There are other foods which will flare up acne in some patients, such as pork, which includes ham and bacon, shellfish, nuts, sharp cheese, eggs, milk and malt. Some of these foods are important for you to have. You should not eliminate foods at the risk of depriving yourself of a well-balanced diet, unless you have been convinced be­yond any doubt that they make your acne worse.

 

In the region of the Great Lakes and in the states of the Northwest there is a deficiency of the important mineral iodine in the water and soil. We know that a lack of iodine in the body causes a disturbance of the thyroid gland. The thyroid is another one of the hor­mone-secreting glands. It regulates the speed or rate of our metabolism. If the thyroid isn’t going full force, it affects all the other internal glands.

 

To replace this lack of iodine in water and food, salt companies have added iodine to some table salt. You may have noticed the words “Iodized Salt” on the label. Using iodized salt in areas which are lacking in natural iodine is desirable. In the localities where ample natural iodine exists the use of iodized salt is not good. In people who are unusually sensitive to even small amounts of iodine it may aggravate acne. Incidentally, iodine is present in some cough medicines, asthma remedies and also in some vitamin mixtures.

 

Iodine is chemically related to a group of drugs called bromides. Some sedatives and other so-called “nerve med­icines” contain bromides. They are also in preparations which claim to give relief from headache, indigestion and “acid conditions.” Soda fountains and restaurants serve them. The use of bromides is so common today that many people are taking these drugs regularly without realizing that bromides have the same effect on acne as iodine.

 

The importance of infected teeth, tonsils and sinuses in the cause of acne has been exaggerated. Some derma­tologists, however, do feel strongly that such a source or “focus” of infection in the body makes acne worse, or at least keeps it going. Certainly it is not good to have the pus from infected tonsils draining into your system all the time. Your body has to keep fighting off these bac­teria and cannot rally enough resistance to the infection which accompanies acne.

 

There are some working conditions which have been found to make acne worse. On some jobs there are dust, heat and humidity to contend with and personal hygiene is poor. Some types of work require rough or woolen clothing, which can irritate the skin or rub bacteria into the follicle openings. Occupations which expose the skin to oil, wax and grease are not desirable for young men with acne. These chemicals affect the lining of the oil-gland ducts and cause pustules even in people who do not have acne. The same thing occurs to the duct openings in many women when they use cosmetics with a greasy base.

 

The question arises — what does your general health have to do with acne? Are you likely to have more colds or other infections than a person free from acne? Are your pep and energy below average? Dermatologists and many acne patients have noticed that their acne is worse in the winter and better in the summer. Perhaps this is because in the winter our resistance is lower than in the summer. In the winter we have more colds or flu and our vitality is lower. During the summer everyone seems to feel better. There is less sickness and we have more en­ergy.

 

The explanation of these observations may have some­thing to do with the greater amount of sunshine we are exposed to in the summer months. We do know that sun­light helps manufacture Vitamin D in our bodies and that this vitamin is very important to good health, Often the foods we eat in the summer are richer in vitamins and other essentials to good nutrition. It is suspected that during the winter many of us become slightly ane­mic, not enough to be serious, but just enough to make us always more or less fatigued. We feel, as the saying goes, “a little under par.” This may be due to the ab­sence from our diet of fresh fruits and some vegetables which are rich in iron and other minerals.

It is true that acne occurs mainly in active young people who are not suffering from any disease. Yet, what about the general level of health of most young people today? Do they receive adequate sleep and rest? Is the food they eat well balanced and nourishing? Does it con­tain enough energy value to make up for the energy spent during a day’s work and play? For most growing young men and women all too often the answers are “No.” In fact, it even makes me tired just to think of the daily routine of some young people. It is a mystery to me how one patient I knew kept going. Up early on a school day, he would run out the door tucking his shirt under his belt with one hand and clasping his books to his body with the other. If he thought he had an extra minute, he might stop in the kitchen for a piece of toast. This was not likely, unless he heard his mother’s voice pleading with him to please have some breakfast. Somehow, despite all the rushing, he barely managed to get to class just as it began. A busy morning of studies was interrupted by a feverishly gulped lunch consisting of foods which would go down with the greatest of ease. He would return to class until midafternoon and then go out to the football field. After two or three hours of strenuous scrimmage the rush would be on again to get home in time for dinner. This was eaten slightly more slowly under the critical eye of his father. Then he would try to do his homework just as the day’s strain began to affect his weary body. All this was a little too much for his brain, which soon lost the struggle with sleep. Despite pangs of conscience, the homework was usually put off until the next night with the hope that there would be more time then. This story must be so familiar to you that I am sure I do not have to tell you that the next night was not any different.

