Document JvDj93qVZe0EvMywD71MXkr4Z

cu Q December 10, 1957 11Q0 In the vear 1899 Carl Herxheimer first described acnefo tions in persons exposed to chlorinated compounds. Ke usee the te "chloracne*' for this problem. It was initially believed that chlorine itself vas responsible for the eruption. Hevever, several year later, it became obvious that chlorinated hydrocarbons were the provoking agents. Since that time industrial acne has become a rather common skin disease which may result from exposure to petroleum, cutting oils, coal tar fractions and chlorinated hydrocarbons of known chemi cal structure, such as chlorinated naphthalenes, diphenyls ana diphenyl- oxides. In addition to pilosebaceous changes some of the chlorinated hydrocarbons are notoriously hepatotoxic and neurotoxic. The activities of substances known to be acnegenic for man have been studied in a large variety of experimental animals, as well as in human subjects. The animals have included rabbits, mice, rats, docs, cats and guinea pigs. Adams and his group, in 1941, described the reaction of rabbit skin to acnegens and claimed that the relative acnecenicity of a compound could be determined on the basis of the epithelial hyperplasia with its resultant thickening of the skin and follicle enlargement. Braun reported the production of follicular hyperkeratosis in the dog and rabbit following the application of a chlorinated naphthalene. We have not been able to produce piloseba ceous changes equivalent or comparable to human chloracne in the animals mentioned by local application, inhalation or ingestion of a known acnegen. The notable exception, c h -ip skin of the external ear canal of the rabbiitc,, vwhiicch has been =-"cwn by har.vr:c.*: - 1" to respond rather vigorously to ocnegenic stimulation. Acne lesions may be induced in human skin by the repeated local application of such acnegenic substances as penta- and hexachloror.aph thalene. Since such substances are also hepatotoxic, the experi ments must of necessity be carried out with great care. Object ive The purpose of this investigation was to determine the acne- inducing properties, in human skin, of three samples of sodium 2,4,5trichlorophenate as compared with Halovax-1014 , a known acnegen. Katerials and Method A. The materials employed in this experiment were as follows: Sample No. 3 was prepared from the plant Sodium Trichlorophenate; pK 10.0, and contained 22.4 percent T.C.P.* Sample No. 4 was prepared by distilling trichlorophenol and then taking it up in caustic to form the phenate; pH 9.9, and contained 33.5 percent T.C.P. Sample No. 5 was Sodium Trichlorophenate, prepared according to Diamond Alkali Company procedure in which dilution and filtra tion were employed; pH 9.9, and contained 31.0 percent T.C.P. Halovax-1014 - a mixture of hexa and pentachloronaphthalene was used as the positive control substance. B. 1. Subjects: 12 human volunteers were employed for this inves tigation. . They were white males Of ages ranging from 47 to 78 2. Application of materials: Each material was diluted with Plastibase (an oleaginous, non-water absorbing base containing 95 percent Liquid Petrolatum and 5 percent Polyethylene), in * The material was obtained from a process exposure to which resulted in over 200 cases of chloracne and systemic effects^ " " concentrations which 'were demonstrated to re relatively rcr.irritatinc to rabbit skin. The concentrations of the test materials were increased in accordance with the skin response > during the test as indicated below. A mixture of each mate rial in Plastibase was applied once daily on flexural surface of forearm over a skin area measuring approximately 70 square centimeters. After application, the forearm was bandacec and retained for 24 hours until the next aoolication. Duration of Exposure, Concentra"ion and Total Dose in Each Subject Sample Number 3 Subject J.P. J.A. C.P. Duration of Exposure (cays) 43 43 43 Concentrations 2.5% 5 3 ; CTT.S + 3.5% 25 gms 2.5% 44 gms + 3.5% 14 gms 2.5% 44 QTT.S + 3.5% 21 gms Total Dose (gms) 2.2 1.6 1.8 4 J.C. 48 5.0% 4 T.S + o 40 gms 3.0 K.M. 28 5.0% 31 gms + 7.0% 10 gms 2.2 R.T. E.J. 21 5.0% 35 gms 21 5.0% 31 gms 1.8 1.6 5 E.W. K.S. J.R. 43 2.5% 36.8 gms -F 3.5% 11 gms 1.4 43 2.5% 38 gms + 3.5% 19 gms 1.6 21 2.5% 6 gms + 3.5% 19 gms 0.7 Halowax1014 C.F. H.H. 43 20.0% 50 gms 48 20.0% 59 gms 10.0 11.B \ 3. Cutaneous biopsies: 3io.ps: es were ta;:er. 'rc." the test =r.c - control sites in each subject prior to the initial applica tion of the materials and at regular intervals during the duration of the exposure. 