16 Acne Vulgaris

ETIOLOGY
BASIC INFORMATION
DEFINITION
Acne vulgaris is a chronic disorder of the piloseba-
ceous apparatus caused by abnormal desquama-
tion of follicular epithelium leading to obstruction of
the pilosebaceous canal, resulting in inflammation
and subsequent formation of papules, pustules,
nodules, comedones, and scarring. Based on their
appearance, the acne lesions can be divided into
inflammatory (presence of papules, pustules, and
nodules) or noninflammatory (open and closed
comedones) For inflammatory acne, lesions can be
classified as papulopustular, nodular, or both. The
American Academy of Dermatology classification
scheme for acne denotes the following three levels:
1. Mild acne: Characterized by the presence of
comedones (Figs. E1 and E2) (noninflamma-
tory lesions), few papules and pustules (gen-
erally <10), but no nodules.
2. Moderate acne: Presence of several to many
papules and pustules (10 to 40) along with
comedones (10 to 40). The presence of >40
papules and pustules along with larger, deep-
er nodular inflamed lesions (Figs. E3 and E4)
(up to five) denotes moderately severe acne.
3. Severe acne: Presence of numerous or exten-
sive papules and pustules as well as many
nodular lesions (Fig. E5).
SYNONYM
Acne
ICD-10CM CODES
L70.0 Acne vulgaris
L70.1 Acne conglobata
L70.2 Acne varioliformis
L70.3 Acne tropica
L70.4 Infantile acne
L70.5 Acne excoriee des jeunes filles
L70.8 Other acne
L70.9 Acne, unspecified
L73.0 Acne keloid
- patients, levels of dehydroepiandrosterone
ease, with the principal abnormality being
comedone formation.
blockage in the ducts. The obstruction leads
to the formation of comedones, which can
become inflamed because of overgrowth of
Propionibacterium acnes.
humid, tropical climate), medications (e.g.,
iodine in cough mixtures, hair greases), indus-
trial exposure to halogenated hydrocarbons.
existing acne (e.g., excessive washing by
some patients to help rid them of their black-
heads or oiliness).
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
- influence is controversial.
ma cutis
WORKUP
products)
and androstenedione should be measured.
For women with regular menstrual cycles,
serum androgen measurements generally
are not necessary.
TREATMENT
NONPHARMACOLOGIC THERAPY
used for treatment of moderate inflammatory
acne vulgaris. Light in the violet/blue range
can cause bacterial death by a photoreaction
in which porphyrins react with oxygen to gen-
erate reactive oxygen species, which damage
the cell membranes of P. acnes. Treatment
usually consists of 15-min exposures twice
weekly for 4 wk. Phototherapy may be effec-
tive for short-term treatment of acne, but
long-term efficacy and how it compares with
conventional acne therapy is unclear.
is recommended. A high-glycemic diet may
worsen acne, although the strength of its
ACUTE GENERAL Rx
Treatment generally varies with the type of
lesions (comedones, papules, pustules, cystic
lesions) and the severity of acne. Table 1 sum-
marizes an acne treatment algorithm. First-line
treatment for mild acne vulgaris includes ben-
zoyl peroxide, a topical retinoid, or a combination
of topical medications, including topical antibiot-
ics. Use of topical treatments for 6 to 8 weeks
is required to judge their efficacy. Table E2
describes prescription topical therapies for acne.
treated with retinoids or retinoid analogs.
Topical retinoids are comedolytic and work by
normalizing follicular keratinization. Commonly

