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Acne Vulgaris

Presentation

History

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.

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

Acne, grade II; closed comedones.

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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.

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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 comedones, and papulopustules, plus cysts.

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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.

Differential Diagnoses

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Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003 Jul. 49(1 Suppl):S1-37. [QxMD MEDLINE Link].
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Media Gallery

Acne, grade I; multiple open comedones.
Acne, grade II; closed comedones.
Acne, grade III; papulopustules.
Acne, grade IV; multiple open comedones, closed comedones, and papulopustules, plus cysts.
Acne with reactive hyperpigmentation; before treatment.
Acne with reactive hyperpigmentation; after treatment.

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Author

Jaggi Rao, MD, FRCPC Clinical Professor of Medicine, Division of Dermatology and Cutaneous Sciences, Director of Dermatology Residency Program, University of Alberta Faculty of Medicine and Dentistry, Canada

Jaggi Rao, MD, FRCPC is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, Canadian Dermatology Association, Canadian Medical Association, Canadian Medical Protective Association, Pacific Dermatologic Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

Jennifer Chen, MD Department of Family and Community Medicine, University of Toronto Faculty of Medicine, Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Additional Contributors

Joshua A Zeichner, MD Assistant Professor, Director of Cosmetic and Clinical Research, Mount Sinai School of Medicine; Chief of Dermatology, Institute for Family Health at North General

Joshua A Zeichner, MD is a member of the following medical societies: American Academy of Dermatology, National Psoriasis Foundation

Disclosure: Received consulting fee from Valeant for consulting; Received grant/research funds from Medicis for other; Received consulting fee from Galderma for consulting; Received consulting fee from Promius for consulting; Received consulting fee from Pharmaderm for consulting; Received consulting fee from Onset for consulting.

Acne Vulgaris Clinical Presentation

History

Physical Examination

References

Tables

Contributor Information and Disclosures

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