Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris
- Diane Thiboutot, MD
Diane Thiboutot, MD
- Professor and Vice Chair of Dermatology Research
- Penn State University College of Medicine
- Andrea Zaenglein, MD
Andrea Zaenglein, MD
- Professor of Dermatology and Pediatrics
- Penn State/ Milton S. Hershey Medical Center
- Section Editors
- Robert P Dellavalle, MD, PhD, MSPH
Robert P Dellavalle, MD, PhD, MSPH
- Section Editor — Dermatology
- Associate Professor of Dermatology and Public Health
- Denver VA Medical Center, University of Colorado School of Medicine and Colorado School of Public Health
- Moise L Levy, MD
Moise L Levy, MD
- Section Editor — Pediatric Dermatology
- Clinical Professor of Dermatology and Pediatrics
- Baylor College of Medicine
- Professor of Medicine
- Dell Medical School/University of Texas, Austin
- Mark V Dahl, MD
Mark V Dahl, MD
- Section Editor — Acne and Rosacea
- Professor Emeritus
- Mayo Clinic College of Medicine
Acne vulgaris is the most common cutaneous disorder affecting adolescents and young adults. Patients with acne can experience significant psychological morbidity and, rarely, mortality due to suicide [1,2]. The psychological effects of embarrassment and anxiety can impact the social lives and employment of affected individuals. Scars can be disfiguring and lifelong. In one prospective study of 90 patients with acne, a significant improvement in self-esteem was found with treatment of the acne . Thus, it is imperative that clinicians are familiar with acne vulgaris and its treatment.
The pathogenesis, clinical manifestations, diagnosis, and differential diagnosis of acne vulgaris will be reviewed here. The treatment of acne vulgaris is discussed elsewhere. (See "Treatment of acne vulgaris" and "Hormonal therapy for women with acne vulgaris" and "Oral isotretinoin therapy for acne vulgaris" and "Light-based, adjunctive, and other therapies for acne vulgaris".)
Estimates of the prevalence of acne vulgaris in adolescents range from 35 to over 90 percent [4,5]. Acne tends to resolve in the third decade, but it may persist into or develop de novo in adulthood. The exact prevalence in adults is uncertain, and studies using a clinical examination typically find a lower prevalence than surveys asking for patients to self-report acne.
Postadolescent acne predominantly affects women, in contrast to adolescent acne, which has a male predominance . In one survey of over 1000 adults, self-reported acne in men and women was documented as follows :
●20 to 29 years: 43 and 51 percent, respectively
- Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br J Dermatol 1997; 137:246.
- Dalgard F, Gieler U, Holm JØ, et al. Self-esteem and body satisfaction among late adolescents with acne: results from a population survey. J Am Acad Dermatol 2008; 59:746.
- Newton JN, Mallon E, Klassen A, et al. The effectiveness of acne treatment: an assessment by patients of the outcome of therapy. Br J Dermatol 1997; 137:563.
- Stathakis V, Kilkenny M, Marks R. Descriptive epidemiology of acne vulgaris in the community. Australas J Dermatol 1997; 38:115.
- Collier CN, Harper JC, Cafardi JA, et al. The prevalence of acne in adults 20 years and older. J Am Acad Dermatol 2008; 58:56.
- Goulden V, Clark SM, Cunliffe WJ. Post-adolescent acne: a review of clinical features. Br J Dermatol 1997; 136:66.
- Jeremy AH, Holland DB, Roberts SG, et al. Inflammatory events are involved in acne lesion initiation. J Invest Dermatol 2003; 121:20.
- Brüggemann H, Henne A, Hoster F, et al. The complete genome sequence of Propionibacterium acnes, a commensal of human skin. Science 2004; 305:671.
- Brüggemann H. Insights in the pathogenic potential of Propionibacterium acnes from its complete genome. Semin Cutan Med Surg 2005; 24:67.
- Kistowska M, Gehrke S, Jankovic D, et al. IL-1β drives inflammatory responses to propionibacterium acnes in vitro and in vivo. J Invest Dermatol 2014; 134:677.
- Li ZJ, Choi DK, Sohn KC, et al. Propionibacterium acnes activates the NLRP3 inflammasome in human sebocytes. J Invest Dermatol 2014; 134:2747.
- Qin M, Pirouz A, Kim MH, et al. Propionibacterium acnes Induces IL-1β secretion via the NLRP3 inflammasome in human monocytes. J Invest Dermatol 2014; 134:381.
- Shibata M, Katsuyama M, Onodera T, et al. Glucocorticoids enhance Toll-like receptor 2 expression in human keratinocytes stimulated with Propionibacterium acnes or proinflammatory cytokines. J Invest Dermatol 2009; 129:375.
- Kim J, Ochoa MT, Krutzik SR, et al. Activation of toll-like receptor 2 in acne triggers inflammatory cytokine responses. J Immunol 2002; 169:1535.
