Neobook — clinical reference

Overview

Definition and Pathophysiology

Clinical Presentation

Differential Diagnosis

References and Guidelines

Notes for HCPs

Clinical Highlights

Overview

Condition

Name: Acne Vulgaris
ICD-10 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 = Unspecified acne

Epidemiology

Prevalence

Acne vulgaris is one of the most prevalent skin conditions worldwide, affecting approximately 85% of adolescents
In South Africa, acne is common in both urban and rural populations, but more severe forms are observed in individuals living in urban areas
Adult acne affects up to 12% of women and 3% of men over the age of 25

Sex Differences

More common in males during adolescence due to higher androgen levels, but in adulthood, acne is more common in females
Post-adolescent acne is predominantly seen in women, especially those with hormonal imbalances like polycystic ovary syndrome (PCOS)

Age of Onset

Acne commonly starts during puberty, with a peak onset between ages 12 and 17
It may persist into adulthood or begin during adulthood, especially in women aged 25-40 years
Neonatal and infantile acne can occur but are generally self-limiting

Regional and Socioeconomic Variations

Urban populations are more affected, possibly due to environmental and lifestyle factors such as pollution, cosmetic use, and dietary habits
Acne tends to be more severe in individuals with darker skin due to a higher risk of post-inflammatory hyperpigmentation (PIH)

Impact on Quality of Life

Acne can lead to significant psychosocial stress, including anxiety, depression, and reduced self-esteem
It often impacts daily activities, interpersonal relationships, and work productivity
Scarring from acne can cause long-term disfigurement, further affecting mental health and quality of life

Risk Factors

Genetic factors

Strong familial predisposition, with genetic factors contributing up to 81% of the variance in acne susceptibility
Increased risk if first-degree relatives have had severe acne

Hormonal factors

Androgens play a key role in acne pathogenesis by stimulating sebaceous glands and increasing sebum production
Conditions like PCOS and hormonal fluctuations during menstruation, pregnancy, or menopause exacerbate acne

Lifestyle and environmental factors

High glycaemic index diets and excessive dairy consumption have been associated with more severe acne
Use of oil-based cosmetics, occlusive wear (e.g., helmets, headbands), and exposure to certain chemicals or pollutants can worsen acne

Psychosocial stressors

Emotional stress is linked to acne flare-ups through increased androgen production and sebaceous gland activity
Repetitive mechanical trauma, such as picking or scrubbing the skin, can exacerbate acne and lead to scarring

Medical conditions

Endocrine disorders like PCOS, adrenal hyperplasia, or Cushing's syndrome can result in persistent or severe acne
Use of systemic corticosteroids, certain anticonvulsants, and lithium can cause or exacerbate acne

Dietary factors

High intake of processed foods, sugary drinks, and dairy has been associated with an increased risk of acne
However, the evidence linking chocolate to acne is still inconclusive

Other factors

Smoking has been implicated in comedonal acne, especially in adult females
Poor skin hygiene, such as infrequent cleansing, may contribute to clogged pores and worsening of acne

Definition and Pathophysiology

Definition

Acne vulgaris is a common, chronic inflammatory skin disorder primarily affecting the pilosebaceous units (hair follicles and sebaceous glands)
It is characterised by a range of lesions including comedones (whiteheads and blackheads), papules, pustules, nodules, and cysts, often leading to scarring
The condition typically occurs during adolescence but can persist or begin in adulthood
Acne vulgaris affects various body regions, predominantly the face, chest, back, and shoulders
Diagnosis is clinical, based on the type and severity of lesions, and no laboratory testing is typically required unless hormonal abnormalities are suspected

Pathophysiology

Increased Sebum Production

Androgens (e.g., testosterone and dihydrotestosterone) stimulate sebaceous glands to produce excess sebum
Hyperseborrhoea creates a lipid-rich environment, ideal for the proliferation of Cutibacterium acnes (formerly Propionibacterium acnes)
Sebum retention within the follicle contributes to comedone formation

Follicular Hyperkeratinisation

There is abnormal desquamation of keratinocytes within the pilosebaceous follicle, leading to the formation of a microcomedo
Accumulation of dead skin cells within the follicle blocks the normal drainage of sebum, further contributing to the formation of closed (whiteheads) or open (blackheads) comedones

Bacterial Colonisation

C. acnes, a commensal anaerobic bacterium, proliferates in the blocked follicle due to the anaerobic conditions created by the trapped sebum
The presence of C. acnes triggers both innate and adaptive immune responses, resulting in inflammation

Inflammatory Response

The immune system reacts to C. acnes by releasing inflammatory cytokines such as IL-1β, TNF-α, and IL-8
This leads to the formation of inflammatory lesions, such as papules, pustules, and nodules
The rupture of comedones or the follicular wall releases keratin, bacteria, and lipids into the dermis, exacerbating inflammation and causing nodulocystic acne in severe cases

