Acne Vulgaris

Acne vulgaris is a chronic inflammatory skin condition that affects millions worldwide. It occurs when hair follicles become clogged with oil (sebum) and dead skin cells, leading to whiteheads, blackheads, pimples, and in severe cases, nodules and cysts.

Causes & Pathophysiology

Acne develops due to four primary factors:

• Excess sebum production — Androgens stimulate sebaceous glands to produce more oil
• Follicular hyperkeratinization — Dead skin cells clog hair follicles
• Bacterial colonization — Cutibacterium acnes (formerly Propionibacterium acnes) multiplies in clogged follicles
• Inflammation — Immune response causes redness, swelling, and pain

Contributing factors: Hormonal changes (puberty, menstrual cycle, pregnancy), genetics, certain medications (corticosteroids, lithium), stress, and diet.

Symptoms & Clinical Presentation

Acne lesions can be non-inflammatory or inflammatory:

Lesion Type	Description	Severity
Comedones	Open (blackheads) or closed (whiteheads) — non-inflammatory	Mild
Papules	Small, red, tender bumps	Mild to Moderate
Pustules	Papules with pus at the tip	Moderate
Nodules	Large, painful, solid lumps deep in the skin	Severe
Cysts	Deep, painful, pus-filled lesions that can scar	Severe

Common locations: Face (especially forehead, cheeks, chin), neck, chest, upper back, and shoulders.

Risk Factors

• Age: Adolescents and young adults (highest risk)
• Hormonal changes: Puberty, menstrual cycles, pregnancy, PCOS
• Family history: Genetics play a significant role
• Occlusive products: Heavy cosmetics, oily sunscreens, certain hair products
• Medications: Corticosteroids, lithium, phenytoin, isoniazid
• Diet: High-glycemic foods and dairy may exacerbate acne
• Stress: Can worsen existing acne

Severity Grading

Grade	Description	Clinical Features
Grade 1 (Mild)	Comedonal acne	Open and closed comedones, few papules
Grade 2 (Moderate)	Papulopustular acne	Comedones, papules, pustules — limited to face
Grade 3 (Moderate-Severe)	Nodulocystic acne	Numerous papules, pustules, nodules, cysts; possible scarring
Grade 4 (Severe)	Severe nodulocystic / conglobate acne	Large, painful nodules and cysts; extensive scarring; trunk involvement

Diagnosis & Investigations

Acne is diagnosed clinically based on history and physical examination. No specific tests are routinely required, but the following may be considered:

• Hormonal evaluation: For females with signs of hyperandrogenism (hirsutism, irregular menses, PCOS)
• Microbial culture: If Gram-negative folliculitis is suspected
• Biopsy: Rarely needed, for atypical presentations

Differential diagnosis: Rosacea, folliculitis, perioral dermatitis, keratosis pilaris, acneiform drug eruptions

Treatment & Management

Topical Medications (First-line for mild-moderate acne)

Oral Medications (For moderate-severe acne)

Procedural Treatments

• Chemical peels: Salicylic acid, glycolic acid, Jessner's solution
• Comedone extraction: Manual removal of comedones
• Intralesional corticosteroids: For large, inflamed nodules/cysts
• Laser and light therapy: For acne and post-acne scarring
• Drainage and extraction: For large cysts or abscesses

Diet & Lifestyle Recommendations

• Low-glycemic diet: Reduce sugar, refined carbs; increase whole grains, vegetables
• Limit dairy: Some studies suggest skim milk may worsen acne
• Stay hydrated: Drink adequate water
• Gentle skin care: Wash twice daily with mild cleanser; avoid harsh scrubbing
• Non-comedogenic products: Use oil-free, non-comedogenic cosmetics and sunscreens
• Avoid picking/popping: Can lead to scarring and infection
• Stress management: Exercise, meditation, adequate sleep

Complications

• Post-inflammatory hyperpigmentation (PIH): Dark spots after acne heals
• Acne scarring: Atrophic (ice pick, boxcar, rolling) or hypertrophic/keloidal scars
• Psychological impact: Low self-esteem, anxiety, depression, social withdrawal
• Acne fulminans: Rare, severe ulcerative acne with systemic symptoms
• Pyoderma faciale: Severe cystic acne in adult women

Prognosis

Acne is a chronic condition that can persist for years. Most patients improve significantly with appropriate treatment. However:

• Mild acne often resolves with topical treatment within 8-12 weeks
• Moderate-severe acne may require 4-6 months of treatment
• Some individuals may continue to have acne into their 30s and 40s
• Isotretinoin provides long-term remission in 85% of patients after one course
• Scars and hyperpigmentation may require additional cosmetic procedures

Prevention

• Gentle, twice-daily face washing with mild cleanser
• Use oil-free, non-comedogenic skincare and cosmetic products
• Avoid touching face with unwashed hands
• Keep hair clean and away from face
• Avoid picking, squeezing, or popping lesions
• Manage stress through healthy coping mechanisms
• Consider low-glycemic diet and limit dairy if acne-prone

When to See a Doctor

• Over-the-counter products haven't worked after 4-6 weeks
• Acne is severe, painful, or leaving scars
• Acne is causing emotional distress or affecting self-esteem
• You develop large, painful nodules or cysts
• Acne suddenly worsens or appears after starting a new medication
• For females with signs of hormonal imbalance (irregular periods, excess hair growth)

Frequently Asked Questions

References & Further Reading

• Zaenglein AL, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945-973.
• Nast A, et al. European evidence-based (S3) guideline for the treatment of acne. J Eur Acad Dermatol Venereol. 2016;30(8):1261-1268.
• Thiboutot D, et al. Hormonal therapy for acne. J Am Acad Dermatol. 2019;81(5):1213-1224.
• Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Acne Guidelines, 2021.
• Williams HC, et al. Acne vulgaris. Lancet. 2012;379(9813):361-372.