A c n e Vu l g a r i s :

Pathogenesis,
Trea tment, and
N e e d s As s e s s m e n t
Siri Knutsen-Larson, MDa,1, Annelise L. Dawson, BAa,1,
Cory A. Dunnick, MDa,*,
Robert P. Dellavalle, MD, PhD, MSPHb
KEYWORDS
 Acne vulgaris  Epidemiology  Treatment

EPIDEMIOLOGY
Acne is a highly common skin condition. Still, estimates of acne prevalence vary substantially given

the absence of a universally accepted diagnostic

or grading schema. Additionally, estimates
continue to change as the prevalence of acne
decreases secondary to improved treatment
modalities.9 Acne is most common in adolescents,
affecting approximately 85% of teenagers.9,10
Acne prevalence after adolescence decreases
with increasing age, but disease burden in younger
adults is still quite high.8 A common misconception by the medical and lay community is that
acne is a self-limited teenage disease and, thus,
does not warrant attention as a chronic disease.
Nevertheless, the chronicity of many cases of
acne as well as the well-documented psychologic
effects of chronic acne contributes to the burden
of the disease.2,3,11
The average age of onset of acne is 11 years in
girls and 12 years in boys.12,13 Acne is increasing
in children of younger ages, with the appearance
of acne in patients as young as 8 or 9 years of
age. This trend toward earlier development of
acne is thought to be related to the decreasing
age-of-onset of puberty that has been observed
in the United States.14 Acne is more common in
males in adolescence and early adulthood, which

a
Department of Dermatology, University of Colorado Denver, PO Box 6511, Mail Stop 8127, Aurora, CO 80045,
USA
b
Dermatology Service, Denver Department of Veterans Affairs Medical Center, University of Colorado School
of Medicine, Colorado School of Public Health, 1055 Clermont Street, Mail Code #165, Denver, CO 80220, USA
1
Both authors contributed equally to this article.
* Corresponding author. Department of Dermatology, University of Colorado Denver School of Medicine,
Aurora Court F703, PO Box 6510, Aurora, CO 80045.
E-mail address: cory.dunnick@ucdenver.edu

Dermatol Clin 30 (2012) 99106

doi:10.1016/j.det.2011.09.001
0733-8635/12/$ see front matter 2012 Elsevier Inc. All rights reserved.

derm.theclinics.com

Acne vulgaris is a common skin condition with

substantial cutaneous and psychologic disease
burden. Studies suggest that the emotional impact
of acne is comparable to that experienced by
patients with systemic diseases, like diabetes
and epilepsy.13 In conjunction with the considerable personal burden experienced by patients
with acne, acne vulgaris also accounts for
substantial societal and health care burden. Americans use more than 5 million physician visits for
acne each year, leading to annual direct costs in
excess of $2 billion.4,5 Acne is the most common
diagnosis made by dermatologists and is also
commonly made by nondermatologist physicians.6,7 The pathogenesis and existing treatment
strategies for acne are complex.8 This article
discusses the epidemiology, pathogenesis, and
treatment of acne vulgaris. The burden of disease
in the United States and future directions in the
management of acne is also addressed.

100

Knutsen-Larson et al
is a trend that reverses with increasing age.12,13 It
is well known that adult acne is more common in
women. Adult acne typically represents chronic
acne persisting from adolescence, not new-onset
disease.15,16
Other factors impacting acne prevalence and
severity include ethnicity and genetic propensity.
Acne age of onset and disease character vary
among patients of different ethnicities. Scarring
and pigmentary changes are common in skin of
color. Propensity to scar and to develop hyperpigmentation is highest among Hispanic and African
American patients, respectively.12,17 These longterm disease consequences are challenging to
treat and contribute to the disease burden. In
addition, genetic factors impact the propensity
to develop acne. Adolescent and adult acne is
more common in children of parents with a history
of acne.12,18,19
Several modifiable factors alter acne risk. Cigarette smoking, for example, raises acne risk with
disease severity worsening in a dose-dependent
fashion with increasing number of cigarettes
smoked daily.13 Although evidence regarding the
impact of dietary factors on acne is equivocal,
studies suggest that dairy intake increases acne
risk.2022 Finally, traditional opinion in dermatology
holds that acne tends to improve during summer
months when sun exposure is greater. 23 This
finding is supported by an observed seasonal
decrease in physician visits for acne during
summer months.24 Nevertheless, no studies exist
to support this association and use of UV light to
treat acne has been rejected.23 Undoubtedly,
acne is a complex disease process influenced by
both genetic and environmental factors.