Role of Androgens

Androgens stimulate sebaceous glands to enlarge and increase sebum production
In women, conditions such as polycystic ovary syndrome (PCOS) and hyperandrogenism can exacerbate acne
Increases in circulating androgens during puberty contribute to the onset of acne

Genetic Factors

There is a strong genetic predisposition to acne, with first-degree relatives of individuals with severe acne being at higher risk
Genetic variations influence sebum production, inflammation, and follicular keratinisation, contributing to the development of acne

Other Contributory Factors

Dietary factors:
- High glycaemic load diets and dairy products may exacerbate acne by increasing insulin-like growth factor (IGF-1) levels
Environmental factors:
- Exposure to pollutants, harsh skincare products, and physical occlusion (e.g., helmets, masks) can trigger or worsen acne
Stress:
- Psychological stress can exacerbate acne through hormonal and immune mechanisms, leading to increased sebum production and inflammation

Complications

Persistent inflammation can result in post-inflammatory hyperpigmentation (PIH), particularly in darker skin types
Severe cases may lead to permanent scarring, including ice-pick, boxcar, and rolling scars

Clinical Presentation

Symptoms

Comedones

Closed comedones (whiteheads):
- Small, flesh-coloured papules caused by the obstruction of the follicle
Open comedones (blackheads):
- Darkened lesions due to oxidation of melanin in the trapped sebum
Often the earliest and mildest form of acne, particularly in adolescents

Papules and Pustules

Papules:
- Small, red, raised bumps indicating inflammation
Pustules:
- Similar to papules but contain visible pus at the centre
These lesions are commonly inflamed and sensitive to touch

Nodules and Cysts

Nodules:
- Large, painful, solid lumps beneath the surface of the skin
Cysts:
- Deep, painful, pus-filled lesions, which can result in scarring
These are associated with severe acne, typically requiring more aggressive treatment to prevent long-term scarring

Post-inflammatory Hyperpigmentation (PIH)

Dark spots or patches remaining after acne lesions heal, particularly common in individuals with darker skin tones
Often a significant cosmetic concern and may persist for months

Scarring

May result from deep, inflamed lesions (nodules, cysts) or manipulation of acne lesions by patients (picking or squeezing)
Types of scarring include ice-pick, boxcar, and rolling scars

Pain and Tenderness

Acne lesions, especially nodules and cysts, can be painful, particularly when inflamed or irritated by physical contact

Signs

Affected Areas

Acne commonly affects areas with a high density of sebaceous glands, including the face, neck, upper back, chest, and shoulders
Distribution and severity of lesions may vary based on age, sex, and hormonal factors

Skin Texture

Comedonal acne gives the skin a rough or bumpy texture due to the presence of multiple blocked follicles
Active inflammatory lesions such as papules and pustules contribute to a visibly inflamed, reddened appearance

Post-lesion Hyperpigmentation and Scarring

Residual hyperpigmentation or hypopigmentation may occur after lesions heal, especially in individuals with darker skin
Permanent scarring can follow severe forms of acne or improper treatment

Diagnostic Criteria

Clinical Diagnosis

Diagnosis of acne vulgaris is typically based on clinical examination and lesion identification
The presence of comedones, inflammatory lesions (papules, pustules), and nodulocystic lesions is key in classifying the type and severity of acne

Classification

Mild:
- Predominantly comedonal acne with few papules or pustules
Moderate:
- Presence of both inflammatory (papules, pustules) and non-inflammatory lesions (comedones)
Severe:
- Nodular or cystic acne with extensive involvement of the skin and significant risk of scarring

Additional Diagnostic Considerations

Hormonal Acne

Seen particularly in adult women, characterised by lesions along the jawline and chin
Associated with hormonal imbalances, such as polycystic ovary syndrome (PCOS), or exacerbated during menstruation

Differential Diagnosis

Conditions such as rosacea, folliculitis, or perioral dermatitis may mimic acne
Key differentiators include the absence of comedones in rosacea and the distribution pattern of lesions

Exacerbating Factors

Cosmetic products, medications (e.g., corticosteroids), and certain occupational exposures may worsen acne
Emotional stress and dietary factors (high glycaemic load foods, dairy) are also potential triggers

Functional Impact

Quality of Life

Acne can lead to psychosocial distress, anxiety, depression, and low self-esteem
Severe cases may significantly impair daily functioning and social interactions

Differential Diagnosis

Conditions to Consider

Rosacea

Chronic inflammatory condition often mistaken for acne, characterised by erythema, telangiectasia, papules, and pustules on the central face
Absence of comedones distinguishes it from acne

Folliculitis

Infection or inflammation of the hair follicles, presenting as pustules or papules
Typically occurs on the back, chest, or buttocks, and often associated with bacteria (e.g., Staphylococcus aureus)

Perioral Dermatitis

Presents with papules and pustules around the mouth, sparing the vermillion border
Commonly associated with topical corticosteroid use, but unlike acne, it lacks comedones

Gram-Negative Folliculitis

Occurs in patients on long-term antibiotics for acne, presenting as pustules or cysts on the face
Requires bacterial culture for diagnosis

