Definition
A.Acne vulgaris is a disorder of the sebaceous glands and hair follicles of the skin, which are most numerous on the face, back, and chest. The sebaceous glands become inflamed and form papules, pustules, cysts, open or closed comedones, and/or nodules on an erythemic base. In severe cases, scarring can result.
Incidence
A.Nearly 80% to 90% of all adults experience acne during their lifetime. Acne vulgaris, commonly seen in adolescence, may even extend into the third or fourth decade of life.
Pathogenesis
A.Sebum is overproduced and collects in the sebaceous gland. Sebum, keratinized cells, and hair collect in the follicle. With Propionibacterium acnes (also known as Cutibacterium acnes) present, the duct becomes clogged, and lesions (noninflammatory and/or inflammatory) evolve.
Predisposing Factors
A.Age (adolescence).
B.External irritants to skin (makeup, oils, equipment contact on skin).
C.Hormones (oral contraceptives with high progestin content).
D.Medications (lithium, halides, hydantoin derivatives, rifampin).
E.Hot, humid weather.
Common Complaints
A.Outbreak of pimples on face, chest, shoulders, and back that do not resolve with over-the-counter (OTC) treatment.
B.Acne rosacea: Telangiectasia, flushing, and rhinophyma present.
Other Signs and Symptoms
A.Mild: Comedones open (blackhead) and closed (whitehead).
B.Moderate: Comedones with papules and pustules.
C.Severe: Nodules, cysts, and scars.
Subjective Data
A.Elicit the age of onset of outbreak, duration, and course of symptoms.
B.Determine what makes the lesions worse or better.
C.Ask whether there are certain times of the month of year when lesions are better or worse.
D.Identify the patient’s current method of cleanser or moisturizer treatment.
E.Ask if the patient has ever been treated by a provider for this problem. If so, determine the treatment and results of the treatment.
F.Assess whether other family members have this same problem.
G.Ask the patient for a description of the patient’s environment and occupation.
H.Explore with the patient any current stress factors in his or her life.
Physical Examination
A.Inspect:
1.Observe skin for location and severity of lesions.
2.Rate severity of lesions as mild, moderate, or severe:
a.Mild: Few papules/pustules, no nodules.
b.Moderate: Several papules/pustules, rare nodules.
c.Severe: Many papules/pustules with many nodules.
3.Take a picture of areas of affected skin for chart and document date. Use this for future appointments as a reference to compare results for follow-up visits.
Diagnostic Tests
A.No tests are generally required.
B.Culture lesions to rule out gram-negative folliculitis with patients on antibiotics.
C.Consider hormone testing if other primary causes of acne are considered (follicle-stimulating hormone, luteinizing hormone, testosterone levels).
Differential Diagnoses
A.Acne vulgaris.
B.Acne rosacea.
C.Steroid rosacea.
D.Folliculitis.
E.Perioral acne.
F.Drug-induced acne.
G.Sebaceous hyperplasia.
H.Keratosis pilaris.
I.Hidradenitis suppurtiva.
J.Acne cosmetica.
K.Tropical acne.
Plan
A.General interventions:
1.Document location and severity of lesions. Assess quality of improvement at each office visit.
2.The primary goal of treatment is prevention of scarring. Good control of lesions during puberty and early adulthood is required for best results. Anticipate ups and downs during the normal course and treatment.
B. 
See Section III: Patient Teaching Guide Acne Vulgaris.
1.Instruct the patient on the proper cleansing routine. The patient should wash affected areas with mild soap (Purpose, Cetaphil) twice a day and apply medications as directed.
2.Warn the patient that washing the face more than two to three times a day can decrease oil production and cause drying.
3.Discuss current stressors in the patient’s life and discuss treatment options.
4.Recommend exercise routine 3 to 5 days a week.
5.Recommend oil-free sunscreens. Ultraviolet (UV) light is beneficial; however, there is a need to use with caution when retinoids and tetracycline have been prescribed.
C.Pharmaceutical therapy: It may take 2 to 3 months before results are visible when using these medications:
1.Mild to moderate: Treatment of choice is combination topical:
a.Benzoyl peroxide, 2.5%, 5%, 10%; begin with 2.5% at bedtime. May graduate to 5% or 10% twice daily, if needed, as tolerated. When ordering with Retin-A apply the benzoyl peroxide in the a.m. and the Retin-A in the p.m. Combination therapy of Retin-A and/or topical antibiotic is more effective.
b.Topical tretinoin 0.1% (Retin-A Micro); use at bedtime. Apply 20 to 30 minutes after washing skin:
i.With Retin-A use, the patient may see rapid turnover of keratin plugs.
ii.Instruct the patient to avoid abrasive soaps.
iii.Warn the patient regarding photosensitivity.
c.Clindamycin gel 1% applied once daily.
d.Erythromycin gel 3% applied once daily.
2.Moderate to severe: Use the previous topical retinoid and benzoyl peroxide medications in addition to one of the following oral medications:
a.Doxycycline 50 to 100 mg twice daily or 100 mg once daily treatment of choice
b.Tetracycline 500 mg twice daily:
i.Instruct the patient to take tetracycline on an empty stomach and to avoid dairy products,
antacids, and iron.
ii.Warn the patient about photosensitivity. This medication may be used as a maintenance dose at 250 mg daily or every other day for those patients who break out after discontinuing antibiotic therapy. No drug resistance is seen with tetracycline.
c.Minocycline 50 mg taken one to three times daily:
i.Have the patient drink plenty of fluids.
ii.Central nervous system (CNS) side effects (headaches) have been seen.
d.Oral contraceptives with higher doses of estrogen have also been effective for girls.
3.Severe: Medications as prescribed per dermatologist.
Follow-Up
See patients every 6 to 8 weeks for evaluation.
A.Mild: Adjust dose depending on local irritation.
B.Moderate (oral and topical medications):
1.Adjust dose according to irritation.
2.Taper oral antibiotics with discretion and/or continue topical medications.
3.Oral antibiotics may be tapered and discontinued when inflammatory lesions have resolved.
Consultation/Referral
A.Consult with a physician if treatment is unsuccessful after 10 to 12 weeks of therapy or if acne is severe.
B.The patient may need dermatology consultation.
Individual Considerations
A.Pregnancy:
1.Acne may flare up or improve during pregnancy.
2.Medications preferred during pregnancy are topical agents.
3.Teratogens include tretinoin, tetracycline, and minocycline.
a.When using teratogenic medications, contraception must be practiced to avoid pregnancy to prevent severe fetal malformations.
b.Begin contraception 1 month prior to starting the medication and 1 month after finishing the medication.