British Journal of Dermatology (1976) 95, 153.

Pilo-sebaceous duct physiology

III. OBSERVATIONS ON THE NUMBER AND SIZE OF PILO-SEBACEOUS
DUCTS IN ACNE VULGARIS

W. J. CUNLIFFE, W. D. H. PERERA, P. THACKRAY, M. WILLIAMS,

R. A. FORSTER AND S. M. WILLIAMS

Departments of Dermatology, The General Infirmary, Leeds, and

Leeds (St James's) University Hospital

Accepted for publication 14 November 1975

SUMMARY
We have used surface microscopy to measure the pilo-sebaceous duct orifices at different sites in 150
subjects. Our data have shown that there are more pilo-sebaceous units on the face compared to the
back and that these exits are smaller on the face. Despite the small exit the sebum excretion rate per
gland on the forehead was not significantly different from that on the back. Thus the number of pilo-
sebaceous duct units and the pilo-sebaceous canal exit size are possible factors in the localization of acne.

The principal factors in the pathogenesis of acne are an enhanced sebum excretion rate (CunlifFc &
Shuster, 1969a), variations in the biochemical composition of sebum (Powell & Beveridge, 1970:
Cotterill e/a/., 1972; Peter &Eichenscher, I973)caused to some extent by bacterial enzymes (Marples,
Downing & Kligman, 1971), and sebum outflow resistance (CunlifFe & Shuster, 1969a). Acne is most
evident on the face and there are several reasons why this could be so. First, there could be an en-
hanced response of the sebaceous gland to androgens, probably involving an increased rate of con-
version of testosterone to its more active metabolite (Sansone & Reisner, 1971). Secondly, there may
be an increased sebum outflow resistance on the face compared to the other sites. Plewig (1974) has
demonstrated an increased epithelial turnover in the pilo-sebaceous canal on the face compared to the
back. Kligman (1974) has shown that the keratin in the facial pilo-sebaceous canals is softer and more
pliable than the rigid keratin found in the canals on the back. Furthermore, acne is uncommon in
the open-mouthed follicles of the nose, and large inflammatory spots are more frequently seen arising
from closed comedones; the inference being that the acne may be less evident in areas with larger
pores. We therefore thought it worthwhile looking at the size of the pilo-sebaceous ducts in an attempt
to explain the localization of acne.

MATERIALS AND METHODS

We have investigated a total of 150 subjects with acne. One hundred and thirty-nine had acne of a
similar degree on the face and back; eleven had no acne on the back. The subjects investigated repre-
sented a fairly homogeneous population and were selected for the various tests simply by their
attendance at the acne clinic. No patient was on therapy at the time or for 4 weeks before the study.
Measurements of the pilo-sebaceous duct orifice were made at three sites: the mid-point of the fore-
head; the chest 2.5 cm below the sternal angle; and the upper back. A template was used to ensure
153
154 W.J.Cunliffe et al.
that the same area of the back was read in each individual; two medial and lateral areas were chosen.
The method of measuring, which has been described elsewhere (Cunliffe, Forster & Williams, 1974),
involves staining the skin with Oil Red O and viewing with a Leitz MZ microscope (x 50 magnifica-
tion). A graticule incorporated into the eyepiece allows the diameter of the pilo-sebaceous duct exit to
be measured. We also measured the sebum excretion rate from the forehead by the method of Strauss
& Pochi (1961) modified by Cunliffe & Shuster (1969b). Despite certain minor technical problems we
were able to collect sebum from the back, particularly if we chose an area slightly medial to the
scapula, the paper being held in position by a blue lined bandage fixed with nylon mesh over the
anterior chest.
RESULTS
During the study we obtained data on the number of pilo-sebaceous ducts at all sites. We found (Fig.
i) significantly more ducts on the forehead compared to the back and in turn there were many more
ducts on the back compared to the chest. The pilo-sebaceous exits on the forehead were significantly
smaller than on the back and those on the back were smaller than those on the chest (Fig. 2). We also

320 -
I
280 -
0-005 r ( 2 )
E 240 -
"I 0-004
1 200
I 160 - I 0-003
u
S 120
§ 0-002
o
I 80
^ 0-001
40

