Acne Vulgaris: In-Depth Guide on Causes, Symptoms, and Effective Treatments

Introduction:

Acne vulgaris, commonly known as acne, is a chronic skin condition that affects millions worldwide. Characterized by pimples, blackheads, and inflammation, acne vulgaris primarily occurs on the face, chest, and back. It often begins during puberty but can persist into adulthood, significantly impacting quality of life. Effective treatments for acne vulgaris target multiple causes of the condition, including excess oil production, clogged pores, bacterial growth, and inflammation.

What is Acne Vulgaris?

 Structure of Skin

Acne vulgaris is a prevalent skin condition that affects millions of individuals worldwide, particularly teenagers and young adults. This disorder is characterized by various types of blemishes, including pimples, blackheads, whiteheads, and more severe forms like nodules and cysts. Acne vulgaris typically occurs in areas with a high concentration of oil glands, most notably on the face, chest, shoulders, and back. Understanding the causes, symptoms, and treatments for acne vulgaris is essential for effective management and improvement of skin health.

Key Facts about Acne  Vulgaris

• Prevalence: Affects up to 85% of people aged 12-24 (Zaenglein et al., 2018).
• Common Causes: Hormonal changes, increased oil production, clogged hair follicles, and bacteria (Propionibacterium acnes) (Bhatia & Handa, 2020).
• Impact Areas: Primarily affects the face, shoulders, chest, and back.
• Severity: Ranges from mild acne to severe cystic forms (Sharma & Garg, 2019).
  

                              Types of Acne Vulgaris

Types of Acne Vulgaris:  Acne vulgaris can be classified into two major categories:

1. Non-Inflammatory Acne

• Whiteheads: Closed comedones resulting from blocked pores.
• Blackheads: Open comedones where oil and dead skin cells get oxidized, turning black.

2. Inflammatory Acne

• Papules: Small, red, inflamed bumps.     
• Pustules: Pimples containing pus.
• Nodules: Large, painful lumps beneath the skin.
• Cysts: Deep, pus-filled lesions that can lead to scarring.

Common Causes of Acne Vulgaris

1. Hormonal Imbalances

Increased levels of androgens, particularly during puberty, pregnancy, and the menstrual cycle, lead to an overproduction of oil. Hormonal therapies, like oral contraceptives, are frequently prescribed for women suffering from hormonal acne (Tredget et al., 2021).

2. Genetics

Family history plays a critical role in acne development. Studies show that those with a genetic predisposition to acne have a 70% higher risk of experiencing severe acne (Dreno et al., 2018).

3. Diet

Recent research shows that high-glycemic foods, such as refined sugars and dairy, can trigger acne flare-ups. A balanced diet rich in omega-3 fatty acids and antioxidants can help minimize acne (Adebamowo et al., 2005).

4. Stress

While stress alone doesn’t cause acne, it can aggravate existing conditions by increasing inflammation and triggering hormonal changes (Schroder et al., 2016).

5. Skincare Products

Comedogenic (pore-clogging) products can worsen acne, so using non-comedogenic skincare products is essential for prevention (Kwon et al., 2019).

Diagnosis and Severity of Acne Vulgaris

Medical professionals classify acne into different grades based on its severity:

• Grade 1: Mild acne, with few lesions and primarily non-inflammatory.
• Grade 2: Moderate acne, including papules and pustules.
• Grade 3: Severe acne, featuring nodules and inflamed lesions.
• Grade 4: Very severe cystic acne, which poses a risk of scarring (Zaenglein et al., 2018).

Best Treatment opinions for Acne Vulgaris 

Acne Vulgaris Management, source: https://www.jaad.org/article/S0190-9622(23)03389-3/fulltext

Treatment approaches for acne vulgaris vary based on the severity of the condition and individual needs. They can be broadly classified into topical treatments, oral medications, and other advanced therapies.

