Acne vulgaris

Acne is a chronic inflammatory disease of the pilosebaceous unit. While often dismissed as a "rite of passage," its impact on quality of life is significant.

• Onset and Distribution:
  Patients report persistent lesions typically localized to "sebaceous" areas: the face, back, and chest.

• Triggers:
  Many note flares associated with hormonal shifts (puberty, menstrual cycles, pregnancy) or periods of high stress.

• Product History:
  They may mention the use of "heavy" or oily skincare products (comedogenic cosmetics).

• Family History:
  A positive family history is common, often predicting a more severe or prolonged course.

• Treatment Fatigue:
  Patients often present after trying multiple over-the-counter washes or "hacks" with little to no success.

Diagnosis is clinical, based on the presence of pleomorphic (varied) lesions.

• Comedones (The hallmark of acne):  

  • Open (Blackheads): Dilated pores filled with oxidized melanin and sebum.

  • Closed (Whiteheads): Small, flesh-colored follicular papules.

• Inflammatory Lesions:
  Erythematous papules and pustules.

• Severe Features:
  Large, painful, deep-seated nodules or cysts. These are the primary drivers of permanent scarring.

• Secondary Changes:
  Look for evidence of excoriation (picking) and the specific "ice-pick," "rolling," or "boxcar" scars.

Crucial Note for Darker Skin Tones

• Post-Inflammatory Hyperpigmentation (PIH):
  In Black, Asian, and Hispanic patients, PIH is often the primary concern, rather than the active acne itself. Dark spots can persist for months after the inflammatory lesion has healed, leading to significant distress.

• Pomade Acne:
  Look for closely packed comedones along the anterior hairline, often caused by oils or waxes used for hair styling.

• Keloidal Scarring:
  There is a higher risk of developing hypertrophic or keloid scars, especially on the jawline, chest, and back.

• Erythema Masking:
  In very dark skin, the "redness" of an inflammatory papule may appear more violaceous (purple) or brown, making it harder to assess severity at a glance

Management aims to reduce sebum production, clear comedones, and settle inflammation to prevent permanent scarring.

General Principles:

1. • Education: Explain that improvement takes 6–8 weeks; "spot treating" is less effective than treating the whole affected area.

   • Skincare: Recommend "non-comedogenic" or "oil-free" cleansers and moisturizers.

Treatments for acne vulgaris range from topical agents to systemic therapies based on severity:

Topical Retinoids (e.g., Tretinoin 0.025%-0.1%): Apply once daily; useful for comedonal acne and mild inflammatory lesions.

Benzoyl Peroxide (2.5%-10%): Available as wash or leave-on gel; reduces bacterial load. Use daily to avoid irritation.

Antibiotics (e.g., Clindamycin 1% gel): Combine with benzoyl peroxide to prevent resistance, applied once daily.

Oral Antibiotics (e.g., Doxycycline 100mg daily): Effective for moderate to severe cases. Course duration should be minimized to 3-6 months.

Hormonal Agents (e.g., Oral contraceptives): Suitable for females with hormonal influences; requires assessment of risk factors.

Isotretinoin (0.5-1 mg/kg/day): For severe, resistant acne; duration typically 5-6 months under close monitoring. Note: Isotretinoin is teratogenic; women of childbearing age must use contraceptives!! Dapsone is a cheaper alternative worth trying if no isotretinoin available.

DermNet NZ – Acne Vulgaris: https://dermnetnz.org/topics/acne-vulgaris

British Association of Dermatologists – Acne Patient Information: https://www.bad.org.uk/pils/acne/

Journal of Clinical and Aesthetic Dermatology – Acne in Skin of Color (Callender et al.): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080563/