Friday, March 29, 2024
HomeDermatologyAcne Vulgaris

Acne Vulgaris

Practice Essentials

Acne vulgaris is a common chronic skin disease involving blockage and/or inflammation of pilosebaceous units (hair follicles and their accompanying sebaceous gland). Acne can present as noninflammatory lesions, inflammatory lesions, or a mixture of both, affecting mostly the face but also the back and chest.
See the image below.

Acne, grade I; multiple open comedones.

Acne, grade I; multiple open comedones.

View Media Gallery

Acne develops from the following four factors: (1) follicular epidermal hyperproliferation with subsequent plugging of the follicle, (2) excess sebum production, (3) the presence and activity of the commensal bacteria Cutibacterium acnes (formerly Propionibacterium acnes), and (4) inflammation.
In addition, genetics is also a key factor in the pathophysiology of acne.

Signs and symptoms

Acne vulgaris is characterized by noninflammatory, open or closed comedones and by inflammatory papules, pustules, and nodules. Acne vulgaris typically affects the areas of skin with the densest population of sebaceous follicles (eg, face, upper chest, back). Local symptoms of acne vulgaris may include pain, tenderness, or erythema.

Systemic symptoms are most often absent in acne vulgaris. In rare but severe cases, acne vulgaris could lead to acne conglobata, with highly inflammatory nodulocystic acne and interconnected abscesses. Acne fulminans is even more severe than acne conglobata, with systemic symptoms such as fever, joint pain, and general malaise. Additionally, acne vulgaris may have a psychological impact on any patient, regardless of the severity or the grade of the disease.

See Clinical Presentation for more detail.

Diagnosis

Examination in patients with acne vulgaris includes the following features:

Comedonal acne: Presence of open and closed comedones but usually no inflammatory papules or nodules

Mild acne: Presence of comedones and a few papulopustules

Moderate acne: Presence of comedones, inflammatory papules, and pustules; a greater number of lesions are present than in milder inflammatory acne

Nodulocystic acne: Presence of comedones, inflammatory lesions, and large nodules greater than 5 mm in diameter; scarring is often evident

Laboratory tests

Acne vulgaris is a clinical diagnosis. However, laboratory testing may be indicated in the following situations:

Polycystic ovarian syndrome (PCOS): Consider PCOS in female patients with oligomenorrhea, hirsutism and/or acanthosis nigricans in addition to acne. These patients should be evaluated with total and free testosterone, dehydroepiandrosterone sulfate (DHEAS), androstenedione, luteinizing hormone, and follicle-stimulating hormone values, as well as a lipid panel, glucose value, and insulin level.

Cases refractory to long-term antibiotic treatment or when improvement with antibiotics is not maintained: Culture skin lesions to rule out gram-negative folliculitis.

See Workup for more detail.

Management

Treatment of acne vulgaris should be directed toward the known pathogenic factors, including follicular hyperproliferation, excess sebum, C acnes (formerly P acnes), and inflammation. The most appropriate treatment is based on the grade and severity of the acne.

Pharmacotherapy

The following medications are used in the treatment of Cutibacterium (formerly Propionibacterium) acne vulgaris:

Acne products (eg, erythromycin and benzoyl peroxide, clindamycin and tretinoin, clindamycin and benzoyl peroxide, azelaic acid, benzoyl peroxide, topical dapsone)

Retinoidlike agents (eg, topical tretinoin, adapalene, tazarotene, isotretinoin)

Antibiotics (eg, tetracycline, minocycline, doxycycline, sarecycline, trimethoprim/sulfamethoxazole, clindamycin, topical clindamycin, topical erythromycin, daptomycin, minocycline topical foam)

Selective aldosterone antagonists (eg, spironolactone)

Androgen receptor inhibitors (eg, clascoterone topical) 

Estrogen/progestin combination oral contraceptive pills (eg, ethinyl estradiol, drospirenone, and levomefolate; ethinyl estradiol and norethindrone; ethinyl estradiol and norgestimate; ethinyl estradiol and drospirenone)

When a topical or systemic antibiotic is used, it should be used in conjunction with benzoyl peroxide to reduce the emergence of resistance.

Nonpharmacotherapy

Diet therapy, such as a low-glycemic diet and avoidance of “junk foods,” has been suggested as a nonpharmacologic measure to manage acne vulgaris. Skim milk has been found to have a positive association with acne.

Procedures

Procedural treatments for acne vulgaris include the following:

Manual extraction of comedones

Intralesional steroid injections

Superficial peels that use glycolic or salicylic acid

Light and laser therapy

See Treatment, Guidelines, and Medication for more detail.

RELATED ARTICLES
- Advertisment -

Most Popular