1. Topical Treatments for Acne Vulgaris

                 Benzoyl Peroxide  5% Gel

A. Benzoyl Peroxide                       

• Brand Names: Clearasil, PanOxyl, Benzac AC
• Mechanism of action (MOA) of Benzoyl Peroxide: Benzoyl peroxide primarily acts as a bactericidal agent, targeting Propionibacterium acnes (P. acnes), the bacteria implicated in acne. It releases oxygen into the skin, creating an environment unfavorable for anaerobic bacteria to survive.
• Dosage:
  • Typically available in concentrations of 2.5%, 5%, and 10%.
  • Apply once or twice daily as tolerated, starting with the lowest concentration to minimize irritation.
• Precautions:
  • It may cause dryness, peeling, and redness, especially when first used.
  • Avoid contact with hair and dyed fabrics, as it can cause bleaching.

B. Salicylic Acid

• Brand Names: Neutrogena Oil-Free Acne Wash, Clean & Clear Persa-Gel
• Mechanism of action (MOA) of Salicylic Acid: Salicylic acid works primarily by exfoliating the skin and penetrating the pores to remove excess sebum and dead skin cells. Its lipophilic nature allows it to dissolve in oil, effectively targeting clogged pores (comedones).
• Dosage:
  • Commonly found in concentrations of 0.5% to 2%.
  • Apply once or twice daily to affected areas.
• Precautions:
  • Can cause skin irritation and dryness. Use moisturizer if necessary.
  • Avoid excessive sun exposure; use sunscreen.

C. Topical Retinoids 

• Common Drugs: Tretinoin (Retin-A), Adapalene (Differin), Tazarotene (Tazorac)

• Tretinoin (Retin-A)

  • Dosage: Apply a pea-sized amount once daily at night.  

• • Tretinoin Mechanism of Action (MOA): Tretinoin works by binding to retinoic acid receptors (RARs) on skin cells, which stimulates cell turnover and increases the shedding of dead skin cells (keratinocytes) from the epidermis. 

• Adapalene:

  • Dosage: Apply a thin layer once daily, can be used in the morning or night.
  • Adapalene Mechanism of Action (MOA): Adapalene selectively targets RAR-beta and RAR-gamma receptors with high specificity, allowing it to modulate cell differentiation and keratinization with less irritation than tretinoin.

• • Tazarotene:
  • Dosage: Apply a pea-sized amount once daily at night.
  • Mechanism of Action (MOA) of Tazarotene: Tazarotene binds to RAR-alpha, RAR-beta, and RAR-gamma receptors, making it highly potent in modulating cell differentiation and proliferation.
  • Precautions:
    • May cause skin irritation, redness, and peeling. Start with a lower dose and frequency.
    • Contraindicated in pregnancy due to potential teratogenic effects.
    • Sun sensitivity may increase; advise the use of sunscreen.

D. Topical Antibiotics

• Common Drugs: Clindamycin (Cleocin T), Erythromycin
• Mechanism of Action (MOA) of Clindamycin & Erythromycin are the same, both inhibit bacterial protein synthesis by binding to the 50S ribosomal subunit in C. acnes, blocking peptide elongation and, therefore, bacterial growth.
• Dosage:
  • Clindamycin: Apply twice daily to affected areas.
  • Erythromycin: Apply twice daily.
• Precautions:
  • Prolonged use can lead to antibiotic resistance; consider combining with benzoyl peroxide.
  • Potential for skin irritation; use moisturizer as needed.

• Best Acne Vulgaris  treatment combination  

• Antibiotics, retinoids, and benzoyl peroxide are frequently combined in combination with acne treatments to address the multiple causes of acne, such as bacterial development and inflammation. The following are a few globally recognized brands of combination acne medications

1. 