4. Liver function tests: Thymol turbidity tests and prothrombin time tests were performed in each case prior to the initial application and in the 2nd, 4th and 6th week of the exposure. These were done to detect possible hepatic damage from the percutaneous absorption of the applied material. Results A. Clinical Observations No. 3: During the first few cays after the applications with this material were initiated, the skin at the site of expoi sure became red and pruritic in two of the three subjects. This reaction persisted for the entire period of the appli cation and was intensified when the concentration was in creased in each instance. In the other two subjects, micro scopic comedones developed after 4 weeks and 6 weeks of the exposure (see Histological Findings). In one subject, J.A., clinical follicular enlargement appeared during the third week of application. The redness, pruritus and follicular -reaction subsided gradually after the application of this material was discontinued. No. 4: The cutaneous reaction to this material was clinically characterized by redness and itching. This was severe in two subjects and became more exaggerated when the concentra tion was increased. No folliculitis or follicular enlargement was noted. No . 5: Ery `heir.fi and pruritus char ac ter ized the reaction to this material. It was mild in one and moderate in two sub jects. There was no clinically noticeable follicular chance in any of the subjects. Halowax-1014: The application of the control material was* characterized by redness. In one case the reaction was noticeable in the first week, and in the second subject it appeared at the end of the second week. Folliculitis and enlargement became noticeable within 4 weeks after the application. As the application was continued, the ery thema and folliculitis bacame progressively more severe. Following the discontinuation of the application, the ery thema of the skin gradually subsided, but the folliculitis persisted and the comedones which were induced remained for several months. B. Histological Findings No. 3: In all of the three subjects prominent follicular dilatation and plugging with keratinous material were noted. This fol licular reaction occurred during the second week of appli cation in one subject (J.A.), after 4 weeks of application in a second subject (J.F.), and after 6 weeks in the third subject (C.P.). In some sections of these subjects marked dilatation of the follicle was noted with postule formation within the follicle. The follicular wall in these sections was thin, and keratinous material extended into the sebaceous duct with partial destruction of the follicle and sebaceous I acini. "-rifollicciar cellular ir.riItra*. icr., " 13 c tc in tense, ccrocsec of lymphocytes and histiocytes, was noted in most of the sections. Ecsinophilia was prominent in one case. A perivascular cellular infiltrate was notec in all three subjects, and was prominent in specimens taken from frankly irritated sites. The histological findings in these subjects w-ere quite similar to those seen after the positive control, Halova>:-1014, was applied. (The Na T.C.P. from this batch probably contained 2,3,7,8 tetrachloro dilenzo-p-dioxin.} No. 4: The application of this material to four subjects pro duced mild, perivascular anc perifollicular cellular reac tions. Some follicular plugging was seen after 3 weeks of application of the 7.0 percent concentration of the material in one of the four subjects. This was not observed in the later sections of the same subject. The follicular plugging and cellular reaction appeared to be much less prominent than that which was produced by No. 3. No. 5: The tissue reaction to this material was characterized chiefly by capillary dilatation and a lymphocytic perivas cular and perifollicular reaction which became more promi nent during the last 2 weeks of the application in two subjects. Follicular plugging was negligible. Halowax-1014: In both subjects follicular dilatation, hyperkeratinization and plugging occurred as early as the second week of the application. This reaction was prominent and striking, and increased progressively during the exposure period. In one subject (H.H.) the follicular plugging was pronounced within 4 weeks. At this time a severe perifol licular eosinophilic and lymphocytic reaction, as well as microscopie pustules in the follicle, were also nciec. In this subject destruction of the lover part of the rollicle . was observed and after 4 veeV.s the sebaceous acini had dis- j appeared. In the second subject the sane type of intense follicular hyperkeratinization, dilatation and periadnexal reaction was observed. The peri foilicular and perivascular infiltrate in this subject was composed chiefly of lympho cytes and histiocytes however. After 6 weeks of applica tion characteristic comedo were observed. C . Liver Function Tests There appeared to be no abnormal results in the prothrombin time and thymol turbidity tests. Interpretations In comparing the relative effects on the human pilosebaceous unit of the test materials and Halowax, it must be understood that it was not possible to use concentrations equivalent to Halowax-1014 because the test materials were all primary irritants in concentra tions lower than that of Halowax. Nevertheless, it is evident from the pathological observations -that m a t e r i a l .N o . 