Definition, Clinical Signs, and Symptoms

The term acne usually refers to acne vulgaris, a common disease in which the pilosebaceous
units of the skin become plugged and distended (see Fig. 38-1 in Chapter 38). It differs from
rosacea (formerly called acne rosacea), which causes facial erythema, telangiectasia, and
papules, and occurs later in life. Acne cosmetica and acne mechanica are terms describing
aggravation of the condition by cosmetics or by mechanical irritation such as that from
helmet straps.
Acne lesions generally appear on the face, but the chest, back, or upper arms may also be
affected. Comedones, plugged follicular openings, are noninflammatory lesions that may be
closed (whiteheads) or open (blackheads). The dark pigmentation in open comedones is
caused by oxidation of sebaceous material or melanin rather than by dirt, a common
misperception.1 Inflammatory lesions are typically erythematous and can include pustules
(raised, superficial, pus-filled lesions), papules (raised, solid lesions up to several millimeters
in diameter), and nodules (like papules but larger and deeper in the skin); in severe cases
(acne conglobata), multiple lesions coalesce into abscesses with draining sinus tracts. 2
Although no single severity scale has emerged as standard, clinicians must use some acne
grading scale consistently to evaluate treatment options and clinical response. Often,
clinicians describe acne as mild (few lesions, little or no inflammation), moderate (many
lesions, significant inflammation), or severe (numerous lesions, extreme inflammation and/or
nodules, significant scarring).3 The Combined Acne Severity Classification is one
recommended codification system (Table 39-1).4 Lesion counts per se are not practical for
clinicians, but are used by researchers.
Acne can cause psychological distress, low self-esteem, and social withdrawal, affecting
quality of life as much as more physically disabling diseases such as asthma and diabetes. 5
Considerable psychological morbidity can result from even mild to moderate acne. 6
Questionnaires have been developed to identify the psychosocial impact of acne. 7 The major
long-term complication of acne is scarring, usually ice pick pitting with significant
disfigurement. Scarring can be exacerbated by tissue excoriation caused by picking at or
squeezing the lesions. Early initiation of effective therapy is critical to prevent scarring.8
Acne occurs in people of all ages, but acne vulgaris primarily afflicts teenagers and young
adults. Acne is also associated with systemic diseases such as SAPHO (synovitis, acne,
pustulosis, hyperostosis, osteitis) and Apert syndromes. 9,10 The differential diagnosis of
acneiform eruptions includes acne vulgaris; rosacea; folliculitis caused by gram-negative
bacteria, Pityrosporum, or mechanical irritation; drug-induced acne such as that caused by
topical or systemic corticosteroids, or by anabolic steroids, including those abused by
athletes; and perioral dermatitis.11,12,13,14 Detailed discussions of severe acne variants, such as
acne conglobata and acne fulminans, are beyond the scope of this chapter.11,15