Acne vulgaris is a common chronic skin disease involving blockage and/or inflammation of pilosebaceous units (hair follicles and their accompanying sebaceous gland). Acne can present as noninflammatory lesions, inflammatory lesions, or a mixture of both, affecting mostly the face but also the back and chest.[Clinical Presentation for more detail. Acne, grade I; multiple open comedones Diagnosis Examination in patients with acne vulgaris includes the following features: Comedonal acne: Presence of open and closed comedones but usually no inflammatory papules or nodules Mild acne: Presence of comedones and a few papulopustules Moderate acne: Presence of comedones, inflammatory papules, and pustules; a greater number of lesions are present than in milder inflammatory acne Nodulocystic acne: Presence of comedones, inflammatory lesions, and large nodules greater than 5 mm in diameter; scarring is often evident Laboratory tests Acne vulgaris is a clinical diagnosis. However, laboratory testing may be indicated in the following situations: Polycystic ovarian syndrome (PCOS): Consider PCOS in female patients with oligomenorrhea, hirsutism and/or acanthosis nigricans in addition to acne. These patients should be evaluated with total and free testosterone, dehydroepiandrosterone sulfate (DHEAS), androstenedione, luteinizing hormone, and follicle-stimulating hormone values, as well as a lipid panel, glucose value, and insulin level. Cases refractory to long-term antibiotic treatment or when improvement with antibiotics is not maintained: Culture skin lesions to rule out gram-negative folliculitis. Management Treatment of acne vulgaris should be directed toward the known pathogenic factors, including follicular hyperproliferation, excess sebum, C acnes (formerly P acnes), and inflammation. The most appropriate treatment is based on the grade and severity of the acne. Pharmacotherapy The following medications are used in the treatment of Cutibacterium (formerly Propionibacterium) acne vulgaris: Acne products (eg, erythromycin and benzoyl peroxide, clindamycin and tretinoin, clindamycin and benzoyl peroxide, azelaic acid, benzoyl peroxide, topical dapsone) Retinoidlike agents (eg, topical tretinoin, adapalene, tazarotene, isotretinoin) Antibiotics (eg, tetracycline, minocycline, doxycycline, trimethoprim/sulfamethoxazole, clindamycin, topical clindamycin, topical erythromycin, daptomycin) Selective aldosterone antagonists (eg, spironolactone) Estrogen/progestin combination oral contraceptive pills (eg, ethinyl estradiol, drospirenone, and levomefolate; ethinyl estradiol and norethindrone; ethinyl estradiol and norgestimate; ethinyl estradiol and drospirenone) When a topical or systemic antibiotic is used, it should be used in conjunction with benzoyl peroxide to reduce the emergence of resistance. Nonpharmacotherapy Diet therapy, such as a low-glycemic diet and avoidance of “junk foods,” has been suggested as a nonpharmacologic measure to manage acne vulgaris. Skim milk has been found to have a positive association with acne. Procedures Procedural treatments for acne vulgaris include the following: Manual extraction of comedones Intralesional steroid injections Superficial peels that use glycolic or salicylic acid Light and laser therapy Source
