INTRODUCTION — Acne vulgaris is the most common skin disorder in North America. It affects an estimated 85 percent of adolescents, and is increasingly common among people over age 25. It may cause physical scars as well as embarrassment, anxiety, and shame, all of which can have a negative impact on a person's social life and self-esteem.Severe acne may cause scarring in the form of pits or pockmarks, and local inflammation can be followed by permanent changes in the skin's color, resulting in a darker red or brown tone at the site of healed acne lesions. Skin discoloration is most common in people with darker skin. While acne frequently resolves after adolescence, scarring and changes in skin color can last forever.DEFINITIONS — Pimples are lesions (well-defined abnormal areas) that may be classified as papules, pustules, nodules, or cysts. A papule is a raised lesion that is one centimeter (about one-half inch) or less in diameter A pustule is a papule that contains pus. Nodules are lesions that are one centimeter or larger, often extending deeper or higher than papules. They are often firm to the touch. Cysts are nodules filled with fluid, often pus. A closed comedo (whitehead) occurs when sebum (oils) accumulates beneath a thin layer of skin with little inflammation. An open comedo (blackhead) results when the follicle is spread open by skin cells (keratinocytes) that appear dark due to oxidation (changes that occur due to oxygen exposure).ACNE DEVELOPMENT — Acne develops as a result of blockages that develop in follicles within the skin. Follicles are glands in the skin that secrete sebum, an oily substance that lubricates the hair and skin. There are four basic steps involved in the development of an acne lesion. Hair follicles become blocked with an overabundance of normal skin cells known as keratinocytes. These cells combine with sebum, creating a plug in the follicle. The glands that produce sebum, known as sebaceous glands, enlarge during adolescence and sebum production increases. A high concentration of sebaceous glands is located in the face, neck, chest, upper back, and upper arms. The increase in sebum production provides a favorable environment for the overgrowth of bacteria that normally lives on the skin, called Propionibacterium acnes. Bacterial overgrowth causes local inflammation, which causes rupture of the follicle. This can lead to the formation of a papule or nodule. This can develop into a closed comedo, open comedo, or inflammatory pustule.CAUSESHormonal changes — Hormonal changes during adolescence cause the sebaceous glands to become enlarged and sebum production increases. In most people with acne, hormone levels are normal, but the sebaceous glands are highly sensitive to the hormones. Less often, women's hormone levels are affected by an underlying medical problem known as polycystic ovary syndrome (PCOS).Acne tends to resolve between ages 30 to 40, although it can persist into or develop for the first time during adulthood. Post-adolescent acne predominantly affects women, in contrast to adolescent acne, which predominantly affects men. Acne can flare before a woman's menstrual period, especially in women older than 30 years.External factors — Oil-based cosmetics may contribute to the development of acne. Oils, greases, or dyes in hair products can also worsen skin lesions. Water-based products are less likely to cause irritation.Soaps, detergents, and astringents are often used to treat acne. These treatments remove sebum from the skin surface but do not decrease sebum production; frequent or aggressive scrubbing with these agents can actually worsen acne.Acne mechanica is caused or worsened by heat, friction, and pressure from clothing or other equipment worn on the body. Turtlenecks, bra straps, shoulder pads, adhesive tape, tight-fitting clothing, orthopedic casts, and sports helmets can cause it. Certain groups have an increased risk of acne mechanica, including those who: Have a tendency to develop acne on the shoulders, back, and buttocks Wear potentially irritating clothing or equipment in high temperatures or humid conditions (eg, athletes, military)Diet — The role of diet in acne is controversial. Some studies have found associations between cow's milk and an increased risk of acne, perhaps because of hormones that occur naturally in milk. However, there is no strong evidence that high-fat foods or chocolate increase the risk of acne.Stress — Psychological stress can probably worsen acne. In several studies of students, acne severity appeared to worsen during times of increased stress .TYPES OF ACNEAcne vulgaris — This is the most common type of acne. It usually affects the face, neck, chest, upper back, and upper arms, which contain a high concentration of sebaceous glands. Acne vulgaris is classified according to its severity: Type 1 — Mainly comedones with an occasional small inflamed papule or pustule; no scarring present. Type 2 — Comedones and more numerous papules and pustules (mainly facial); mild scarring. Type 3 — Numerous comedones, papules, and pustules, spreading to the back, chest, and shoulders, with an occasional cyst or