364 MEDICAL MYCOLOGY 



extend to the flexures of the arms, the popliteal space, and the front of the 

 legs. Since infants under three months are unable to scratch themselves, they 

 relieve the irritation by rolling the back of the head and the sides of the face 

 on the pillow, thus spreading the infection. The sebaceous glands are rarely 

 infected in infancy and when they are, it is probably due to stoppage of their 

 mouths by too liberal application of oils by the mother, with subsequent in- 

 vasion by staphylococci. 



From puberty until the twenty-fifth year, the organism growing on the 

 scalp produces little or no symptoms beyond slight dandruff. During this 

 period, the invasion of the pilosebaceous glands not connected with hairs is 

 more common. The glands of the nasolabial folds, between the scapulae and 

 those of the front of the chest are most frequently attacked, rarely those of 

 the forehead (acne frontalis). In the mild cases, the skin becomes coarse and 

 blackheads are formed, occasionally these are infected by staphylococci, giv- 

 ing rise to superficial inflammation (with or without pustules and papules). If 

 the staphylococcal infection extends deep into the corium, it gives rise to deep 

 abscesses, the skin over them is bluish and the abscesses are slow in coming 

 to a head. Very rarely the suppuration may end in a localized necrosis some- 

 what similar to the formation of a carbuncle (acne necrotica). Such lesions 

 are seen only in debilitated persons. The scars left by the rupture and ab- 

 sorption of these pustules also vary in different individuals. In superficial 

 lesions, the scars are difficult to see after the inflammation has subsided. In 

 deep lesions, the scars often leave little pitlike areas scattered over the cheeks 

 and sides of the neck. Sometimes these scars undergo keloid formation, pro- 

 ducing ugly raised keloids. More rarely the scar is deeply situated and gives 

 rise to superficial atrophy of the skin overlying it, so that these atrophic scars 

 are white, suggesting the morphea spots. In the last named conditions, the 

 individual shows a lower basal metabolism, suggesting connection with hypo- 

 function of the thyroid [hypophysis or gonad?]. 



In this period the dandruff scales are small, dry, and greasy, and adhere 

 to the surface of the scalp. The skin is not inflamed and appears normal, but 

 the hair is dry and has lost its luster. From time to time there are exacerba- 

 tions (especially in hot dry climates). The skin becomes irritable, with small 

 erythematous areas and excoriations, due to scratching. Extension occurs on 

 the forehead where the skin becomes red and irritable (corona seborrhoeica). 

 The sebaceous glands become involved, infected with staphylococci, giving 

 rise to small vesicles which, if irritated by friction of the hat, may result in boils. 

 Occasionally this may extend to the eyebrows and eyelashes. The sebaceous 

 glands which are not pilosebaceous are rarely involved by Malassezia, but are 

 infected by staphylococci, producing styes, exfoliative cheilitis of the lips, etc. 



From 30 to 45 years of age, the Malassezia which has been largely restricted 

 to the superficial layer of the scalp now invades the hair follicle and its seba- 

 ceous gland, after a few years destroying them and producing seborrheic 

 alopecia or baldness. The area may start at the crown and spread or at the 



