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[Conditions](https://durgical.com/en/conditions/) · [Dermatology](https://durgical.com/en/conditions/)

# Acne vulgaris

A very common skin disease of hair follicles and oil glands that causes blackheads, whiteheads, pimples and sometimes deep painful lumps and scars.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Skin](https://durgical.com/en/anatomy/skin/)
- [Ovaries](https://durgical.com/en/anatomy/ovary/)

## In embryology

- [Isotretinoin and other retinoids](https://durgical.com/en/embryology/isotretinoin-and-other-retinoids/)

## In the clinical exam

- [Skin examination: primary and secondary lesions](https://durgical.com/en/clinical-exam/skin-examination-primary-and-secondary-lesions/)

## Why it happens

- [Testosterone and its actions](https://durgical.com/en/physiology/testosterone-and-its-actions/)
- [Hair follicles, sebaceous and sweat glands, nails](https://durgical.com/en/histology/hair-follicles-sebaceous-and-sweat-glands-nails/)
- [Glands: exocrine vs endocrine, secretion types](https://durgical.com/en/histology/glands-exocrine-vs-endocrine-secretion-types/)

## What it is

A chronic inflammatory disease of the pilosebaceous unit (hair follicle and sebaceous gland) that produces comedones, papules, pustules and, in severe cases, nodules and cysts, mainly on the face, [chest](https://durgical.com/en/anatomy/region/chest/) and back.

## Who gets it

Affects most adolescents to some degree and often persists into adulthood, especially in women. In Latin American populations with darker skin types, post-inflammatory hyperpigmentation is a frequent and distressing sequel.

## Causes

- Androgen-driven increase in sebum production
- Abnormal keratinisation that plugs the follicle (microcomedone)
- Proliferation of Cutibacterium acnes in the plugged follicle
- Inflammation in and around the follicle

## Risk factors

- Puberty and family history
- Hyperandrogenism (polycystic ovary syndrome, congenital adrenal hyperplasia)
- Drugs: corticosteroids, anabolic steroids, lithium, some anticonvulsants
- Occlusive cosmetics and friction (acne mechanica)
- High-glycaemic diet and dairy may worsen it in some people

## Pathophysiology

Androgens enlarge sebaceous glands and increase sebum. Keratinocytes in the follicle shed abnormally and form a plug (closed comedone, or open comedone when the pore dilates and the content oxidises). C. acnes thrives in this sebum-rich, low-oxygen space and triggers innate immune and inflammatory pathways; rupture of the follicle wall into the dermis causes inflamed papules, pustules and nodules, which may heal with scars.

## Classification

- Comedonal (non-inflammatory) acne
- Mild to moderate papulopustular acne
- Severe nodular or nodulocystic acne
- Special forms: acne conglobata, acne fulminans, drug-induced acne

## Symptoms and signs

- Open comedones (blackheads) and closed comedones (whiteheads)
- Red papules and pustules on the face, chest, shoulders and back
- Deep tender nodules and cysts in severe acne
- Scars (ice-pick, boxcar, hypertrophic) and post-inflammatory dark marks
- Low self-esteem, anxiety or depression

## Red flags

- Sudden severe ulcerating acne with fever and joint pain (acne fulminans)
- Acne with hirsutism, irregular periods or virilisation in women (hyperandrogenism)
- Sudden acne in an adult with features of Cushing syndrome
- Mood change, depression or suicidal thoughts in a person on treatment, particularly isotretinoin
- Missed period or possible pregnancy during isotretinoin therapy

## Diagnosis

**Clinical**
Clinical: lesion types (comedones are the hallmark), distribution and severity, scarring and psychological impact; drug and menstrual history.

**Tests**
Usually none. Androgen testing (total and free testosterone, DHEA-S) and other tests when hyperandrogenism is suspected. Before and during isotretinoin: pregnancy tests and, by local protocol, lipids and [liver](https://durgical.com/en/anatomy/liver/) enzymes.