nodule; moderate scarring. Type 4 — Numerous large cysts on the face, neck, and upper trunk; severe scarring.Acne fulminans — This occurs mainly in adolescent males, and can cause severe inflammatory acne, fever, and joint pain. Patients with this condition should see a dermatologist for treatment, which includes oral steroids and isotretinoin (Accutane®).Rosacea fulminans — This causes an abrupt outburst of large, inflamed pustules. It mainly affects women who have experienced severe stress.Acne rosacea — This causes facial redness as a result of prominent blood vessels on the surface of the skin in the forehead, the chin, and the lower half of the nose. Acne rosacea does not cause comedones (whiteheads or blackheads).DIAGNOSIS — In most cases, the diagnosis of acne vulgaris is obvious and no additional testing is needed. In women with signs or symptoms of polycystic ovary syndrome, further testing may be recommended.TREATMENT — There is no single best treatment for acne, and various treatments or combinations of treatments may be recommended. Since acne lesions take at least eight weeks to mature, treatment should be used for a minimum of two to three months to determine if the treatment is effective. An increase in dose or change in treatment may be considered after that time.General measures — Skin care is an important aspect of acne treatment.Skin hygiene — Patients with acne should wash their face using a mild skin cleanser and warm (not hot) water. Skin cleansers should be slightly acidic and intended for the face (rather than the body). Some providers recommend avoiding use of a washcloth or loofah, and instead using the hands to wash the face. Vigorous washing with a loofah or washcloth, scrubbing, washing frequently, or use of an alkaline or body soap can worsen acne and damage the skin's surface, and thereby worsen acne.Picking or squeezing acne lesions should be avoided as this may worsen acne and cause inflammation and scarring. It can also cause lesions to become infected, which can increase the time and treatments required for healing.Moisturizers — Use of a moisturizer minimizes dryness and skin peeling, which are common side effects of some acne treatments. People with dry skin often benefit from a cream or lotion while people with oily skin may prefer a gel-based moisturizer. Moisturizers without fragrances or dyes are less likely to cause irritation.Sun protection — Some acne treatments increase the skin's sensitivity to sunlight (eg, retinoids, doxycycline). To minimize photosensitivity, sun avoidance and daily use of a sunscreen with SPF 15 or greater are recommended. People with acne should use non-comedogenic or non-acnegenic products to reduce the risk of new comedo development.Noninflammatory acne — The least severe type of acne lesion is the comedo (whitehead or blackhead without redness, swelling, and pus caused by inflammation). It is the most easily treated type of acne .Retinoids — Comedones often respond well to topical retinoid medications, including tretinoin (Retin-A®, Renova, Avita), adapalene (Differin®) and tazarotene (Avage®, Tazorac®). These medications slow the growth of keratin to prevent blockage of hair follicles, which can lead to the development of new comedones and inflammation in existing comedones .Retinoids can cause skin irritation. Adapalene and tretinoin can cause photosensitivity, meaning that they make the skin more sensitive to ultraviolet light. A sunscreen should be used during the day. Retinoids are usually applied twice per day, although people who develop skin irritation can reduce this to once a day or even once every other day.Most retinoids are available in a gel, cream, or lotion. Oily skin tends to respond better to gel, which can have a drying effect, while dry skin may benefit from the moisturizing action of a cream or lotion.Other topical medications — People who cannot tolerate retinoids may try other topical medications, such as salicylic acid, glycolic acid, or an antibiotic, azelaic acid (Azelex®, Finacea®). All of these treatments can be helpful in reducing comedones, and azelaic acid may reduce darkening of skin in people whose acne causes excess pigmentation .Comedo extraction — Removal of a whitehead or blackhead (comedo extraction) may be attempted by a trained healthcare provider. An anesthetic cream may be applied before the procedure, during which the provider uses a sterile device to open the skin and remove the comedo. Four to six weeks of treatment with a retinoid cream may be recommended before comedo extraction is attempted. Patients should not attempt comedo extraction on their own because this can worsen inflammation and cause scarring.Mild to moderate inflammatory acne — Mild to moderate acne with some inflammation is usually treated with topical retinoids (see "Retinoids" above), topical antibiotics, or benzoyl peroxide, which works both as an antibiotic and a comedo preventative. A combination of two medications, usually benzoyl peroxide with a topical antibiotic or retinoid (eg, tretinoin), is more effective in acne with significant inflammation.Benzoyl peroxide — Benzoyl peroxide is usually applied