EPIDEMIOLOGY & gel or cream, applied once or twice daily),

DEMOGRAPHICS such as corticosteroids, anabolic steroids,
lithium, neuroleptics, cyclosporine
U.S.
state in all women (hirsutism, irregular men-
all teenagers being affected to some degree. ses, androgenic alopecia) or children (sebor-
rhea, acanthosis nigricans, onset of acne
18 yr in both genders. between ages 1 and 7 yr and no obvious
external factors)
LABORATORY TESTS
acne until the mid-40s. -
ful. Patients who are candidates for ther-
PHYSICAL FINDINGS & CLINICAL apy with isotretinoin should have baseline
PRESENTATION liver enzymes, cholesterol, and triglycerides
- checked because this medication may result
edones (whiteheads) in elevation of lipids and liver enzymes.
gel applied once daily), tretinoin microsphere
Tretinoin is inactivated by ultraviolet light and
oxidized by benzoyl peroxide; therefore it
should only be applied at night and not used
concomitantly with benzoyl peroxide.
-
tene is pregnancy category X. Salicylic acid
have keratolytic and antiinflammatory prop-
erties and are also useful in the treatment of
comedones. Large, open comedones (black-
heads) should be expressed.

negative urine pregnancy tests should also
be obtained in females 1 wk before initiation
may be present concomitantly of isotretinoin; it is also imperative to main-
tain effective contraception during and 1 mo
upper chest after therapy with isotretinoin ends because
of its teratogenic effects. Pregnancy status
pores should be rechecked at monthly visits.
be added if the comedones become inflamed
or form pustules. The most common adverse
effects are dryness, erythema, and peeling.
Topical antibiotics (erythromycin, clindamycin
lotions or pads) can also be used in patients
with significant inflammation. They reduce P.
acnes in the pilosebaceous follicle and have
 Acne Vulgaris 17

TABLE 1 Acne Treatment Algorithm

Severity (Lesion Type)
A
Mild Mild (Inflammatory/ Moderate Severe (Inflammatory/ Severe (Nodular/
Therapy (Comedonal) Mixed) (Inflammatory/Mixed) Mixed) Scarring)
Initial therapy Topical retinoid BP/retinoid combo BP/retinoid combo BP/retinoid combo + oral Isotretinoin
options*,† BP BP/antibiotic combo BP/antibiotic combo ± topi- antibiotic
Salicylic acid Antibiotic/retinoid combo cal retinoid BP/antibiotic combo + topical
cleanser + BP Antibiotic/retinoid combo retinoid + oral antibiotic
+ BP Antibiotic/retinoid combo + BP
± oral antibiotic + oral antibiotic
Alternative Add BP or retinoid Substitute another combo Substitute another combo Consider changing oral Consider hormonal

and Disorders
Diseases
therapy if not already product product antibiotic therapy for females
options*,†,‡ prescribed Add missing component Add missing component Consider isotretinoin
BP/antibiotic combo (i.e., topical retinoid, (i.e., topical retinoid, BP, Consider hormonal therapy
BP/retinoid combo BP, topical antibiotic) topical antibiotic, oral for females
Antibiotic/retinoid Change type, strength, or antibiotic)
combo formulation of topical Change type, strength, or
retinoid formulation of topical
retinoid I
Consider hormonal therapy
for females
Consider oral isotretinoin
Maintenance Topical retinoid or Topical retinoid or BP/ Topical retinoid or BP/reti- Topical retinoid or BP/retinoid Topical retinoid or BP/
therapy BP/retinoid combo retinoid combo noid combo combo retinoid combo

BP, Benzoyl peroxide.

*If combination products not available to patient, consider substitution of individual components as separate prescriptions.
†Topical dapsone may be considered in place of topical antibiotic.
‡If needed as determined by physician assessment and patient satisfaction.

Pediatrics 118(3):1188-99, 2006; Thiboutot D et al: New insights into the management of acne:
J Am Acad Dermatol 60:S1-50, 2009; Eichenfield LF et al: Evidence-based recommendations for the diagnosis and treatment
of pediatric acne, Pediatrics J
Drugs Dermatol J Am Acad Dermatol 49(Suppl. 1):S1-37, 2003.

