Acne Vulgaris (Acne)

Introduction
Acne vulgaris is a common chronic skin disorder of the pilosebaceous unit, affecting adolescents and young adults but also persisting into adulthood. It is characterized by comedones (blackheads, whiteheads), papules, pustules, nodules, and cysts. Pathogenesis involves excess sebum production, follicular hyperkeratinization, Cutibacterium acnes proliferation, and inflammation. Treatment aims to reduce lesions, prevent scarring, and improve quality of life, with therapy tailored to severity and response.

1. Topical Therapies (First-line for Mild to Moderate Acne)

• Topical retinoids (adapalene, tretinoin, tazarotene): Normalize follicular keratinization, reduce comedones, and have anti-inflammatory properties.

• Benzoyl peroxide: Antibacterial and keratolytic, effective against C. acnes; used alone or in combination to reduce antibiotic resistance.

• Topical antibiotics (clindamycin, erythromycin): Reduce inflammation; always combined with benzoyl peroxide.

• Azelaic acid: Mild anti-inflammatory and comedolytic effect, suitable for sensitive skin or post-inflammatory hyperpigmentation.

• Salicylic acid: Keratolytic, commonly used in over-the-counter formulations for comedonal acne.

2. Systemic Antibiotics (For Moderate to Severe Inflammatory Acne)

• Tetracyclines (doxycycline, minocycline, tetracycline): First-line oral antibiotics.

• Macrolides (erythromycin, azithromycin): Reserved for cases where tetracyclines are contraindicated (e.g., pregnancy, children < 8 years).

• Trimethoprim–sulfamethoxazole: Option for resistant or severe cases.

• Duration: Typically limited to 3–4 months, always combined with topical therapy to minimize resistance.

3. Hormonal Therapies (For Female Patients)

• Combined oral contraceptives (COCs): Reduce androgen activity and sebum production; effective for women with hormonal acne.

• Spironolactone: Anti-androgenic effect, often used in adult females with persistent or resistant acne.

• Cyproterone acetate: Used in some countries for androgen suppression.

4. Oral Isotretinoin (For Severe or Refractory Acne)

• Indications: Severe nodulocystic acne, scarring acne, or failure of standard therapies.

• Dosage: 0.5–1 mg/kg/day, aiming for a cumulative dose of 120–150 mg/kg.

• Monitoring: Requires regular liver function and lipid testing. Strict pregnancy prevention programs are mandatory due to teratogenicity.

5. Adjunctive and Supportive Measures

• Intralesional corticosteroids for large nodules or cysts.

• Light and laser therapies as adjunctive options.

• Gentle cleansing with non-comedogenic skin care products.

• Avoidance of aggressive scrubbing or over-washing.

6. Lifestyle and Preventive Measures

• Low-glycemic diet may help reduce acne severity.

• Stress management to reduce flare-ups.

• Use of non-comedogenic moisturizers and sunscreens.

• Avoidance of picking or squeezing lesions to reduce scarring risk.

7. Multidisciplinary Care

• Dermatologist referral for severe, scarring, or treatment-resistant cases.

• Psychological support in patients experiencing low self-esteem, depression, or anxiety due to acne.