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 (topical) 2.5%–5% — apply once at night

OR

• Tretinoin cream (topical) 0.05% — apply once at night

Moderate acne with scarring

• Doxycycline (PO) 100 mg once daily for 1–3 months

OR

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

AND

• Benzoyl peroxide (topical) 2.5%–5% once at night or

• Tretinoin cream (topical) 0.05% once at night

Nodulocystic and/or Conglobate Acne

• Isotretinoin (PO) 0.025–0.5 mg/kg once daily for at least 3–6 months

AND

• Triamcinolone (intralesional) 40 mg/mL — administer as a single dose (stat) for acne cysts

Monitoring during isotretinoin therapy:

• Liver function tests

• Lipid profile

• Pregnancy test (mandatory in females of reproductive age)

Acne fulminans

• Isotretinoin (PO) 0.025–0.5 mg/kg once daily for at least 4–6 months

AND

• Prednisolone (PO) 45 mg as a single initial dose (stat), then reduce by 5 mg daily until discontinued

Important note

• Isotretinoin is contraindicated during pregnancy because it is highly teratogenic. Effective pregnancy prevention is essential before, during, and for an appropriate period after treatment.

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