hyperplasia, and various endocrine tumors, result

in a higher circulating level of androgens and
are associated with the development of acne
vulgaris.27
The corporal distribution of acne depends on pilosebaceous gland density and morphology and,
thus, is common in regions where these structures
are largest and most abundant: the face, chest,
neck, and back. Noninflammatory acne is characterized by the formation of open or closed
comedones. Open comedones, or blackheads,
demonstrate darkly colored hyperkeratotic plugs
within the follicular opening. This dark coloration
is related to the oxidation of melanin and not dirt,
as is a common public misconception. Closed
comedones, or whiteheads, are white to flesh
toned in color and seem not to have a central
open pore.25
Changes in the skins natural flora accompany
this androgen-related increase in sebum production. Propionibacterium acnes, a normal component of the cutaneous flora, inhabits the
pilosebaceous unit using lipid-rich sebum as
a nutrient source. P acnes, therefore, flourishes
in the presence of increased sebum production,
leading to inflammation via complement activation and the release of metabolic byproducts,
proteases, and neutrophil-attracting chemotactic
factors.25,28 Inflammatory acne vulgaris lesions,
such as papules, pustules, nodules, or cysts,
develop when comedones rupture and contents
of the pilosebaceous unit spill into the surrounding
dermis.25,29 In severe cases, adjacent cysts may
coalesce to form channels or draining sinuses.
Inflammatory acne may produce cutaneous scarring or hyperpigmentation that persists long after
acne resolution.25

PATHOGENESIS
The pathogenesis of acne is a result of multifaceted processes within the pilosebaceous unit resulting in bacterial overgrowth and inflammation.
This condition typically develops at the time of
the pubertal transition when changes in the bodys
hormonal milieu alter pilosebaceous gland function. Initially, follicular epithelial cells differentiate
abnormally and form tighter intracellular adhesions
and, therefore, are shed less readily. This process
leads to the development of hyperkeratotic plugs,
or microcomedones, which enlarge progressively
to form noninflammatory, closed or open comedones. 25 Circulating and cutaneously derived
androgens, often named the primary inciting factor
in the development of acne, induce sebum
production, further contributing to the development of comedones.26 Conditions, such as polycystic ovarian syndrome, congenital adrenal

PREVENTION
External factors play an important role in the development of acne lesions. Cigarette smoking and
dietary factors increase acne risk and disease
severity. In addition, certain skin and hair products
and use of occlusive clothing articles contribute to
acne development. The removal of any of these
factors may lead to an improvement in disease
severity.
The link between smoking and acne is well established.13 Even though smoking avoidance and
cessation should be encouraged in all patients,
this preventive message is especially important
for patients suffering from acne. Practitioners
should emphasize not only that smoking increases
acne risk but also that a dose-dependent relationship exists between daily cigarette use and acne
disease severity.

Acne Needs Assessment

The controversial relationship between diet and
acne has been studied for many years. There is no
reputable evidence to support a link between acne
and chocolate. Recently, however, studies have
suggested an association between milk and
acne.2022 This finding is based on increased
levels of insulinlike growth factor 1 in milk causing
an increase in circulating androgens. Associations
of omega-3 fatty acids, antioxidants, zinc, vitamin
A, and iodine with acne have also been proposed.
However, all of these areas require further
research.30 Dietary modification alone is not
adequate for acne prevention regardless of the
association between diet and acne. Individuals
with acne wishing to make dietary changes should
focus on the avoidance of dairy products as
perhaps the most evidence-based intervention.
Facial and hair products, especially cosmetics
and hair products containing oils, may lead to an
exacerbation of acne lesions.17,31 In addition,
repeated scrubbing with soaps, detergents, and
other agents can cause trauma to underlying
comedones, thereby increasing inflammation.
Thus, individuals with acne should select oil-free
or noncomedogenic products and refrain from
aggressively rubbing the face.32 Other factors
also contribute to pore occlusion, including tight
clothing and head gear. Hence, these articles
should be avoided when possible.

