Acne Vulgaris Clinical Presentation

Updated: Aug 27, 2020
  • Author: Jaggi Rao, MD, FRCPC; Chief Editor: William D James, MD  more...
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Local symptoms of acne vulgaris may include pain, tenderness, and/or erythema.

Systemic symptoms are most often absent in acne vulgaris. In rare but severe cases, acne vulgaris could lead to acne conglobata, with highly inflammatory nodulocystic acne and interconnected abscesses. Acne fulminans is even more severe than acne conglobata, with systemic symptoms such as fever, joint pain, and general malaise.

Patients with polycystic ovarian syndrome (PCOS) often first present to dermatologists for acne. With its long-term complications of obesity, infertility, and malignancy, PCOS needs to be considered when female patients present with acne, particularly with moderate-to-severe acne in adulthood that is refractory to conventional therapies. Additionally, a history of oligomenorrhea (< 9 menses a year) or amenorrhea for more than 3 months should raise further suspicion for PCOS. [31]

Acne vulgaris may have a psychological impact on any patient, regardless of the severity or the grade of the disease. [4]


Physical Examination

Acne vulgaris is characterized by comedones, papules, pustules, and nodules in a sebaceous distribution (eg, face, upper chest, back). A comedone is a whitehead (closed comedone) or a blackhead (open comedone) without any clinical signs of inflammation. Papules and pustules are raised bumps with inflammation. The face may be the only involved skin surface, but the chest, back, and upper arms are often involved.

In comedonal acne, patients develop open and closed comedones but may not develop inflammatory papules or nodules.

See the image below.

Acne, grade I; multiple open comedones. Acne, grade I; multiple open comedones.

Mild acne is characterized by comedones and a few papulopustules. Note the image below.

Acne, grade II; closed comedones. Acne, grade II; closed comedones.

Moderate acne has comedones, inflammatory papules, and pustules. Greater numbers of lesions are present than in milder inflammatory acne. Note the image below.

Acne, grade III; papulopustules. Acne, grade III; papulopustules.

Nodulocystic acne is characterized by comedones, inflammatory lesions, and large nodules greater than 5 mm in diameter. Scarring is often evident. Note the image below.

Acne, grade IV; multiple open comedones, closed co Acne, grade IV; multiple open comedones, closed comedones, and papulopustules, plus cysts.

Studies have found that women with PCOS have slightly increased comedones in the forehead, perioral, or jawline areas, but, otherwise, acne lesion counts, types, and regional burden are largely the same between women with and without PCOS. [32] Other cutaneous manifestations may indicate PCOS, including signs of insulin resistance such as acanthosis nigricans and additional signs of hyperandrogenism such as hirsutism and hair loss. [31] Also see Polycystic Ovarian Syndrome.