Characteristic: Noninflammatory, open or closed comedones and by inflammatory papules, pustules, and nodules.

Typically affects: the areas of skin with the densest population of sebaceous follicles (eg, face, upper chest, back).

Local symptoms: pain, tenderness, or erythema. Sometimes they develop pus at their tips (pustules), but these may also arise independently. In a few patients, some of the papules become quite large and persist for long periods – they are then referred to as nodules. In severely affected patients, the nodules liquefy centrally so that fluctuant cysts are formed.

Systemic symptoms: most often absent in acne vulgaris. In rare but severe cases, acne vulgaris could lead to acne conglobata, with highly inflammatory nodulocystic acne and interconnected abscesses. Acne fulminans is even more severe than acne conglobata, with systemic symptoms such as fever, joint pain, and general malaise. Additionally, acne vulgaris may have a psychological impact on any patient, regardless of the severity or the grade of the disease.

Many factors combine to cause acne characterized by chronic inflammation around pilosebaceous follicles.

• Sebum. Sebum excretion is increased. However, this alone need not cause acne; patients with acromegaly, or with Parkinson’s disease, have high sebum excretion rates but no acne.
• Hormonal. Androgens (from the testes, ovaries and adrenals) are the main stimulants of sebum excretion, although other hormones (e.g. thyroid hormones and growth hormone) have minor effects too.
• Poral occlusion. Both genetic and environmental factors (e.g. some cosmetics) cause the epithelium to overgrow the follicular surface.
• Bacterial. Propionibacterium acnes, a normal skin commensal, plays a pathogenic part.
• Genetic. The condition is familial in about half of those with acne. There is a high concordance of the sebum excretion rate and acne in monozygotic, but not dizygotic, twins.

Treatment should be directed toward the known pathogenic factors involved. Current consensus recommends a combination of topical retinoid and antimicrobial therapy as first-line therapy for almost all patients.
Mild

a. Comedonal
First line: Topical retinoid with or without physical extraction,
Secound line: Alternate retinoid, salicylic acid, azelaic acid.
b. Papular/pustular
First line: Topical antimicrobial combination with benzoyl peroxide wash if mild truncal lesions,
Secound line: Alternate antimicrobials with alternate topical retinoids, azelattic acid, sodium sulfacetamide-sulfur, salicylic acid.
Moderate
Papular/pustular
I. First line: Oral antibiotic with topical retinoid with benzyoyl peroxide,
II. Secound line: Alternate antibiotic, alternate topical retinoids, alternate benzyoyl peroxide,
III. In women: Spironolactone with oral contraceptive with topical retinoids with or without topical antibiotic and/or benzyoyl peroxide,
IV. Isotretinoin if replapses quickly off oral antibiotics does not clear, or scars.
Severe
Nodular/conglobate
a. Isotretinoin,
b. Oral antibiotics with topical retinoid with benzyoyl peroxide,
c. In women: Spironolactone with oral contraceptive with topical retinoids with or without topical or oral antibiotic and/or benzyoyl peroxide.

To confirm diagnosis and start systemic treatment, need consultation.

If the patient feeling depressed while taking isotretinoin then need a specialist consultation.

• ABC Of Dermatology
• Clinical Dermatology
• Andrew’s Diseases of the skin.