TREATMENT
In the United States, there is an overabundance
of treatment recommendations for patients with
acne. Unfortunately, few of these recommendations are evidenced based and comparative
studies are limited.33 In fact, in 2009, the Institute
of Medicine listed acne as a priority for comparative
effectiveness research evaluating treatment regimens.34 Recently published treatment algorithms
include A Global Alliance to Improve Outcomes
in Acne, those endorsed by the American
Academy of Dermatology, and recommendations
from a European expert group on oral antibiotics
to treat acne.32,35,36 These recommendations are
based on expert opinion given the limited evidence
available. All of the guidelines recommend similar
approaches focusing on acne severity and degree
of inflammation. In addition, acne treatment recommendations may be based on skin type, clinical
classification of acne, and preexisting acne
scaring.37 Treatment options include proper skin
care, topical and oral antimicrobials, topical and
systemic retinoids, benzoyl peroxide, and oral
contraceptives for female patients. These treatments are often used in combination to achieve
disease resolution.

A primary initial treatment approach is proper

skin care. This care includes eliminating the aforementioned extrinsic factors as well as encouraging
proper skin hygiene and adherence to prescribed
acne treatment regimens. Although it was previously thought that excessive skin cleansing
contributes to the formation of acne, several small
studies indicate that facial cleansing, even when
performed up to 4 times daily, is not harmful and
may, in fact, diminish acne severity.3840 Patient
education in proper hygiene includes counseling
regarding appropriate skin cleanser and moisturizer selection.41
If skin care alone does not lead to the resolution
of cutaneous lesions, topical and systemic antimicrobials may be used. Topical antibiotics may be
used to treat mild to moderate acne. Systemic
antibiotics are indicated when acne is moderate
to severe or if disease manifestations are
producing marked psychosocial stress for
patients.28 The purpose of this treatment modality
is to decrease the presence of P acnes on the skin
surface and within the pilosebaceous unit.42 Antibiotics confer more than antimicrobial properties.
They also produce antiinflammatory effects, inhibit
neutrophil chemotaxis, and alter compliment pathways, all of which aid in the treatment of acne.28
Various classes of antibiotics, such as sulfonamides, macrolides, tetracyclines, and dapsone,
may be used to treat acne.28,42
Widespread and long-term use of antibiotics
has led to the development of P acnes resistance
and has also been associated with Staphylococcus resistance.28,43,44 Thus, when treating
with antimicrobials, the prescribing clinician must
consider not only local patterns of resistance but
also patient adherence to a regimen that will not
promote selection for resistant bacterial strains.
It is also important to avoid protracted antibiotic
courses. Monotherapy with antimicrobials should
be avoided, especially when using macrolides
that are most often associated with the development of resistance.28,44 Instead, successful treatment is often seen when pairing antimicrobials
with benzoyl peroxide, hormonal therapies, and
retinoid preparations.28,42
In women with mild to moderate acne,
combined oral contraceptives (COCs) can be
used. A recent Cochrane review concluded that
this method of treatment reduces acne severity
when compared with placebo.45 Even though
androgen levels are often normal in women with
acne vulgaris, hormonal therapies combating
androgens seem to benefit these patients.46
Progestins tend to be proandrogenic but most
COCs are estrogen dominant. Estrogen containing
oral contraceptives increase circulating levels of

