It seemed to be an ordinary case of acne. A nineteen-year-old boy had numerous blackheads and pimples, as well as small scars, evidence of former battles fought in his skin down through the adolescent years. We knew it was the H & H disease, due to hormones and heredity. The androgens were pumping up oil production in the sebaceous glands of the face, while at the same time blocking its flow to the surface. The blockage was produced by plugs of dead horny cells, seen as blackheads but known scientifically as comedones. The name derives from the Spanish word for worms and, indeed, as we press them out, they look like little black worms. The black color is not due to dirt, but simply comes from a darkening of the plug due to oxidation. Scrubbing won't remove them any more than sanding a board will remove a nail. Each comedo is deep in the pore of an oil gland. At the time we prescribed vitamin A in large doses to promote shedding of these stagnant cells. Now, we would have prescribed the vitamin A derivative, Accutane®.

Of particular note was a tender inflamed acne cyst on his left upper cheek. These cysts develop when bacteria, trapped by the closed pore, produce inflammatory changes with the accumulation of pus. When the plugged oil gland is unable to dump its product, it finally swells like a balloon until becoming so large that it bursts.