Acne Vulgaris

  • Marina de Almeida Delatti
  • Renan Lage
  • Elisa Moraes
  • Beatrice Abdalla
  • Marcel dos Santos
  • Adilson CostaEmail author


Acne vulgaris is a common and chronic inflammatory disease with a complex pathophysiology, including increased sebum production, follicular hyperkeratinization, bacterial colonization, inflammation, as well as hormonal involvement and genetic association with diet and smoking. The clinical picture consists of inflammatory and noninflammatory lesions mainly on the face and upper trunk that may progress to scarring. Topical and/or systemic treatment should be initiated early with a prolonged course, and also requires good patient compliance.


Acne Pilosebaceous follicle Propionibacterium acnes Hyperkeratinization Comedones Papules Pustules Nodules Cysts Hyperandrogenism Isotretinoin Retinoids Azelaic acid Antibiotics Elaioconiosis Chloracne Benzoyl peroxide 




A hair follicle infundibulum that is dilated and plugged by keratin and lipids. The lesion is referred to as an open comedo when the pilosebaceous unit is open to the surface of the skin with a visible keratinaceous plug. A closed comedo occurs when the follicular opening is unapparent and accumulates whitish keratin.


An encapsulated cavity or sac lined with a true epithelium that contains fluid or semisolid material (cells and cell products such as keratin).


A solid round or ellipsoidal, palpable lesion of diameter larger than 0.5 cm. Depth of involvement and/or substantive palpability, rather than diameter, differentiates a nodule from a large papule or plaque. Nodules are of five main types: epidermal, epidermal-dermal, dermal, dermal-subdermal, and subcutaneous.


A solid, elevated lesion less than 0.5 cm in size in which a significant portion projects above the plane of the surrounding skin.


A circumscribed, raised cavity in the epidermis or infundibulum containing pus; may contain bacteria or be sterile. Pustules may vary in size and, in certain situations, may coalesce to form lakes of pus.