101

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Knutsen-Larson et al
steroid hormone binding globulin which results in
lower circulating levels of testosterone. Different
COCs contain varying levels of progestins and
the implications of this require further research.45
In women with mild to moderate acne who do
not desire childbearing, COCs are a good treatment recommendation. Oral contraceptives are
often paired with other acne therapies.32
Topical retinoids represent the most commonly
prescribed treatment option because they are
effective in both the treatment and prevention of
acne.47 The mechanism of action of retinoids
involves preventing the primary acne lesion, which
decreases inflammation.48 This drug class is an
excellent choice for both initial and maintenance
therapy and assists many patients in achieving
adequate disease control. Depending on the
case, topical retinoids can be paired with
benzoyl peroxide, antimicrobials, or with oral
contraceptives.
Finally, oral isotretinoin is an option for severe,
refractory acne. The mechanism of action includes
decreasing sebaceous gland activity with a resultant decrease in sebum secretion. This action
effectively diminishes overgrowth of P acnes,
which is a key pathogenic factor. The drug also
inhibits keratinocyte hyperplasia and instead
promotes normal differentiation.49 Isotretinoin
must be prescribed carefully because it carries
several black box warnings, including teratogenicity, possible change in mood status, and hypertriglyceridemia, among others.49,50 This drug is the
only acne treatment option that permanently
changes the course of the disorder. However,
because of the considerable side effects, it should
only be used in those with refractory nodular acne.
Given the increasing trend toward treatment
with several agents simultaneously, providers
have come to rely on the use of combination
agents in the treatment of acne. These agents
include pairings of topical antibiotics with benzoyl
peroxide, topical antibiotics with retinoids, and
others. Use of combined agents has been demonstrated to improve patient adherence to
prescribed regimens.51 Given that poor adherence
to complex medication regimens limits treatment
efficacy and contributes to the chronicity and
burden of acne, providers should aim to simplify
treatment regimens and use combined agents
when feasible.

ACNE SCARRING
Despite the many treatment options, acne scars
still develop in some patients. They result from
skin damage during the healing process of acne.
Acne scars are divided into 2 groups: more

common atrophic scars and hypertrophic scars.

Treatments for acne scarring include, but are not
limited to, topical treatments, chemical peels,
dermabrasion, laser, and dermal grafting. Unfortunately, there are no well-accepted guidelines to
optimize acne scar treatment. Additional research
is required to determine cost-effectiveness and
establish the duration of treatment effects.52

BURDEN OF TREATMENT
The annual cost of acne treatment is quite high
given the prevalence and chronicity of the
disease. Acne represents the most common
dermatologic diagnosis in the United States.6,7
A study based on data from 2004 estimates that
the annual direct cost of acne management is
more than $2.5 billion. Acne ranks second only
to skin ulcers and wounds in annual cost burden
for dermatologic illness.4
In addition to the high cost burden, the treatment of acne produces heavy physician demands.
Acne accounts for more than 5 million physician
visits annually, or approximately 8% of all dermatologic health care visits.5,7,53 Two-thirds of physician visits for acne are made by women,
suggesting that women are more likely than men
to seek medical care for acne.53,54 Contrary to
the perception of acne as a disease of adolescents
only, individuals aged older than 18 years account
for more than 60% of acne-related visits. Nevertheless, the health care burden of adolescent
acne is substantial, with patients aged 12 to 17
years composing nearly 40% of the visits.
Although recent studies have demonstrated an
increase in acne prevalence for children aged
younger than 12 years, these patients account
for the minority of health care visits or less than
2% of all physician visits for acne.54

AVAILABLE SERVICES
Acne vulgaris is managed in the outpatient setting
by both specialist and generalist physicians.
Dermatologists provide approximately two-thirds
of all acne care in the United States, followed by
pediatricians (16%), general/family practitioners
(12%), internists (5%), and obstetricians/gynecologists (1%).55 Long wait times and poor geographic distribution of the dermatologic workforce
are 2 factors thought to promote the use of nondermatologist care in acne treatment.56,57 Furthermore, several characteristics, including being
younger than 18 years of age, Hispanic ethnicity,
receipt of care in the West or Midwest, and the
use of public medical insurance, are predictive of
nondermatologist acne care.55

