Acne Vulgaris Defined

Acne Vulgaris afflicts some 80% of the population. What is is? How can you beat it?

You may have heard of this term before:  Acne Vulgaris.  What is this exactly?  Is it as scary as it sounds?

Acne Vulgaris is actually a very common skin condition within the United States and affects 80% of the population at some point in life. It is classified by the appearance of pimples and different abnormalities, generally appearing on the face and upper body.

What causes acne vulgaris anyway?  The skin is constantly shedding skin cells, and sometimes they begin to build up.  This, mixed with bacteria, and natural oil secretions, otherwise known as sebum, blocks the hair follicles within the skin.  The stage is set for acne vulgaris to set in.
Bumps, like blackheads, whiteheads, pimples, cysts, and sometimes abscesses, begin to be visible on the skin, sometimes on the face, chest, shoulders, or back.

How to diagnose:
To diagnose this disease of the skin, doctors first perform a visual examination of the skin.
Common treatments will likely include topical antibiotics and preparations applied to the skin such as salicylic acid or benzoyl peroxide for mild cases of acne.  For more moderate to severe cases of acne, oral antibiotics may be added to your skin care regimen. Isotretinoin taken orally could be prescribed for severe cases of acne.
Acne vulgaris is caused when hormones, skin oils (sebum), and bacteria create inflammation inside hair follicles (the pores within the skin wherever hair grows). Acne Vulgaris is characterized by many varieties of skin abnormalities (lesions). They vary in size and severity, and a few go into the deeper layers of the skin than others do.  Following is a breakdown of the common lesions found in those suffering from acne vulgaris:

Blackheads (open comedones)
Whiteheads (closed comedones)
Pimples (inflamed closed comedones)
Raised, solid bumps (papules)
Surface bumps containing pus (pustules)
Deeper, firm bumps containing pus (nodules)
Larger pockets containing pus (cysts)
Sometimes even larger, deeper pockets containing pus (abscesses)
Both cysts and abscesses are pus-filled pockets, however abscesses are somewhat larger and deeper.

Sebaceous glands, which release an oily substance (sebum), are found in the middle layer of the skin, the der These sebaceous glands are attached to the hair follicles. Sebum, along with dead skin cells, passes up from the sebaceous gland and hair follicle and out to the surface of the skin through the pores.

Hair Follicle Anatomy

Hair Follicle Anatomy

So lets recap:  Acne vulgaris results when oils secreted from the skin, aka sebum, dead skin cells, and bacteria clogs the hair follicles, blocking the sebum from being able to leave through the pores.

A blackhead (open comedone) develops when the follicle is not completely blocked.

A whitehead (closed comedone) develops once the blockage becomes complete.

A pimple is the next progression.  This phase of acne vulgaris occurs when a whitehead becomes inflamed. The blocked sebum-filled hair follicle promotes an overgrowth of the bacterium Propionibacterium acnes, (P. acne bacteria) a bacteria normally found in the skin.  This bacterium feed on the oils, and then breaks down the sebum into substances that irritate the skin. This results in inflammation which causes the skin bumps that are commonly known as acne pimples. If the inflammation becomes deep enough it could cause cysts and sometimes an abscess.



VThe most common trigger of acne vulgaris is puberty.

You may have noticed that acne vulgaris frequents those going through puberty.  This is because an increase of hormones stimulates the sebaceous glands, especially the androgens (such as testosterone), which causes an excess in sebum production. Generally, by the time someone has reached their early to mid 20s, hormone levels tend to decrease enough that acne lessens or disappears. However, this is not the case for  up to 40% of women who may end up having acne into their 40s.

Puberty isn’t the only trigger for acne vulgaris.  Other conditions that involve hormonal changes can affect the occurrence of acne as well:

  • Certain products applied to the skin
    • Certain cosmetics, cleansers, and lotions may worsen acne by clogging the pores.
  • Pregnancy or menstruation
    • Acne vulgaris may occur with each menstrual period in young women and may clear up or substantially worsen during pregnancy.
  • Polycystic ovary syndrome
  • Certain drugs
    • The use of certain drugs, particularly corticosteroids and anabolic steroids, can worsen acne or cause acne flare-ups.
  • High humidity and sweating / Too-tight clothing
    • Clothing that is too tight and high humidity and sweating can trigger acne.

No two cases of acne vulgaris is alike.  Acne naturally varies in severity for people—sometimes worsening, sometimes improving—sometimes for no known reason.  Pinpointing the factors that may cause an outbreak is difficult. For some, acne is worse in the winter and better in the summer, and for others, its the opposite.  Some follow a strict regimen of skin cleansing and topical treatment, while others are minimalists with their skin care.


Most commonly, acne vulgaris occurs on the face but is also common on the neck, shoulders, back, and upper chest. There are three levels of acne severity:

  • Mild acne
  • Moderate acne
  • Severe acne

No matter what level acne vulgaris you’re suffering from, they are all distressing, especially to adolescents, who see each pimple as a major cosmetic challenge.

