Electronic Textbook of Dermatology, Acne and Cysts

ACNE AND CYSTS

Rhett Drugge, M.D.

Acne, most common in teenagers, can also occur in adults and in the first few weeks of life (transplacental hormone influences) and occasionally starts at age 8 or 9. The development of the sebaceous glands and the thickening of childhood skin at this time reflects nature's attempts to provide protection from the elements that primitive man encountered. At ages 12-14, boys and girls were expected to make their own way and catch their own food so nature provided them with the hormone of aggression, testosterone. In general, estrogens decrease sebaceous gland activity and androgens increase it. In women, androgens are produced by the ovaries (markedly so in polycystic ovary disease), the placenta and adrenals, and in men by the testes and adrenals. While males experience a peak in testosterone at age 18, female testosterone peaks at 31. Birth control pills by their estrogenic effects have a mild effect on acne. It is occasionally noticed that some of the more androgenic preparations may aggravate acne and even produce mild hirsutism. A certain amount of trial and error for each individual is therefore necessary to pick out the best contraceptive.

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).

Systemic Treatment

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.

Acne Rosacea

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).