  1. 1.
    Zaputovich AF, Samudio M. Características clínicas y epidemiológicas de pacientes que consultan por acne. Mem Inst Investig Cienc Salud. 2015;13(1):7–16.CrossRefGoogle Scholar
  2. 2.
    Figueiredo A, Massa A, Picoto A, Soares AP, Basto AS, Lopes C, et al. Avaliação e tratamento do doente com acne – Parte I: Epidemiologia, etiopatogenia, clínica, classificação, impacto psicossocial, mitos e realidades, diagnóstico diferencial e estudos complementares. Rev Port Clin Geral. 2011;27(1):59–65.Google Scholar
  3. 3.
    Jappe U. Pathological mechanisms of acne with special emphasis on Propionibacterium acnes and related therapy. Acta Derm Venereol. 2003;83(4):241–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Bagatin E, Rocha MAD. Acne e erupções acneiformes. In: Belda Junior W, Chiacchio ND, Criado PR. Tratado de dermatologia. 2nd ed. São Paulo: Atheneu; 2014. p. 537–57.Google Scholar
  5. 5.
    Montagner S, Costa A. Diretrizes modernas no tratamento da acne vulgar: da abordagem inicial à manutenção dos benefícios clínicos. Surg Cosmet Dermatol. 2010;2(3):205–13.Google Scholar
  6. 6.
    Meneses C, Bouzas I. Acne vulgar e adolescência. Adolesc Saude. 2009;6(3):21–3.Google Scholar
  7. 7.
    White GM. Recent finding in the epidemiologic evidence, classification, and subtypes of acne vulgaris. J Am Acad Dermatol. 1998;39:S34–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Ramos-e-Silva M, et al. Acne in women. Br J Dermatol. 2015;172(Suppl.1):20–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Sobral Filho JF, Nunes Maia HGS, Fonseca ESVB, Damião RS. Aspectos epidemiológicos da acne vulgar em universitários de João Pessoa – PB. An Bras Dermatol. 1993;68:225–8.Google Scholar
  10. 10.
    Ribeiro BM, Almeida LMC, Costa A, Francesconi F, Follador I, Neves JR. Etiopatogenia da acne vulgar: uma revisão prática para o dia a dia do consultório de dermatologia. Surg Cosmet Dermatol. 2015;7(3 Supl 1):S20–6.Google Scholar
  11. 11.
    Zaenglein AL, Thiboutot DM. Acne Vulgar. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatologia. Traduzido por Oliveira RS 2nd ed. Rio de Janeiro: Elsevier; 2011. p. 495–508.Google Scholar
  12. 12.
    Kircik LH. Evolving concepts in the pathogenesis of acne vulgaris. J Drugs Dermatol. 2014;13(6):56.Google Scholar
  13. 13.
    Cunliffe WJ, Holland DB, Clarck SM, Stables GI. Comedogenesis: some aetiological, clinical and therapeutic strategies. Dermatology. 2003;206(1):11–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Kurokawa J, Danby FW, Ju Q, Wang X, Xiang LF, Xia L, et al. New developments in our understanding of acne pathogenesis and treatment. Exp Dermatol. 2009;18(10):821–32.CrossRefPubMedGoogle Scholar
  15. 15.
    Shaheen B, Gonzalez M. A microbial aetiology of acne: what is the evidence? Br J Dermatol. 2011;165:474–85.CrossRefPubMedGoogle Scholar
  16. 16.
    Neves JR, Francesconi F, Costa A, Ribeiro BM, Follador I, Almeida LMC. Propionibacterium acnes e a resistência bacteriana. Surg Cosmet Dermatol. 2015;7(3 Supl 1):S27–38.Google Scholar
  17. 17.
    Makrantonaki E, Ganceviciene R, Zouboulis C. An update on the role of the sebaceous gland in the pathogeneses of acne. Dermato-Endocrinol. 2011;3(1):41–9.CrossRefGoogle Scholar
  18. 18.
    Harvey A, Huynh TT. Inflammation and acne: putting the pieces together. J Drugs Dermatol. 2014;13(4):459–63.PubMedGoogle Scholar
  19. 19.
    Dessinioti C, Katsambas AD. The role of Propionibacterium acnes in acne pathogenesis: facts and controversies. Clin Dermatol. 2010;28(1):2–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Holland D, Jeremy AH, Roberts SG, Seukeran DC, Layton AM, Cunliffe WJ. Inflammation in acne scarring: a comparison of the responses in lesions from patients prone and not prone to scar. Br J Dermatol. 2004;150(1):72–81.CrossRefPubMedGoogle Scholar
  21. 21.
    Aubin GG, Portillo ME, Trampuz A, Corvec S. Propionibacterium acnes, an emerging pathogen: from acne to implant-infections, from phylotype to resistance. Med Mal Infec. 2014;44(6):241–50.CrossRefGoogle Scholar
  22. 22.
    Cordain L. Implications for the role of diet in acne. Semin Cutan Med Surg. 2005;24(2):84–91.CrossRefPubMedGoogle Scholar
  23. 23.
    Jung JY, Yoon MY, Min SU, Hong JS, Choi YS, Suh DH. The influence of dietary patterns on acne vulgaris in Koreans. Eur J Dermatol. 2010;20(6):768–72.PubMedGoogle Scholar
  24. 24.
    Melnik BC, Schmitz G. Role insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Exp Dermatol. 2009;18(10):833–41.CrossRefPubMedGoogle Scholar
  25. 25.
    Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial. Am J Clin Nutr. 2007;86:107–15.CrossRefPubMedGoogle Scholar
  26. 26.
    Danby FW. Nutrition and acne. Clim Dermatol. 2010;28(6):598–604.CrossRefGoogle Scholar
  27. 27.
