brownish crusts. Papules and tubercles are often intermingled. More or less swelling and infiltration are noticeable.
The disease is seen, as a rule, only on the bearded part of the face, either about the cheeks, chin or upper lip, involving a small portion or the whole of these parts. It is also sometimes met with involving the hair follicles just within the nasal orifice, and may even be limited to this region.
Occasionally a sycosiform eruption, usually of the side of the bearded region, leaves behind a smooth or keloidal scar, the disease gradually extending--_ulerythema sycosiforme_ (lupoid sycosis).
An inflammation of the hair-follicles of the scalp apparently sycosiform in character, occurring as discrete or aggregated lesions, is sometimes observed, the follicles being destroyed and atrophy or slight scarring resulting--_folliculitis decalvans_.
#Does conspicuous hair loss occur in sycosis?#
Ordinarily not; the hairs are, especially at first, usually firmly seated, but in those cases in which suppuration is active, and has involved the follicles, they may, as a rule, be easily extracted. In some cases destruction of the follicles ensues and slight scarring and permanent hair loss result.
#State the character of the subjective symptoms.#
Pain and itching and a sense of burning, variable as to degree, may be present.
#What is the course of the disease?#
Essentially chronic, the inflammatory action being of a subacute or sluggish character, with acute exacerbations.
#State the causes of sycosis.#
Upon the upper lip it may have its origin in a nasal catarrh. Entrance into the follicles of pyogenic micrococci is now regarded as the essential factor. This view being accepted, carries with it the possibility of contagiousness.
It is seen in the male sex only, usually in those between the ages of twenty-five and fifty; and is met with in those in good and bad health, and among rich and poor. It is comparatively infrequent.
#What is the pathology of sycosis?#
The disease is primarily a perifolliculitis, the follicle and its sheath subsequently becoming involved in the inflammatory process.
#How would you distinguish sycosis from eczema?#