 

 

Every part of the body in some way feels the influ­ence of this glandular activity and the oil glands of the skin are no exception. To judge from the way they fever­ishly start manufacturing and pumping oil, it would seem as though they were trying to make up for then-years of sluggishness! There is nothing the body can do with this large amount of oil except carry it to the sur­face of the skin. This produces the oily appearance so typical of acne. It has already been explained that ex­cessive oil-gland activity plays an important part in the formation of acne lesions.

Medical science is trying to find out just what it is about the function of the sexual glands that causes this surge of oil. So far, there is not too much that is certain. We do know that it has something to do with the bal­ance between the different hormones that the sex glands produce in the body. This in turn is related to the func­tion of all the other glands in the body which produce hormones. All these glands are interdependent upon each other for the normal function and growth of the body. One cannot work without the other. When one is tem­porarily acting strangely, all the others may be affected. Medical knowledge is progressing rapidly and some day we will know the solution to this mystery.

There are other activities going on in the body which affect your acne. The way your tissues, including the skin, grow and maintain their health depends upon a complex series of reactions within the body. These vital reactions are called the metabolism of the body. The food you eat plays an important role in these reactions.

 

Over the years, many foods have been studied to de­termine how they affect acne in relation to your body metabolism. Some studies have seemed to show that starchy foods, such as potatoes and bread, have an un­favorable influence on acne. In the process of digestion starches are changed into sugar by the body. This sugar, like other foods after they have been broken down in the body, eventually ends up in the blood stream. It is trans­ported by the blood to every organ of the body as nour­ishment and fuel for the tissues. The skin gets its share of sugar in this manner. When the skin receives larger amounts than it can use, it has been claimed that the excess sugar interferes with the health of the skin. Con­sequently, starchy foods and sweets are considered by some to be one factor in at least the aggravation of acne lesions.

 

From this point of view, it would be understandable why “sweets,” which of course are mainly straight sugar, seem to aggravate some cases of acne. Such foods as pastries, syrups and jellies contain large amounts of sugar. Candies are almost pure sugar. The sugar from these foods has the same effect on the skin as the starchy foods. Perhaps you have observed that your eruption is worse after eating lots of sweets and starches.

Another group of foods which have been suspected of playing a part in causing acne are the fatty foods. Just why they seem to make some acne eruptions worse is not clearly understood. Some scientists who have studied this problem feel that when large amounts of fatty foods are eaten, the secretion of the oil glands is increased or slightly changed in nature. It has been observed by a few dermatologists that acne flares up in some patients when they eat large helpings of foods such as cream, butter, mayonnaise and fatty cuts of meat. Cooking food in large amounts of oil and grease will do the same thing. This is particularly true of fried foods such as fried po­tatoes and pork chops.

The unfavorable effect that starches and fats have on some patients with acne is primarily a matter of medical observation. It has by no means been proven beyond all doubt in the laboratory. However, sometimes physicians are slow to find the exact explanation for conditions which are common knowledge.

 

 

Undoubtedly many of you have heard of the all-important role that chocolate is supposed to play in acne. This is probably the most commonly reputed cause. One mother who had brought her young daughter to see me could hardly restrain herself long enough for me to ex­amine the patient before she said, “Every time Joan eats chocolate her face breaks out. She is always eating candy and can’t seem to get enough of it. I’ve told her that her pimples are caused by sweets and yet she continues to eat them. I don’t know how a doctor can help her if she keeps on this way.” The young girl agreed with what her mother said.

