(Acne atrophica; Acne frontalis; Acne necrotica)
Definition. A rare, chronic, inflammatory disease, characterized by papulopustules usually occurring about the forehead and scalp, occasionally in other locations, and leaving a depressed scar similar to that of variola.
It is convenient to group under this heading, cases that have been described as acnitis, follicles, acne necrotica, impetigo rodens, hydradenitis suppurative, acne urticata, acne augminata, acne telangiectodes and ulerythema acneiforme, because they are essentially the same and any differentiation of them would lead to great confusion.
Symptoms. The initial lesions are small pale macules or papules which soon become reddish-brown, deep-seated, indolent papules, pea-to bean-sized and frequently pierced by a hair. Later vesicles and pustules develop, covered with flat, adherent, yellowish-brown crusts under which will be found sharply defined, rounded ulcers. These crusts may increase in size but eventually fall off, leaving reddish-brown, clear cut, variola-like scars which finally become white. The common location of these lesions is on the forehead at the margin of the scalp but they may be located on the scalp, about the nose, ears and, rarely, more generally distributed. They are usually few in number, ten to thirty, occasionally many more. They may be discrete or aggregated and rarely assume linear, circinate or serpiginous formations. The subjective sensations are slight, if any, and the course is chronic, often lasting for years.
Etiology and Pathology. The exact cause is unknown but it is probably due to microbic invasion. It affects both sexes at the middle period of life and has been found in relation to gout, rheumatism, tuberculosis, syphilis and various gastrointestinal disorders. Sabouraud believes that both the microbacillus of seborrhea and the staphylococci play causal parts but many hold that, instead of a direct microbic cause, toxins of organisms, like the tubercle bacillus, are really etiological. Microscopically the process is inflammatory, involving the pilosebaceous structures with destruction of the follicle and surrounding corium.
Diagnosis. Variola presents constitutional symptoms and a typically rapid efflorescence of its lesions. Acne vulgaris is known by its comedones, absence of ulceration and rare occurrence on the scalp. Pustular syphilids have a wider distribution, present other evidences of syphilis and possibly a clear history of infection. Folliculitis decalvans, in its pustular form, is characterized by small pin-head-sized pustules, each pierced by a hair, is limited to the scalp and beard and usually shows resulting patches of alopecia.
Prognosis and Treatment. While persistent, these cases usually yield to treatment eventually, although recurrence and scarring may be expected. Any predisposing disease, such as syphilis or tuberculosis, will form the basis for constitutional treatment and seborrhea, which frequently exists, may need relief. Physiological methods are more important than the local treatment which usually calls for soap and water cleanliness, although the same antiseptic lotions and ointments as suggested for the treatment of acne may be needed. The X-rays are probably the best local treatment for extensive cases, but the galvano- or thermocautery or solidified carbon dioxide may be used to destroy individual lesions. There is a broad field from which to select internal remedies but I can attest to the value of the following: Arsen. iod., Colchicum, Kali brom., and Silicea.