THE CHEMISTRY OF ACNE VULGARIS 257 \ The thought now occurs that the known emotional problems and emotional flux of puberty, the pubertal crisis, can evoke sweating which in turn can greatly increase the amount of sebum flow. As is generally accepted (and is the subject of a study by the author now with the New York City Board of Health and Board of Education), acne does not occur in all teenagers. Ache vulgaris is, then, not a universal response, or adaptation. At this date, only a suspicion can be recorded that it may have to do with unusually severe problems in adaptation. Now, the basic pattern of development of the comedone of ache vulgaris can be postulated as follows: A. The marked physical growth of puberty is accomplished largely via the Pituitary Growth Hormone. It, or a parallel hormone, causes simple increase in size of the sebaceous gland, with a directly propor- tional increase in sebum output. The PGH, which regulates protein armbolism, may relate again to the formation of the horny plug in the hair follicle, since this is a protein product. B. The stress or alarm reaction consists of increased nerve impulses to the hypothalamus, which in turn stimulates the anterior pituitary to put forth ACTH, which in turn again causes increased adreno- cortical hormone secretions. The adrenocortical SFN hormones--which cause nitrogen metabolism or breakdown--can foster the development of acne, apparently by an effect on the hair follicle hyperkeratotic or parakeratotic scale. Corticosterone and cortisone can induce the resting phase in the hair cycle--at which time the acne lesion appears. The increased 17 ketosteroid urinary output at puberty may reflect stimulation of the entire adrenal cortex rather than androgenic steroids only. C. Alarm or stress---the emotional stresses of puberty--produce increased nerve impulses (anatomically sympathetic pharmacologically parasympathetic) to the sweat glands, which in turn produce a tremendously increased amount of sebaceous gland secretion. Thus the great increase in sebaceous materiM behind the narrow plugged follicular orifice gives rise to the cornedone. (A whole series of secondary infections, and bacterial allergic pheno- mena must be considered in the evolution of acne pustule.) As the stresses of adolescence subside, the tendency for comedone formation abates spontaneously. The decisi9e reasons for acne vulgaris appear to be the adaptations unique to puberty. As these adaptations are inevitable, and culturally desirable, the treatment of acne vulgaris still remains in the exclusive sphere of derma- tology.

258 JOURNAL OF THE SOCIETY OF COSMETIC CHEMISTS Many further studies of corroboration .of the presented theory will be required. Several among' these are: (a) the effect of climate on acne (theoretically, in cold climates where sweating is minimal, there should be less acne) (b) a close study of the psychologic adjustments of severe ache patients, as opposed to clear skinned adolescents (c) the role of adrenocortical steroids in producing beard growth, in affecting the hair cycle, and in causing fotlicular plugging (d) the value of cultural conditioning at puberty, as a cause for acne, must be examined by checking the acne incidence in entirely isolated cultures---if any such remain 22 the effect of catabolic agents in preventing or lessening follicular epithelial hyperkeratoses a check to see whether hypopituitary dwarfs are free of acne and whether giants and adolescents suffering frem hyperpituitarism have a greater incidence of acne. •3 (g) greater attention to the pharmacologic inhibitors of perspiration-- both topical and parenteral--in the adjuvant treatment of acne vulgaris. ½) (f) SUMMARY A new concept of the pathogenesis of ache vulgaris has been' thus pre- sented, after stripping away misconceptions that is consonant with the known facts about ache, and that should prove a valuable instrument in furthering the understanding and proper therapy of the condition. The basic new consideration is that acne vulgaris is a disease of adaptation, and is, in the light o• understanding in 1957, inevitable in a certain percentage of adolescents. BIBLIOGRAPHY • Kooij, R., Dingenmasse, E., Huis Int Veld, L. G., Verbeek, A., Hofman, W. J., "Urine Hormone Levels in Ache," Neder. Tijdschr. Gertecsc., 97, 2261-2269, 1953. • Talbot, N. B., Sobel, E. H., McArthur, J. W., Crawford, J. D., Functional oendocrino- logy from Birth through Adolescence, Harvard University Press, 1952. a Bongiovanni, A. M., and ,Eberlein, W. R., "Clinical and Metabolic Variations in Adrenogenital Syndrome," Pediatrics, 16, 628-634, 1955. 4 Personal communication, Mrs. Olga I-Irul•y. 5 Miescher, G., and Schoenberg, A., "Untersuchungen ueber die Funktion der Talg- druessen," Brell. Schweiz. Akad. d. Wled. Wissensch., 1, 101-114 (1944). 0 Kligman, A., and Ginsberg, D., "Immunity of Adult Scalp to Infection M. Andocrins," f. Invest. Derre., 14, 345-358 (1.950).• ? Kligman, A. M., and Shelley, W. B., "Biology of the Human Sebaceous Gland." Abstract of paper to be presented at Society of Invest. Dermatology Meeting, June lst 1957. s Van Scott, E., and MacCardle, R., "Keratinization of the Duct of the Sebaceous Gland and Growth Cycle of the Hair Follicl'e in the Histogenesis of Acne in Human' Skin," f. Invest. Derre., 27, 405-430 (1957). , 9 Rothman, S., "Resorption dutch die Haut ß in Bethe," Handbuch d. Norm. u. Path. Physiol., 4, 107-151, Berlin, J. Springer (1929).