Pityrosporum Folliculitis

Yeast (Malassezia) infection of the hair follicles, presenting as small pustules on the chest, back, and shoulders
Typically worsened by heat, humidity, and sweat, with no comedones present

Seborrhoeic Dermatitis

A chronic inflammatory condition causing erythema and scaling, particularly around the nasolabial folds, scalp, and eyebrows
Lacks the pustules and comedones seen in acne

Hidradenitis Suppurativa

Chronic, painful skin condition affecting apocrine glands, often in the axillary or inguinal areas
Characterised by recurrent nodules, abscesses, and sinus tracts, but lacks comedones

Drug-induced Acne

Medications like corticosteroids, anabolic steroids, and lithium can induce acneiform eruptions, often involving the trunk
Lesions tend to be monomorphic (similar size and shape) and may not involve comedones

Polycystic Ovary Syndrome (PCOS)

Endocrine disorder causing acne, hirsutism, and irregular menstrual cycles in women
Typically associated with hormonal acne presenting on the lower face and jawline

Keratosis Pilaris

A benign condition presenting with rough, small bumps on the upper arms, thighs, and cheeks
Unlike acne, these lesions are usually asymptomatic and lack inflammation

Demodex Infestation

Mites found in hair follicles, causing papulopustular eruptions similar to acne
More common in immunocompromised individuals or those with rosacea

Key Differentiators

Rosacea

Absence of comedones and presence of flushing, erythema, and telangiectasia
Involvement primarily limited to the central face (nose, cheeks)

Folliculitis

Pustules centred on hair follicles with a surrounding red halo
Often associated with bacterial infection; responds to antibacterial treatment

Perioral Dermatitis

Distribution around the mouth, sparing the lip border
Often triggered by topical steroid use or heavy moisturisers

Gram-Negative Folliculitis

Occurs after prolonged antibiotic use for acne; bacterial culture will confirm diagnosis
Pustules often clustered, with sudden onset after antibiotic therapy

Pityrosporum Folliculitis

Small, uniform pustules, often itchy, with worsening in humid environments
Distinguished by a lack of comedones and failure to respond to typical acne treatments

Seborrhoeic Dermatitis

Greasy scales and erythema without pustules or comedones
Predominantly affects areas rich in sebaceous glands (scalp, eyebrows, nasolabial folds)

Hidradenitis Suppurativa

Painful, deep-seated nodules and abscesses in the intertriginous areas
Chronic condition with sinus tract formation and scarring, but no comedones

Drug-induced Acne

Monomorphic acneiform eruption, usually on the chest and back
Occurs after initiation of medications such as steroids or lithium

PCOS

Acne associated with hormonal imbalance, typically presenting on the lower face and jawline
Associated with other signs of hyperandrogenism (hirsutism, irregular menses)

Keratosis Pilaris

Small, rough, keratotic papules, primarily on extensor surfaces
Lacks the inflammatory or pustular component seen in acne

Demodex Infestation

Papules and pustules often mistaken for acne, typically in adults
May be confirmed by skin scraping and microscopy

Diagnostic Tests

Initial Tests

Clinical Examination

Visual inspection of the skin is usually sufficient for diagnosis
Classification of acne type (comedonal, papulopustular, nodulocystic) and severity (mild, moderate, severe) is based on lesion types, number, and distribution

Hormonal Evaluation (if indicated)

Serum Androgen Levels:
- In females with signs of hyperandrogenism (irregular menses, hirsutism), measure testosterone, DHEA-S (dehydroepiandrosterone sulfate), and LH/FSH ratio to rule out polycystic ovary syndrome (PCOS) or other endocrine disorders
Serum Cortisol:
- If suspected, check cortisol levels to exclude conditions like Cushing’s syndrome

Blood Tests (for systemic conditions)

Full Blood Count (FBC):
- May be indicated if systemic symptoms are present or if there is suspicion of an underlying infection or systemic disease contributing to skin changes
Fasting Glucose or HbA1c:
- To rule out insulin resistance, particularly in patients with PCOS
Liver Function Tests:
- For patients on long-term systemic therapies like isotretinoin or antibiotics, baseline and monitoring liver function is important

Advanced Tests

Microbial Culture (if indicated)

Not routinely required but useful in cases of treatment-resistant acne or if secondary bacterial infection (e.g., Gram-negative folliculitis) is suspected, particularly in patients who have been on long-term antibiotic therapy

Endocrine Assessment

Further evaluation may be warranted in patients with irregular menses, infertility, or other signs of androgen excess. This can include imaging (e.g., pelvic ultrasound for PCOS) or more detailed hormone panels

Imaging Studies

Pelvic Ultrasound (if PCOS is suspected)

In women with suspected hormonal acne, particularly those with irregular periods or hirsutism, an ultrasound can confirm polycystic ovaries

