eMedicine Specialties > Dermatology > Diseases of the Adnexa

Acne Vulgaris: Differential Diagnoses & Workup

Author: James Fulton Jr, MD, PhD, Center for Cosmetic Dermatology; Consultant, Vivant Pharmaceuticals, LLC
Contributor Information and Disclosures

Updated: Aug 6, 2009

Differential Diagnoses

Acne Conglobata
Rosacea
Acne Fulminans
Sebaceous Hyperplasia
Acne Keloidalis Nuchae
Syringoma
Acneiform Eruptions
Tuberous Sclerosis
Folliculitis
Perioral Dermatitis

Other Problems to Be Considered

Demodex folliculitis
Bacterial folliculitis
Papular sarcoidosis

Workup

Laboratory Studies

The diagnosis of acne vulgaris is clinical. 

  • In a female patient with dysmenorrhea or hirsutism, a hormonal evaluation should be considered. Patients with evidence of virilization must have their total testosterone levels measured. Many authorities also measure free testosterone, DHEA-S, leuteinizing hormone, and follicle-stimulating hormone levels.
  • Skin lesion cultures to rule out gram-negative folliculitis are warranted if the patient does not respond to treatment or improvement is not maintained.
  • Also see the Medscape Acne Resource Center.

Histologic Findings

The microcomedo is characterized by a dilated follicle with a plug of dense keratin. With progression of the disease, the follicular opening becomes dilated, and an open comedo results. The follicular wall thins, and it may rupture. Inflammation and bacteria may be evident, with or without follicular rupture. Follicular rupture is accompanied by dense inflammatory infiltrate throughout the dermis. Later, extensive fibrosis and scarring may develop.

More on Acne Vulgaris

Overview: Acne Vulgaris
Differential Diagnoses & Workup: Acne Vulgaris
Treatment & Medication: Acne Vulgaris
Follow-up: Acne Vulgaris
Multimedia: Acne Vulgaris
References
Further Reading
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References

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  2. Norris JF, Cunliffe WJ. A histological and immunocytochemical study of early acne lesions. Br J Dermatol. May 1988;118(5):651-9. [Medline].

  3. Thiboutot D, Gilliland K, Light J, Lookingbill D. Androgen metabolism in sebaceous glands from subjects with and without acne. Arch Dermatol. Sep 1999;135(9):1041-5. [Medline].

  4. Lucky AW, Biro FM, Simbartl LA, Morrison JA, Sorg NW. Predictors of severity of acne vulgaris in young adolescent girls: results of a five-year longitudinal study. J Pediatr. Jan 1997;130(1):30-9. [Medline].

  5. Holland DB, Cunliffe WJ, Norris JF. Differential response of sebaceous glands to exogenous testosterone. Br J Dermatol. Jul 1998;139(1):102-3. [Medline].

  6. Pochi PE, Strauss JS. Sebaceous gland activity in black skin. Dermatol Clin. Jul 1988;6(3):349-51. [Medline].

  7. Kim J, Ochoa MT, Krutzik SR, et al. Activation of toll-like receptor 2 in acne triggers inflammatory cytokine responses. J Immunol. Aug 1 2002;169(3):1535-41. [Medline].

  8. Webster GF. Inflammatory acne represents hypersensitivity to Propionibacterium acnes. Dermatology. 1998;196(1):80-1. [Medline].

  9. Ingham E, Eady EA, Goodwin CE, Cove JH, Cunliffe WJ. Pro-inflammatory levels of interleukin-1 alpha-like bioactivity are present in the majority of open comedones in acne vulgaris. J Invest Dermatol. Jun 1992;98(6):895-901. [Medline].

  10. Fulton JE, Black E. Dr. Fulton's Step-by-Step Program for Clearing Acne. New York, NY: Harper & Row; 1983.

  11. Smith RN, Mann NJ, Braue A, Makelainen H, Varigos GA. The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol. Aug 2007;57(2):247-56. [Medline].

  12. A Agatston. The South Beach Diet. first. Rodale Press; 2003.

  13. Mulder MM, Sigurdsson V, van Zuuren EJ, et al. Psychosocial impact of acne vulgaris. evaluation of the relation between a change in clinical acne severity and psychosocial state. Dermatology. 2001;203(2):124-30. [Medline].

  14. Shaw JC, White LE. Persistent acne in adult women. Arch Dermatol. Sep 2001;137(9):1252-3. [Medline].

  15. Kligman AM. Postadolescent acne in women. Cutis. Jul 1991;48(1):75-7. [Medline].

  16. Kellett SC, Gawkrodger DJ. The psychological and emotional impact of acne and the effect of treatment with isotretinoin. Br J Dermatol. Feb 1999;140(2):273-82. [Medline].

  17. Mango D, Ricci S, Manna P, Miggiano GA, Serra GB. Clinical and hormonal effects of ethinylestradiol combined with gestodene and desogestrel in young women with acne vulgaris. Contraception. Mar 1996;53(3):163-70. [Medline].

