In Reply.—
Dr Valentine raised important questions regarding the significance of isolation of multiple aerobic-anaerobic organisms from infected cysts. Although Staphylococcus aureus and Streptococcus pyogenes are known skin pathogens, other organisms have also been recognized as important contributors to these infections.1,2 Cysts can become infected by adjacent skin and mucus membrane flora, and the presence of local signs of inflammation and pus formation support the role of these organisms. As noted by Dr Valentine, local inflammation can also be due to non-bacterial factors, as is noted in acne. However, utilizing techniques that are also appropriate for cultivation of anaerobic bacteria may reveal that many "sterile" cysts were actually infected with these organisms. Only 39 of our patients had no bacterial growth noted in their cysts.3 The clinical appearance of those "sterile" cysts was similar to those that showed bacterial growth. It may be that previous antimicrobial therapy, that was given