Comparing Mild Acne and Severe Acne

Mild Acne Vulgaris:  People with mild acne develop only a small amount (less than 20) non inflamed blackheads or whiteheads, or a small number of little, mildly irritated pimples. Pustules, which resemble pimples with yellow tops, may also develop. Blackheads appear as small flesh-colored bumps with a dark center. Whiteheads have a similar appearance, however they lack the dark center of a blackhead. Pimples are mildly uncomfortable and have a white center surrounded by a small area of reddened skin.

Moderate Acne Vulgaris:  People with moderate acne have more blackheads, whiteheads, pimples, and pustules, as described above.

Severe Acne Vulgaris:  People with severe acne have a very large numbers of blackheads and whiteheads, pimples, and pustules or cystic (deep) acne. In cystic acne, people have 5 or more cysts, which are nodules that appear red and large, are painful and filled with pus.These may merge under the skin into larger, oozing abscesses.

Scarring:  If you suffer from a mild case of acne vulgaris, you likely will be unmarked by scars. However, if you are tempted to squeeze pimples or try to open them in other ways, you increase inflammation and the depth of injury to the skin.  This makes scarring more likely. The more severe cases of acne vulgaris, however, will likely leave scars. The cysts and abscesses of severe acne often rupture and, after healing, typically leave scars behind. Scars range from tiny, deep holes (icepick scars); wider pits of varying depth; or large, irregular indentations. The scars left by a case of acne last a lifetime and, for some people, are a source of emotional stress. Scars also may be dark.  These scars are called post inflammatory hyper-pigmentation.

Examples of Acne


Acne commonly causes whiteheads, blackheads, and pimples.

Acne With Large Blackheads and Whiteheads

This photo shows large blackheads (open comedones) and whiteheads (closed comedones).

Blackheads in the Ear

This photo shows blackheads (open comedones) in the ear.

Acne Affecting the Body

Acne conglobata is the most severe form of acne.  It causes severe scars and other complications due to abscesses on the skin. Severe acne can appear on the arms, abdomen, buttocks, and even the scalp.

Acne Conglobata on the Face

Acne Conglobata on the Face

Pyoderma Faciale (Rosacea Fulminans)

Pyoderma Faciale (Rosacea Fulminans)

Acne fulminans and pyoderma faciale (also called rosacea fulminans) are severe, rare and possibly related.  They typically occur suddenly.


  • Examination of the skin

Doctors base the diagnosis of acne vulgaris on an examination of the skin. Doctors are looking for specific symptoms, such as blackheads or whiteheads, in order to determine if the person has acne vulgaris and not another skin disorder, such as rosacea.

Once the diagnosis is confirmed, doctors grade the severity of the acne vulgaris as mild, moderate, or severe based on how many lesions are present, as well as what type.


Acne vulgaris, no matter the severity, usually clears up spontaneously by the early to mid 20s.  Some people, however, usually women, have acne into their 40s. Some adults develop mild, occasional, single acne lesions.

Mild acne vulgaris usually heals without leaving scars behind. Moderate to severe acne vulgaris heals but more often leaves scars.

Those who suffer from acne vulgaris usually experience  much emotional stress, especially for adolescents. This can trigger social withdrawal.  In come cases counseling may be needed.


  • For whiteheads and blackheads, an exfoiliant such as salycilic acid, sometimes tretinoin cream is recomended.
  • For mild acne vulgaris, seeing an experienced esthetician could yield favorible results.  You may decide to see a dermatologist, where a skin treatment with tretinoin cream, sometimes with benzoyl peroxide or an antibiotic, or both will be recomended.
  • For moderate acne vulgaris, again, a skilled esthetician may yield favorable results.  Some prefer to see a dermatologist, where antibiotics by mouth in combination with skin treatment as for mild acne vulgaris.
  • For severe acne vulgaris, a skilled esthetician may be able to sooth the skin, but treatment of this grade of acne should be left in the hands of a dermatologist, usually  isotretinoin by mouth will be recomended.
  • For cystic acne vulgaris, a skilled esthetician can provide comfort and sooth the skin, but a dermatologist should be treating this severe form of acne vulgaris, usually using an injection of corticosteroids

Generally, caring for acne vulgaris is very simple. Affected areas should be gently washed once or twice a day with a mild cleanser.  A skilled esthetician can guide you to the right preparations for your skin. Antibacterial or abrasive soaps, using alcohol pads, and heavy frequent scrubbing will not provide any added benefit and may actually further irritate the skin.

Cosmetics, and even hair care products (hair often rests on acne prone skin) should be water-based because oil based products can worsen acne vulgaris.

No one can definitively say if restricting specific foods (for example, pizza or chocolate) will cause or repair acne vulgaris.  However, it is common sence to follow a healthy, balanced diet. Think of the old saying, “you are what you eat.”. A low-glycemic index diet and elimination of milk and dairy products might be considered if treatment for acne is ineffective

Did You Know…

Acne vulgaris can be made worse by vigorous washing and scrubbing. It could cause further irritation of the skin.