some antiinflammatory effects. The combina-
- for treatment of severe nodulocystic acne. It is
effective in patients who have a mixture of
comedonal and inflammatory acne lesions.
effective than either product used alone;
however, they are much more expensive than
the individual generic components.
and benzoyl peroxide gel applied on alternate
evenings; drying agents (sulfacetamide-sulfa
lotions [Novacet, Sulfacet]) are also effec-
tive when used in combination with benzoyl
peroxide; oral antibiotics (doxycycline 100
mg qd or erythromycin 1 g qd given in 2 to
3 divided doses) are effective in patients with
moderate to severe pustular acne. Patients
not responding well to these antibiotics can
be switched to minocycline 50 to 100 mg bid.
Table E3 summarizes oral antibiotics for acne
vulgaris.
with moderate to severe inflammatory acne
unresponsive to topical drugs can be treated
with systemic agents: antibiotics (erythromy-
cin, tetracycline, doxycycline, minocycline),
isotretinoin (available on a restricted basis),
or oral contraceptives. Periodic intralesional
triamcinolone (Kenalog) injections by a der-
matologist are also effective. The possibility
of endocrinopathy should be considered in
patients responding poorly to therapy.
therapy. Table E4 summarizes alternative treat-
ments for acne vulgaris.
indicated for acne resistant to antibiotic thera-
py and severe acne. It inhibits P. acne’s coloni-
zation by reducing sebum production and has
PEARLS &
antiinflammatory and keratolytic effects. It is CONSIDERATIONS
available only on a restricted basis. Dosage is
0.5 to 1 mg/kg/day in 2 divided doses (maxi- -
mum of 2 mg/kg/day); duration of therapy is pected if inflammatory acne worsens after
generally 20 wk for a cumulative dose ≥120 several months of oral antibiotic therapy.
mg/kg for severe cystic acne. Before using this
medication patients should undergo baseline retinoid therapy before improving.
laboratory evaluation (see “Laboratory Tests”). COMMENTS
This drug is absolutely contraindicated during
pregnancy because of its teratogenicity. It Indications for systemic therapy of acne are:
should be used with caution in patients with
history of depression. Physicians, distributors,
pharmacies, and patients must register in the
www.ipledgeprogram.com) hyperpigmentation
before using isotretinoin.
Patients should be educated that in most cases
acid used to normalize keratinization and acne can be controlled but not cured and that
reduce inflammation. It can be used in preg- at least 4 to 6 wk of initial therapy should
nant women. be required before significant improvement is
- noted.
els and therefore sebum production. They
represent a useful adjunctive therapy for all may be severe and long-lasting.
types of acne in women and adolescent girls.
Commonly used agents are norgestimate/ SUGGESTED READINGS
ethinyl estradiol (Ortho Tri-Cyclen) and dro-
spirenone/ethinyl estradiol (Yasmin). Available at ExpertConsult.com
REFERRAL RELATED CONTENT
Referral for intralesional injection and derm- Acne (Patient Information)
abrasion should be considered in patients with
severe acne unresponsive to conventional Fred F. Ferri, MD
Acne Vulgaris 17.e1

TABLE E2 Prescription Topical Therapies for Acne Vulgaris

Drug Brand* Formulation
Antibiotics
Clindamycin Cleocin T
ClindaMax
Clindets
Clindagel
Evoclin
Clindamycin/BP† BenzaClin
Duac
Acanya
Onexton
Dapsone Aczone
Erythromycin Emgel, Erygel
Eryderm, Erymax, T-Stat
Staticin
Akne-Mycin

Erythromycin/BP† Benzamycin
Sulfacetamide Klaron
Plexion
Clenia
Rosula
Azelaic acid Azelex
Retinoids
Adapalene Differin

Adapalene/BP† Epiduo
Tazarotene Tazorac

Fabior
Tretinoin Retin-A

Retin-A Micro
Avita
Atralin
Tretinoin/Clindamycin†

BP, Benzoyl peroxide; ZA, zinc acetate.

*Listed are examples; this list is not exhaustive. Many of these preparations have generic alternatives.
†Combination therapy product.

