• Acne is a common disorder of the pilosebaceous glands, characterized by follicular occlusion and inflammation, which affects predominantly adolescents.
• Acne vulgaris is the form of acne most commonly seen in adolescents. It is characterized by various types of lesions, including microcomedones, closed comedos, open comedos, papules, pustules, nodules, and cysts.

• Grade I: noninflammatory acne; comedones
• Grade II: moderate, inflammatory acne with comedones, papules, and occasional pustules
• Grade III: severe localized inflammatory acne
• Grade IV: severe, generalized inflammatory acne with pustules, nodules, and cysts

• Gram-negative acne
• Cosmetic acne: some moisturizing creams and oil-containing hair care products may produce comedonal acne.
• Occupational acne: certain products can cause obstruction of sebaceous follicles, including mineral oil, petroleum, coal tar, pitch, and halogenated aromatic hydrocarbons.
• Drug-induced acne: seen with use of androgens, steroids, barbiturates, phenytoin, isoniazid, rifampin, bromides, and iodides.
• Acne neonatorum: in infants post-delivery.

• Androgenic hormones (gonadal and adrenal)
• Bacterial colonization of sebum with anaerobic diphtheroids, Propionibacterium acnes, and coagulase-negative staphylococci
• Free fatty acids
• Abnormal keratinization of sebaceous and follicular ducts
• Progesterone may affect acne through a mechanism other than sebum secretion
• Cosmetics, creams, drugs

• Microcomedone: impaction of keratin, lipids, bacteria, and rudimentary hair within the sebaceous follicle. These are small and subclinical, but they are the precursors to all acne lesions.
• Open comedo (blackhead): epithelium-lined sac filled with keratin and lipid with a widely dilated orifice; cylindrical, 1 to 3 mm in length; black from melanin pigment in epidermis.
• Closed comedo (whitehead): flask-shaped, small, skin-colored, slightly elevated papules just beneath the skin’s surface. When the follicular wall ruptures, it expels sebum into the surrounding dermis, which initiates the inflammatory process.
• Papules: develop from obstructed follicles that have become inflamed.
• Pustules: these superficial or deep lesions are larger and more inflamed than papules.
• Nodules: formed when deep pustules rupture and form abscesses. These lesions are warm, tender, and painful. Over 8 to 10 weeks, granulation tissue forms, and healing with scar formation occurs. These usually occur at the jawline, earlobes, and neck.
• True cysts: lined by epithelium and usually result as an end product of pustules or nodules. They are not very common.

• Occurs in 85% of young people from 12 to 24 years of age.

• Permanent acne scars
• Cellulitis

• Acne improves with age, but 5% to 10% of young adults still complain of significant acne.

• Malassezia furfur (fungus) infection
• Pityrosporum disease

• Adenoma sebaceum from tuberous sclerosis

• Flat warts
• Acne rosacea
• Hidradenitis suppurativa

Question: Onset of acne?
Significance: Normally during Tanner stage II.

Question: Location?
Significance: Gives clues to cosmetic or occupational acne.

Question: Current skin-care regimen?
Significance: Can indicate what level of treatment is necessary.

Question: Use of over-the-counter medications?
Significance: Assesses current therapy.

Question: Use of prescription medications?
Significance: Assesses current therapy.

Question: Evidence of an androgenic disorder (amenorrhea, hirsutism, obesity)?
Significance: Guides therapeutic plan.

• Examine face, chest, and back. The face is usually affected, but the chest, back, thighs, buttocks, and upper arms can also be affected. Acne spares the hands, forearms, calves, feet, and axilla.
• Determine types of lesions present, number of each type, intensity of inflammation, extent of hyperpigmentation, and scarring.

• Benzoyl peroxide: bacteriostatic effect on Propionibacterium acnes; comedolytic action increases superficial vascular supply, with accelerated healing of lesions. Dose: comes in 1%, 2.5%, 5%, and 10% strengths; aqueous gels are tolerated better than compounds in alcohol or acetone base; start with 5% gel once a day and increase in 2 weeks to twice a day; may use 10% if 5% is not effective. Adverse effects: peeling and irritation; contact dermatitis; potential to bleach clothing.
• Tretinoin (vitamin A derivative): normalizes the epithelial lining of the follicle; increases production of follicular epithelial cells, resulting in expulsion of the compacted debris within the lumen; results in clearing of comedones and microcomedones. Creams are less irritating, followed by gels, then liquid. Start with 0.025% cream or 0.1% microsphere every other day at bedtime 20 minutes after washing with a mild soap. Apply a pea-sized amount only. May increase to higher strength if not effective. After 1 to 2 weeks of therapy, some irritation may occur. If it is severe, discontinue medication for a short time. After 3 to 4 weeks, a pustular eruption can occur, indicating the dislodging of microcomedones; treatment should continue. Adverse side effects: peeling and irritation; hyperpigmentation and hypopigmentation; sun sensitivity.
• Adapalene (Differin; a naphthoic acid with retinoid activity): modulates cell differentiation and formation of keratin within the hair follicle. Dose: available in 0.1% gel. Apply a pea-sized amount nightly after gently washing face with mild soap. Irritation and initial worsening of acne lesions may occur. Adverse side effects: redness, dryness, scaling, pruritis, and burning.
• Other exfoliants: washes and lotions usually contain salicylic acid, resorcinol, sulfur, or phenol; abrasive scrubs contain almond shells, aluminum oxide, or pumice. May cause drying and peeling, and remove oil from the skin, but they fail to prevent new lesions from occurring. Not as effective as benzoyl peroxide and tretinoin.