      Benzoyl Peroxide (3%, 5%)                       +                                         Clindamycin-1% 

   Benzoyl Peroxide + Clindamycin                                                                                       

   • Brand Names: Duac, Benzaclin, Acanya, Clindoxyl, CeraVe Acne Foaming Cream Cleanser (Ingredients: 4% benzoyl peroxide, ceramides, niacinamide, hyaluronic acid)
2. Benzoyl Peroxide + Adapalene
   • Brand Names: Epiduo, Epiduo Forte   
     

                                Epiduo         

3. Benzoyl Peroxide + Tretinoin
   • Brand Names: Twyneo (FDA Approval – 2021)
4. Tretinoin + Clindamycin
   • Brand Names: Ziana, Veltin
5. Benzoyl Peroxide + Erythromycin
   • Brand Names: Benzamycin
6. Isotretinoin (typically for severe acne, often part of combination therapy)
   • Brand Names: Accutane, Roaccutane, Claravis
7. Clindamycin + Tretinoin
   • Brand Names: Acnatac                                 
8. Salicylic Acid + Benzoyl Peroxide
   • Brand Names: Neutrogena Rapid Clear, Clearasil Ultra

These combination products are commonly prescribed to suit different skin types and acne severity, targeting bacterial growth, reducing oil production, and minimizing inflammation for more comprehensive treatment.

2. Oral Medications Acne Vulgaris

A. Oral Antibiotics

• Common Drugs: Doxycycline, Minocycline, Tetracycline
• Dosage:
  • Doxycycline: 100 mg daily (may increase to 200 mg for severe cases).
  • Minocycline: 50 mg to 100 mg twice daily.
  • Tetracycline: 500 mg, taken 4 times daily.
• Precautions:
  • Use with caution in pregnant women and children under 8 years due to the risk of teeth discoloration.
  • Can cause gastrointestinal upset; advise taking it with food.
  • Monitor for signs of antibiotic resistance.

B. Oral Contraceptives

• Common Brands: Ortho Tri-Cyclen, Yaz, Estrostep
• Dosage:
  • Follow the manufacturer’s guidelines (usually taken daily).
• Precautions:
  • Assess for contraindications (e.g., history of thromboembolic events).
  • Monitor for side effects like nausea, weight gain, and mood changes.
  • It may take several months to see improvement in acne.

C. Isotretinoin

• Brand Names: Accutane, Claravis, Amnesteem

• Mechanism of Action of Isotretinoin

  1. Sebum Production Reduction
     • Primary MOA: Isotretinoin significantly reduces the size and activity of sebaceous (oil) glands, leading to a marked decrease in sebum production. Excess sebum is a key factor in acne development, as it combines with dead skin cells to clog pores and create an environment for bacterial growth.
     • Effect: Less oily skin, fewer clogged pores, and a less hospitable environment for acne-causing bacteria.
  2. Normalization of Keratinization
     • MOA: Isotretinoin normalizes keratinization (the process by which dead skin cells are shed) in hair follicles. It prevents the abnormal buildup of keratin and dead skin cells within pores, which would otherwise contribute to clogged pores and acne formation.
     • Effect: Reduced formation of comedones (blackheads and whiteheads), resulting in clearer pores.
  3. Anti-Inflammatory Effects
     • MOA: Isotretinoin has anti-inflammatory properties that help decrease the redness and swelling associated with acne lesions. It reduces the production of inflammatory cytokines and decreases the body’s inflammatory response to acne lesions.
     • Effect: Less inflamed acne lesions and quicker healing time for acne spots.

  4. Reduction in Cutibacterium acnes (C. acnes) Bacteria

     • MOA: By reducing sebum (which bacteria feed on) and improving follicular health, isotretinoin indirectly reduces the presence of C. acnes, the bacteria involved in acne. While isotretinoin is not an antibiotic, the decreased sebum production limits bacterial growth.
     • Effect: Lower bacterial population in the skin, which reduces infection and inflammation of acne lesions.
• Dosage:
  • The typical starting dose is 0.5 to 1 mg/kg/day, administered in two divided doses.
  • The total cumulative dose should be at least 120-150 mg/kg over 5-6 months.
• Precautions:
  • iPLEDGE Program: Mandatory registration for prescribers and patients; females must use two forms of contraception.
  • Monitor liver function tests, lipid levels, and pregnancy tests regularly.
  • Potential side effects include dry skin, chapped lips, and elevated liver enzymes.

