ACNE AND CYSTS
Rhett Drugge, M.D.
Oily seborrhea and acne often go hand in hand, and there is often a family tendency. The varieties of acne are: comedone acne, papular acne, acne excoriee des jeunes filles, acne pustulosa, atrophic acne, indurated acne, cystic acne, acne cachecticorum, acne conglobata (tunnelling), acne keloidalis, tropical acne, acne neonatorum and chloracne (occupational).
Tetracycline, which operates by reducing the amount of lipase in the sebaceous secretion or bay altering the skin flora, some of which might be instrumental in producing irritant triglycerides, wax esters and free fatty acids in the pore, can be extremely effective. Often after initial success, control wears off gradually. This can be especially true if poor patient compliance leads to sporadic dosing. It is good practice to start off with three or four doses daily and gradually reduce to twice or once a day, depending on the progress. It takes 4-6 weeks to assess the effectiveness, and if little improvement occurs, the patient may be switched to minocycline, erythromycin or clindamycin. The latter carries the risk of pseudomembranous colitis (somewhere between 1:10,000 and 1:100,000 or more). Clostridium difficile resistant to clindamycin causes the diarrhea; vancomycin may prevent this strain from surviving. If severe diarrhea occurs, the patient should be hospitalized and can be successfully treated. Patients and their families must therefore be warned. Second generation cephalosporins appear to have good activity against acne as well.
Severe or resistant acne appears to respond dramatically to cis-retinoic acid (tretinoin). The usual course of therapy is 4-6 months at a dosage of 1 to 1.5 mg/kg/day. This approach clears the vast majority of acne patients for a substantial time although re-treatment after two months hiatus is necessary in a handful of cases. Careful guard must be taken against pregnancy in fertile women as the teratogenicity of the medication while being used leads to profound abnormalities in many cases. Hepatoxicity is possible as a consequence of overdosage. Pseudotumor cerebri (papilledema, diplopia and headache) needs to be guarded against.
Treatment of Acne Scars
Dermabrasion and sandpapering help cure icepick scars, although less of this is being done today with the increased use of cis-retinoic acid. Carbon dioxide slush treatment is almost always helpful. Cross-hatching scarification occasionally is helpful, and chemical peeling with either 25% trichloracetic acid or phenol is effective in skilled hands. Punch and suture, or drill and Gelfoam for small deep pits occasionally are helpful. Laser resurfacing with CO2 lasers and Erbium Yag lasers are some of the more modern therapuetics for scar revision.
Rosacea is a term used to describe a chronic condition characterized by diffuse inflammation of the central portion of the face with seborrhea, telangiectasia and acneiform eruptions. It appears to be the result of repeated flushing, which in most instances is related to frequent intake of hot spicy foods, e.g., hot coffee, tea, soup or alcohol. Anything too hot, too cold, too sweet, too sour or too spicy aggravates the condition.
Complications epidermal cysts include bony erosion affecting underlying structures (ref. case).