Acne Needs Assessment

Use of nondermatologist care in acne treatment
is relevant because it may not be equivalent to the
care provided by dermatologists. Studies report
differences in prescribing patterns and varying
regimen complexity between dermatologists and
general practitioners. In particular, generalists are
less likely to prescribe topical retinoids and are
more likely to prescribe antibiotic monotherapy,
which are trends not in line with the present
recommendations.47,58
Overall, generalists receive limited training in the
treatment of dermatologic disease. US medical
schools provide on average only 21 hours of
dermatology training before graduation, and
dermatologic training in pediatric and internal
medicine residencies is limited.5961 Dermatologists diagnose acne many times more frequently
then do their generalist counterparts and this
quantity of experience also contributes to the
expertise of dermatologists in treating acne.7,62
Even so, the role of nondermatologist care of
acne should not be undervalued, given the
substantial burden of acne. Medical school and
residency training programs should place greater
emphasis on dermatologic education. Future
efforts to develop standardized, evidence-based
acne treatment guidelines may assist nondermatologists in providing comparable acne care.
In addition to the acne treatment by physicians,
there has also been a growing trend toward the
use of physician assistants (PAs) and other midlevel providers in the management of dermatologic
disease. In fact, dermatologists are second only
to ophthalmologists in their use of PAs. In 1997,
1 in every 32 patients visiting a dermatology clinic
was seen by a PA, which is a proportion that is
thought to have increased markedly since that
time. PAs work under the supervision of a physician; however, more than one-quarter of patients
seeing a PA for dermatologic complaints are not
directly evaluated by a physician.63 To the authors
knowledge, no exact figures are available for the
use of PAs in the treatment of acne specifically.
Nevertheless, anecdotal experience indicates
that acne is a condition commonly managed by
dermatology PAs and that the use of PAs to evaluate acne may diminish the costs associated with
acne management. Further analyses of the efficacy and cost of PA management of acne are
warranted.
In addition to the care resources offered
through physicians and midlevel providers, many
online resources are available to patients suffering
from acne. The American Academy of Dermatology (www.aad.org) offers detailed patient information on acne and also hosts a searchable
database that aids patients in locating

dermatologists in their geographic region. AcneNet (http://skincarephysicians.com/acnenet/

index.html) provides similar patient material online. Social networking and other online media
sources host abundant content describing acne
management. Although much of this online
content is unregulated and should be interpreted
carefully, numerous reliable health information
sources exist. Physicians should be aware of
the many accurate online resources to which
they can direct patients as well as the unregulated
content their patients may be accessing.

FUTURE DIRECTIONS
Going forward, several priorities should guide
acne research and management efforts. First, it
is imperative that comparative effectiveness
research is emphasized and evidence-based
treatment strategies are established for acne.
Not only will this enhance patient outcomes but
this will also allow for better control of the costs
and physician demands associated with acne
treatment. The establishment of optimal treatment
regimens would be expected to diminish the chronicity and, hence, burden of acne disease.
Furthermore, standardized recommendations
would help enable nondermatologist physicians
to provide appropriate care and assist in meeting
the demands of acne management. Likewise,
medical school and residency training programs
must emphasize dermatology education. Generalists commonly manage dermatologic illness and
their ability to effectively do so relies heavily on
adequate training.
Efforts to explore alternative care resources
should be supported. Already, the use of PAs
and other midlevel providers has been established
in dermatologic practice. Further analyses of the
efficacy and cost-effectiveness of midlevel
provider care should be pursued. Additionally, in
recent years, the use of the teledermatology and
Internet-based dermatologic care in the treatment
of acne has been explored. The use of digital
images to monitor treatment progress has been
proposed and may be reliable with certain assessment measures, such as total inflammatory lesion
count.64 Similarly, online follow-up visits for acne
have been demonstrated to produce equivalent
patient outcomes.65 The use of digital and online
resources to treat acne may diminish cost burden
and assist in making dermatology services available to patients in regions with limited dermatologic resources.
Finally, cellular phone and Internet technology
may be used to promote adherence to treatment
regimens through the use of patient reminders.