• Erythromycin (2%) and clindamycin (1% phosphate salt) solution, gel, and lotion forms; apply once or twice a day. Use in combination with tretinoin or benzoyl peroxide.
• Azelaic acid 20% (cream) has both antimicrobial and comedolytic properties. Dose: A thin film should be applied twice daily after cleansing with a gentle soap. Adverse side effects: generally well tolerated but may cause a temporary stinging sensation in some patients.

• Antibiotics: decrease population of Propionibacterium acnes; reduce amount of free fatty acids. Use: drugs used include tetracycline, minocycline, and erythromycin. Dapsone and clindamycin should be used under the guidance of an experienced dermatologist. Begin with tetracycline or erythromycin at a dose of 500 mg to 1 g daily in two or three divided doses. Minocycline, 50 to 100 mg daily, is also an effective regimen. Doxycycline 50 to 100 mg daily in one or two doses is another option for antibiotic therapy. Decrease dose after 4 weeks if improvement is noted. Some patients may be maintained on 250 mg of tetracycline or erythromycin every 1 to 2 days. May use oral antibiotics in combination with topical therapy. Adverse effects: tetracycline may cause anorexia, nausea, diarrhea, yeast vaginitis; and rare effects include: drug eruption, anemia, neutropenia, phototoxicity. Erythromycin may cause nausea, vomiting, diarrhea, and occasional drug eruptions.
• Isotretinoin (vitamin A derivative): reserved for cases of severe acne because of significant toxicity, and should be used only by doctors familiar with its use. Decreases sebum production to a minimum, normalizes formation of keratin, prevents comedo formation and decreases inflammation. Use: usual daily dose is 0.5 to 1 mg/kg/d divided into two doses; may give up to 2 mg/kg/d; length of therapy is 15 to 20 weeks; improvement continues after stopping the medication. Adverse effects: cheilitis (90%), xerosis (78%), dry mouth (70%), epistaxis (46%), conjunctivitis (40%), desquamation (16%). Isotretinoin is a severe teratogen, and, therefore, requires that female candidates for this therapy have intensive education. They MUST NOT become pregnant during therapy. There is no teratogenic effect on sperm.

• Topical tretinoin cream at bedtime every other night for 1 week and then every night, or
• Topical adapalene (Differin) gel at bedtime, or
• Topical benzoyl peroxide at bedtime

• Topical tretinoin, adapalene, or benzoyl peroxide every night
• Plus topical antibiotics once or twice a day
• If resistant to this therapy add an oral antibiotic

• Topical tretinoin or adapalene every night plus benzoyl peroxide every morning
• Topical antibiotics twice a day
• Systemic antibiotics if necessary
• Consider azeleic acid (Azelex) 20% cream, twice a day if pustules or scars are hyperpigmented (use instead of benzoyl peroxide and tretinoin)

• Topical tretinoin or adapalene every night plus benzoyl peroxide every morning
• Topical antibiotics twice a day
• Systemic antibiotics twice a day
• In addition, consider referral to dermatologist for isotretinoin (Accutane).

• Superficial papules will resolve in 5 to 10 days with little scarring except for post-inflammatory hyperpigmentation.
• Deep papules usually have more intense inflammation and can take weeks to resolve. There may also be scarring.
• Antibiotics should be tapered and discontinued as soon as possible after significant acne resolution by a trial withdrawal.
• Improvement is seen after 4 to 6 weeks of therapy.

• Lesions must not be picked at or squeezed. This may result in scarring.
• Avoid cleansers, cosmetics, and moisturizers that are comedogenic.
• Hair products with oil should be avoided. Also avoid wearing hair on the forehead.

• Frequent, vigorous washing or excessive scrubbing of the face with abrasives is unnecessary, and may lead to dermatitis.
• Astringents and rubbing alcohol make the skin’s surface less oily but have minimal beneficial effect on the acne. They may irritate the skin.

Q: What types of soaps should those with acne use?
A: It is best to use a gentle cleansing soap, such as Dove, Neutrogena, or Purpose twice a day. Washing with the fingertips is best, rather than using a scrubbing pad or washcloth.

Q: Does the acne have to be moderate to severe to use tretinoin?
A: Actually, tretinoin is one of the best topical medications to use for mild comedonal acne. It should be used every other night for a week and if there is no irritation, it can be increased to every night.

Q: Does diet affect acne?
A: Cola, chocolate, sweets, milk, ice cream, shellfish, nuts, and fatty foods have not been shown to have any effect on severity of acne.

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