 

She had become convinced that her mother was right, but there was something about candy which she could not resist. The more she tried to control herself, the stronger became this uncontrollable urge for candy. The whole situation made her miserable. Actually, it is more likely that the struggle she was having with herself did more harm to her acne than the sweets. As much as I would like to say so, this does not mean that chocolate or sweets are good for acne! But in moderation and in most instances they do not cause as much trouble as one would suppose. We are certain of one fact and that is that sweets are not by any means the sole or main cause of acne.

 

The presence of acne is so disturbing to some young people that they will follow so-called advice even when it is obviously unreasonable. Despite the pleading of par­ents, or the reasoning of friends, they will persist in hot pursuit of the latest “cure.” After a time, when the re­sults have not been as expected, they will try a new ap­proach with equal determination until, alas, that too has failed.

 

I remember a young girl rather on the plump side and very self-conscious about it who somehow got the idea that all she had to do to cure her acne was to lose ten pounds. She started out to do this by simply not eating, except for a snack now and then when she could no longer stand her hunger. Naturally her parents were very disturbed, but she continued with a vengeance until even she could see that, if anything, her acne was worse.

There is so much talk about allergy these days, it is no wonder that people ask if acne is an allergy. The answer is no. When the science of allergy was new, many acne patients were tested to see if it could be shown that they were allergic to some food or pollen. It was found that acne patients were no more nor less allergic than people who did not have acne.

Another misconception of the cause of acne is that it is due solely to some kind of infection in the body. Bad tonsils and decayed teeth have been removed with the mistaken hope that this alone would cure acne. It is true that any such source of infection should be corrected for the benefit of the body as a whole. It may even help some types of acne. However, this does not mean that most cases of acne can be cured by any such procedure by itself.
You may have heard that acne comes from an infec­tion of the skin or even believe that it is catching! At one time, skin specialists felt that infection played an impor­tant role in acne. Some even thought that a special organ­ism was the cause. Today, most dermatologists have abandoned this idea. They do admit that bacteria are present in the lesions of acne, sometimes in large num­bers, as in pustules and infected cysts. But they feel that these organisms are only of secondary importance, just as bacteria will infect any cut or bruise. This concept is borne out by the fact that acne cannot be treated like a true infection, as, for example, one might treat a boil. At least it does not respond to such treatment alone. 

 

Patients sometimes ask, “How about a shot of penicil­lin, Doctor, won’t that help?” The answer is, “Not very much.” When penicillin was discovered, the theory that acne was caused by bacterial infection was further ex­ploded. The opportunity arose to study this problem during World War II through a research project estab­lished by the Army Medical Department. Penicillin was being found to have such valuable healing powers on so many types of infections, it was important to prove as quickly as possible just which infections it would cure and which ones it would not. The sooner this was known, the more lives would be saved.

 

While this work was under way, it was decided to see if penicillin was effective against acne. To find out what it would do, many patients with severe acne were treated with large amounts of penicillin, but it was soon shown that acne is one of the conditions which is not helped by penicillin. To be sure, the badly infected cysts con­taining pus showed some improvement, but the under­lying acne eruption was unaffected. So we can conclude from this that the evidence is against acne being caused by a simple infection. There is another reason for not using penicillin on everyone with acne. Some people be­come allergic to penicillin and if they should ever need it for a serious infection, they might not be able to toler­ate it. This risk is not worth taking, as a rule.

 

Since penicillin was discovered newer drugs have been found which kill bacteria. They have at least two advan­tages over penicillin. One is that they can be taken in pill form, which is very comforting for those who are “allergic” to needles. Secondly, they are effective in kill­ing a wider variety of bacteria. But while these new antibiotics may be lifesavers under certain conditions, they too are no cure for acne, though sometimes helpful.

 

In a manner which is misleading and grossly misrepre­sented, “sex” has been connected with acne in the minds of some people. It is easy to understand why. Acne is most common in that age group in which sexual curiosity and experience are on the ascent. It is not surprising, therefore, that a relationship between sex and acne would be suspected by some. One of the mistaken ideas you may have heard is that acne is due to the lack of sexual activity and experience. On the other hand, there are equally strong claims that it is due to sexual overindul­gence and dissipation, perhaps in the form of mastur­bation.