- Lomholt HB, Kilian M. Population genetic analysis of Propionibacterium acnes identifies a subpopulation and epidemic clones associated with acne. PLoS One 2010; 5:e12277.
- Sugisaki H, Yamanaka K, Kakeda M, et al. Increased interferon-gamma, interleukin-12p40 and IL-8 production in Propionibacterium acnes-treated peripheral blood mononuclear cells from patient with acne vulgaris: host response but not bacterial species is the determinant factor of the disease. J Dermatol Sci 2009; 55:47.
- Agak GW, Qin M, Nobe J, et al. Propionibacterium acnes Induces an IL-17 Response in Acne Vulgaris that Is Regulated by Vitamin A and Vitamin D. J Invest Dermatol 2014; 134:366.
- Imperato-McGinley J, Gautier T, Cai LQ, et al. The androgen control of sebum production. Studies of subjects with dihydrotestosterone deficiency and complete androgen insensitivity. J Clin Endocrinol Metab 1993; 76:524.
- Lucky AW, Biro FM, Huster GA, et al. Acne vulgaris in premenarchal girls. An early sign of puberty associated with rising levels of dehydroepiandrosterone. Arch Dermatol 1994; 130:308.
- Lucky AW, Biro FM, Simbartl LA, et al. Predictors of severity of acne vulgaris in young adolescent girls: results of a five-year longitudinal study. J Pediatr 1997; 130:30.
- Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol 2003; 49:S1.
- Cordain L, Lindeberg S, Hurtado M, et al. Acne vulgaris: a disease of Western civilization. Arch Dermatol 2002; 138:1584.
- Thiboutot DM, Strauss JS. Diet and acne revisited. Arch Dermatol 2002; 138:1591.
- Bershad S. The unwelcome return of the acne diet. Arch Dermatol 2003; 139:940.
- Spencer EH, Ferdowsian HR, Barnard ND. Diet and acne: a review of the evidence. Int J Dermatol 2009; 48:339.
- Grossi E, Cazzaniga S, Crotti S, et al. The constellation of dietary factors in adolescent acne: a semantic connectivity map approach. J Eur Acad Dermatol Venereol 2016; 30:96.
- Adebamowo CA, Spiegelman D, Danby FW, et al. High school dietary dairy intake and teenage acne. J Am Acad Dermatol 2005; 52:207.
- Danby FW. Acne and milk, the diet myth, and beyond. J Am Acad Dermatol 2005; 52:360.
- Adebamowo CA, Spiegelman D, Berkey CS, et al. Milk consumption and acne in adolescent girls. Dermatol Online J 2006; 12:1.
- Adebamowo CA, Spiegelman D, Berkey CS, et al. Milk consumption and acne in teenaged boys. J Am Acad Dermatol 2008; 58:787.
- Di Landro A, Cazzaniga S, Parazzini F, et al. Family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults. J Am Acad Dermatol 2012; 67:1129.
- Thiboutot D. Acne: hormonal concepts and therapy. Clin Dermatol 2004; 22:419.
- Cappel M, Mauger D, Thiboutot D. Correlation between serum levels of insulin-like growth factor 1, dehydroepiandrosterone sulfate, and dihydrotestosterone and acne lesion counts in adult women. Arch Dermatol 2005; 141:333.
- Holmes MD, Pollak MN, Willett WC, Hankinson SE. Dietary correlates of plasma insulin-like growth factor I and insulin-like growth factor binding protein 3 concentrations. Cancer Epidemiol Biomarkers Prev 2002; 11:852.
- Smith RN, Mann NJ, Braue A, et al. The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial. J Am Acad Dermatol 2007; 57:247.
- Bowe WP, Joshi SS, Shalita AR. Diet and acne. J Am Acad Dermatol 2010; 63:124.
- Ballanger F, Baudry P, N'Guyen JM, et al. Heredity: a prognostic factor for acne. Dermatology 2006; 212:145.
- Xu SX, Wang HL, Fan X, et al. The familial risk of acne vulgaris in Chinese Hans - a case-control study. J Eur Acad Dermatol Venereol 2007; 21:602.
- Goulden V, McGeown CH, Cunliffe WJ. The familial risk of adult acne: a comparison between first-degree relatives of affected and unaffected individuals. Br J Dermatol 1999; 141:297.
- Bataille V, Snieder H, MacGregor AJ, et al. The influence of genetics and environmental factors in the pathogenesis of acne: a twin study of acne in women. J Invest Dermatol 2002; 119:1317.
- Rasmussen JE, Smith SB. Patient concepts and misconceptions about acne. Arch Dermatol 1983; 119:570.
- Green J, Sinclair RD. Perceptions of acne vulgaris in final year medical student written examination answers. Australas J Dermatol 2001; 42:98.
- Yosipovitch G, Tang M, Dawn AG, et al. Study of psychological stress, sebum production and acne vulgaris in adolescents. Acta Derm Venereol 2007; 87:135.