O'O
Forehead Bock Chest Forehead Bock Ohest

FIGURE I. Thenumber (mean+ s.e. mean) of pilo-sebaceous units on the forehead, upper back and
anterior chest. 120 subjects were investigated. Back, N = 47, P< O'Oi; Chest, 7'< o-oi.
FIGURE 2. The pilo-sebaceous exit size (mean + s.e. mean) on the forehead, upper back and anterior
chest. Forehead, P< o-ooi; Back, N = 47, P< o-ooi.

compared the number and size of the pilo-sebaceous duct exits on the medial and lateral parts of the
back. There were significantly more ducts on the upper back laterally and these ducts were significantly
smaller than on the medial part of the back (Table i). Fig. 3 shows the sebum excretion rate per duct
per min. Although there was some difference in four subjects, there was no overall significant differ-
ence between the sebum excretion rate per gland on the forehead and back.
DISCUSSION
We have confined this study to the forehead, back and chest since these are the sites usually involved
in acne vulgaris. Our data have shown that there are considerably fewer pilo-sebaceous units on the
back than on the forehead and even fewer on the chest. It is clear from this result that the forehead
is at greater risk than the back or chest as the number of ducts per unit area is higher. Our study did
not include the scalp, as the scalp, probably because of the terminal hair follicles, is not involvedin acne.
Our absolute counts are similar to those reported by Benfenati & Brillianti (1939) and Powell &
Beveridge (1970) who investigated the number of ducts on the face by an indirect method. These
 Filo-sebaceous duct physiology 155
TABLE 1. The number and size of the pilo-sebaceous ducts on the lateral and medial parts of
the back (mean + s.e.mean)

Medial Lateral No. of subjects

No./cm' 72-0+2-0 84-6 + 3-6 35 < o-oi

Size (mm') 0-0030 + 0-0002 0-0039 ± 0-0002 65 < o-oi

1-4 n

10

%. 0-6

0-2

Forehead Bock

FIGURE 3. The sebum excretion rate per gland per min on the forehead and upper back. P< 0-98;
Forehead, / - 0-70; Back, x = 071.

authors used osmium tetroxide to visualize the tiumber of fat droplets on collecting paper. It is per-
haps surprising that both methods show the same result since the indirect method, at least in our
hands, gives variable results. On the other hand, we are not entirely certain whether we are counting
only the sebaceous follicles (the main type of follicle involved in acne, Kligman, 1974) or whether we
are also counting the smaller vellus follicles. There is no doubt, however, that the number of ducts we
count does not vary during the investigation; nor is there any variation in the area of the exit during
the measurement. This direct method is reproducible and the Oil Red O probably stains the lipid
bound keratin—enabling us to measure accurately the size of the pilo-sebaceous exit. We realize
that some patients have acne predominantly localized to the back rather than to the face and we
appreciate that there must be other factors localizing acne to different sites, such as variations in local
androgen metabolism or in the cellular dynamics of the pilo-sebaceous keratin (Baillie, Thompson
& Milne, 1966; Plewig, 1974).
Poiseuille's formula (Noakes, 1963), which relates the outflow resistance in a simple tube to flow
properties, indicates that the resistance is inversely proportional to the fourth power of the radius and
this is in contrast to other factors which vary only linearly. Thus it is reasonable to assume that in the
pilo-sebaceous canal, although it is not a simple tube, the resistance to the outflow of sebum will vary
with the radius of the duct orifiee. Therefore, the smaller the pilo-sebaceous duct orifice the higher
the resistance.
It would therefore appear that the localization of acne may also be explained by the size of the pilo-
sebaceous duct exit; the smaller duct exits, such as are seen on the forehead, being related to a higher
prevalence of acne at that site.
156 W.J.Cunliffe et al.