Have you ever heard anyone say, “When you grow up and get married your acne will go away”? Let’s talk about this for a moment. While it is true that marriage makes our lives more complete sexually as well as in other ways, it is not by any means the solution to acne.

 

What I mean is illustrated by one young lady who was twenty years old when I first saw her. She had suffered since she was thirteen years old with very severe acne over the face, chest and back. Despite the scarring it had left, she was a pretty girl. I have always had a great deal of admiration for this young lady because despite the damage that acne had caused to her skin, she was an at­tractive person with a cheerful disposition. If she felt bitter about the misfortune to her complexion, she did not show it. At the age of twenty-two she married a fine young man. I felt that I knew both of them well and this seemed like a good marriage because there was mu­tual respect and love. Despite this, her acne was very stubborn in responding to treatment. So as you can see, it is not right to assume that just as soon as you find a mate, your acne will clear up by itself.

 

While it is true that starting with adolescence you are increasingly aware of mature sexual impulses, acne is not related to sex in the sense of too much or too little sexual activity. These old-fashioned ideas only further confuse young men and women who are trying to understand the sensations which they feel within themselves.

 

In our schools and homes sexual matters are all too frequently cloaked in secrecy and mystery. The mere mention of this subject is to some a source of embarrass­ment. Therefore, if you have heard that acne is due to some aspect of your sexual life, you may have feelings of shame about your eruption, especially if it is on your face where everyone can see it. It is not any wonder that you find yourself in a dilemma. Where can you turn for guidance? What are you doing or not doing that is caus-ing the eruption? It seems that the more you try to sup­press these deep feelings, the more intense they become. Your sexual impulses become a thing of worry and fear, instead of a normal, accepted part of maturing. As we go along, this subject will come up again because a good understanding of the sexual part of your life is vital to your happiness. For the time being, be reassured that your sexual conduct is not causing your eruption.

 

And finally, there is one last myth to be dispelled about the cause of acne. Acne occurs with such great frequency in the teens and twenties that most everyone has had some sign of it, no matter how small. This has usually led some wise old relative who has watched sev­eral generations of children become adults to comment, “It’s just a part of growing up,” or “Leave it alone, you’ll grow out of it.” As with many observations by our elders there is a lot of truth in this. Acne is, in a sense, a part of growing up. However, just because acne occurs with such frequency that it is considered almost normal, one cannot conclude that it should be ignored. Measles is also an experience almost everyone has had; neverthe­less, it is an unpleasant experience and occasionally a serious one. Similarly, if severe acne is left to be out­grown, you can go through a miserable period while waiting, to say nothing of always regretting the after­effects.

 

Misinformation of this sort, while sometimes well meant, unfortunately is of no real help to you who have acne. If anything, it only confuses you as you try one remedy after another. The mirage of a clear skin is always before you. The hope never dies that this time you have found the answer to your complexion problem. The only thing that ever does happen is that your medi­cine cabinet becomes filled to overflowing and many a harmless sweet tooth goes unsatisfied for fear of awaken­ing the next morning with a brand-new “pimple.”

Eating on the run without taking the time to sit down and have a well-balanced meal of a variety of foods is certain to make your diet low in building materials. Be­sides that you would not be getting the essentials which supply the fuel for all the energy you use up. Among other things you would not be getting your vitamins. You have probably heard about vitamins and their im­portance to growth and health. They are necessary in order for the body to get the full value out of the foods you eat. Acne is not actually due to a deficiency of vita­mins, yet it is not at all uncommon to see improvement in the appearance of the skin when large doses of certain vitamins are added to the diet.

 

Vitamins are not only essential to one’s general health, they are also important to the health of the skin. When they are absent from a diet, the skin is affected in vari­ous ways. Dryness and roughening of the skin occur when Vitamin A is deficient. Vitamin B really consists of a whole subgroup of vitamins within itself. But since they are all found in the same foods, they are lumped together and called Vitamin B Complex. When one or all are missing from the diet, many changes in the skin may appear, such as cracking and crusting at the corners of the mouth. The tongue can become smooth, red and tender. The exposed parts of the skin, such as the back of the hand, may become darkened and scaly or the face and scalp may become oily and reddened. A good quan­tity of Vitamin B Complex in one’s diet is especially important to the skin. When Vitamin C is not a daily part of the diet, the gums become soft. Brushing your teeth is enough to make them bleed. You will learn about the foods which you should eat to get these vita­mins when we discuss what you can do to help your com­plexion.

