Acne

Acne is a multifactorial chronic inflammatory disease of the pilosebaceous unit, most common during adolescence but may persist into adulthood.

It results from a combination of:

• Increased sebum production (androgen-driven)

• Follicular hyperkeratinization (plugging)

• Colonization with Cutibacterium acnes

• Inflammation

It presents with polymorphic lesions affecting mainly the face, chest, shoulders, and back.

Acne can significantly affect psychological well-being, causing low self-esteem, anxiety, and depression.

Epidemiology

• Common in teenagers (peak 15–19 years)

• Can affect adults, especially women

• More severe in males during adolescence

• Often worsens with hormonal changes

Risk Factors

• Puberty (androgen surge)

• Family history

• Oily cosmetics

• Steroids (systemic or topical)

• Anticonvulsants

• Lithium

• Polycystic ovarian syndrome (PCOS)

• Stress

• High glycemic index diet

Pathophysiology

Four key mechanisms:

1. Follicular plugging (microcomedone formation)

2. Increased sebum production

3. Bacterial proliferation (C. acnes)

4. Inflammatory response

This leads to formation of comedones, papules, pustules, nodules, and cysts.

Clinical Types

Non-inflammatory acne

• Open comedones (blackheads)

• Closed comedones (whiteheads)

Inflammatory acne

• Papules

• Pustules

• Nodules

• Cysts

Severe variants

• Nodulocystic acne

• Acne conglobata

• Acne fulminans (rare, systemic symptoms present)

Signs & Symptoms

• Open and closed comedones

• Pustules

• Nodular lesions

• Cystic lesions

• Oily skin

• Post-inflammatory hyperpigmentation

• Scarring (ice-pick, boxcar, rolling scars)

Commonly involves:

• Face

• Chest

• Shoulders

• Back

Diagnostic Criteria

Clinical diagnosis based on:

• Presence of comedones (essential for diagnosis)

• Inflammatory lesions (papules, pustules, nodules)

• Distribution on sebaceous areas

• Chronic or relapsing course

No laboratory test is required for routine cases.

Investigations

Usually not required.

Consider in selected cases:

• Hormonal profile (if irregular menses, hirsutism suspected PCOS)

• Fasting blood sugar (if metabolic syndrome suspected)

• Liver function tests (before isotretinoin)

• Lipid profile (before isotretinoin)

• Pregnancy test (before isotretinoin in females)

Treatment

Treatment depends on severity.

Non-Pharmacological Treatment

• Avoid precipitating factors (stress, oily cosmetics, steroids)

• Avoid picking or squeezing lesions

• Use mild soap and lukewarm water

• Avoid harsh antibacterial cleansers

• Maintain healthy lifestyle (exercise, balanced diet)

• Avoid excessive use of ointments

• Reduce high glycemic foods

Pharmacological Treatment

Mild to Moderate Acne (without scarring)

Apply:

• Benzoyl peroxide 2.5–5% once at night

OR

• Topical retinoid 0.05% once at night

Moderate Acne with Scarring Risk

• Doxycycline 100 mg daily for 1–3 months

OR

• Erythromycin 250 mg every 6 hours for 1–3 months

AND

• Benzoyl peroxide or topical retinoid

Nodulocystic / Conglobate Acne

• Isotretinoin (PO) 0.025–0.5 mg/kg/day

• Duration: at least 3–6 months

Monitor:

• Liver function

• Lipid profile

• Pregnancy test (mandatory in females)

Highly teratogenic – strict pregnancy prevention required.

Acne Fulminans

• Isotretinoin 0.025–0.5 mg/kg/day for 4–6 months

• Prednisolone 45 mg initially, reduce 5 mg daily until stopped

Complications

• Permanent scarring

• Hyperpigmentation

• Psychological distress

• Depression

Prevention

• Avoid triggering factors

• Avoid self-medication

• Early treatment to prevent scarring

• Proper skin hygiene

• Healthy diet and lifestyle

• Avoid steroid misuse