- Chiu A, Chon SY, Kimball AB. The response of skin disease to stress: changes in the severity of acne vulgaris as affected by examination stress. Arch Dermatol 2003; 139:897.
- Ganceviciene R, Graziene V, Fimmel S, Zouboulis CC. Involvement of the corticotropin-releasing hormone system in the pathogenesis of acne vulgaris. Br J Dermatol 2009; 160:345.
- Vora S, Ovhal A, Jerajani H, et al. Correlation of facial sebum to serum insulin-like growth factor-1 in patients with acne. Br J Dermatol 2008; 159:990.
- Aizawa H, Niimura M. Elevated serum insulin-like growth factor-1 (IGF-1) levels in women with postadolescent acne. J Dermatol 1995; 22:249.
- Nagpal M, De D, Handa S, et al. Insulin Resistance and Metabolic Syndrome in Young Men With Acne. JAMA Dermatol 2016; 152:399.
- Tsai MC, Chen W, Cheng YW, et al. Higher body mass index is a significant risk factor for acne formation in schoolchildren. Eur J Dermatol 2006; 16:251.
- Halvorsen JA, Vleugels RA, Bjertness E, Lien L. A population-based study of acne and body mass index in adolescents. Arch Dermatol 2012; 148:131.
- Galobardes B, Davey Smith G, Jeffreys M, et al. Acne in adolescence and cause-specific mortality: lower coronary heart disease but higher prostate cancer mortality: the Glasgow Alumni Cohort Study. Am J Epidemiol 2005; 161:1094.
- Zaenglein AK, Thiboutot DM. Acne Vulgaris. In: Dermatology, 2nd ed, Bolognia JL, Jorizzo JL, Rapini RP, et al (Eds), Elsevier, [Philadelphia] 2008. p.495.
- Lucky AW. Quantitative documentation of a premenstrual flare of facial acne in adult women. Arch Dermatol 2004; 140:423.
- Stoll S, Shalita AR, Webster GF, et al. The effect of the menstrual cycle on acne. J Am Acad Dermatol 2001; 45:957.
- Pochi PE, Shalita AR, Strauss JS, et al. Report of the Consensus Conference on Acne Classification. Washington, D.C., March 24 and 25, 1990. J Am Acad Dermatol 1991; 24:495.
- Zaenglein AK, Graber EM, Thiboutot DM, et al. Acne vulgaris and acneiform eruptions. In: Dermatology in General Medicine, 7th ed, Wolff K, Goldsmith LA, Katz SI, et al (Eds), McGraw Hill, 2008. p.690.
- Seukeran DC, Cunliffe WJ. The treatment of acne fulminans: a review of 25 cases. Br J Dermatol 1999; 141:307.
- Campione E, Mazzotta AM, Bianchi L, Chimenti S. Severe acne successfully treated with etanercept. Acta Derm Venereol 2006; 86:256.
- Sand FL, Thomsen SF. Adalimumab for the treatment of refractory acne conglobata. JAMA Dermatol 2013; 149:1306.
- Shirakawa M, Uramoto K, Harada FA. Treatment of acne conglobata with infliximab. J Am Acad Dermatol 2006; 55:344.
- Suei Y, Taguchi A, Tanimoto K, et al. Case report. synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome. Dentomaxillofac Radiol 1996; 25:287.
- Eichenfield LF, Krakowski AC, Piggott C, et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics 2013; 131 Suppl 3:S163.
- Friedlander SF, Baldwin HE, Mancini AJ, et al. The acne continuum: an age-based approach to therapy. Semin Cutan Med Surg 2011; 30:S6.
- Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol 2016; 74:945.
- Timpatanapong P, Rojanasakul A. Hormonal profiles and prevalence of polycystic ovary syndrome in women with acne. J Dermatol 1997; 24:223.
- Goldstein SM, Wintroub BU. Adverse Cutaneous Reactions to Medication: A Physician's Guide, CoMedica Inc, New York 1994. p.55.
- Pilosebaceous follicles
- Types of acne lesions
- Role of androgens
- External factors
- Family history
- Insulin resistance
- Body mass index
- CLINICAL MANIFESTATIONS AND CLASSIFICATION
- Acne variants
- - Acne fulminans
- - Acne conglobata
- - SAPHO syndrome
- - PAPA syndrome
- - Gram-negative folliculitis
- - Neonatal acne and infantile acne
- - Childhood acne
- - Acne excoriée des jeunes filles
- - Solid facial edema
- DIAGNOSTIC EVALUATION
- Physical examination
- DIFFERENTIAL DIAGNOSIS
- Non-acne dermatoses
- Acneiform eruptions
- - Drug-induced acne
- - Acne cosmetica
- - EGFR inhibitor acneiform eruption
- - Occupational acne
- - Tropical acne
- - Radiation acne
- - Apert syndrome
- INFORMATION FOR PATIENTS