 

The expression “athlete’s acne” is used by dermatolo­gists because acne is sometimes very severe in young men who are extremely active in sports. Physical condition­ing and training is an accepted part of an athlete’s life. You assume that athletes are perfect physical specimens who would never have acne. However, a well-trained athlete is like a race horse in the sense that every effort has been made to bring to perfection all his special capa­bilities. In doing this, great stress is put on the body as a whole, causing excessive fatigue, and this may explain the frequency of acne in athletes. I have noticed the same thing in women who are professional dancers. Hours of rehearsal topped by performances are as stren­uous physically as any basketball or football game.

Besides the physical strain on your body which has just been mentioned you are under another type of strain or, to use another word, tension. The development taking place in your growing body has already been discussed. But so far, no mention has been made of another type of change which is occurring. This is the change in your at­titude towards yourself and those about you. These changes are the ones which affect your emotional life.

 

Acne starts during a period in your life which is filled with new experiences. High school is one of the first of these. The longer hours of classes and attention to your studies require more effort and concentration than any­thing you have known before. Early business ventures with a long day’s work and greater responsibility are quite different from any former experience. Besides these adjustments which must be made there are changes tak­ing place in your relationships with your parents. No longer can you be completely dependent on your par­ents. You have to make your own decisions and solve many of your own problems. Or perhaps you feel that your parents cannot get used to the idea that you are no longer a child. Another new aspect of your life is the feelings you have towards members of the opposite sex. This is a big change, indeed, about which revolve many emotional problems.

 

It may well be that the emotional stress and strain which result from these new needs for adjustment are partly to blame for the overactivity of your oil glands. This should not be so hard to understand since there are many examples in everyday life which illustrate how your emotions cause various skin reactions. Everyone knows that after a bad fright one may blanch, break out in a cold sweat or get “goose pimples.” Certainly you have seen blushing occur after an embarrassing incident. You may have noticed even that your face becomes very oily towards the end of a busy day at work or during a period of emotional excitement. These commonplace observations show beyond doubt that emotions do affect the skin and they suggest that emotions may be one of the forces at work in causing acne.

 

Very often those who have acne observe that during periods of tension they are worse. Perhaps emotional ex­citement increases the blood supply to the skin and oil glands, causing them to become overactive. Perhaps the hormone balance is affected, tipping it even more out of balance. So far, we do not know the exact explana­tion.

Some acne eruptions should be called “after vacation” acne because of the way they break out when the sum­mer is over. Just recently a young high school girl told me that her skin was fine all summer. She returned to school in September and in two weeks her acne reap­peared. Perhaps there is some other explanation for what happened, but it is likely that the tensions of school life were responsible.

Recently a group of doctors made an interesting study on some acne patients which seems to throw some light on the connection between acne and emotional tension. First they learned as much as possible about the patient’s childhood and background. Then they made the patient angry by saying something to him that the doctors knew used to make him angry as a child. Before and right after this the oil on the skin was measured. It was found that the amount of oil on the skin was always greater after than before the patient had been made angry. This experiment suggests what many have observed and thought, namely that at least one emotion, anger, makes the oil glands overactive.

Greasy hair dressings and oily shampoos are not the things to use if you have dandruff. Of course, this is just contrary to the advice you probably have received from your barber or beautician. And it still may not make sense to you because after you have dressed your hair with a greasy preparation or had an oil shampoo, your scalp may have seemed free of dandruff. This is true, but for two bad reasons: i) Greasy hair dressings tempor­arily plaster down dandruff by covering it with an addi­tional layer of artificially supplied oil. 2) The oil sham­poo does the same thing plus rinsing out some of the existing dandruff of the moment. As soon as these prepa­rations have dried, your dandruff will be right back where it was before, perhaps a little worse.