Additional Diagnostic Considerations

Acne Severity Scales

Standardised tools such as the Global Acne Grading System (GAGS) or the Leeds acne grading technique can be used to assess the severity of acne and monitor treatment response
These grading systems take into account lesion type and distribution across different body regions

Assessment of Quality of Life

Acne can significantly impact patients' mental health, particularly in severe cases. Tools like the Dermatology Life Quality Index (DLQI) can be used to assess the psychological and social impact of the condition on patients

Clinical Pitfalls

Recurrent or severe acne in adult women

Always consider underlying hormonal imbalances such as PCOS or hyperandrogenism, especially if acne is predominantly located on the lower face and jawline

Long-term antibiotic use

Be cautious of potential development of antibiotic resistance and secondary infections like Gram-negative folliculitis in patients who have been on antibiotics for extended periods

Isotretinoin Therapy

Prior to starting isotretinoin, baseline blood tests including lipid profile and liver function tests are necessary. Monitoring is essential throughout treatment due to the risk of hepatotoxicity and hyperlipidaemia

Referral to Dermatology

Consider referring patients with severe, scarring, or treatment-resistant acne for specialist management, which may include isotretinoin or hormonal therapy

Management

First-line Therapy

Pharmacological Therapy

Topical Retinoids

Tretinoin:
- Available in 0.025%-0.1% concentrations, applied once daily
Adapalene:
- 0.1%-0.3% gel, applied once daily
Tazarotene:
- 0.05%-0.1% cream or gel, applied once daily
Efficacy:
- Retinoids reduce comedones, prevent follicular plugging, and have anti-inflammatory properties, making them a cornerstone in acne management

Benzoyl Peroxide

Available in 2.5%-10% formulations, applied once or twice daily
Efficacy:
- An antibacterial agent that reduces C. acnes proliferation and prevents antibiotic resistance when combined with topical or oral antibiotics

Topical Antibiotics

Clindamycin:
- 1% gel or lotion, applied once daily
Erythromycin:
- 2% gel or ointment, applied once or twice daily
Efficacy:
- Useful in treating inflammatory lesions, often combined with benzoyl peroxide to prevent bacterial resistance

Oral Antibiotics

Doxycycline:
- 50-100 mg once or twice daily
Minocycline:
- 50-100 mg once or twice daily
Tetracycline:
- 250-500 mg twice daily
Efficacy:
- Effective for moderate to severe inflammatory acne, particularly on the back and chest. Recommended for short-term use (3-6 months) to minimise antibiotic resistance

Oral Isotretinoin

Initial dose:
- 0.5 mg/kg/day, titrated to 1 mg/kg/day based on tolerance, usually taken for 15-20 weeks
Efficacy:
- Highly effective in severe nodulocystic acne and treatment-resistant cases, leading to long-term remission. Requires careful monitoring due to potential side effects (e.g., teratogenicity, elevated liver enzymes)

Hormonal Therapy (for females)

Combined Oral Contraceptives (COCs)
- Ethinyl oestradiol and cyproterone acetate or drospirenone
- Efficacy: Reduces androgen production, improving hormonal acne, particularly in patients with polycystic ovary syndrome (PCOS)
Anti-androgens
- Spironolactone: 50-100 mg daily
- Efficacy: Blocks androgen receptors, decreasing sebum production, and reducing inflammatory acne lesions in women with hormonal imbalances

Non-Pharmacological Therapy

Physical Treatments

Light Therapy:
- Blue light or photodynamic therapy (PDT) to reduce C. acnes colonisation. Useful in combination with topical treatments
Chemical Peels:
- Glycolic acid or salicylic acid peels may help in managing comedonal acne and post-inflammatory hyperpigmentation
Intralesional Corticosteroids:
- For inflamed nodules and cysts, intralesional injections (e.g., triamcinolone) can reduce inflammation and prevent scarring
Comedone Extraction:
- For resistant comedones, manual extraction by a dermatologist may be performed

Lifestyle Modifications

Dietary Adjustments
- Encouraging a low glycaemic index diet and reducing dairy intake, particularly skimmed milk, may improve acne severity
- Efficacy: Emerging evidence suggests that diet plays a role in acne pathogenesis, though further research is required
Skin Care Routine
- Regular cleansing with gentle, non-comedogenic products
- Avoidance of oil-based cosmetics and hair products that can worsen acne

Second-line Therapy

Alternative Antibiotics

Trimethoprim-sulfamethoxazole or cephalexin may be used in cases where tetracyclines are contraindicated or ineffective
Efficacy:
- Effective in treating resistant inflammatory acne, though not first-line due to increased side effects

Additional Oral Medications

Oral Dapsone:
- 50-100 mg daily, for patients who do not respond to conventional antibiotics
Efficacy:
- Used in cases of inflammatory acne, particularly in females, but requires monitoring for side effects like haemolysis in patients with G6PD deficiency

Referral

Indications for Specialist Referral

Dermatologist
- For severe nodulocystic acne, scarring acne, or failure of first-line therapies
- When isotretinoin therapy is indicated, requiring specialist monitoring
Endocrinologist
- For patients with suspected PCOS or hyperandrogenism, especially those with irregular menstrual cycles or signs of virilisation

