Acne most commonly presents as follicle-based comedones, inflammatory papules
or pustules on the face, neck, chest and back. Most patients with acne are teenagers, but
neonatal acne and adult acne are common also. According to some dermatologist, acne
causes profound negative psychological and social effects on the quality of life of patients.
Lots of adolescent patients have reported that lack of confidence and depression leading
to a lower quaity of life. The potential for hyperpigmentation and scarring into adulthood
affects later quality of life as well. Thus, more patients are presenting to health care provider seeking treatment and prevention. This report will help us capture more information about acne.
Acne is the most common skin condition characterized by red pimples on the skin,
especially on face, due to inflamed or infected sebaceous glands and prevalent cheifly
among adolescents. The onset of acne is usually around puberty, but in a minority of cases
it may also start sooner or later.
Figure 01. Two patients exhibited acne vulgaris.
Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit (comprising
hair follicle, hair shaft and sebaceous gland, so acne vulgaris sometimes call folliculitis).
Acne vulgaris is the most common form of acne and among the most common dermatological conditions worldwide with an estimated 650 million people affected. Acne vulgaris
is considered a chronic disease owing to its prolonged course, pattern of recurrence and
relapse. Moreover, acne vulgaris causes profound negative psychological and social effects
on the quality of life patient.
ANATOMY & PHYSIOLOGY
The skin & its accessory structure (hair, nails and glands) make up the integumentary
system of the body. The skin has many important function: (1) As a protective membrane
over the entire body; (2) Containing 2 types of glands that produce important secretions
(sebaceous glands produce sebum and sweat glands produce sweat); (3) Sensing for pain,
temperature, pressure and touch; (4) Thermoregulation.
Figure 02. Skin. (A) Three layers of the skin; (B) Epidermis.
Epidermis is the outermost layer or the surface epithelium of the skin, totally cellular
layer of the skin, containing keratin. The cells in the basal layer, or the deepest layer of
the epidermis, are constantly growing and multiplying and are the source of other cells
in the epidermis. As the basal layer cells divide, they are pushed upward by a stream of
younger cells. Cells in the most superficial layer of the epidermis, or stratum corneum,
flatten, shrink, lose their nuclei and die, becoming filled with keratin (so these cells are
also called keratinocytes).
Figure 03. Skin under the microscope. (A) Epidermis; (B) Dermis and Hypodermis.
Dermis, directly below the epidermis, is composed of blood and lymph vessels and
nerve fibers, as well as other accessory organs of the skin, which are the hair follicles,
sweat glands and sebaceous glands. The dermis is composed of interwoven elastic and
- Hair follicle is a sac within which each hair grow.
- Sweat glands are small glands found on almost all body surface, deep in the dermis
and straightens out to extend up through the epidermis. The tiny opening on the surface
is a pore. Sweat is almost pure water, with dissolved materials. Sweat cools the body as
it evaporates into the air.
- Sebaceous glands are located in the dermis over the entire body, with the exception
of the hands, feet and lips. They secrete an oily substance called sebum, containing lipids,
lubricates the skin and minimizes water loss. Sebaceous glands are closely associated with
hair follicles, and their ducts open into hair follicle through which the sebum is released.
The sebaceous glands are influenced by sex hormones, which cause them to hypertrophy
at puberty and atrophy in old age. Increased production of sebum is one of the reasons
can cause acne formation.
Hypodermis, or subcutaneous layer, is the deepes layer of the skin, specializes in the
formation of fat.
Most people experience acne during adolescence, with over 95% of teenage boys and
85% of teenage girls affected. About 20% of them have moderate-to-severe acne, and as
many as 50% continue to suffer from acne in adulthood. About 12% of women and 3%
of men will continue to have clinical acne until age 44. According to the analysis for the
Global Burden of Disease study indicated that acne was the eight most prevalent disease globally in 2010. Acne is most common in facial skin (about 85%), next is dorsal
skin (about 50%) and chest (about 25%).
When we classified based on dermal acne density, according to Global Evaluation,
acne vulgaris can be divided into 5 groups:
- Level 0. There is no lesion; residual pigmentation and erythema may be seen.
- Level 1. Almost no lesion; with a few scattered open or closed comedones and very
- Level 2. Mild acne, in which < 50% of the face (or other part) is involved with a few
comedones, papules and pustules.
- Level 3. Moderate acne, in which > 50% of the face (or other part) is involved with
many papules, pustules, comedons and a maximum of one nodule.