Heavy dandruff and itching of the scalp usually go together. If the itching is severe, it can be very annoy­ing and it is very difficult to avoid scratching the scalp. Sometimes the scalp is scratched so hard that the surface is bruised and small crusted areas of infection appear. Sores of this nature are not uncommonly seen scattered throughout the scalp when there is a lot of dandruff present.

Dandruff can persist for a long time and sometimes the inflammation and infection can be severe. When this happens, there appear in the scalp patches of waxy, red­dish scales or crusts. The health of the scalp and the vi-tality of the hair are impaired and some loss of hair may occur.

In severe acne these parts of the body may be com­pletely covered. However, it is not uncommon for the eruption to be confined to just one of these regions alone. For example, acne lesions may appear only over the fore­head, the chin or the cheeks. Sometimes acne just follows along the hairline of the sides of the face or the forehead. Or it may only involve the back and/or the chest, leav­ing the face relatively clear.

In the early days of World War II, it was not realized that diseases of the skin could be serious enough to affect the ability of our troops to fight. In fact, the Army and Navy Medical Corps had few specialists trained in dis­eases of the skin. However, before the first year of the war was ended, it was obvious from the large number of severe skin cases reported on all fronts that dermatolo­gists were needed.

Those who served as dermatologists with the Medical Corps saw numerous cases of severe acne. The soldier with acne presented a more serious problem than that of the civilian. The eruption in military personnel was found to be most severe over the chest and back, from the friction or pressure of carrying a pack or other heavy equipment. The pain produced by the pressure of these loads against the masses of sensitive lesions disabled the men as much as some battle wounds.

Troops stationed in the tropics especially suffered from acne because the heat and humidity aggravated their condition. Poor facilities for personal hygiene were an­other reason why acne was so common among them. Often, many days or weeks went by before it was pos­sible to get a bath or a change of clothes. Under such conditions acne became a major problem to those who had it, and also to the skin specialists whose responsibility it was to treat it.

A close inspection of the skin will sometimes show that there are numerous blackheads present. Probably you have been very conscious of your blackheads. Try­ing to remove them is a common pastime with young people. Sometimes they spend hours in front of a mirror trying to squeeze them out. When you do not know how to remove blackheads properly, it can be a rather painful process. Incorrectly removing these acne lesions bruises the skin and causes more damage and a more unsightly appearance than the blackhead itself.

I have seen acne patients come into the treatment room to have their blackheads removed quite certain they are going to be hurt. It is always a pleasant surprise for them to learn that, properly done, it is a painless procedure. Insignificant in size though they may be, these black­heads are at the root of many acne lesions. Therefore, you should know what blackheads are and how they are formed.

You will remember that the oil-gland secretion gets to the surface of the skin through the channels of the hair follicles, which act as ducts. The openings at the end of these ducts on the surface of the skin are called the oil-gland or follicle openings. It is in these openings that blackheads occur. The formation of blackheads is partly due to the presence of dried and hardened oil from the glands below which makes a plug at the opening of the duct. Contrary to popular belief, the dark color of blackheads is not from dirt. That is why blackheads can­not be removed simply by washing. The black discolora­tion comes from chemical changes in the composition of the dried, fatty plug due to exposure to air over a period of time.

Another reason why blackheads form is that the fol­licle openings may become obstructed by the overgrowth of the horny-layer cells. When the layers of the skin were described, it was mentioned that in acne the horny-layer cells in and about the follicle openings reproduce at a greater rate than they die and shed. Now we see that one of the results of this is the clogging of the follicle open­ings. This horny-layer growth, occurring as it does in millions of these openings, gives the skin a coarse, gritty feeling and a dusky or dirty appearance. It is going to take considerably more than mere scrubbing of the skin to help your acne.

The tender inflamed lesions containing pus which are so typical of acne arise in slowly progressive stages start­ing with these simple blackheads. When the plugged oil-gland openings containing the blackheads and the skin immediately about them become swollen, inflamed and tender, they are called papules. As these papules get worse and enlarge into more intensely inflamed lesions containing pus, they are called pustules. By the time the inflammation of an acne lesion has gotten to the point where papules and pustules are formed, the blackhead may no longer be visible. In fact, many papules and pustules occur without a blackhead ever being seen. In-visible plugging deep down in the oil-gland duct is the cause of many inflammatory acne lesions.