Monitoring

Routine Follow-up

For patients on oral isotretinoin, monthly monitoring of liver function tests, lipid profiles, and pregnancy tests in women of childbearing age is essential
For those on oral antibiotics or hormonal therapy, periodic assessments for side effects and efficacy are recommended

Long-term Management

Maintenance therapy with topical retinoids is recommended once acne is controlled to prevent relapse
Consider tapering oral therapies once significant improvement is achieved, transitioning to topical agents to maintain control

Patient Education

Medication Adherence

Emphasise the importance of consistent use of medications, especially topical agents, as acne treatment takes time to show visible results
Educating patients on potential side effects and how to manage them is crucial for long-term adherence

Skin Care Practices

Encourage avoidance of aggressive skin scrubbing, which can aggravate acne and cause scarring
Provide guidance on selecting non-comedogenic skin care products and cosmetics

Medications

Drug Name

Topical Retinoids

Tretinoin
Adapalene
Tazarotene

Benzoyl Peroxide

Benzoyl Peroxide

Topical Antibiotics

Clindamycin
Erythromycin

Oral Antibiotics

Doxycycline
Minocycline
Tetracycline

Oral Isotretinoin

Isotretinoin

Hormonal Therapy (for females)

Combined Oral Contraceptives (COCs)
Spironolactone

Posology (Dosage)

Drug	Dosage & Frequency	Clinical Notes
Topical Retinoids
Tretinoin	0.025%-0.1% cream or gel, applied once daily at bedtime.	Retinoids are effective in preventing comedones and treating inflammatory lesions.
Adapalene	0.1%-0.3% gel, applied once daily in the evening.
Tazarotene	0.05%-0.1% cream or gel, applied once daily.
Benzoyl Peroxide
Benzoyl Peroxide	2.5%-10% gel or wash, applied once or twice daily.	Benzoyl peroxide has strong antibacterial properties and prevents antibiotic resistance when combined with topical antibiotics.
Topical Antibiotics
Clindamycin	1% gel or lotion, applied once daily.	Effective in reducing inflammatory lesions, particularly when combined with benzoyl peroxide.
Erythromycin	2% gel, applied once or twice daily.
Oral Antibiotics
Doxycycline	50-100 mg once or twice daily.	Used for moderate to severe inflammatory acne, especially for chest and back lesions.
Minocycline	50-100 mg once or twice daily.
Tetracycline	250-500 mg twice daily.
Oral Isotretinoin
Isotretinoin	0.5-1 mg/kg/day, typically taken for 15-20 weeks.	Highly effective for severe, scarring, or resistant acne, with long-term remission possible.
Hormonal Therapy (for females)
Combined Oral Contraceptives (COCs)	Varying formulations of oestrogen and progestin, typically taken once daily.	Useful for hormonal acne, particularly in females with PCOS or hyperandrogenism.
Spironolactone	50-100 mg daily.

Side Effects

Topical Retinoids

Dryness
Irritation
Photosensitivity
Side effects can be mitigated by applying moisturisers and using sunscreen

Benzoyl Peroxide

Skin irritation
Bleaching of hair or clothing
Combining with moisturisers can help reduce irritation

Topical Antibiotics

Skin irritation
Possible development of bacterial resistance
Should always be combined with benzoyl peroxide to minimise resistance

Oral Antibiotics

Gastrointestinal upset
Photosensitivity (particularly doxycycline)
Possible bacterial resistance with prolonged use
Lupus-like syndrome (minocycline)
Should be used short-term (3-6 months) to prevent resistance

Oral Isotretinoin

Dry skin and lips
Elevated liver enzymes
Hyperlipidaemia
Teratogenicity (strict pregnancy prevention measures required)
Patients on isotretinoin need regular monitoring for side effects

Hormonal Therapy (for females)

Nausea
Weight gain
Risk of thromboembolism (with COCs)
Hormonal therapy is beneficial for women with menstrual cycle-related acne or PCOS

Interactions

Topical Retinoids

Benzoyl Peroxide: Deactivates retinoids if used together (apply at different times of day)
Photosensitising Agents: Increased risk of sunburn when combined with other agents like antibiotics or acne treatments

Oral Antibiotics

Oral Contraceptives: May reduce efficacy of oral contraceptives (recommend additional contraception)
Isotretinoin: Should not be combined due to risk of increased intracranial pressure

Oral Isotretinoin

Tetracyclines: Increased risk of pseudotumor cerebri (avoid combination)
Vitamin A Supplements: Risk of hypervitaminosis A (should be avoided)

Hormonal Therapy (for females)

Spironolactone and Potassium-Sparing Diuretics: Risk of hyperkalaemia
Tetracyclines and Oral Antibiotics: Reduced contraceptive efficacy (recommend additional contraception)

