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Acne vulgaris or acne is an extremely common skin disease affecting nearly 80% of persons at some time between the ages of 11 and 30. It can cause severe psychological problems and interfere with the normal socialization process of adolescents. Very effective therapy is available that should be utilized at the first sign of acne. In this day and age, no child or adult should have to suffer from the embarrassment or scaring from untreated acne.

Etiology of Acne

Acne is caused by the obstruction of specialized follicles which are located mainly on the face, back, and chest. Excessive amounts of a substance called sebum are produced by the sebaceous or oil glands. It is a thick white oily substance. There are excessive numbers of cells that slough off the walls of the follicles. The sloughed cells can obstruct the opening or outlet of the follicle and result in an inflamed lesion called a comedo. Many times these inflamed lesions will become infected with bacteria called Propionibacterium Acnes. This bacteria results in an inflammatory reaction which may cause increasing redness and swelling of the acne lesion.

Almost all adolescents will get some acne. About 15% will seek medical care. Acne tends to begin during or right before puberty. This is because puberty is characterized by an increase in sex hormones. These hormones cause development of secondary sex characteristics in both males and females. Persons who get severe acne do not necessarily have an over production of hormones, but rather a hyper-response to the hormones.


Comedonal acne is one of the mildest forms of acne. It is usually not red or inflamed. Lesions occur on the central forehead, chin, and nose. They usually occur in the preteenage or early teenage years. Increased sebum production and abnormal sloughing of the cells cause it. Usually, there is no bacterial infection and minimal inflammation. It responds best to topical tretinoin(Retin-A) or adapalene(Differin Gel). Salicylic acid can be used alternatively. Tretinoin is usually applied once daily and comes in a cream which is available in 0.025%, 0.05%, and 0.1% concentrations. The gel is available in 0.01 and 0.025% concentrations. It is reasonable to start with a small amount applied to a quarter-size area to see what type of reaction occurs, if any, overnight. If no significant reaction occurs, then the lower dose is started. The concentration can be increased as tolerated. It is important to realize that it may take one to two months for the acne to improve.

Mild inflammatory acne is usually the next stage. It also tends to develop in women in their twenties. Usually there is some component of bacterial infection. Mild cases will respond quite nicely to topical antibiotics or benzyol peroxide. Benzyol peroxide is available over the counter. Occasionally, several different topical antibiotics will need to be tried to find out which one works best.

Inflammatory acne is more severe. This type of acne causes more scaring and will cause deep, inflammatory nodules. Another name for this condition is cystic acne. Usually topical tretinoin is applied once daily with an oral antibiotic. Again, it may take four to eight weeks to reduce the bacteria and curtail the formation of new inflammatory lesions. Large lesions may be injected with steroids. Widespread cystic acne will usually require isotretinoin(Accutane) therapy. A four-to five-month course is usually required. Birth control pills may be effective in treating females with moderately severe acne.


As mentioned above, there are three different factors that contribute to the development of acne:

1. Overproduction of sebum from the sebaceous glands,

2. Abnormal sloughing of the cells that form the inside of the glands, and

3. Growth of bacteria called Propionibacterium Acnes.

Treatment is aimed at modifying or reducing one or more of these three factors.

1. Reduce the production of sebum. This can only be accomplished by oral medication. Estrogens(such as birth control pills) are sometimes quite effective in the treatment of acne. This can only be used in females. A water pill called spironolactone can also be effective. Isotretinoin(Accutane) is extremely effective and is used quite extensively for severe acne.

2. Abnormal and excessive sloughing of the cells that form the inner lining of the gland. Isotretinoin also decreases the sloughing of cells and can be quite effective. Oral antibiotics also have an indirect effect on improving this problem. Topical medication is quite effective in decreasing the sloughing of cells. Topical medicines that are helpful are tretinoin(Retin-A), salicylic acid, adapalene(Differin gel) and tazarotene.

3. Proliferation of bacteria called Propionibacterium Acnes. This results in an inflammatory reaction and makes the acne appear very red and sometimes swollen. Oral medications for this include tetracycline, erythromycin, minocycline, doxycycline, Bactrim, clindamycin and isotretinoin. Topical medications to reduce the bacteria include erythromycin, clindamycin, benzyol peroxide and azelaic acid. A combination of benzyol peroxide and erythromycin is extremely effective and goes by the brand name of Benzamycin. Benzyol peroxide is also combined with glycolic acid. Using oral steroids as well as isotretinoin can also reduce inflammation. Inflammation can be reduced by topical metronidazole (MetroGel). Injecting the acne lesions with steroids can also be effective.


Usually, topical medications are effective for most cases of mild acne. Benzyol peroxide is usually applied once or twice daily. It is in a gel or lotion form. The percentage of benzyol peroxide is five or ten percent. Any time a new topical medication is started, it should be applied to a quarter-sized area of the face to see what, if any, reaction occurs over the following 24 hours. Benzyol peroxide will cause dryness of the skin and sometimes only the lower percentage can be tolerated. Benzamycin can be used twice a day and is very effective in mild to moderate acne. If there is an excessive amount of inflammation, then an oral antibiotic is added to the topical medication. It may take four to eight weeks for the acne to improve after starting any of the topical or oral medication.


Isotretinoin is a natural metabolite of vitamin A. It can markedly reduce sebum production and in many cases can cause complete remission of the acne for years if not permanently. A four-to five-month course is usually given with about 0.1 to 1 mg/kg of body weight. This can be divided into two doses. Higher doses often result in a longer remission. The total cumulative dose seems to determine the duration of remission. Sixty percent of patients remain free of acne after a single course of therapy. Unfortunately, isotretinoin has several side effects. These include arthralgia, tendonitis, and elevated triglycerides. The most worrisome side effect is a strong tendency to cause birth defects if taken inadvertently during pregnancy. Female patients must obtain a pregnancy test prior to starting therapy and must use effective contraception until at least one month after therapy has been discontinued. Usually, only one month of medication is given at one time and a pregnancy test is obtained at each monthly visit. Blood tests for liver disease, cholesterol and triglycerides are usually obtained prior to starting therapy and then a month later.


It is important to realize that diet has little or no effect whatsoever on the course of acne. This is a myth that has been around for years, but has no merit whatsoever. Another myth is that acne is due to not cleaning the skin appropriately. This is totally untrue and excessive cleansing of the skin may even make acne worse.


The development of new drugs for the treatment of acne has dramatically altered our approach to the treatment of acne. Now the majority of patients can be completely cured of this physically and emotionally scaring illness.

Leyden J. Therapy for Acne Vulgaris. N Engl J Med. 1997 April 17;336 No. 16:1156-62

Wiedermann BL, et al. Acne. Griffith' 5 Minute Clinical Consult. 2004, Electronic version 4.0.139.

The information provided above is offered as a community service about health-care issues and is not a substitute for individual consultation. Advice on individual problems should be obtained from your personal physician. This information is based on research by the author and represents his interpretation of the literature.

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Readers may send questions to our email address. This column is for informational purposes only and is not a substitute for professional or medical advice.

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