If your acne eruption has been present for many months or years, most likely there will be other lesions present besides blackheads, papules and pustules. You know already that due to the formation of blackheads the oil-gland ducts become plugged. The plugging pre­vents the sebum from getting to the surface of the skin, yet the gland keeps right on manufacturing and pump­ing out more oily material. Often there is only one thing that the gland can do with all this backed-up secretion, and that is to balloon out. Due to this injury to the gland it is very easy for a bacterial infection to get started. Eventually the infection produces an inflamed, tender, pus-containing, saclike structure under the .surface of the skin. This is called a cyst. Sometimes infection does not occur; then the cyst appears as a firm, cream-colored papule which contains fatty material but not pus.

Most cysts are about the size of a large green pea. But sometimes they can get as large as a walnut or even larger. The bigger they are, the more local damage they cause to the skin. The number of cysts that are present in an acne eruption varies. There may be only an occa­sional cyst in an area like the back of the ears, for ex­ample, or there may be many cysts scattered throughout the entire acne eruption. The destruction that these le­sions cause to the deeper layers of the skin very often re­sults in scarring.

Scarring is due to an overgrowth of the connective-tissue fibers of the dermis at the site of formerly active acne lesions. At first the connective tissue attempts to wall oflf the inflammation and infection to prevent them from spreading. Later it replaces the parts of the skin which have been destroyed. Scarring does not always occur in acne. Most papules and pustules and even some cysts eventually heal without leaving a scar. But certain pustules and some cysts which have been present for a long time cause a lot of damage to the deep layers of the skin and usually leave broad, flat scars.

Directly beneath and attached to the epidermis is the second layer of the skin, which is called the dermis. It is much thicker than the epidermis and it contains many different types of structures. First of all, there are inter­lacing strands of tissue called fibers which make up the framework of the dermis. Some of these have an elastic quality and keep the skin taut. As we grow older, these fibers lose their elasticity, causing wrinkles. Incidentally, there is not much we can do about preventing wrinkles or even removing them once they appear, despite what you may have heard or read on the subject. The other fibers which make up the bulk of the dermis framework are known as the connective tissue of the skin. After a deep injury to the skin these fibers overgrow, replacing the cells of the epidermis and even the elastic fibers. It is in this way also that the scars of acne are formed.

In this mesh of tissue fibers are blood vessels, nerves and hair follicles which contain the hair shafts and their roots. The dermis also contains some of the glands of the skin, of which there are two types: the sweat glands and the oil glands.

We are interested mainly in the oil glands because their overactivity has so much to do with acne. These vital glands, which are called sebaceous glands, consist of tiny sacs of oil-filled cells. The majority of them are attached to the follicles of the almost invisible hairs of the skin. Their oily secretion, sebum, flows out from the glands through tiny openings into the space between the walls of the hair follicles. The latter then serve as channels or ducts to carry the oil to the surface of the skin. Sebum is a fatty substance and it acts as a lubricant and pro­tective coating to the skin, keeping it smooth and soft. Late in life the flow of sebum slows down and that is why so many elderly people have dry skin. Too much ex­posure to the sun, wind and cold can temporarily “de-fat” the skin in the young and old alike. And as you will learn, there are conditions under which the skin becomes too oily, one of which is acne.

The third and deepest layer of the skin, the subcuta­neous layer, is mainly a mass of fatty tissue. In it are blood vessels and nerves of larger size than those in the dermis and some sweat glands. It serves as padding for the body as well as support for the two layers of skin which rest on it. There are other structures of the skin which have not been mentioned, but for our purposes we need not discuss them.

The skin as a whole has many different functions. It protects the body from extreme heat or cold. It acts as a barrier to strong sunlight. It serves as a cover for the muscles, tendons and bones, protecting them from ex­posure and injury. Through its nerve endings it is the organ which tells us the nature of the world about us by feel and touch. In the same way, it relays messages to our emotions of tenderness and love. In a less tangible but very important way, it is the boundary between each individual and everything else that moves about him. And finally, it has been called the “organ of expression” because it reflects our emotions in so many ways.