COMMON DERMATOSES
Acne vulgaris
Anjali Mahto
Abstract
Acne vulgaris is a chronic skin condition caused by blockage or
inflammation of the hair follicles and their associated sebaceous
glands e together known as the pilosebaceous units. It typically af-
fects areas with the highest density of sebaceous follicles; this in-
cludes the face, upper chest and back. Although all age groups can
be affected, it is primarily a disorder of adolescence. It can present
as non-inflammatory comedones (blackheads, whiteheads), inflamma-
tory papules, pustules, nodules and cysts, or a mixture of lesions. This
can result in symptoms of local tenderness and erythema. Acne is
extremely common and thought to affect most people at some point
in their lives. Twenty per cent progress to severe acne, which can
lead to permanent scarring. The condition can be associated with sig-
nificant psychosocial complications including low self-esteem, altered
body image, social isolation and depression. The aims of treatment are
to prevent long-term complications.1
Keywords Acne; antibiotics; contraceptive pill; diet; isotretinoin; light
and laser therapies; spironolactone
Epidemiology
Acne accounts for more than 3.5 million general practitioner
appointments per year.2 It affects 80% of people at some point
between 11 and 30 years of age. During adolescence, acne is
more common in male than female patients. Acne can also occur
in adults and is more prevalent in women. It can develop for the
first time over the age of 25 years and is thought to affect up to
20% of women and 8% of men. Of those suffering with the
disease, 20% have severe disease that is likely to lead to scarring.
Pathogenesis
Acne develops from a complex interplay between multiple fac-
tors. Genetics are thought to play an important role, as the
number and size of sebaceous glands and their activity is
inherited. Twin studies show that the concordance rate for the
prevalence and severity of acne is extremely high. The herita-
bility of acne is almost 80% in first-degree relatives.
Sebaceous gland activity is under the influence of hormones,
in particular the androgen dihydrotestosterone. During adoles-
cence, the body produces androgen hormones from the gonads
and adrenal glands. These hormones act directly on the seba-
ceous gland to increase sebum production and excretion.
Increased sebum combined with abnormal follicular hyper-
keratinization results in ‘sticky’ keratinocytes blocking the pilo-
sebaceous duct, and comedo formation. Bacterial colonization
with the anaerobic Propionibacterium acnes can follow. P. acnes
Anjali Mahto MBBCh BSc MRCP is a Consultant Dermatologist at the
Cadogan Clinic, London, UK. Competing interests: none declared.
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Key points
C Acne is a disorder of the pilosebaceous unit and typically af-
fects areas with a high density of sebaceous follicles
C Acne presents as comedones, papules, pustules, nodules and
cysts
C Severe acne can lead to permanent scarring of the skin
C Diagnostic investigations may be required in an adult woman
with signs of hyperandrogenism
C There are multiple methods of treatment to achieve acne
control, including topical and oral agents in addition to light
and laser therapies
stimulates inflammation via a number of proinflammatory me-
diators, including interleukins-12 and -8 and tumour necrosis
factor.3
Other causes
A small number of other causes that have been implicated in the
pathogenesis of acne. These include cosmetic agents and hair
pomades, medications (corticosteroids, lithium, iodides), hyper-
androgenism and mechanical occlusion with headbands, shoul-
der pads and backpacks.
Diagnosis
History
A patient with acne usually presents with a history of ‘spots,’
most commonly affecting the face, back, chest and shoulders.
Systemic symptoms are often absent, but the patient may
describe local symptoms of pain, erythema or tenderness.
Additionally, acne can have a psychological impact, regardless of
the severity of disease.
When taking a history, it is important to enquire about the
duration of symptoms, aggravating factors, any over-the-counter
preparations that have been tried, and the psychosocial impact of
the disease, particularly at work or school. In female patients,
consider whether acne could be secondary to hyperandrogenism,
and enquire about irregular menstrual cycles, hirsutism, andro-
genic alopecia, premenstrual flaring of acne lesions or sudden-
onset severe acne.
Psychosocial factors are often overlooked but must not be
taken lightly. Acne can have a severe negative impact on a per-
son’s life and is often underestimated by healthcare pro-
fessionals. Validated quality-of-life scoring systems such as the
Cardiff Acne Disability Index can be used to monitor psycho-
logical state. Individuals in whom acne is having a marked
psychosocial impact may need more aggressive treatment or
early referral to a specialist.
Examination
Acne is characterized by comedones, papules, pustules, nodules
and cysts, as follows.
1 Ó 2017 Published by Elsevier Ltd.
 COMMON DERMATOSES