**Imaging**
Not needed; pelvic ultrasound only if polycystic [ovary](https://durgical.com/en/anatomy/ovary/) syndrome is being evaluated.

## Differential diagnosis

- Rosacea (no comedones, flushing, telangiectasia)
- Perioral dermatitis
- Bacterial or Malassezia (pityrosporum) folliculitis
- Drug-induced (steroid) acneiform eruption
- Hidradenitis suppurativa

## Goal of treatment

Control lesions, prevent scars and pigment marks, and reduce psychological burden, choosing treatment by severity and limiting antibiotic use to avoid resistance.

## Treatment

**Medical**
Topical retinoids (adapalene, tretinoin) for comedones and as maintenance, with benzoyl peroxide and azelaic acid; topical antibiotics such as clindamycin are always combined with benzoyl peroxide to limit resistance.

**Medical**
Moderate to severe inflammatory acne: oral tetracyclines (doxycycline, minocycline) for a limited time with a topical retinoid and benzoyl peroxide; tetracyclines are avoided in pregnancy and young children and cause photosensitivity. In women, combined oral contraceptives or spironolactone act on androgens.

**Medical**
Oral isotretinoin for severe nodular, scarring or refractory acne. It is highly teratogenic: a pregnancy-prevention programme with two forms of contraception and repeated negative pregnancy tests is mandatory, and people on it must not donate blood or share the drug.

**Follow-up**
Nursing and medical monitoring on isotretinoin: pregnancy tests, lipids and liver enzymes per protocol, mood and suicidal thoughts, dry [skin](https://durgical.com/en/anatomy/skin/), lips and eyes, and sun protection.

**Lifestyle**
Gentle non-comedogenic skin care, not picking or squeezing lesions, and daily sun protection to limit dark marks.

## Complications

- Permanent atrophic or hypertrophic scars and keloids
- Post-inflammatory hyperpigmentation, common in darker skin
- Depression, anxiety and social withdrawal
- Birth defects if isotretinoin is taken during pregnancy (retinoid embryopathy) and pregnancy loss

## Prognosis

Usually improves after adolescence but can persist for years. Early effective treatment prevents most scarring; isotretinoin gives long remission in most people with severe acne.

## Prevention

- Early treatment of inflammatory acne to prevent scars
- Non-comedogenic cosmetics and avoiding picking
- Strict pregnancy prevention during and after isotretinoin treatment for the advised period

## Test yourself

Think of the answer, then tap the question to see it.

## What are the four key factors in the pathogenesis of acne?

Increased sebum (androgens), follicular hyperkeratinisation, Cutibacterium acnes and inflammation.

## What is the hallmark lesion that separates acne from rosacea?

The comedone (blackhead or whitehead); rosacea has no comedones.

## Why are topical antibiotics combined with benzoyl peroxide in acne?

To reduce the emergence of resistant bacteria.

## What is the most important safety measure with isotretinoin?

Strict pregnancy prevention (two contraceptive methods and repeated negative pregnancy tests) because the drug is highly teratogenic.

## Which oral antibiotic class is used for moderate inflammatory acne and in whom is it avoided?

Tetracyclines such as doxycycline; avoided in pregnancy and in young children because of tooth and bone effects.

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## Related conditions

- [Polycystic ovary syndrome](https://durgical.com/en/conditions/polycystic-ovary-syndrome/)
- [Cushing syndrome](https://durgical.com/en/conditions/cushing-syndrome/)
- [Miscarriage (early pregnancy loss)](https://durgical.com/en/conditions/miscarriage/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Acne](https://medlineplus.gov/acne.html) (MedlinePlus (U.S. National Library of Medicine), 2024); [Isotretinoin](https://medlineplus.gov/druginfo/meds/a681043.html) (MedlinePlus (U.S. National Library of Medicine), 2024).

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Source: https://durgical.com/en/conditions/acne-vulgaris/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/acne-vulgaris/