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Pustular Acne, Staphyloderma and Its Treatment with Tolbutamide

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Pustular Acne, Staphyloderma and Its Treatment with Tolbutamide Canad. M. A. J. April 15,1959, vol. 80 COHEN AND COHEN: AcNE AND TOLBUTAMIDE 629 PUSTULAR ACNE, STAPHY- a reliable guide to the androgen level.4 It has been LODERMA AND ITS TREAT. our custom to prescribe cestrogens in severe cases, MENT WITH TOLBUTAMIDE* in males and also in females with exacerbations at the menstrual period. We use diethylstilbcestrol, J. L. COHEN, M.D., Windsor, Ont. and 0.25 mg. daily for 12-15 days of the month for ALAN D. COHEN, M.D.,t males, and in females 0.25 mg. once daily from Detroit, Mich. seven days after completion of the menses until THE PROBLEM OF ACNE, speaking pathologically, is the onset of the next period. This avoids distur- not very serious, but if we consider the total picture bance of the cycle of ovulation. (Estrogens inhibit including psychological ramifications which affect the gonad-stimulating function of the anterior the social life of the individual, it becomes a pituitary gland.4 One must be careful not to use disease of major importance. This aspect has been excessive doses because they may inhibit ovulation, well documented by Marshall.' and in the male gyrecomastia may result. The treatment of acne is not a simple "magic Bacteria are an important factor in the develop- bullet" affair. The specific systemic measures usually ment of follicular plugging and pustular lesions employed in addition to local therapy depend with acne. Cocci have been found in the follicles upon the seriousness of the skin condition. These and not in the inflammatory infiltrate about the additional measures include hormone therapy, sebaceous glands. Bacteriological studies in our antibiotic therapy, dietary control, vitamin supple- cases revealed that the organisms cultured from ments, ultraviolet and x-ray therapy, and adminis- acne pustules included: (1) haemolytic Staph. tration of toxoids and vaccines. Local and x-ray albus; (2) non-hemolytic Staph. albus; (3) haemo- therapy is aimed at combating sebaceous gland lytic Staph. aureus; (4) non-heemolytic Staph. hyperplasia and seborrhcea, and eradicating follicu- aureus; and (5) mixed forms of diphtheroids as lar plugging to prevent new foci. contaminants. In some cases there was no bacterial In severe cases of acute pustular acne, local growth. Sensitivity tests were performed in all therapy alone is of little value. The underlying cases of staphylococcal infection from the purulent predisposing causes, whether hormone disturbances secretion of the pustule, and organisms were or metabolic defects, must be taken into considera- tabulated as resistant and sensitive to antibiotics. tion. Antibiotics are of doubtful value topically The following antibiotics were used orally: sulfon- but are of value systemically in some forms of amides, penicillin, erythromycin, chloramphenicol, acne.2' 3 oleandomycin, tetracycline, novobiocin. Antibiotics We agree with other investigators that vitamin were used in the deep, nodular, cystic, pustular A has a definite value, particularly in the comedo- types of moderate to severe acne. Isoniazid was papular type of acne. Clinical evidence of vitamin also used in some cases. A few patients needed A deficiency, such as follicular keratosis about the the addition of an antibiotic to control the pustular elbows and knees of certain patients, can often element of the eruption. All types of antibiotics be found. We use Aquasol A, 50,000 units once were used, but the best results were obtained with daily for three months. We often combine 50,000 chloramphenicol and erythromycin. We were never units of synthetic vitamin A with 500 mg. of impressed with the end results obtained with any vitamin C. The role of vitamin A in the treatment antibiotic, except where we encountered a deep of acne has received wide study.6 When acne is cellulitis requiring incision and drainage. After one characterized by comedo formation and numerous week, a favourable response was obtained, only to small papules (especially when the comedo phase be followed by a new flare-up in the pustular is excessive), we employ a dosage of 100,000 units element of the lesions. Relapses were frequent of vitamin A per day for 3-5 months. after discontinuance of the antibiotics. Most of The role of hormones in the management of these pustular cases received courses of ascending acne has been and still is controversial, but again doses of staphylococcus ambotoxoid injections, 1:5 good results have been achieved by us, as by dilution increasing to the undiluted mixture. many workers,4 with the use of cestrogenic sub- stances. TOLBUTAMIDE THERAPY It has been shown that the urinary excretion of Shortly after the introduction of tolbutamide on 17-ketosteroids is increased in patients receiving the Canadian