 Comedones are the most basic acne lesion and can be open
or closed. Closed comedones (whiteheads) are small plug-
ged follicles whose contents are not exposed to the skin
surface. Open comedones (blackheads) are small follicles
with dilated openings onto the skin. The black colour results
from oxidation of the debris within the follicle.
 Papules are small, usually red, raised elevations of the
skin.
 Pustules resemble papules but have a central pocket of
pus.
 Nodules and cysts are larger painful swellings usually
more than 5 mm in size.
Examination can reveal other skin lesions that have devel-
oped as a consequence of the acne. These include atrophic or
pitted scars, post-inflammatory erythema or hyperpigmentation,
and keloids. The latter two are more common with darker skin.
When making a clinical assessment, an attempt should be made
to categorize disease severity. There are multiple acne severity
grading systems, largely developed for use in clinical trials, that
may not be entirely suitable for daily clinical practice. However,
expert opinion is that separating disease status into mild, moderate
and severe categories can help guide management (Table 1).
Differential diagnoses
The diagnosis of acne is usually straightforward. Table 2 offers a
list of conditions that can mimic it.
Investigations
Diagnostic investigations are not typically required in acne as the
diagnosis is clinical. However, in female patients with signs of
hyperandrogenism, hormonal investigations can be required to
exclude conditions such as polycystic ovarian syndrome (PCOS)
and congenital adrenal hyperplasia.1
Usual screening blood tests include total and free testosterone
luteinizing hormone, follicle-stimulating hormone, dehydroepi-
androsterone, 17-hydroxyprogesterone, prolactin, 21b-hydroxy-
lase. These should be checked in the luteal phase of the
menstrual cycle, that is, just before the onset of menses. To
improve accuracy, patients should be asked to stop oral contra-
ceptives 1 month before testing. It is also worth bearing in mind
Assessing acne severity
Severity Description
Mild Open and closed comedones and few
inflammatory lesions
Mild/moderate Comedones with occasional inflammatory
papules and pustules that are confined to the
face
Moderate Many comedones with small and large
inflammatory papules and pustules; more
extensive
Severe Many comedones and inflammatory lesions
with nodules and cysts tending to coalesce;
face and truncal involvement, evidence of
scarring
Table 1
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Differential diagnosis
C Rosacea
C Folliculitis
C Perioral dermatitis
C Pityrosporum folliculitis
C Demodex folliculitis
C Milia
Table 2
that many adult women with an androgen drive to their acne do
not have elevated circulating hormone concentrations.
Management
Topical treatments4
Retinoids: these agents are derived from vitamin A. They correct
abnormal follicular hyperkeratinization and inhibit new come-
done formation. The most commonly used topical retinoids
include tretinoin, adapalene and isotretinoin. Skin irritation and
redness can occur in the early phase of treatment. These agents
thin the stratum corneum and can increase photosensitivity; pa-
tients should therefore be given advice regarding sun protection.
Benzoyl peroxide: benzoyl peroxide is a bactericidal agent with
the ability to reduce P. acnes populations in the sebaceous folli-
cles. It is useful for both inflammatory and non-inflammatory
acne lesions, and is not associated with bacterial resistance.
Products containing benzoyl peroxide are available over the
counter or by prescription, and are used once or twice daily.
Antibiotics: topical antibiotics, commonly clindamycin, are
often used for their activity against P. acnes. There is a risk of
bacterial resistance with these agents so they are not used as
monotherapy. Topical antibiotics are usually combined with
either retinoids or benzoyl peroxide. Topical antibiotic usage
should if possible be limited to no more than 12 weeks.
Azelaic acid: this can be used as a second-line option for acne if
other treatments are unsuitable or not tolerated. There are fewer
scientific data on this agent, and results are mixed.
Oral treatments
Antibiotics: these have anti-inflammatory properties and activity
against P. acnes. Oral antibiotics can be successfully combined
with topical retinoids or benzoyl peroxide in moderate acne.
First-line agents include tetracycline, oxytetracycline, doxycy-
cline and lymecycline. There is good evidence that these agents
can reduce inflammatory lesion counts and severity. Other an-
tibiotics used include erythromycin, azithromycin and trimeth-
oprim. Tetracycline antibiotics should not be used during
pregnancy, but erythromycin is a safe alternative in this situa-
tion. Average treatment time is about 12 weeks.
Hormonal therapies: the combined oral contraceptive pill can be
used to control acne in women requiring contraception. Oes-
trogen in the contraceptive pill reduces sebum production. It also
reduces ovarian production of androgens by suppressing
2 Ó 2017 Published by Elsevier Ltd.
 COMMON DERMATOSES