3, which was prepared from the plant Sodium Trichlorophenate, produced follicular hyperkera tinitation, dilatation, severe changes in the follicle and sebaceous -acini, as well as a perifollicular reaction, all of which were seen in the Halowax-1014 treated skin. That these changes were not as severe as. Halowax-1014 in all instances may be attributed to the fact that it was necessary to employ much lower concentrations of material No. 3. Although 20 percent Halowax was employed in the con trol subjects, it was not possible to apply concentrtions greater r than 3.5 percent of material No. 3. Since the follicular alterations produced by material No. 4 were mild by comparison to No. 3 (even though higher concentrations of No. 4 were used), this does demonstrate that its effect on the pilosebaceous system of human skin is considerably less intense. The pilcsebaceous effects of material No. 5 may be considered to be even less than either No. 4 or No. 3, since follicular hvperkeratir.ization plugging ana sebaceous gland changes were negligible. From these experimental observations in human skin we may con clude that the plant Na T.C.P. in the concentration employed in the experiment is definitely acnecenic. By comparison, the sample to Na T.C.P. prepared by the distillation method (No. 4) and the dilu tion method (No. 5) are much less acnecenic. The fact that No. 4 ana No. 5 did not induce significant pilosebaceous plugging and dilatation does not exclude them as potential acnegens if con centration plays an important role in their acne-inducing action. It does, however, demonstrate that in equivalent concentrations the potential acnegenicity of Nos. 4 and 5 is considerably less than material No. 3. Recently it was determined by Kimmig at the acnegenic material in this reaction product i te trachlorodibenzodioxin. Under the conditions of the investigation, the application of the test materials, as w'ell as the control, appeared to produce no systemic effects. Two types of liver function tests performed periodically during the exposure demonstrated no abnormal changes. The response of the follicle and sebaceous epithelium to the material contained in Na T.C.P. is quite fascinating. What we are observing in the sebaceous gland is not in the realm of cell death, degeneration or true atrophy. We may speculate as to what does c-ccu locally. The epithelium of the outer root sheat of the distal part of the follicle, infundibulum and sebaceous duct proliferate anc pro duce keratin which is retained in the duct and infundibulum. This stimulation also affects the undifferentiated cells lining the se baceous acini which usually give rise to lipid forming cells. Undif ferenti'ated epithelial cells are formed and the sebaceous acini are transformed into small masses of undifferentiated keratinizing epi thelial cells which eventually become part of the temporarily thick wall of the comedo. Kith further keratinization these cells do not continue to proliferate actively and the final structure is a kera tin filled funnel or cyst lined with thin flat epithelium sans sebaceous cells. The disappearance of sebaceous elements has been noted with specific polycyclic aromatic hydrocarbons which are carcinogenic. There is no evidence, however, to demonstrate that the acnegenic halogenated compounds are carcinogenic. In conclusion let me review the evolution of the microscopic changes when the human pilosebaceous unit is stimulated by specific acnecenic substances. This is the sequence: 1. Follicular pore dilatation and hyperkeratinization. This may extend to sebaceous duct. 2. Modulation of follicular epithelium and sebaceous duct cells to produce a hyperplastic fer^'-ti-ated-fey.- keratinizing epithelium. 3. Progressive disappearance of lipid forming cells and lower part of follicle. In some instances the hair follicle con tinues to grow' actively and in a few instances sebaceous acini remain attached to the plugged follicle. - -1 - 10- 4. Periacnexal and perivascular infiltrate with lymphocytes, some plasma, cells. In two instances, marked eosinophilic infiltrate noted. 5. Hyperplastic lining of comedo thins out to a single cell lined sac. 6. This persists or becomes a small cyst attached to the epidermis. This study demonstrated that one sample from a reaction vessel producing sodium trichlorophenate induced chloracne in volunteer subjects when the diluted material (2.5%) was applied daily for as long as 43 cays. No systemic reactions were observed. Two other samples of sodium trichlorophenate prepared by other methods failed to produce acneform lesions. REFERENCES 1. Hambrick,* G. W . , Jr. The Effect of Substituted Naphthalenes on the Pilcsebaceous Apparatus of Rabbit and Man. J. of Invest. Derm., 28..-S9-103, 1957. 2. Hambrick, G. W . , Jr. and Blank, H. Whole Mounts for the Study of the Skin and its Apoencages. J. of Invest. Derm., 23:437, 1954 . 3. Kimmig , J. and Schulz, K. H. Chloracne Caused by Chlorinated Aromatic Cyclic Ethers. Naturwissenschaften, 44:11 (337-338), 1957. 4. Kiminig , J. and Schulz, K. H. Occupational Acne (so-called Chlorine A c n e ) , Due to Chlorinated Aromatic Cyclic Ether. Dermatologica (Basel), 115:4 (540-546) Illus. 4, 1957. 1