ACNE VULGARIS
Acne Vulgaris is a chronic and common skin condition that most often affects adolescents. This condition forms different types of presentations on the skin including, spots, redness and inflammation.
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Acne is one of the most common skin conditions in the UK leading to 3.5 million visits to primary care every year.
Acne is the most common skin disease in the US and affects 80% of the population at some point in life [1]
Acne is more common in males during adolescence but in adulthood, higher in women [2]
The Global Burden of Disease Study 2010 found that acne vulgaris is the eighth most common skin disease, with an estimated global prevalence of 38% [3]
Approximately 85% of people between the ages of 12 and 24 experience at least minor acne [4]
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Blocked hair follicles
Testosterone
Acne in families
Periods
Pregnancy
Polycystic Ovary Syndrome
Certain medications- steroids, lithium, anti-epileptics
Smoking
High glycaemic index
Cosmetics [10]
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Medical Students
Acne Classification
Non-inflammatory acne:
Comedones (open = blackheads, closed = whiteheads)
Inflammatory acne:
Papules (inflammation from comedone contents)
Pustules (result from further inflammation)
Sebum & Follicular Plugging
Sebum has antibacterial, antioxidant, and protective roles
Increased sebum production (due to puberty, pregnancy, etc.) contributes to acne
Disrupted keratinisation in the pilosebaceous unit → follicular blockage
Cutibacterium acnes (C. acnes)
Considered a low-virulence, opportunistic pathogen
Associated with inflammatory acne, soft tissue infections, and skin damage
Triggers immune response leading to inflammation
Inflammatory Mediators
Acne lesions are associated with increased levels of:
E-selectin (leukocyte recruitment via IL-1 and TNF-α)
Vascular adhesion molecules, interleukins, integrins
CD3+ and CD4+ T cells, macrophages
Patients
Acne happens when too much oil (sebum) is made and pores get blocked
Hormones (like during puberty or pregnancy) can increase oil production
Blocked pores lead to whiteheads, blackheads, or pimples
A natural skin germ called C. acnes can make the skin red and swollen
The body reacts with inflammation, causing spots or painful bumps [5,6,7,8,9]
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Skin trauma (eg. usage of soaps, detergent, or other agents)
Food habits (high glycemic index)
Stress
Insulin resistance
Increased BMI
Endocrine disorders
Greasy skin
Genetics
Age (12-24) [11,12]
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Involves the neck, chest, back and other parts of the body
Blackheads (open comedones) and whiteheads (closed comedones)
Small, tender red bumps
Yellow or white spots
Swelling
Redness
Dark/red marks
Scarring [5]
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Clinical diagnosis (risk factors and presentation of acne)
Hormonal evaluation
Bacterial cultures [12]
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Rosacea
Peri-oral (around the mouth) dermatitis
Folliculitis (inflammation of the follicles) and boils
Drug-induced acne
Keratosis pilaris (a dry skin condition caused by keratin build-up) [1]
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Medical Students
Personalise discussion based on:
Acne severity and possible causes
Pros and cons of treatments
Reproductive health considerations (e.g. contraception)
Discuss contraindicated treatments in pregnancy (e.g. topical retinoids, oral tetracyclines)
Lifestyle Advice
Avoid over-cleansing the skin
Use pH-neutral or slightly acidic cleansers
Avoid oil-based products (e.g. make-up, sunscreen)
Reduce skin irritation by:
Starting treatment gradually or on alternate days
Minimising skin contact to reduce scarring
Mild to Moderate Acne
Offer a 12-week course of one of:
Topical adapalene + benzoyl peroxide
Topical tretinoin + clindamycin
Topical benzoyl peroxide + clindamycin
Monotherapy: topical benzoyl peroxide if others are contraindicated or not tolerated
Formulation Tips:
Use creams/lotions for dry/sensitive skin
Use gels for oily skin
Moderate to Severe Acne
Offer a 12-week course of one of:
Topical adapalene + benzoyl peroxide
Topical tretinoin + clindamycin
Topical adapalene + benzoyl peroxide
+ oral lymecycline or doxycyclineTopical azelaic acid + oral lymecycline or doxycycline
Use topical benzoyl peroxide alone if others are unsuitable