Complications

Acute Complications

Status Epilepticus

Inflammatory Flare-ups

Severe, sudden exacerbations of acne with nodules and cysts
May require aggressive treatment such as intralesional corticosteroids or oral isotretinoin

Secondary Bacterial Infections

Acne lesions, particularly if picked or manipulated, can become infected, leading to cellulitis or abscess formation
Requires antibiotic therapy to manage the infection

Post-inflammatory Hyperpigmentation (PIH)

Darkened patches of skin remaining after inflammatory acne lesions heal, particularly in individuals with darker skin types
Can persist for months and requires management with topical agents like retinoids or chemical peels

Psychosocial Impact

Sudden flare-ups of acne can lead to emotional distress, anxiety, and reduced self-esteem
Psychological support and counselling may be necessary for individuals severely impacted by their appearance

Acute Scarring

Severe inflammatory acne, if untreated, can rapidly lead to permanent scarring (ice-pick, boxcar, or rolling scars)
Early intervention with appropriate acne treatments is critical to prevent long-term disfigurement

Chronic Complications

Permanent Scarring

Untreated or improperly managed severe acne (nodulocystic acne) can result in permanent disfiguring scars
Patients may require interventions such as laser therapy, dermabrasion, or microneedling to improve the appearance of scars

Persistent Post-inflammatory Hyperpigmentation

Hyperpigmentation can persist for months to years, especially in patients with darker skin
Long-term topical therapies and sun protection are often required for management

Quality of Life Impairment

Acne can lead to ongoing psychological issues such as depression, social isolation, and body dysmorphia, affecting daily functioning and interpersonal relationships
Psychological support or referral to mental health services may be beneficial

Antibiotic Resistance

Prolonged use of oral or topical antibiotics without proper management can lead to resistant strains of C. acnes
Limits future treatment options and increases the need for alternative therapies, such as oral isotretinoin

Medication Side Effects

Long-term use of treatments like oral antibiotics, isotretinoin, or hormonal therapies can lead to adverse effects, including gastrointestinal upset, hepatotoxicity, and hormonal imbalances
Regular monitoring and adjustment of therapy are essential to minimise these risks

Preventive Measures

Early and Effective Treatment

Starting treatment early, especially in cases of moderate to severe acne, can prevent the development of complications such as scarring and hyperpigmentation

Patient Education

Educating patients on proper skincare routines, adherence to treatments, and the risks of picking or manipulating acne lesions can reduce the risk of scarring and infections

Monitoring for Side Effects

Regular follow-up is essential for patients on long-term therapies such as isotretinoin or oral antibiotics to monitor for side effects and ensure optimal treatment outcomes

Impact on Quality of Life

Psychosocial Impact

Acne can significantly impair self-confidence and social interactions, leading to emotional distress
Addressing both the physical and psychological aspects of acne is crucial for improving patient well-being

Economic Burden

Long-term treatment of severe acne and its complications (e.g., scarring interventions) can be financially burdensome for patients
Regular follow-up and effective management can reduce the need for costly future interventions

Patient Education

Lifestyle Modifications

Skincare Routine

Wash your face twice daily with a gentle, non-comedogenic cleanser to remove dirt and excess oil
Avoid scrubbing or using abrasive exfoliants, which can irritate the skin and worsen acne
Use non-comedogenic moisturisers and sunscreens to protect the skin without clogging pores

Avoid Picking or Squeezing Lesions

Picking or squeezing acne can lead to scarring, delayed healing, and secondary bacterial infections
Encourage patients to resist the urge to manipulate lesions and seek professional treatments if necessary

Dietary Adjustments

Limit consumption of high glycaemic index foods (e.g., sugary snacks, white bread) and dairy products, which may exacerbate acne
Maintain a balanced diet rich in fruits, vegetables, whole grains, and lean proteins to support overall skin health

Stress Management

Practise stress-reduction techniques such as mindfulness, yoga, or deep breathing exercises, as stress can worsen acne
Engage in regular physical activity, which can improve mood and reduce stress, potentially helping with acne control

Preventive Measures

Consistency with Medications

Educate patients on the importance of adhering to prescribed treatments, even if results are not immediate
Topical treatments may take several weeks to show improvement, so consistency is key to achieving desired outcomes

Sun Protection

Use broad-spectrum sunscreens with an SPF of at least 30 daily to prevent post-inflammatory hyperpigmentation, especially when using retinoids or other acne medications that increase sun sensitivity
Reapply sunscreen regularly, especially after swimming or sweating

Avoiding Triggers

Inform patients to avoid using greasy or oil-based skincare and hair products that can clog pores and worsen acne
Discourage the use of heavy makeup or cosmetics that may contribute to breakouts. Opt for non-comedogenic, oil-free products

Support Resources

Patient Support Groups

Encourage patients to join local or online acne support groups where they can share experiences and coping strategies with others facing similar challenges

Educational Materials

Provide access to reliable sources of information about acne, including pamphlets, websites, or apps, to help patients understand the condition and manage it effectively
Direct patients to reputable skincare product lines that are non-comedogenic and suited for acne-prone skin