- Level 4. Severe acne, in which the entire (or > 75% other part) is involed, covered
with many papules, pustules, comedones and some nodules.
When we classified based on the degree of inflammation of acne, acne vulgaris can
be divided into 2 groups:
- Group 1: Non-Inflammatory Acne. This group of acne comprises of blackheads
and whiteheads. They are also called closed comedones (whiteheads) and opened comedones (blackheads). Blackheads are tiny, dark bumps; and whiteheads are tiny, white or
skin colored bumps. They are mild, non-inflammatory acne.
- Group 2: Inflammatory Acne. This group of acne comprises of papules, pustules,
nodules and cystic acne. Papules (also known as pimples) are raised, red bumps with no
white pus. Pustules are raised, red bumps with white pus. Nodules are hard and large red
painful lumps. Cystic acne are hard, large and red painful lumps with presence of cysts.
They are moderate-to-severe, inflammatory acne.
Figure. Classification of acne based on the degree of inflammation of acne.
SYMPTOMS & DIAGNOSIS
Acne signs and symptoms vary depending on the severity of disease:
1. Non-inflammatory acne.
- Whiteheads. Whiteheads, also called closed comdones, are small, round and white
bumps on the skin’s surface. This type of acne occurs when a pore becomes clogged with
sebum, dead skin cells and debris. In the case of whiteheads, these comedones have small
opening at the top of the skin. Air is not able to enter the follicle, melanin is not oxidized
so the pores have white color. Whiteheads commonly appear on the face, neck, chest and
- Blackheads. Blackheads, also called opened comedones, are small bumps that
appear on your skin due to clogged hair follicles. Blackheads look like black dots that
have formed on your skin. In the case of blackheads, these comedones have its follicles
with very large opening. Melanin is oxidized and turns the clogged pores a black color.
This form of acne is often found on face, back, chest, neck, arms, shoulders, etc.
2. Inflammatory acne.
- Papules. Papules are small, inflammatory, irritated pimples or swelling on the skin.
More distension of the comedones results in follicular rupture and inflammatory lesions
such as papules. Papules are hard when you touch them. Papules do not have pus because
only some leukocytes present at this stage.
- Pustules. Pustules are small pimples on the skin containing pus. In the case of pustules, inflammatory reaction increases, lots of leukocytes present and attack the bacteria
which cause infection and then release pus into the follicles to form pustules. Pustules are
similar to papules except yellowish, liquid pus.
- Nodules and cysts. Nodules are very large, inflammatory pimples. When inflamed
follicles erupts along the bottom, nodules will be formed. If the lesions are filled with
large amount of pus due to inflammatory reaction, the cysts will be formed. Inflammatory
lesions can be very painful and potentially lead to permanent scarring.
The diagnosis of acne vulgaris is based on the prehistory, physical examination and
clinical symptoms. Lesions most commonly develop in areas with the greatest concentration of sebaceous glands include the face, neck, chest, upper arms and back. The doctor
has to look at all of these parts to diagnose acne vulgaris. Androgen level test sometimes
is used to diagnose whether the patient has Cushing’s syndrome or PCOS. Proper diagnosis leads to higher treatment efficacy.
Acne can cause many complications that affect the quality of life of the patients.
1. Hyperpigmentation. Post-inflammatory hyperpigmentation (also known as PIH)
is a type of hyperpigmentation that can affect the face and body. It appears as flat spots
of discolouration, from pink to red, brown to black, depending on the skin tone and the
depth of discolouration. PIH often affects people with acne. Acne is a type of folliculitis.
This inflammation triggers melanocytes, or melanin-producing cells, to release excessive
melanin. The excessive melanin darken and discolor the wounded area, remaining there
long after the wound has recovered.
2. Scars. Scars are important permanent sequelae of acne. Up to 95% of patients with
acne have scars, with 30% developing severe scars.
Scars are important permanent sequelae of acne211,212. Up to 95% of patients
with acne have scars, with 30% developing severe scars
The approach to treating acne vulgaris depends on its presentation and severity. Some
studies suggests treating acne vulgaris as a chronic disease, such that early, aggressive and
maintainance therapy leads to better outcomes. According to different factors of pathology which contribute acne, other therapies are used, include: medical therapy, physical
modalities, psychological therapy, lifestyle management, etc.
