Pyoderma faciale was introduced as a distinctive entity by O'Leary and Kierland,34 while an excellent report of twenty-nine cases  has been  provided by Massa and Su.35 The disease affects only female patients, mainly in the 20-30 year age group, although two over the age of 40  years  have been observed. Pyoderma  faciale is characterized by the sudden onset of deep and superficial cystic lesions of the face with interconnecting sinus tracts;  there  is a conspicuous  lack of comedones. A reddish to cyanotic erythema  of  the face  and local oedema are  common.  The  affected area  is sharply demarcated from normal skin and tends to be localized in the central part of the face .

  The paranasal, malar  regions and  chin  are  almost always involved. The forehead is frequently affected, but the lateral facial area and nasal area less so. Fewer patients have involvement of the neck; lesions  on the back, chest or shoulders are uncommon  and,  when present, are relatively minimal. A localized form of this process can uncommonly  occur,  involving  only the cheeks, for example, but may be explained on the basis that some of these cases were seen shortly after the onset of disease.36

  One study of pyoderma faciale35 reported that, in most patients, the onset and spread of the process was rapid, occurring in less than one month in 75 per cent of patients and within 1-3 months in 17 per cent. In 8 per cent,  lesions  developed  over  a 3-6  month period. Constitutional symptoms were uncommon though occasionally fatigue and  loss of weight were noted. Pyoderma  faciale can be an  emotionally, socially and physically devastating condition and many sufferers have  to discontinue their work and social obligations for as long as one year because of their skin condition.

  A previous history of acne was elicited in less than 50 per cent of the patients studied.35 Most females had no medical illnesses but a small number had  prior medical problems,  the significance  of which is  uncertain: rheumatoid arthritis, ulcerative colitis and thyroid disease.  Twenty-eight  per  cent  of  patients  recalled  a traumatic emotional experience  (for example, the death of a loved one, divorce, severe family turmoil, or  a major medical problem such as gastrointestinal bleeding or depression) before the onset of lesions.

  An elevated leucocyte  count  and sedimentation rate was found, not surprisingly, in some of these pyoderma faciale patients. Positive antinuclear  antibodies and rheumatoid factors were seen in fewer than 10 per cent of patients, the meaning of which is unclear.

  Most patients had multiple cultures taken, which in 26  per cent were totally negative. Thirty-six per cent had growth of only Staphylococcus epidermidis.  Of the remaining most showed growth of multiple organisms, most often Staph, epidermidis, Coiynebacterium  species and P.  acnes.  Staphylococcus aureus was isolated in 10 per cent. No patient  had  significant Gram-negative infection. Treatment Since pyoderma faciale is so acutely disfiguring hospitalization is required for about 60 per cent of patients, for up  to six weeks. Most patients  have been treated with high-dose oral antibiotics,  in particular, with tetracycline (1 g/day) and, to a lesser extent, with minocycline. Virtually all patients receive, in addition, some topical therapy such as benzoyl peroxide, topical antibiotics, UVB, intralesional injections of triamcinolone and incision and drainage, to reduce  the acute inflammation and soreness.

  In the paper by Massa and Su, remission was defined as return of facial complexion to the predisease state or clearing with only occasional development  of new lesions.35 This was achieved in 62 per cent of patients by six months and in 88  per cent by one year. Although remission was achieved in most patients, 58 per cent required treatment for longer than one year, usually oral  antibiotics  in  conjunction with  topical benzoyl peroxide or topical antibiotics.

  This author's department recently had the opportunity of treating two patients with isotretinoin very successfully . Prolonged remission for over eighteen months occurred. Isotretinoin may be the  drug of choice in pyoderma faciale.