Dermatological Consultation

In cases of severe, resistant, or scarring acne, referral to a dermatologist may be necessary for advanced treatments such as isotretinoin or laser therapy

Medication Adherence

Importance of Medication

Emphasise the importance of following the prescribed medication regimen to achieve optimal results and prevent flare-ups
Educate patients about the potential side effects of treatments and how to manage them effectively (e.g., dryness with retinoids, photosensitivity with antibiotics)

Medication Diary

Encourage patients to keep a diary of their medication use, noting any side effects or changes in their skin condition
Using a medication reminder app or a pill organiser can help ensure consistent use of treatments

Symptom Tracking

Symptom Diary

Advise patients to track their acne symptoms, including the frequency and severity of breakouts, to identify triggers or patterns
Monitoring progress over time can help healthcare providers adjust treatments as needed and enhance patient outcomes

Communication with Healthcare Providers

Regular Check-ins:
- Remind patients to maintain open communication with their healthcare team and schedule regular follow-up visits to monitor treatment effectiveness and side effects
- Encourage patients to report any worsening of symptoms or new side effects promptly for timely intervention
Discussing Concerns:
- Encourage patients to voice any concerns or questions they have about their treatment plan or skincare routine
- Addressing concerns early can help improve adherence and lead to better outcomes

Holistic Approaches

Complementary Therapies

Discuss safe complementary therapies such as light therapy or mild chemical peels, ensuring these options are integrated with their current treatment plan
Emphasise the importance of a holistic approach to acne management that includes both medical treatments and lifestyle modifications

Long-Term Management

Ongoing Care

Educate patients that managing acne is often a long-term process requiring ongoing care and adjustments in treatments
Setting realistic expectations about the timeframe for improvement and the potential need for long-term maintenance therapy can help reduce frustration

Active Role in Care

Encourage patients to take an active role in their skincare by making informed decisions about products and treatments
Provide tools and resources to empower patients to manage their condition effectively, reducing the likelihood of flare-ups and complications

References and Guidelines

Key References

Goh C, Cheng C, Agak G, et al. Acne Vulgaris. In: Kang S, Amagai M, Bruckner AL, Enk AH, Margolis DJ, McMichael AJ, Orringer JS, editors. Fitzpatrick's Dermatology in General Medicine. 9th ed. New York: McGraw-Hill; 2019
Elbuluk N, David J, Barbosa VH, Taylor SC. Acne Vulgaris. In: Taylor SC, Kelly AP, editors. Dermatology for Skin of Colour. 2nd ed. New York: McGraw-Hill; 2022
Rojek NW, Worswick S, Shinkai K, Fox LP. Acne Vulgaris. In: Papadakis MA, McPhee SJ, Rabow MW, editors. Current Medical Diagnosis & Treatment 2025. New York: McGraw-Hill; 2025
Usatine RP, Bambekova PG, Shiu VF. Acne Vulgaris. In: The Colour Atlas and Synopsis of Family Medicine. 3rd ed. New York: McGraw-Hill; 2021

Clinical Guidelines

National Institute for Health and Care Excellence (NICE). Acne vulgaris: management (NG198):
- Offers guidance on the diagnosis and management of acne in primary and secondary care settings. Focuses on evidence-based treatment options, patient education, and referral criteria for severe cases
American Academy of Dermatology (AAD). Guidelines of care for the management of acne vulgaris:
- Comprehensive evidence-based recommendations for the diagnosis and treatment of acne, covering both pharmacological and non-pharmacological interventions. Highlights management strategies for different severities of acne
South African Dermatology Society (SADS). Acne vulgaris treatment guidelines:
- Provides guidelines tailored to the South African healthcare context, with a focus on accessible and culturally relevant treatment options. Emphasises the use of available pharmacological therapies and patient education
World Health Organization (WHO). Skin Diseases - mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings:
- Guidelines for the diagnosis and management of common skin conditions, including acne vulgaris, in low-resource settings. Encourages early intervention and practical management strategies to improve skin health globally

Notes for HCPs

Clinical Pearls and Pitfalls

Ensure patient adherence to treatment

Educate patients about the importance of consistency with their acne treatment regimen, as many therapies take several weeks to show results
Emphasise the need to continue using medications as prescribed, even after improvement, to prevent recurrence

Manage side effects effectively

Be mindful of potential side effects such as dryness and irritation with topical retinoids or gastrointestinal upset with oral antibiotics
Provide patients with guidance on mitigating these side effects (e.g., using non-comedogenic moisturisers, taking antibiotics with food)

Monitor for hormonal acne

In females with acne resistant to conventional treatments or with signs of hyperandrogenism (e.g., irregular menses, hirsutism), consider underlying hormonal imbalances like polycystic ovary syndrome (PCOS)
Hormonal therapies such as combined oral contraceptives or spironolactone can be highly effective in these cases

