Acne vulgaris is a chronic inflammatory condition of the pilosebaceous unit, leading to a mix of non-inflammatory and inflammatory lesions, with risk of long-term scarring and pigment changes.
💡 Four key factors contribute to acne:
Increased sebum production (driven by androgens)
Abnormal follicular keratinisation → comedone formation
Colonisation by Cutibacterium acnes (P. acnes)
Local inflammation triggered by bacterial and immune activity
In severe or persistent acne, chronic inflammation can lead to dermal damage and scarring.
| Category | Examples |
|---|---|
| Hormonal | Puberty, menstrual cycle, PCOS |
| Genetic | Family history of acne |
| External | Occlusive cosmetics, stress, oily environments |
| Medication-related | Steroids, lithium, anticonvulsants |
| Lesion Type | Description |
|---|---|
| Open comedones | Blackheads (oxidised sebum) |
| Closed comedones | Whiteheads |
| Papules/pustules | Inflamed raised lesions |
| Nodules/cysts | Deep, painful, may scar |
🚨 Scarring and pigmentary changes are more likely in nodulocystic or untreated acne.
Primarily a clinical diagnosis
Hormonal investigations (e.g. testosterone, LH/FSH) may be warranted in women with signs of hyperandrogenism or suspected PCOS
Mild to Moderate Acne:
Topical agents (retinoids, benzoyl peroxide, antibiotics) — often used in fixed combinations
Consider 12-week treatment courses for efficacy
Moderate to Severe Acne:
Add oral agents (usually tetracyclines like lymecycline or doxycycline)
Combine with topical retinoids or benzoyl peroxide to limit resistance
Evaluate for systemic hormonal treatment in women
💡 Never combine oral and topical antibiotics — risk of resistance.
Combined oral contraceptives (e.g. ethinylestradiol + anti-androgenic progestins)
Co-cyprindiol (Dianette) may be used short-term but carries increased VTE risk
Treatment should be individualised based on hormonal profile, tolerance, and risk factors
Reserved for severe, scarring, or treatment-resistant acne
Prescribed only under specialist supervision
Contraindicated in pregnancy – requires pregnancy prevention programme
| Indication | Examples |
|---|---|
| Severe or nodulocystic acne | Deep, scarring lesions |
| Failure of treatment | After 2 full topical or oral courses |
| Scarring or pigmentation | Visible marks post-resolution |
| Psychological impact | Depression, anxiety, social withdrawal |
🚨 Mental health impact from acne should not be underestimated — refer early if needed.