twice per day. It may be combined with a topical retinoid, in which case the benzoyl peroxide is applied in the morning and the retinoid is applied at night. It can irritate the skin, sometimes causing redness and scaling, and can bleach clothing, towels, bedding, and hair.Topical antibiotics — Topical antibiotics control the growth of acne bacteria and reduce inflammation. Topical antibiotics include erythromycin, clindamycin, azelaic acid, and metronidazole . As with all creams, lotions, and gels, topical antibiotics can cause skin irritation.Moderate to severe inflammatory acne — For patients with moderate to severe inflammatory acne, oral antibiotics or an oral retinoid known as isotretinoin may be recommended. Women often benefit from hormonal treatment with a combination contraceptive. Topical medication may be used in combination with oral treatments .Increased acne severity may mean that a large area of the body is affected, cysts are great in number or size, or that scarring has occurred. Patients with large cysts and severe scarring are treated differently than those with moderate scarring .Oral antibiotics — Oral antibiotics work to inhibit the growth of the acne-producing bacterium. Antibiotics taken in oral form act more rapidly and effectively than topical antibiotics . However, side effects associated with oral antibiotics include the development of vaginal candidiasis (yeast infection) in women, possibly decreased effectiveness of birth control pills, gastrointestinal symptoms (stomach upset), and the promotion of antibiotic resistance.Tetracycline is the most commonly prescribed oral antibiotic for acne because it is effective and relatively inexpensive. It must be taken on an empty stomach. It cannot be used during pregnancy or in children less than 12 years of age.Minocycline or doxycycline is useful in the treatment of acne, but these antibiotics can also cause side effects. Doxycycline can cause sun sensitivity, and can cause ulcers in the esophagus unless taken with adequate fluid. Minocycline can cause vertigo (dizziness), discoloration of the teeth, pseudotumor cerebri (an increase in the pressure of the fluid surrounding the brain and spinal cord, causing headache), and a lupus-like syndrome.Oral isotretinoin (Accutane) — Oral isotretinoin (Accutane®) is a potent retinoid medication that is extremely effective in the treatment of severe acne . It acts by blocking three events in the acne growth cycle: sebum secretion, inflammation, and the overgrowth of keratin that leads to comedones. It is the only medication that alters the natural course of acne, leaving nearly 40 percent of patients cured for life and over 80 percent in stable long-term remission. It is effective in treating the most disfiguring effects of acne.It is usually taken in pill form twice daily with food for 20 weeks, then stopped; the dose depends upon the patient's weight. A micronized form of isotretinoin is now available, which can be taken once per day with or without food. It is as effective as the non-micronized formula. In some cases, acne can initially worsen, requiring treatment with corticosteroids. Improvement often continues for up to five months after treatment is complete. Side effects and risks — Despite its positive effects, oral isotretinoin can have serious side effects and should be used with caution. Taking isotretinoin during pregnancy can cause miscarriage and life-threatening malformations in the baby. For these reasons, there are strict rules in the United States for healthcare providers, pharmacists, and patients regarding the use and prescription of oral isotretinoin. These rules do not apply to men or to women who are not able to become pregnant (eg, women who have undergone hysterectomy or who are post-menopausal). Prescriptions of isotretinoin are regulated by the iPLEDGE program which requires the following: All women must have two negative pregnancy tests before receiving a prescription, and then they must have monthly pregnancy tests throughout the course of treatment. Any woman who is or might become sexually active with a male partner must use two forms of birth control for at least one month before starting therapy and continue until one month after completion of therapy. Women who could become pregnant must fill their prescription within seven days of receiving it; after this time, a new prescription must be written.Information about oral isotretinoin can be found at the United States Food and Drug Administration web site, Non-pregnancy related side effects of isotretinoin may include: Dryness or shedding of skin, inflammation of the lips, itching, and sensitivity to ultraviolet light. There is concern about the relationship between isotetinoin and depression and suicidal behavior. While there is not enough evidence to conclude that it causes depression or suicidal behavior, patients taking isotretinoin should report any sadness, depression, or anxiety to their healthcare provider. Isotretinoin can cause increases in triglycerides (fatty substances related to cholesterol), liver damage, pancreatitis, and bone marrow suppression. Other problems include