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  • Almost universal in puberty; may begin in premenarchal girls and present or persist into the fourth or fifth decade.

  • Comedones are the hallmark. Severity varies from comedonal to papular or pustular inflammatory acne to cysts or nodules.

  • Face, neck, and upper trunk may be affected.

  • Scarring may be a sequela of the disease or picking by the patient.


Acne vulgaris is polymorphic. Open and closed comedones, papules, pustules, and cysts are found.

In younger persons, acne vulgaris is more common and more severe in males. Acne may persist into adulthood. Twelve percent of women and 3% of men over age 25 have acne vulgaris. This rate does not decrease until the fourth or fifth decade of life. The skin lesions parallel sebaceous activity. Pathogenic events include plugging of the infundibulum of the follicles, retention of sebum, overgrowth of the acne bacillus (Cutibacterium acnes) with resultant release of and irritation by accumulated fatty acids, and foreign-body reaction to extrafollicular sebum. Antibiotics may help control acne because of their antibacterial or anti-inflammatory properties.

Hyperandrogenism may be a cause of acne in women and may be accompanied by hirsutism or irregular menses. Polycystic ovary syndrome (PCOS) is the most common identifiable cause. Acne may develop in patients who use systemic corticosteroids or topical fluorinated corticosteroids on the face. Acne may be exacerbated or caused by cosmetic creams or oils as well as androgenic supplements or masculinizing hormone therapy in transgender individuals.


There may be mild tenderness, pain, or itching. The lesions occur mainly over the face, neck, upper chest, back, and shoulders. Comedones (tiny, flesh-colored, white or black noninflamed superficial papules that give the skin a rough texture or appearance) are the hallmark of acne vulgaris (eFigure 6–93). Inflammatory papules, pustules, ectatic pores, acne cysts, and scarring are also seen (Figure 6–31)(eFigure 6–94)(eFigure 6–50) (eFigure 6–95)(eFigure 6–53)(eFigure 6–96).

eFigure 6–93.

Comedonal and inflammatory, papulopustular acne in an Asian patient. (Used, with permission, from Kanade Shinkai, MD.)

eFigure 6–94.

Acne vulgaris, severe papulopustular and nodular cystic form with scarring. (Reproduced with permission from Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley HS. The Color Atlas and Synopsis of Family Medicine, 3rd ed. McGraw-Hill, 2019.)

eFigure 6–95.

Cystic acne. (Used, with permission, from Lindy Fox, MD.)

eFigure 6–96.

Post inflammatory hyperpigmentation and resolving acne in a Black patient. (Used, with permission, from Kanade Shinkai, MD.)

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