From Paller AS, Mancini AJ: Hurwitz clinical pediatric dermatology: a textbook of skin disorders of childhood and adolescence, ed
5, Philadelphia, 2016, Elsevier.
Acne Vulgaris 17.e2

TABLE E3 Oral Antibiotics for Acne Vulgaris

Drug Usual Dosage* Comments/Side-Effects
Commonly used
Tetracycline 250-500 mg Dental staining <9 yr
Dairy products decrease absorption

Minocycline 50-100 mg Dental staining <9 yr

55, 65, 80, 105, 115 mg ER Dairy products decrease absorption
(1 mg/kg once daily)

Doxycycline 50-100 mg Dental staining <9 yr

75, 100, 150 mg ER, once Dairy products decrease absorption
daily
20 mg (“subantimicrobial
dose”)
Erythromycin 250-500 mg
most experts given increased resistance
Less commonly used
Trimethoprim- 80/400 mg, 160/800 mg
sulfamethoxazole use for acne strongly discouraged
Clindamycin 75-150 mg
Cephalexin 250-500 mg

ER, Extended release formulation; GI, gastrointestinal; IBD, inflammatory bowel disease; PTC, pseudotumor cerebri; SJS, VVC, vulvovaginal candidiasis.
*Usually given twice daily for acne unless otherwise noted in table.
From Paller AS, Mancini AJ: Hurwitz clinical pediatric dermatology: a textbook of skin disorders of childhood and adolescence, ed 5, Philadelphia, 2016, Elsevier.

TABLE E4 Alternative Treatments for Acne Vulgaris

Treatment Comment
Comedone extraction Performed with comedone extractor
Injections Intralesional triamcinolone injected into large cysts or nodules
Light therapy Blue light (may photoinactivate P. acnes)
Red light (may have antiinflammatory effect)
Combination blue-red light
Intense pulsed light (IPL)
Photodynamic therapy (PDT)
Laser therapy KTP, pulsed dye laser (rarely used)
Resurfacing laser (including both nonablative and ablative resurfacing lasers); useful for acne scarring
Dermabrasion/dermasanding Useful for acne scarring
Collagen injection Useful for acne scarring
Chemical peels Useful for acne scarring and hyperpigmentation
Punch grafts/tissue augmentation Useful for acne scarring
Trichloroacetic acid Useful for atrophic acne scars
Radiation therapy Outdated modality

KTP, Potassium titanyl phosphate.

From Paller AS, Mancini AJ: Hurwitz clinical pediatric dermatology: a textbook of skin disorders of childhood and adolescence, ed 5, Philadelphia, 2016, Elsevier.
Acne Vulgaris 17.e3

FIG. E1 Acne vulgaris: comedonal. Open com-

edones present as blackheads. (From Paller AS,
Mancini AJ: Hurwitz clinical pediatric dermatology: a
FIG. E2 Acne vulgaris: comedonal. Closed comedones present as whiteheads. (From Paller AS, Mancini
textbook of skin disorders of childhood and adoles-
AJ: Hurwitz clinical pediatric dermatology: a textbook of skin disorders of childhood and adolescence, ed 5,
cence, ed 5, Philadelphia, 2016, Elsevier.)
Philadelphia, 2016, Elsevier.)

FIG. E3 Acne vulgaris: inflammatory. Note the erythematous papules and FIG. E4 Acne vulgaris: inflammatory. This adolescent female has inflamma-
pustules, as well as open and closed comedones. (From Paller AS, Mancini, AJ: tory papules and papulopustules, as well as hirsutism. (From Paller AS, Mancini
Hurwitz clinical pediatric dermatology: a textbook of skin disorders of childhood AJ: Hurwitz clinical pediatric dermatology: a textbook of skin disorders of child-
and adolescence, ed 5, Philadelphia, 2016, Elsevier.) hood and adolescence, ed 5, Philadelphia, 2016, Elsevier.)

FIG. E5 Acne vulgaris: nodulocystic. (From Paller

AS, Mancini AJ: Hurwitz clinical pediatric dermatology: a
textbook of skin disorders of childhood and adolescence,
ed 5, Philadelphia, 2016, Elsevier.)