Recognise antibiotic resistance risks

Limit the duration of oral antibiotic therapy to 3-6 months and always combine with benzoyl peroxide to reduce the risk of bacterial resistance
Consider alternative treatments like oral isotretinoin for resistant cases rather than prolonging antibiotic use

Customise treatments based on acne severity

Tailor treatment plans based on the severity of acne and lesion type (e.g., comedonal vs. inflammatory acne)
Mild acne may respond well to topical retinoids and benzoyl peroxide, while moderate to severe cases may require oral antibiotics or isotretinoin

Be vigilant about isotretinoin side effects

Regularly monitor patients on isotretinoin for potential side effects, including hepatotoxicity, hyperlipidaemia, and teratogenicity
Ensure that women of childbearing age follow strict contraceptive measures while on isotretinoin, as the drug is highly teratogenic

Address psychosocial impacts

Recognise that acne can have significant emotional and psychological consequences, including depression, anxiety, and body dysmorphia
Provide or refer patients for psychological support if needed, particularly in cases of severe or scarring acne

Consider long-term maintenance therapy

Once acne is controlled, patients should continue on maintenance therapy (e.g., topical retinoids) to prevent relapse
Maintenance treatments are especially important for patients who have experienced severe acne or scarring

Educate patients on proper skin care

Advise patients to avoid abrasive cleansers and scrubbing, which can irritate the skin and worsen acne
Recommend the use of non-comedogenic skin care products, including moisturisers and sunscreens, to maintain skin health without exacerbating acne

Tailor treatments for different skin types

Be aware that patients with darker skin tones may be more prone to post-inflammatory hyperpigmentation (PIH) and scarring
Treatments should be adapted to minimise irritation and prevent PIH, with the addition of skin-lightening agents when necessary

Provide clear instructions for medication use

Ensure patients understand the correct application of topical treatments (e.g., applying retinoids at night) and the importance of sun protection
Discuss the potential for side effects and how to manage them, particularly for medications like isotretinoin or oral antibiotics

Follow-up and monitor response

Schedule regular follow-up appointments to monitor treatment response, manage side effects, and adjust treatment plans as needed
Use standardised acne grading scales to assess progress and ensure timely modifications to therapy

Clinical Highlights

Diagnose acne vulgaris based on clinical presentation, recognising the different types of lesions (comedones, papules, pustules, nodules) and severity of the condition
Consider differential diagnoses such as rosacea, folliculitis, and perioral dermatitis, especially in atypical presentations
Start treatment with topical retinoids and benzoyl peroxide for mild to moderate acne, and escalate to oral antibiotics or isotretinoin for more severe cases
Monitor for side effects, especially with oral isotretinoin (e.g., hepatotoxicity, teratogenicity) and ensure patients adhere to necessary precautions such as pregnancy prevention
Hormonal therapy (e.g., combined oral contraceptives or spironolactone) can be beneficial for females with hormonal acne or PCOS
Emphasise the importance of a consistent skincare routine, including the use of non-comedogenic moisturisers and sunscreens
Counsel patients on the psychological impact of acne, addressing potential anxiety, depression, or low self-esteem, and consider referring for mental health support if needed
Educate patients on lifestyle factors that can exacerbate acne, such as high glycaemic diets and stress, and suggest dietary modifications when appropriate
Prevent long-term complications such as scarring and post-inflammatory hyperpigmentation by initiating early and appropriate treatment
Encourage long-term maintenance therapy with topical retinoids to prevent relapse after acne has been controlled
Schedule regular follow-ups to assess treatment efficacy, adjust medications, and monitor for potential side effects, especially in patients on long-term therapies
Promote patient education on the risks of picking or squeezing acne lesions, which can lead to secondary infections and scarring
Ensure multidisciplinary care by coordinating with dermatologists or endocrinologists when managing severe, resistant, or hormonally influenced acne

Field	Triage	Clinical Setting	Condition Type
Dermatology	Routine	Primary Care	Chronic

Overview

Condition

Epidemiology

Risk Factors

Definition and Pathophysiology

Definition

Pathophysiology

Clinical Presentation

Symptoms

Signs

Diagnostic Criteria

Additional Diagnostic Considerations

Functional Impact

Differential Diagnosis

Conditions to Consider

Key Differentiators

Diagnostic Tests

Initial Tests

Advanced Tests

Additional Diagnostic Considerations

Clinical Pitfalls

Management

First-line Therapy

Pharmacological Therapy

Non-Pharmacological Therapy

Second-line Therapy

Referral

Monitoring

Patient Education

Medications

Drug Name

Posology (Dosage)

Side Effects

Interactions

Complications

Acute Complications

Chronic Complications

Preventive Measures

Impact on Quality of Life

Patient Education

Lifestyle Modifications

Preventive Measures

Support Resources

Medication Adherence

Symptom Tracking

Holistic Approaches

Long-Term Management

References and Guidelines

Key References

Clinical Guidelines

Notes for HCPs

Clinical Pearls and Pitfalls

Clinical Highlights

Recommended reads

Drugs mentioned

ICD-10 codes