The fundamental stimulus provoking the onset of acne vulgaris is probably hormonal; the hormone concerned has not been identified, although the imbalance appears to be weighted towards the androgens. Acne may develop during treatment with corticosteroids and it is also an accompanime'at of acromegaly. (Estrogen given by mouth or by subcutaneous implantation undoubtedly controls acne. Nevertheless, except in special circumstances and as short-term therapy, this is not recommended because the large doses that are necessary may have undesirable effects, such as interference with testicular activity, permanent gynascomastia and disturbance of the menstrual rhythm. Most cases occur in the years succeeding puberty, at an age when people are sensitive about their appearance, and when they are usually impatient of delay in obtaining a cure. It must be admitted that the benefits of treatment appear only slowly; and, when natural defervescence of acne takes place over a period of years, scarring is sometimes so severe that-the consequences may justify seeking advice from the plastic surgeon.
The routine treatment is to peel the skin. Sulphur, resorcin and salicylic acid (4 per cent. of each), zinc oxide (24 per cent.) and soft yellow paraffin to 100 per cent. is applied to the affected areas at night and washed off in the morning. In order to achieve an effect it is sometimes necessary to increase the strength of the sulphur to 8 or even 12 per cent. and, in very tough skins, to use a strong peeling paste such as resorcin and camphor (10 per cent. of each), precipitated sulphur 30 per cent., anhydrous lanoline 15 per cent. and soft yellow paraffin 35 per cent. Some skins which will not tolerate these strong substances (particularly the sulphur) have to be treated with ultra-violet light, applied in a dose to produce a good peel, once weekly. An alternative is an abrasive but chemically inert paste called Brasivol which is prepared to contain particles which are fine, medium or coarse : the pastes are used in that order for a month at a time.
Oral treatment with antibiotics is applicable to severe cases which cannot be satisfactorily controlled with local treatment oxytetracycline can be given by' south, I g. daily for two to three weeks followed by 0.5 g. daily for a further two or three weeks. Local antiseptics are also useful, and the skin can be washed with surgical spirit or hexachlorophene.
Diet has little to offer as a rule but occasionally the avoidance of chocolate, or of foods containing lard or of some other foodstuff, is dramatically successful. Vitamin A by mouth in a dose of 100,000 units daily also definitely helps a few cases, although in the majority it has no effect.
In severe cases cysts develop ; they are very liable to secondary infection for which, apart from antibiotics, surgical treatment and æstrogen therapy may be required. Stilboestrol is given in a daily dose of 3 mg. for six weeks, and peeling is employed simultaneously.
Hitherto radiotherapy has been used in the treatment of acne vulgaris but this form of treatment should be abandoned because of its possible harmful effects in young people.
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