  18. Eady EA, Farmery MR, Ross JI, Cove JH, Cunliffe WJ. Effects of benzoyl peroxide and erythromycin alone and in combination against antibiotic-sensitive and -resistant skin bacteria from acne patients. Br J Dermatol. Sep 1994;131(3):331-6. [Medline].

  19. Cunliffe WJ, Holland KT. The effect of benzoyl peroxide on acne. Acta Derm Venereol. 1981;61(3):267-9. [Medline].

  20. Eady EA, Jones CE, Gardner KJ, Taylor JP, Cove JH, Cunliffe WJ. Tetracycline-resistant propionibacteria from acne patients are cross-resistant to doxycycline, but sensitive to minocycline. Br J Dermatol. May 1993;128(5):556-60. [Medline].

  21. Bottomley WW, Cunliffe WJ. Oral trimethoprim as a third-line antibiotic in the management of acne vulgaris. Dermatology. 1993;187(3):193-6. [Medline].

  22. Fernandez-Obregon AC. Azithromycin for the treatment of acne. Int J Dermatol. Jan 2000;39(1):45-50. [Medline].

  23. Koulianos GT. Treatment of acne with oral contraceptives: criteria for pill selection. Cutis. Oct 2000;66(4):281-6. [Medline].

  24. Redmond GP. Effectiveness of oral contraceptives in the treatment of acne. Contraception. Sep 1998;58(3 Suppl):29S-33S; quiz 68S. [Medline].

  25. Strauss JS, Pochi PE. Effect of cyclic progestin-estrogen therapy on sebum and acne in women. JAMA. Nov 30 1964;190:815-9. [Medline].

  26. Thorneycroft IH, Stanczyk FZ, Bradshaw KD, Ballagh SA, Nichols M, Weber ME. Effect of low-dose oral contraceptives on androgenic markers and acne. Contraception. Nov 1999;60(5):255-62. [Medline].

  27. Shaw JC. Low-dose adjunctive spironolactone in the treatment of acne in women: a retrospective analysis of 85 consecutively treated patients. J Am Acad Dermatol. Sep 2000;43(3):498-502. [Medline].

  28. Jacobs DG, Deutsch NL, Brewer M. Suicide, depression, and isotretinoin: is there a causal link?. J Am Acad Dermatol. Nov 2001;45(5):S168-75. [Medline].

  29. Jick SS, Kremers HM, Vasilakis-Scaramozza C. Isotretinoin use and risk of depression, psychotic symptoms, suicide, and attempted suicide. Arch Dermatol. Oct 2000;136(10):1231-6. [Medline].

  30. [Guideline] Strauss JS, Krowchuk DP, Leyden JJ, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. Apr 2007;56(4):651-63. [Medline].

  31. Cunliffe WJ, Goulden V. Phototherapy and acne vulgaris. Br J Dermatol. May 2000;142(5):855-6. [Medline].

  32. Papageorgiou P, Katsambas A, Chu A. Phototherapy with blue (415 nm) and red (660 nm) light in the treatment of acne vulgaris. Br J Dermatol. May 2000;142(5):973-8. [Medline].

  33. Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol. Aug 2007;57(2):247-56. [Medline].

  34. Agatston A. The South Beach Diet. Emmaus, Pa: Rodale Press; 2003.

  35. Knowles SR, Shapiro L, Shear NH. Serious adverse reactions induced by minocycline. Report of 13 patients and review of the literature. Arch Dermatol. Aug 1996;132(8):934-9. [Medline].

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Further Reading

An excellent reference textbook is Plewig G, Kligman AM; Acne and Rosacea, New York, NY: Springer-Verlag, 1993.

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Keywords

acne vulgaris, acne lesion, follicular papules, comedones, inflammatory papules, inflammatory pustules, inflammatory nodules, follicular epidermal hyperproliferation and hyperkeratinization, excess sebum, Propionibacterium acnes, P acnes, microcomedo, microcomedone, acne fulminans, comedonal acne, nodulocystic acne, congenital adrenal hyperplasia, polycystic ovary syndrome

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Contributor Information and Disclosures

Author

James Fulton Jr, MD, PhD, Center for Cosmetic Dermatology; Consultant, Vivant Pharmaceuticals, LLC
James Fulton Jr, MD, PhD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, American Society for Laser Medicine and Surgery, Dermatology Foundation, International Society of Cosmetic and Laser Surgeons, and Skin Cancer Foundation
Disclosure: vivant pharmaceuticals Ownership interest Consulting

Medical Editor

Alexa F Boer Kimball, MD, MPH, Associate Professor of Dermatology, Harvard University School of Medicine; Vice Chair, Department of Dermatology, Massachusetts General Hospital; Director of Clinical Unit for Research Trials in Skin (CURTIS), Department of Dermatology, Massachusetts General Hospital
Alexa F Boer Kimball, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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