Some acne vulgaris treatments are useful for some people, but not for others. For example, oral contraceptives may be recomended to women who suffer from acne vulgaris. Results for this treatment can take more than 6 months.  Spironolactone (a pharmaceutical drug that blocks the action of the hormone aldosterone) also has shown to be helpful for some women. Various other therapies that use different colored light have helped people who have inflammation (with pimples or pustules).

As with any disease, acne vulgaris treatment depends on the severity of the condition at the time the patient is seen by the dermatologist. Mild acne vulgaris only requires a simple treatment regimen that poses the the lowest number of risks of side effects. More severe acne vulgaris, or acne that just does not respond to other mild forms of treatment, requires additional, more targeted treatment plans. A good treatment plan will always include education for the patient, support, as well as the most practical options for the patient, as each person is different and has differing needs.  Some people, most often those with a more severe form of acne vulgaris, may need to see a specialist.

Mild acne

There are a number of drugs used to treat mild acne, and these are applied topically to the skin.  These drugs work in various ways. If using a topical antibiotic, the drug will work by killing bacteria and/or drying up or unclogging the pores (comedolytics). There are other methods.  They are older nonprescription creams, however, many use them and get the desired result. These contain salicylic acid, resorcinol, or sulfur, and these work by drying out the pimples and causing slight exfoliation, or, peeling.

Most commonly, the topical drug for blackheads and whiteheads is called tretinoin.  This drug, tretinoin, usually gives great results, and is very effective but the down side is that it is irritating to the skin and it makes the skin more sensitive to sunlight. Doctors generally use this drug with cautioun. They will usually start the patient with infrequent applications at a low concentration.  Over time, based on how the patient does with this, the doctor may choose to gradually increase the concentration and/or the amount of time it is to be applied. There are some people, however, who can’t tolerate tretinoin. These people are usually given topical adapalene, azelaic acid, and glycolic or salicylic acid, all of which are very beneficial for acne vulgaris in their own respective ways.

If you are someone who also has inflammation (with pimples or pustules) as part of their acne vulgaris diagnosis, you are likely going to be given tretinoin in combination with benzoyl peroxide, a very effective topical antibiotic, or both.  Most commonly, a patient will be prescribed these two topical antibiotics:

  1. Clindamycin and
  2. Erythromycin.

Speak to your doctor about all the things you use on your skin, because topical antibiotics should not be used except when taken in combination with a retinoid or benzoyl peroxide.  Since benzoyl peroxide is available with or without a prescription, you need to let your prescribing doctor know of everything used on your acne vulgaris.  Some people have very positive results using glycolic acid instead of or in addition to tretinoin.

Depending on what dermatologist you see, treatment may include the removal of blackheads and whiteheads (called extraction) by a doctor or esthetician, using instruments called comedone extractors and sterile needles. (If seeing an esthetician, each State determines if the practicing esthetician is able to use sterile needles, otherwise known as lancets.)

Some acne vulgaris is not managed will by topical treatments alone.  In these instances, antibiotics taken by mouth (such as doxycycline, minocycline, tetracycline, and erythromycin) can be prescribed in addition to topical treatments.  

Moderate acne

Moderate acne vulgaris is usually going to be treated with antibiotics given orally (by mouth). Most commonly, you will see antibiotics such as doxycycline, minocycline, tetracycline, azithromycin, erythromycin, and sometimes trimethoprim/sulfamethoxazole. People sometimes are prescribed a topical treatment as for mild acne vulgaris as well as an oral antibiotic. People may need to take their antibiotics for up to 12 weeks (three months) to reach their maximum desired benefits.

Due to the fact that oral antibiotics can be harsh to your system, if possible, after a period of time, they are usually stopped and treatment will be focuesed on topical preperations alone in order to maintain control. Since acne vulgaris can recur after short-term treatment, therapy may need to be continued for months to years.

Severe acne

There are times when antibiotics do not work for the most severe cases of acne vulgaris.  In these instances, oral isotretinoin is the best treatment.  Your prescribing doctor will explain to you that Isotretinoin, a drug that is related to the topical drug tretinoin, is the only drug that can claim to potentially cure acne.  Your prescribing doctor, however, should also explain that isotretinoin can have very serious side effects. Isotretinoin can harm a developing fetus, and therefore, women taking it are required to use at the very least two forms of birth control before starting treatment, during treatment, and after treatment so they do not become pregnant. Other, less serious side effects may occur as well, all of which should be discussed thoroughly with the precribing doctor to make sure this course of treatment is right for the patient.

Therapy using isotretinoin will typically continue for 16 to 20 weeks, but sometimes more depending on the response of the patient.

After this extensive, in depth article about acne vulgaris, do you have any other questions?  I am eaget to know, so please leave your questions in the comments sections below.

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