103

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Knutsen-Larson et al

List of Acronyms
COCS
IGF-I
P Acnes

Combined oral contraceptives

Insulin like growth factor I
Propionibacterium Acnes

7.

8.

Adolescents and young adults, the patients most

impacted by acne, are simultaneously highly
receptive to the use of technology and prone to
medication noncompliance. Improved treatment
adherence could help to diminish the acne
burden of disease. Physicians must proceed
creatively yet cautiously as they develop new
approaches to manage acne and control disease
burden.

SUMMARY
Acne vulgaris is a common dermatologic disease
that results in high monetary and physician use
demands in the United States. The pathogenesis
and treatment of acne is complex and requires
ongoing research to establish best-practice guidelines. In the meantime, physicians should emphasize existing evidence-based recommendations,
including the use of topical retinoids and avoidance of antibiotic monotherapy, in the treatment
of acne. Moreover, clinicians must continue to
pursue innovative strategies, such as the use of
nonphysician providers, teledermatology, and
other technologic resources, as a means by which
to enhance acne management and limit the
substantial burden of this prevalent disease.

REFERENCES
1. Mallon E, Newton J, Klassen A, et al. The quality of
life in acne: a comparison with general medical
conditions using generic questionnaires. Br J Dermatol 1999;140:6726.
2. Dalgard F, Gieler U, Holm JO, et al. Self-esteem and
body satisfaction among late adolescents with acne:
results from a population survey. J Am Acad Dermatol 2008;59:74651.
3. Uhlenhake E, Yentzer BA, Feldman SR. Acne vulgaris and depression: a retrospective examination.
J Cosmet Dermatol 2010;9:5963.
4. Bickers DR, Lim HW, Margolis D, et al. The burden of
skin diseases: 2004. J Am Acad Dermatol 2006;
55(3):490500.
5. Fleischer AB Jr, Feldman SR, Rapp SR. Introduction.
The magnitude of skin disease in the United States.
Dermatol Clin 2000;18(2):xvxxi.
6. Thompson TT, Feldman SR, Fleischer AB. Only 33% of
visits for skin disease in the US in 1995 were to

9.

10.

11.

12.
13.

14.

15.

16.

17.

18.

19.

20.
21.

22.

23.

24.

dermatologists: is decreasing the number of dermatologists the appropriate response? Dermatol Online
J 1998;4(1):3.
Stern RS. Dermatologists and office-based care of
dermatologic care in the 21st century. J Investig
Dermatol Symp Proc 2004;9(2):12630.
Collier C, Harper J, Cantree W, et al. The prevalence
of acne in adults 20 years and older. J Am Acad
Dermatol 2007. Available at: http://www.eblue.org.
Accessed January 10, 2011.
Stathakis V, Kilkenny M, Marks R. Descriptive epidemiology of acne vulgaris in the community. Australas
J Dermatol 1997;38:11523.
Kraning K, Odland G. Prevalence, morbidity and
cost of dermatologic diseases. J Invest Dermatol
1979;73:395401.
Gollnick HPM, Finlay AY, Shear N. Can we define
acne as a chronic disease? Am J Clin Dermatol
2008;9(5):27984.
Dreno B, Poli F. Epidemiology of acne. Dermatology
2003;206:710.
Schafer T, Nienhaus A, Vieluf D, et al. Epidemiology
of acne in the general population: the risk of
smoking. Br J Dermatol 2001;145:1004.
Friedlander SF, Eichenfield LF, Fowler JF, et al. Acne
epidemiology and pathophysiology. Semin Cutan
Med Surg 2010;29:24.
Goulden V, Clark S, Cunliffe W. Post adolescent
acne: a review of clinical features. Br J Dermatol
1997;136:6670.
Goulden V, Stables I, Cunliffe WJ. Prevalence of
facial acne in adults. J Am Acad Dermatol 1999;
41(4):57780.
Taylor SC, Cook-Bolden F, Rahman Z, et al. Acne
vulgaris in skin of color. J Am Acad Dermatol
2002;46(Suppl 2):S98106.
Ghodsi SZ, Orawa H, Zouboulis CC. Prevalence,
severity, and severity risk factors of acne in high
school pupils: a community-based study. J Invest
Dermatol 2009;129:213641.
Goulden V, McGeown CH, Cunliffe WJ. The familial
risk of adult acne: a comparison between firstdegree relatives of affected and unaffected individuals. Br J Dermatol 1999;141:297300.
Davidovici BB, Wolf R. The role of diet in acne: facts
and controversies. Clin Dermatol 2010;28:126.
Spencer EH, Ferdowsian HR, Barnard ND. Diet and
acne: a review of the evidence. Int J Dermatol 2009;
48:33947.
Adebamowo C, Spiegelman D, Berkey CS, et al.
Milk consumption and acne in teenaged boys.
J Am Acad Dermatol 2008;58:78793.
Gfesser K, Worret WI. Seasonal variations in the
severity of acne vulgaris. Int J Dermatol 1996;35:
1167.
Hancox JG, Sheridan SC, Feldman SR, et al.
Seasonal variation of dermatologic disease in the