market for the treatment of diabetes, ACTH therapy. In patients with Cushing's disease, our attention was drawn to the rapid recovery of in persons before puberty, and in eunuchs, 17-keto- moderately severe acne in two women who were steroid excretion is low and acne is not present. on this therapy. In view of the rapid improvement The excretion level rises at puberty, especially with in these two patients, a series of 23 additional the development of secondary sex characteristics, patients were given tolbutamide therapy and care- and at this time acne manifests itself. It has also fully followed up. Some had deep pustular acne, been shown that the excretion of 17-ketosteroids is chronic staphyloderma, recurrent furunculosis, sycosis vulgaris, hidradenitis suppurativa or hidros- *Mobenol, supplied by courtesy of Frank W. Horner Ltd., Montreal. adenitis axillaris, and other resistant pustular in- tResident, Department of Dermatology, Wayne University, College of Medicine, Receiving Hospital, Detroit, Mich. fections of the skin. Canad. M. A. J. 630 COHEN AND COHEN: AcNE AND TOLBUTAMIE April 15, 1959, vol. 80 TABLE I. Results with tolbutamide Initials Age and Sex Diagnosis Treatment Fair Good Excellent J.A. 24 F. Pustular acne Antibiotics, x-ray and local therapy 2 mos. S.B. 16 F. Pustular acne X-ray and local therapy 1Y/ mos. M.C. 49 F. Hidradenitis suppurativa Antibiotics, x-ray and local therapy 3 mos. H.D. 20 M. Severe pustular acne vulgaris IAntibiotics, x-ray therapy 3 mos. J.F. 19 F. Papulo-pustular acne vulgaris X-ray and local therapy 4 mos. G.G. 18 M. Sycosis barbae vulgaris, pustular lesions Antibiotics, x-ray therapy 1 mo. M.J. 17 F. Acne vulgaris X-ray and local therapy 1 mo. B.H. 17 M. Pustular sycosis barbie X-ray, local therapy, antibiotics 2 mos. D.I. 23 M. Very severe pustular acne X-ray therapy, local treatment 4 mos. LL. 16 F. Deep pustular acne Antibiotics, x-ray and local therapy 2 mos. B.M. 20 F. Cystic, pustular acne vulgaris X-ray and local therapy 2 mos. J.R. 23 F. Severe pustular acne vulgaris X-ray and local therapy 2 mos. G.T. 16 M. Papulo-pustular acne vulgaris X-ray therapy 3 mos. M.W. 18 F. Deep pustular acne X-ray, local therapy, antibiotics 3 mos. J.P. 17 F. Papulo-pustular acne vulgaris X-ray, local therapy, antibiotics 2 mos. M.A. 21 F. Papulo-pustular acne vulgaris X-ray and local therapy 1 mo. B.N. 22 M. Severe pustular acne vulgaris X-ray therapy and antibiotics 3 mos. P.C. 38 M. Rosacea with acneiform lesions Antibiotics, local and x-ray therapy 2 mos. R.D. 18 M. Pustular acne vulgaris X-ray and local therapy 1 mo. P.F. 26 F. Pustular acne vulgaris X-ray arid local therapy Nausea and diarrhcea W.G. 32 M. Acne rosacea X-ray therapy and antibiotics 2 mos. J.H. 22 M. Severe pustular acne X-ray therapy and antibiotics 3 mos. G.M. 16 M. Deep pustular acne X-ray therapy and antibiotics 4 mos. B.W. 57 F. Acne rosacea with deep acneiform lesions and moderate rhinophyma X-ray and local therapy, antibiotics 4 mos. H.N. 47 M. Sycosis barbie vulgaris X-ray therapy and antibiotics 3 mos. A.M. 19 F. Pustular acne vulgaris X-ray therapy 2 mos. METHOD insecure and afraid to face the public, and required tranquillizers. This patient had been treated by us Only patients who were resistant to therapy by by all known methods of acne therapy, including the usual methods of treatment were included in diet, Vleminckx' packs, resorcin, and sulphur lotions, this study. They were instructed to continue taking stilbeestrol and most of the antibiotics. He responded carbohydrates in their diet, including candy and to acne surgery and chloramphenicol, injections of fruit if desired. All those with severe acne received staphylococcal toxoid, vitamins, and ultraviolet liglht, 12 hours. The but with relapses. In May 1958, he was given tolbuta- one tablet (0.5 g. tolbutamide) every mide 0.5 g. (Mobenol) twice daily. He began to milder cases received one tablet (0.5 tolbutamide) show very marked and continued improvement. The per day. These patients were seen at regular inter- purulent lesions diminished gradually until no evi- vals and their blood sugar was determined at fre- dence of pyoderma was seen, but only acne sequele quent intervals. The results were always* within with scarring. He is receiving CO2 therapy and will normal limits. require facial skin planing. RESULTS CASE 2.-Since 1954, Mrs. M.N. (a stenographer) had been treated for pyoderma faciale, consisting of The results obtained have been summarized in intense reddish cyanotic erythema associated with Table I. All patients experienced a sharp decrease superficial and deep abscesses and cystic lesions. Some in new pustular and cystic lesions and diminution cysts were connected with communicating channels both in size and soreness. All were greatly im- and sinus tracts with deepseated pustular and linear proved, in marked contrast to the results obtained scarring.
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