Acne Vulgaris

What is it?

Acne vulgaris is a chronic inflammatory skin condition that affects the pilosebaceous units (hair follicles and their associated oil glands). The condition manifests primarily as comedones (blackheads and whiteheads), papules (small red bumps), pustules (pus-filled lesions), and in severe cases, nodules and cysts. Acne predominantly affects the face, chest, and upper back — areas with the highest concentration of oil glands.

Who is affected?

Acne is one of the most common skin conditions worldwide, affecting approximately 9.4% of the global population. While traditionally associated with adolescence, acne can occur at any age:

• Age distribution: Most commonly begins during puberty (ages 12-18), but adult acne is increasingly recognized, particularly in women aged 25-45
• Gender: During adolescence, boys tend to have more severe acne; in adulthood, women are more frequently affected
• Prevalence: Up to 85% of adolescents experience some degree of acne
• Risk factors: Family history, hormonal fluctuations, certain medications, and use of comedogenic (pore-clogging) skincare products

What causes it?

Acne develops through a combination of four main factors:

• Excess sebum production — the oil glands produce too much sebum (skin oil), often driven by hormonal changes
• Follicular hyperkeratinization — dead skin cells accumulate and block the follicle opening
• Bacterial colonization — Cutibacterium acnes (formerly Propionibacterium acnes) multiplies within blocked follicles
• Inflammation — the immune system responds to bacterial growth, causing redness and swelling

Contributing factors include hormonal fluctuations (puberty, menstrual cycle, polycystic ovary syndrome), genetic predisposition, stress, certain medications (corticosteroids, lithium), and dietary factors (high glycemic foods, dairy — though evidence varies).

What are the clinical features?

Acne presents with various lesion types that can be categorized as:

Non-inflammatory lesions:

• Open comedones (blackheads) — dilated pores with oxidized sebum appearing dark
• Closed comedones (whiteheads) — small flesh-colored bumps from blocked follicles

Inflammatory lesions:

• Papules — small, raised red bumps indicating inflammation
• Pustules — papules with visible pus at the surface
• Nodules — larger, painful, solid lesions deep within the skin
• Cysts — deep, pus-filled lesions that may cause scarring

Disease progression:

Acne severity ranges from mild (mostly comedones) to severe (widespread nodules and cysts). Without treatment, inflammatory acne may lead to permanent scarring and post-inflammatory hyperpigmentation (dark spots).

How is it diagnosed?

Diagnosis is made clinically by a dermatologist through visual examination. No laboratory tests are required for typical acne. The physician will assess:

• Lesion types present — comedones, papules, pustules, nodules, cysts
• Distribution and extent — areas affected and overall severity
• Scarring — presence and type of acne scars
• Contributing factors — medications, hormonal signs, skincare routine

In women with signs of hormonal imbalance (irregular periods, excess hair growth), blood tests may be ordered to evaluate hormone levels.

What treatment options are available?

Treatment is tailored to acne severity and may include:

Topical treatments (applied to skin):

• Retinoids (adapalene, tretinoin) — normalize follicular keratinization
• Benzoyl peroxide — antibacterial agent that reduces C. acnes
• Topical antibiotics (clindamycin, erythromycin) — reduce bacteria and inflammation
• Azelaic acid — antibacterial and anti-inflammatory properties

Oral treatments:

• Antibiotics (doxycycline, minocycline) — for moderate-to-severe inflammatory acne
• Hormonal therapy (combined oral contraceptives, spironolactone) — for women with hormonal acne
• Isotretinoin — for severe, treatment-resistant acne

Procedures:

• Comedone extraction
• Chemical peels
• Intralesional corticosteroid injections for nodules
• Laser and light therapies

What you can do at home:

• Cleanse gently twice daily with a mild cleanser
• Use non-comedogenic skincare and makeup products
• Avoid picking or squeezing lesions
• Apply sunscreen daily (especially when using retinoids)

Key points for patients

• Acne is a medical condition, not a hygiene problem — over-washing can worsen symptoms
• Effective treatments exist, but results take time (typically 6-12 weeks)
• Consistency with treatment is essential for success
• Early treatment can prevent scarring
• Consult a dermatologist if over-the-counter products are ineffective after 2-3 months
• Isotretinoin requires careful monitoring but can provide long-term remission for severe acne