Acne Needs Assessment

25.
26.

27.

28.

29.
30.
31.
32.

33.
34.

35.

36.

37.
38.

39.

40.

41.
42.

USA: a study of office visits from 1990 to 1998. Int J

Dermatol 2004;43:611.
Brown SK, Shalita A. Acne vulgaris. Lancet 1998;
351(9119):18716.
Chen W, Thibouot D, Zouboulis CC. Cutaneous
androgen metabolism: basic research and clinical
perspectives. J Invest Dermatol 2002;119(5):
9921007.
Imperato-McGinley J, Gautier T, Cai L, et al. The
androgen control of sebum production. Studies of
subjects with dihydrotestosterone deficiency and
complete androgen insensitivity. J Clin Endocrinol
Metab 1993;76:5248.
Tan AW, Tan HH. Acne vulgaris: a review of antibiotic
therapy. Expert Opin Pharmacother 2005;6(3):
40918.
Rubin E. Essential pathology. 3 edition. Baltimore
(MD): Lippincott Williams & Wilkins; 2001.
Bowe W, Joshi S, Shalita A. Diet and acne. J Am
Acad Dermatol 2010;61(1):12441.
Nguyen Q, Kim Y, Schwartz R. Management of
acne vulgaris. Am Fam Physician 1994;50(1):8999.
Gollnick H, Cunliffe W, Benson D, et al. Management
of acne: a report from a global alliance to improve
outcomes in acne. J Am Acad Dermatol 2003;49:
S137.
Williams HC, Dellavalle RP, Garner S. Acne vulgaris.
Lancet 2011. [Epub ahead of print].
Ratner R, Eden J, Wolman D, et al. Initial national
priorities for comparative effectiveness research.
Institute of Medicine. Washington, DC: National
Academies Pr; 2009.
Strauss J, Krowchuk DP, Leyden J. Guidelines of
care for acne vulgaris management. J Am Acad Dermatol 2007;6(4):65163.
Dreno B, Bettoli V, Oschendorf F, et al. European
expert group on oral antibiotics in acne. European
recommendations on the use of oral antibiotics for
acne. Eur J Dermatol 2004;14:3919.
Haider A, Shaw J. Treatment of acne vulgaris. JAMA
2004;292(6):72635.
Choi JM, Lew VK, Kimball AB. A single-blinded,
randomized, controlled clinical trial evaluating the
effect of face washing on acne vulgaris. Pediatr Dermatol 2006;23(5):4217.
Draelos ZD. The effect of daily facial cleanser for
normal to oily skin on the skin barrier of subjects
with acne. Cutis 2006;78(Suppl 1):3440.
Choi YS, Suh HS, Yoon MY, et al. A study of the efficacy of cleansers for acne vulgaris. J Dermatolog
Treat 2010;21:2015.
Goodman G. Cleansing and moisturizing in acne
patients. Am J Clin Dermatol 2009;10:S16.
Leyden J, Rosso JD, Webster G. Clinical considerations in the treatment of acne vulgaris and other
inflammatory skin disorders: a status report. Dermatol Clin 2009;27:115.