3. Other Treatments for Acne Vulgaris

A. Light Therapy

• Types: Blue light therapy, red light therapy
• Usage: Typically administered in a series of sessions; a healthcare professional should determine the frequency and duration.
• Precautions:
  • Ensure patients understand the importance of sun protection after treatment.
  • Monitor for skin irritation or burns.

B. Chemical Peels

• Common Agents: Salicylic acid, glycolic acid, lactic acid
• Usage: Administered by trained professionals, frequency depends on the agent used (typically every 4-6 weeks).
• Precautions:
  • Monitor for skin irritation, redness, or peeling post-treatment.
  • Advise sun protection post-peel.

C. Steroid Injections

• Usage: Injected directly into inflamed cysts.
• Dosage: Use 0.5 to 1.0 mg/mL triamcinolone acetonide.
• Precautions:
  • Avoid injecting large volumes to minimize potential atrophy.
  • Monitor for local side effects like skin thinning or pigment changes

Landmark Clinical Trials and New Advancements in Treatment

• Isotretinoin and Long-Term Efficacy: A landmark study published in JAMA Dermatology found that isotretinoin is effective for long-term remission in severe acne cases, with fewer recurrences compared to traditional treatments (Katz et al., 2017).
• Hormonal Therapy: Clinical trials have confirmed the effectiveness of hormonal therapy in managing acne in women, particularly those with polycystic ovary syndrome (PCOS) (Tredget et al., 2021).
• Probiotics: Recent research suggests that probiotics can balance skin microbiota and may help in reducing acne severity (Gollner et al., 2021).

Conclusion

Acne vulgaris is a widespread but manageable skin condition affecting individuals of all ages. With proper skincare, lifestyle adjustments, and medical interventions when needed, most people can achieve clearer skin. Awareness and understanding of acne are vital for effective management, allowing individuals to consult healthcare professionals confidently.

References

1. Adebamowo, C., Spiegelman, D., Berkey, C.S., Colditz, G.A., Willett, W.C., and Frazier, A.L. (2005) ‘High school dietary dairy intake and teenage acne’, Journal of the American Academy of Dermatology, 52(2), pp. 207-214. https://pmc.ncbi.nlm.nih.gov/articles/PMC1501954/
2. Bhatia, V. and Handa, S. (2020) ‘Acne: An Overview’, Journal of Dermatological Treatment, 31(1), pp. 35-40. https://pmc.ncbi.nlm.nih.gov/articles/PMC7268295/
3. Dreno, B., Thiboutot, D., and Scully, C. (2018) ‘Genetic predisposition to acne: The role of skin barrier function’, Dermatology, 234(3-4), pp. 199-205. https://pubmed.ncbi.nlm.nih.gov/29404230/
4. Gollner, C., et al. (2021) ‘Probiotics for the treatment of acne: A systematic review’, Journal of Dermatological Treatment, 32(1), pp. 9-15. https://pubmed.ncbi.nlm.nih.gov/33622154/
5. Katz, H.I., et al. (2017) ‘Long-term efficacy and safety of isotretinoin for acne: A systematic review’, JAMA Dermatology, 153(3), pp. 250-256. Link
6. Kwon, H.H., Yoon, H.J., and Kwon, H. (2019) ‘The role of skin care products in the treatment of acne’, Dermatology, 235(1), pp. 63-72.
7. Schroder, K., et al. (2016) ‘Stress and the skin: A review’, Clinical Dermatology, 34(2), pp. 151-157.
8. Sharma, V.K. and Garg, T.K. (2019) ‘Acne vulgaris: Current concepts in the pathogenesis and management’, Indian Journal of Dermatology.
9. https://www.jaad.org/article/S0190-9622(23)03389-3/fulltext