This hypothesis may not necessarily be valid for it could be argued that through the smaller ducts
on the forehead only a small amount of sebum is excreted, whereas the larger ducts on the back may
convey proportionally larger amounts of sebum. However, our sebum excretion rate studies show that
the same volume of sebum flows through the much larger ducts on the back. Assuming that there is no
difference in the viscosity of sebum or in the length of the pilo-sebaceous canals, calculation of the
outflow resistance from Poiseuille's formula shows that it is five times greater on the forehead than it
is on the back. Where the outflow resistance is greater such as on the forehead the pilo-sebaceous units
are therefore more likely to become obstructed especially under such conditions as keratin hydration,
which is known to reduce significantly the pilo-sebaceous exit size (Williams, Cunliffe & Gould, 1974).
We have therefore demonstrated that the localization of acne can to some extent be explained by
both the number of the pilo-sebaceous units and the size of the pilo-sebaceous exit. This fits well with
the clinical observation that acne is uncommon in areas where the pores clinically appear larger, such
as on the medial part of the back, the medial part of the cheek and the nose.

ACKNOWLEDGMENTS

We wish to thank Vick International and the Leeds Area Health Authority for their financial support.
We also wish to thank Mrs L.Lane and Mrs J.Hodson for typing the manuscript.

REFERENCES
BENFENATI, A. & BRILLIANTI, F . (1939) Sulla Distribuzione delle Ghiandole Sebacee nella cute del corpo humano.
Archivio italiano di dermatologia, sifilografia e venereologia, 1$, 33, quoted by J.S.Strauss & P.E.Pochi (1968)
in: Jadassohn's Handbuch der Haut- und Ceschlechtskrankheiten Erganzungwerk, Vol, I, Pt. I (Ed. by O.Gans
and G.K.Steigleder), p. 184. Springer, Berlin.
BAILLIE, A.H., THOMPSON, J. & MILNE, J.A. (1966) The distribution of hydroxysteroid dehydrogenase in human
sebaceous glands. British Journal of Dermatology, 78, 451.
COTTERILL, J.A., CUNLIFFE, W.J., WILLIAMSON, B. & BULUSU, L . (1972) Further observations on the pathogenesis
of acne. British Medical Journal, iii, 444.
CUNLIFFE, W J . & SHUSTER, S. (1969a) Pathogenesis of acne. Lancet, i, 68s.
CUNLIFFE, W.J.& SHUSTER, S. (1969b) The rate of sebum excretion in man. British Journal of Dermatology, 81, 697.
CUNLIFFE, W.J., FORSTER, R.A. & WILLIAMS, M . (1974) A surface microscope for clinical and laboratory use.
British Journal of Dermatology, 90, 619.
KLIGMAN, A.M. (1974) An overview of acne. Journal of Investigative Dermatology, 62, 268.
KNUTSON, D . D . (1974) Ultra structural observations in acne vulgaris; the normal sebaceous follicle and acne
lesions. Journal of Investigative Dermatology, 62, 288.
MARPLES, R.R., DOWNING, D . T . & KLIGMAN, A.M. (1971) Control of free fatty acids on human surface lipid by
Corynebacterium acnes. Journal of Investigative Dermatology, 56, 127.
NOAKES, G.R. (1963) Nezv Intermediate Physics, Macmillan, London.
PLEWIG, G . (1974) Follicular keratinisation. Journal of Investigative Dermatology, 62, 308.
PERERA, W.D.H., CUNLIFFE, W.J., WILLIAMS, S. & EDWARDS, J.C. (1976) Assessment of density of pilo-sebaceous
duct on the forehead: a comparison of methods. British Journal of Dermatology, in press.
PETER, G . & EICHENSCHER, K . (1973) Relationen in der Lipidzusammensetzung von Comedonen, palmarer
Hautoberflache and Talgdrusen. Archiv fiir Dermatologische Eorschung, 247, 329.
POWELL, E . & BEVERIDGE, G . W . (1970) Sebum excretion and sebum composition in adolescent men with and
without acne vulgaris. British Journal of Dermatology, 82, 243.
SANSONE, G. & REISNER, R.M. (1971) Differential rate of conversion of testosterone to dihydrotestosterone in acne
and normal human skin—a possible pathogenic factor in acns. Journal of Investigative Dermatology, 56, 366.
STRAUSS, J . S . & POCHI, P.E. (1961) The quantitative gravimetric determination of sebum production. Journal of
Investigative Dermatology, 36, 243.
WILLIAMS, M . , CUNLIFFE, W . J . & GOULD, D . (1974) Pilo-sebaceous duct physiology. 1. Effect of hydration on
pilo-sebaceous duct orifice. British Journal of Dermatology, 90, 631.