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Now something must be said about a condition of the scalp which often appears with acne. This condition is commonly known as dandruff. For each hair of the scalp there is at least one oil gland. When there is over-activity of the oil glands of the skin as in acne, it is usu­ally accompanied by an oily scalp. Due to the length and thickness of the hair on the head, it is much more diffi­cult for the excess oil to be removed from the scalp than from the face or trunk. Consequently, layer after layer of oil settles on the scalp, and remains there.

Bacteria are present on everyone’s scalp, just as there normally are on the skin. Under ordinary conditions they do not cause any trouble. But an excessively oily scalp makes a particularly good place for bacteria to re­produce and grow. The irritation of the oil and, second­arily, the infection from the bacteria set up a mild in­flammation or dermatitis in the superficial cells of the scalp, which die and shed. The dead cells mix with the dried oil to form flakes and it is this scaling or flaking of the scalp which we know as dandruff. This probably will come as a surprise to most of you because it is usually be­lieved that dandruff is caused by an excessively dry scalp. Actually, it results from an excessively oily scalp.

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.

Acne appears on those parts of the body where there are the greatest number of oil glands in the skin. The oil glands are most plentiful on the face, shoulders, chest and back. It is also in these same areas that the skin has a very rich blood supply. It is likely that these blood vessels as well as the oil glands have their share of respon­sibility in causing acne.

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.

In order to discuss acne properly, it will be necessary from time to time to use medical terms, which will be explained as they are used. But first there is a nonmedical word, “pimple,” which is so commonly used, as well as misused, that something should be said about it if only to explain it away. It is neither a good descriptive word, since it means different things to different people, nor an accepted scientific term. Therefore, in its place, the correct medical term “lesion” will be used. An acne le­sion is any one of the changes which occurs in the ap­pearance of the skin. The most common lesion of acne, the one that starts all the trouble as you will soon see, is the “blackhead.”

One of the main characteristics of acne is the oiliness of the skin. Sometimes one can see an oily film over the parts of the face where the oil glands occur in greatest numbers, particularly about the sides and front of the nose, chin and forehead. If one wipes his finger over these areas, a film of oil will easily come off on it. Some of you have probably noticed that if pressure is placed on the side of the nose, you can squeeze out a whitish creamy substance. This is the way sebum looks while it is still in the oil glands and ducts. It only becomes oily as it is secreted onto the skin.

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.

Before we discuss your acne, you need to know some­thing about the skin itself, what purposes it serves and particularly the way it is constructed. Once you have a clear picture in your mind of the different structures of the skin, it will be much easier for you to understand why you have acne and what to do for it.

The skin is not simply a solid mass like a blanket cov­ering the body, but rather a multilayered structure. Each layer is made up of different structures, the parts of which are so small that they can be seen only with the aid of a microscope. When you look at your skin, you see the surface of the topmost layer, which is called the epidermis. It consists of several rows of cells piled one upon another. The outermost cells are toughened to pro­tect the delicate cells beneath. These toughened cells on the surface form the “horny layer” of the skin. On the palms and soles, where the skin needs greater protection, the horny layer is greatly thickened and resembles a pig’s hide.

As the skin grows, the horny-layer cells die and are shed, new ones replacing them from below. Normally, this shedding occurs so slowly that we are not aware that it is taking place. But following a sunburn, for example, it occurs rapidly and the peeling which results is familiar to everyone. In acne, the horny-layer cells in and about the oil-gland openings grow more rapidly than they are shed, piling cell upon cell. This is one of the character­istic changes which occurs in the skin with acne. And it will explain a good deal of your trouble.

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.