gonadotropin release. Finally, oral contraceptives increase he- Diet: the relationship between diet and acne has been controver-
patic synthesis of sex hormone-binding globulin (SHBG), sial. Given current data, no specific dietary changes are recom-
resulting in an overall decrease in free testosterone. mended in isolation to treat acne. There is, however, emerging
Spironolactone can be used off-label in the UK by specialists evidence that high glycaemic index diets can be associated with the
in the treatment of acne. It has a number of antiandrogenic condition. There is also limited evidence that some dairy products
properties. The drug binds to the androgen receptor and reduces (particularly skimmed milk) can also have a role.
androgen production. It also increases SHBG concentrations,
resulting in less free circulating testosterone. Pregnancy must be Intralesional corticosteroid injections: intralesional injections
avoided as there is a risk of feminization of the male fetus. Spi- of corticosteroids, usually triamcinolone acetamide diluted to 5
ronolactone has a useful role against acne in adult women, mg/ml or less, can be used to flatten nodules or cysts within 48
especially in the context of PCOS. e72 hours. Injections can be useful for isolated cysts where a
quick response is required and should only be performed by a
Isotretinoin: isotretinoin is a systemic retinoid that is highly specialist as there are a number of potential adverse effects,
effective in severe, recalcitrant acne vulgaris. It also has a role in including atrophy and infection.
acne that is resistant to treatment with other agents, relapses In addition to recognized medical treatments, patients should
quickly after completion of antibiotic therapy, or is having a be given basic skincare advice to manage their acne. The skin
profound psychological impact. In the UK, it can only be pre- should be gently cleansed twice daily, and comedogenic creams
scribed under the supervision of a dermatologist. and cosmetics should be avoided. A
Isotretinoin acts as an anti-inflammatory agent, reduces
sebum production and corrects abnormal epidermal differentia-
KEY REFERENCES
tion. Treatment is usually deemed complete when a cumulative
1 Zaenglein A, Pathy A, Schlosser B, et al. Guidelines of care for the
dose of 120e150 mg/kg has been reached. The drug is terato-
management of acne vulgaris. J Am Acad Dermatol 2016; 74(5):
genic so female patients of childbearing age are required to take
945e73.
oral contraception in conjunction with it.
2 National Institute for Health and Care Excellence. Acne vulgaris.
Common adverse events include dry mucous membranes,
London: NICE, 2014.
myalgia, photosensitivity and headaches. There have also been
3 Rao J. Acne vulgaris. Emedicine 2016, http://emedicine.medscape.
reported and well-publicized cases of mood disorders in associ-
com/article/1069804-overview (accessed 22 October 2016).
ation with isotretinoin. Although no clear cause-and-effect rela-
4 Nast A, Dreno B, Bettoli V, et al. European evidence based (S3)
tionship has been definitively established, patients should be
guidelines for the treatment of acne. J Eur Acad Dermatol Venereol
warned of this potential link.5
2012; 26(suppl 1): 1e29.
5 Goodfield M, Cox N, Bowser A, et al. Advice on the safe intro-
Light and laser treatments: there is growing interest in new
duction and continued use of isotretinoin in acne in the UK. Br J
non-invasive therapies for acne. Light and laser therapies
Dermatol 2010; 162: 1172e9.
(photodynamic therapy, blue light, intense pulsed light) are
commercially available, particularly in the private sector. A
recent Cochrane review of these treatments concluded that high-
quality evidence for these treatments is lacking. However, some
of these treatments appear promising, and additional studies are
required to fully assess their true clinical effect.

TEST YOURSELF
To test your knowledge based on the article you have just read, please complete the questions below. The answers can be found at the
end of the issue or online here.

Question 1 Question 2
A 15-year-old boy presented with ‘spots’ on his face. An 18-year-old woman presented with severe acne. She had had
acne for 5 years, but topical treatment had had only had a modest
On examination, what are the earliest characteristic changes effect. She was becoming increasingly distressed by her appear-
in acne? ance and was considering not taking up her university place,
A Comedones where she felt her appearance would be commented on by many
B Pustules people. Her drug treatment had included topical retinoids, ben-
C Erythema zoyl peroxide and oral antibiotics.
D Pigmentation
E Papules What is the most appropriate treatment for her now?
A Oral isotretinoin

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 COMMON DERMATOSES

B Oral contraceptive pill What is the most important advice to give when commencing
C Photodynamic therapy this treatment?
D Oral spironolactone A Consider an oral contraceptive to avoid pregnancy
E Oral antibiotics B Use factor 8 sunblock when exposed to the sun
C Be aware that psychosis is a possible unwanted effect
D Avoid vigorous exercise
Question 3
E Apply an emollient skin cream
A 21-year-old woman had severe acne unresponsive to topical
treatments. She was advised to take oral isotretinoin.

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