aching joints or muscles, bony growths, increased pressure in the brain, decreased night vision, and opacities of the cornea (the clear, front part of the eye). Also, because isotretinoin is related to vitamin A, taking it can cause elevated vitamin A levels.While many of these side effects are managed without stopping the drug, others can be dangerous and require that the patient immediately stop taking it. Regular contact with a physician is essential, as are regular blood tests to monitor cholesterol, triglycerides, liver function, and blood counts.Hormone therapy — The hormones progestin, and especially estrogen, can counterbalance the effect of androgens (hormones responsible for acne development). Estrogen treatment in the form of a birth control pill is often recommended for women with moderate or severe acne. (See "Patient information: Hormonal methods of birth control").Not all oral contraceptives should be used for the treatment of acne; some can actually worsen acne. Women should discuss the best options with their healthcare provider.Other medications are available to reduce the effects of androgens, including spironolactone, cimetidine, flutamide, and ketoconazole. Spironolactone can cause high blood levels of potassium, and monitoring of potassium levels and blood pressure is usually recommended.The benefits of combination contraceptives and other hormonal medications may not be seen until three to six months after treatment is started.Treatment during pregnancy — Many acne treatments are not safe for use during pregnancy. Women who are pregnant or intending to become pregnant should consider stopping all acne treatments before they become pregnant. If acne therapy becomes necessary, treatment options include oral or topical erythromycin and topical azelaic acid.When to seek help — Patients with noninflammatory acne may treat their acne with non-prescription products initially. Patients who do not improve after three months, and those with inflammatory acne usually benefit from seeing a healthcare provider for prescription drug management.SUMMARY Acne may cause physical and psychological scars and can have a negative impact on a person's social life, employment, and self-esteem. Although acne is usually a short-term problem, scarring and changes in skin color can last forever. Acne develops as a result of blockages in the skin's follicles. Follicles are glands in the skin that secrete sebum, an oily substance that lubricates the hair and skin. Hormonal changes during adolescence cause the sebaceous (oil-producing) glands to enlarge. This increases sebum production, which allows bacteria to overgrow. In most people with acne, hormone levels in the blood are normal, but the sebaceous glands are highly sensitive to these hormones. The role of diet in acne is controversial. Some studies have found associations between cow's milk and an increased risk of acne, perhaps because of hormones that occur naturally in milk. However, there is no strong evidence that high-fat foods or chocolate increase the risk of acne. There is no single best treatment for acne, and various treatments or combinations of treatments may be recommended. Since acne lesions take at least eight weeks to mature, treatment should be used for a minimum of two to three months. An increase in dose or change in treatment may be considered after that time. Oils, greases, or dyes in hair products and cosmetic creams can irritate the skin; water-based products are less likely to cause irritation. Clothing that rubs or chafes should be avoided. Patients with acne should wash their face with a mild skin cleanser, and warm (not hot) water. Vigorous washing, scrubbing, washing frequently may worsen acne and damage the skin's surface. Rubbing or picking the skin can worsen inflammation and scarring. Noninflammatory acne is usually treated with a topical retinoid cream, lotion, or gel. Persons with mild to moderate inflammatory acne may be treated with a retinoid cream, in addition to a topical benzoyl peroxide and oral antibiotic. People with moderate to severe inflammatory acne may be treated with oral antibiotics, oral isotretinoin (Accutane®), and for women, hormonal therapy, such as birth control pills. Many acne treatments increase the skin's sensitivity to sunlight. To minimize photosensitivity, sun avoidance and a sunscreen with SPF 15 or greater are recommended. Patients with mild acne may use non-prescription products to treat their acne initially. Patients who do not improve after three months of non-prescription treatment, and those with inflammatory acne usually benefit from seeing a healthcare provider for prescription treatments.WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation. Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.Some of the most pertinent include:Patient Level Information:Patient information: Polycystic ovary syndrome (PCOS) Patient information: Sunburn Patient information: Hormonal methods of birth control Professional Level Information:Approach to acne vulgaris-IA number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.
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