Alternatives:
Replace lymecycline/doxycycline with trimethoprim or oral macrolide if contraindicated
Use combined oral contraceptives with topicals in women (if suitable)
Co-cyprindiol for moderate-severe acne after other treatments fail
When to Refer
Refer to dermatology team if:
Severe acne scarring persists ≥12 months after clearance
Do Not Use
Topical or oral antibiotics as monotherapy
Combination of topical + oral antibiotics
Patients
Discuss what may be causing your acne
Talk through treatment options, pros and cons
If you're considering pregnancy or using contraception, mention this as some acne treatments may not be safe
Everyday Care
Don’t over-wash your skin – gentle is best
Use pH-balanced or slightly acidic cleansers
Avoid oil-based products like some make-up or sunscreen
Try not to touch your face too much – it can increase the chance of scarring
Start treatments slowly to avoid skin irritation
Mild to Moderate Acne
Your doctor may offer a 12-week course of one of these:
A skin treatment combining adapalene + benzoyl peroxide
Tretinoin + clindamycin
Benzoyl peroxide + clindamycin
If you can't use some medicines, benzoyl peroxide alone may be suggested
Choose:
Creams/lotions for dry skin
Gels for oily skin
Moderate to Severe Acne
Doctors may offer a 12-week course of:
Topical adapalene + benzoyl peroxide
Tretinoin + clindamycin
Adapalene + benzoyl peroxide, with oral antibiotics like lymecycline or doxycycline
Azelaic acid + an oral antibiotic
If oral antibiotics cause side effects or aren’t safe, other antibiotics like trimethoprim or macrolides may be used
Women may be offered the contraceptive pill with creams instead of antibiotics
In some cases, stronger pills like Dianette® may be used if nothing else worksSpecialist Referral
If acne scars remain after a year of clear skin, you might be referred to a specialist dermatology team
Not Recommended
Antibiotics alone (topical or oral)
Using both oral and topical antibiotics together [1]
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Self-image and depression
Ice pick scars- small, deep holes in the skin
Rolling scars- rolling or uneven appearance found in the skin
Boxcar scars- round or oval pits in the skin
Can be treated as a type of cosmetic surgery but is not usually funded under the NHS (exceptions have included cases which can cause significant psychological distress) [10]
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Acne will clear more quickly if you scrub your skin clean
Wearing makeup causes acne breakouts
Acne will clear once the teenage year has finished
Tanning helps clear up acne
Squeezing/popping pimples will be rid of acne quicker
Chocolate is bad for your skin
Eating greasy foods can cause acne
Cutting out gluten will help clear the skin
Dairy can cause acne [13,14]
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What are the possible reasons for my acne flares?
Is there a long-term treatment to manage my acne and prevent exacerbations?
Are there any changes I need to make to my skincare routines?
Should I avoid certain foods to help manage acne?
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The British Association of Dermatologists
Talkhealth
Acne Support
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[1] https://cks.nice.org.uk/topics/acne-vulgaris/background-information/prevalence/#:~:text=An
[2] https://pubmed.ncbi.nlm.nih.gov/23657180/
[3] https://www.nature.com/articles/s41598-020-62715-3
[4] https://pubmed.ncbi.nlm.nih.gov/23210645/
[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051853/
[7] https://www.nature.com/articles/s41598-022-25436-3#:~:text=Cutibacterium
[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780801/
[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3051853/
[10] https://www.nhs.uk/conditions/atopic-eczema/causes/
[11] https://www.almirall.com/your-health/your-skin/skin-conditions/acne/risk-factors
[12] https://bestpractice.bmj.com/topics/en-gb/101
[13] https://www.aad.org/public/diseases/acne/acne-myths
[14] https://www.healthline.com/health/beauty-skin-care/acne-and-diet-myths#acne-and-dairy
Source: Mind The Gap
Acne Vulgaris
Nodulo-cystic acne (a severe form of acne)
Source: DermNetNZ.org
Acne Vulgaris
Acne found on the back
Source: Waikato District Health Board
Acne Vulgaris
Mild acne
Source: VisualDx and Skinsight
Acne Vulgaris
Multiple bumps of inflammatory acne with a faint redness
Source: DermNetNZ.org
Acne Vulgaris
Post-inflammatory pigmentation due to acne