- Medical therapy. A topical medication is a medication that is applied to particular
place on or in the body. An oral medication is a medication that can be taken orally and
swallowed through the mouth that will be absorbed in the gastrointestinal tract. Because
a topical medication works at the affected sites, it works quickly and effectively. Before
application, the face should be washed with warm water or a topical cleanser and dried
Mild acne. Mild acne can be treated with over-the-counter (OTC) medications
such as gels, soaps, creams, and lotions, that are applied to the skin. For noninflammatory acne, tropical retinoid and salicylic acid or azelaic acid could be
used to treat. For inflammatory acne, the doctor should combine these medicine
with some low-effective antibiotics.
Moderate-to-severe acne. The doctor should combine oral antibiotic, topical
retinoid and benzoyl peroxide to treat moderate-to-severe acne. If there is no
effect, alternative medications should be used. For acne caused by hormonal
disease (Cushing’s syndrome, PCOS in women, etc.), the doctor carefully use
hormonal therapy (oral contraceptives, spironolactone, dexamethasone, etc.)
to treat the symptoms. Isotretinoin is approved only for severe cystic acne.
- Physical modalities. Logical surgical treatment is helpful in quickly resolving the
comedones. Light electrode desiccation can be used to treat acne. The use of photodynamic therapy and various forms of light, laser or radiofrequency energy, which are capable
of destroying sebaceous glands and killing P. acnes, is under investigation. These methods
is an efficient, cost-effective, safe, no pain.
- Psychological therapy. For stressed patients, psychological therapy is considered
the best one. Different methods of stress reduction such as doing yoga, listening to music,
taking a deep sleep, etc. should be used to help stressed patients. When stress is reduced,
acne also decreases.
- Lifestyle managements. Changing the patient’s diet is the simpliest and easiest way
to treat mild acne. Heat-treated foods, such as vegetables, fruits, greentea, etc. should be
added to the diet.
There are many kinds of medicine for treating acne, they are divided into 4 groups:
- Group 01: Salicylic acid. Salicylic acid helps to correct the abnormal shedding of
dermocytes. For mild acne, salicylic acid helps unclog the pores to resolve, so the sebum
will be easier to escape and prevent the acne lesion formation. It does not have any effect
on sebum production and it does not kill bacteria. The effects will stop when you stop
using it, that means the pores will clog up again and the acne maybe returns.
Figure. Salicylic acid medicine.
- Group 02: Antibiotic medicine. Because bacteria as Propionibacterium acnes can
cause acne vulgaris, some medicines attack and destroy the bacteria associated with acne
can be used to treat acne and maybe prevent its development. Because it does not affect
on sebum production or the skin follicle cells are shed. When you stop using it, the acne
maybe comes back.
Benzoyl peroxide. Benzoyl peroxide is believed that this compound works by
destroying the bacteria associated with acne. It usually takes at least 4 weeks to
work and it must be used continously to keep acne at bay.
Topical antibiotics. Topical clindamycin and erythromycine are available in a
number of formulations. In general, they are well tolerated and are effective in
mild inflammatory acne. They should be combined with benzoul peroxide or
topical retinoid and applied directly to the skin.
Oral antibiotics. Some oral antibiotics are often used include: doxycycline,
minocycline and tetracycline, all of which are quite effective in many cases of
acne vulgaris. Oral erythromycine is also available. Using antibiotics to treat
acne maybe leads to antibiotic resistance, limiting its usefullness, so be careful
when you use antibiotics.
- Group 03: Retinoid (Vitamin A3). Retinoid works to keep pimples from being
able to form. It effects the growth of cells and decreases swelling and inflammation. Your
acne may appear to get worse before it gets better because it will work on the pimples
that have already started forming beneath your skin. So, it must be used continously and
maybe 8 to 12 weeks to get results.
- Group 04: Hormonal medicines. Hormonal medicines usually are used carefully
to treat symptoms of hormone disorders, including acne. Women with PCOS, late-onset
adrenal hyperplasia, late-onset acne, severe acne and acne unresponsive to other oral and
topical therapies are good candidates for hormonal treatment.
Oral contraceptives. Birth control pills contain female hormones (estradiol,
progesterone, etc.) that work by counteracting the effect of male hormones on
acne through negative feedback. The oral contraceptives block both adrenal
and ovarian androgens which cause acne vulgaris. The adverse reaction asso-
ciated with oral contraceptives: vomiting, weight gain, breast tenderness, etc.
Spironolactone. Spironolactone is an oral drug that can block the action of
the other hormones on sebaceous glands, so it will inhibit sebum production.
It it especially helpful for women who have acne that worsens around the time
Dexamethasone. Dexamethasone reduces androgen excess and ma alleviate
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