43. Eady EA. Bacterial resistance in acne. Dermatology

1998;196(1):5966.
44. Eady EA, Gloor M, Leyden JJ. Propionibacterium
acnes resistance: a world wide problem. Dermatology 2003;206(1):546.
45. Arowojolu A, Gallo M, Lopez L, et al. Combined oral
contraceptive pills for the treatment of acne.
Cochrane Database Syst Rev 2009. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/17253506.
Accessed January 15, 2011.
46. Bolognia J, Jorizzo J, Rapini R. Dermatology, vol 1.
2nd edition. Philadelphia: Elsevier; 2003.
47. Yentzer BA, Irby CE, Fleischer AB, et al. Differences
in acne treatment prescribing patterns of pediatricians and dermatologists: an analysis of nationally
representative data. Pediatr Dermatol 2008;25(6):
6359.
48. James W. Acne. N Engl J Med 2005;352(14):
146372.
49. Ward A, Brogden R, Heel R, et al. Isotretinoin. A
review of its pharmacological properties and therapeutic efficacy in acne and other skin disorders.
Drugs 1984;28(1):637.
50. Brelsford M, Beute T. Preventing and managing the
side effects of isotretinoin. Semin Cutan Med Surg
2008;197(3):197206.
51. Yentzer BA, Ade RA, Fountain JM, et al. Simplifying
regimens promotes greater adherence and
outcomes with topical acne medications: a randomized controlled trial. Cutis 2010;86:1038.
52. Fabbrocini G, Annunziata M, Darco V, et al. Acne
scars: pathogenesis, classification and treatment.
Dermatol Res Pract 2010;2010:893080.
53. Stern RS. Medication and medical service utilization
for acne 1995-1998. J Am Acad Dermatol 2000;43:
10428.
54. Yentzer BA, Hick J, Reese EL, et al. Acne vulgaris in
the United States: a descriptive epidemiology. Cutis
2010;86:949.
55. Armstrong AW, Idriss N, Bergman H. Physician
workforce for acne care in the United States, 2003
through 2005. Arch Dermatol 2009;145(10):11956.
56. Resneck J Jr. Too few or too many dermatologists?
Difficulties in assessing optimal workforce size.
Arch Dermatol 2001;137(10):1295301.
57. Tsang MW, Resneck JS Jr. Even patients with changing
moles face long dermatology appointment wait-times:
a study of stimulated patient calls to dermatologists.
J Am Acad Dermatol 2006;55(1):548.
58. Balkrishnan R, Fleischer AB Jr, Paruthi S, et al.
Physicians underutilize topical retinoids in the
management of acne vulgaris: analysis of U.S.
national practice data. J Dermatolog Treat 2003;
14:1726.
59. McCarthy GM, Lamb GC, Russell TJ, et al. Primary
care-based dermatology practice: internists need
more training. J Gen Intern Med 1991;6:526.

105

106

Knutsen-Larson et al
60. Ramsay DL, Weary PE. Primary care in dermatology:
whose role should it be? J Am Acad Dermatol 1996;
35:10058.
61. Prose NS. Dermatology training during the pediatric
residency. Clin Pediatr 1988;27:1003.
62. Fleischer AB, Herbert CR, Feldman SR. Diagnosis of
skin disease by non-dermatologists. Am J Manag
Care 2000;6:114956.
63. Clark AR, Monroe JR, Feldman SR, et al. The
emerging role of physician assistants in the delivery

of dermatologic health care. Dermatol Clin 2000;

18(2):297302.
64. Bergman H, Tsai KY, Seo SJ, et al. Remote assessment of acne: the use of acne grading tools to evaluate digital skin images. Telemed J E Health 2009;
15(5):42630.
65. Watson AJ, Bergman H, Williams CM. A randomized
trial to evaluate the efficacy of online follow-up visits
in the management of acne. Arch Dermatol 2010;
146(4):40611.