Edwin J. Levy

THE USE OF SULFADIMETHOXINE (MADRIBON*) IN THE TREATMENT OF PAPULOPUSTULAR AND CYSTIC ACNE VULGARIS

Acne vulgaris in varying degrees of severity affects 90 per cent of adolescents’ and constitutes about one seventh of the skin disorders seen in dermatological practice? Although a disorder of multiple origin,3acne is essentially the result of hormonal imbalance,6 coincident with adolescence.4-’ The fact that acne occurs in girls administered progesterone and in women with masculinizing tumors or under androgen treatment, but not in eunuchs, is presumptive evidence that this disorder stems from androgen-estrogen imbalan~e.~ Because it flares with emotional tension, the psychogenic factor must also be considered in its causation!, If an acne lesion is observed from its onset, it is seen to begin as a comedo or “blackhead”, which is a hard mass of keratin and sebum blocking the dilated follicular orifice.l0‘ l1 This comedo may increase in size and ultimately rupture the delicate wall of the follicle. Keratin and sebum then escape into the corium and set up a foreign body reaction. Clinically, these changes are manifested by various stages from erythematous follicular papules to pustular and cystic lesions. The skin, however, is never sterile, but supports a luxuriant growth of nonpathogenic organisms comprising the so-called resident flora; this consists of aerobic micrococci and Corynebacterium, and anaerobic Micrococcus saccharolyticus and Propionibacterium acnes, the latter 2 outnumbering the aerobic organisms by 10 to 100 times. Pathogenic bacteria also reside temporarily on the skin surface, but the natural defenses of the intact skin adequately control them. Present knowledge indicates that acne is not primarily a bacterial disease. In fact, in most acne patients it can be demonstrated that the early pustule is sterile. If the conditions are favorable, however, pathogens or possibly even normally nonpathogenic organisms may cause infection in the previously sterile acne lesion. While infection per se may not prolong the course of acne vulgaris, it certainly adds to the embarrassment and emotional stress of the adolescent threatened with acne scarring and permanent disfigurement. Several chemotherapeutic agents have been used in recent years for the treatment of acne vulgaris in an attempt to prevent the skin damage that results from infection during the pustular stage? Accounts have been published of the beneficial effects of long-term use of broad-spectrum antibiotics in this disease?, 8 . 12-14 However, certain side effects have imposed distinct limitations on their use!, 16 One of the more serious drawbacks has been the emergence of resistant strains of bacteria;lB-1Q thus, the antibiotics often become The basic pathological changes are in the pilosebaceous a p p a r a t u ~ . ~ , * ,