    Costa A, Michalany NC, Alchorne MMA, Lima HC. Acne vulgar: estudo piloto de avaliação do uso oral de ácidos graxos essenciais por meio de analyses clínica, digital e histopatológica. An Bras Dermatol. 2007;82(2):129–34.CrossRefGoogle Scholar
  28. 28.
    Costa A, Talarico AS, Duarte COP, Pereira CS, Weimann ETS, Matos LS, et al. Evaluation of the quantitative and qualitative alterations in the fatty acid contentes of the sebum of patients with inflammatory acne during treatment with systemic lymecycline and/or oral fatty acid supplementation. Dermatol Res Pract. 2013;2013:120475. doi: Scholar
  29. 29.
    Thiboutot D, Gollnick H, Bettoli V, Dréno B, Kang S, Leyden JJ, et al. New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol. 2009;60(5):S1–49.CrossRefPubMedGoogle Scholar
  30. 30.
    Taylor GA, Shalita AR. Benzoyl peroxide-based combination therapies for acne vulgaris. A comparative review. Am J Clin Dermatol. 2004;5:261–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Bowe W, Kober M. Therapeutic update: acne. J Drugs Dermatol. 2014;13(3):235–8.PubMedGoogle Scholar
  32. 32.
    Dréno B, Bettoli V, Ochsendorf F, Layton A, Mobacken H, Degreef H. European recommendations on the use of oral antibiotics for acne. Eur J Dermatol. 2004;14:391–9.PubMedGoogle Scholar
  33. 33.
    Goodfield MJD, Cox NH, Bowser A, McMillan JC, Millard LG, Simpson NB, et al. Advice on the safe introduction and continued use of isotretinoin in acne in the U.K. 2010. Br J Dermatol. 2010;162(6):1172–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Quéreux G, Volteau C, N’Guyen JM, Dréno B. Prospective study of risk factors of relapse after treatment of acne with oral isotretinoin. Dermatology. 2006;212(2):168–76.CrossRefPubMedGoogle Scholar
  35. 35.
    Zaba R, Schwartz R, Jarmuda S, Czarnecka-Operacz M, Silny W. Acne fulminans: explosive systemic form of acne. J Eur Acad Dermatol Venereol. 2011 May;25(5):501–7.CrossRefPubMedGoogle Scholar
  36. 36.
    Palleschi GM, Bruscino N, Cristofaro G. A case of acne fulminans presenting with systemic symptoms resembling acute appendicitis with maculopapular purpura-like eruption exacerbated by systemic steroids. Dermatol Ther. 2013;26(4):367–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Giavedoni P, Mascaró-Galy JM, Aguilera P, Estrach-Panella T. Acne fulminans successfully treated with cyclosporine and isotretinoin. J Am Acad Dermatol. 2014 Feb;70(2):e38–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Brănişteanu DE, Cotrutz CE, Luca MC, Molodoi DA, Stoica LE, Ianoşi SL, Cianga CM, Brănişteanu DC. Morphopathological stigmata in acne fulminans. Romanian J Morphol Embryol. 2015;56(3):1185–90.Google Scholar
  39. 39.
    Zanelato TP, Gontijo GM, Alves CA, Pinto JC, Cunha PR. Disabling acne fulminans. An Bras Dermatol. 2011;86(4 Suppl 1):S9–12.CrossRefPubMedGoogle Scholar
  40. 40.
    Lages RB, Bona SH, Silva FV, Gomes AK, Campelo V. Acne fulminans successfully treated with prednisone and dapsone. An Bras Dermatol. 2012;87(4):612–4.CrossRefPubMedGoogle Scholar
  41. 41.
    Dréno B, Layton A, Zouboulis CC, López-Estebaranz JL, Zalewska-Janowska A, Bagatin E, Zampeli VA, Yutskovskaya Y, Harper JC. Adult female acne: a new paradigm. J Eur Acad Dermatol Venereol. 2013 Sep;27(9):1063–70.CrossRefPubMedGoogle Scholar
  42. 42.
    Addor FA, Schalka S. Acne da mulher adulta: aspectos epidemiológicos, diagnósticos e terapêuticos. An Bras Dermatol. 2010; 85(6):789–95.Google Scholar
  43. 43.
    Preneau S, Dreno B. Female acne – a different subtype of teenager acne? J Eur Acad Dermatol Venereol. 2012 Mar;26(3):277–82.CrossRefPubMedGoogle Scholar
  44. 44.
    Kim GK, Michaels BB. Post-adolescent acne in women: more common and more clinical considerations. J Drugs Dermatol. 2012 Jun;11(6):708–13.PubMedGoogle Scholar
  45. 45.
    Dessinioti C, Antoniou C, Katsambas A. Acneiform eruptions. Clin Dermatol. 2014;32(1):24–34.CrossRefPubMedGoogle Scholar
  46. 46.
    Chen W, Thiboutot D, Zouboulis CC. Cutaneous androgen metabolism: basic research and clinical perspectives. J Invest Dermatol. 2002;119(5):992–1007.CrossRefPubMedGoogle Scholar
  47. 47.
    Ozdemir S, Ozdemir M, Görkemi H, et al. Specific dermatologic features of the polycystic ovary syndrome and its association with biochemical markers of the metaboli syndrome and hyperandrogenism. Acta Obstet Gynecol Scand. 2010;89(2):199–204.CrossRefPubMedGoogle Scholar
  48. 48.
    Kamangar F, Shinkai K. Acne in the adult female patient: a practical approach. Int J Dermatol. 2012 Oct;51(10):1162–74.CrossRefPubMedGoogle Scholar
  49. 49.
    Costa A, Lage D, Moisés TA. Acne e dieta: verdade ou mito? An Bras Dermatol. 2010;85(3):346–53.CrossRefPubMedGoogle Scholar
  50. 50.
    Tenaud I, Khammari A, Dreno B. In vitro modulation of TRL-2, CD1d and IL-10 by adapalene on normal human skin and acne inflammatory lesions. Exp Dermatol. 2007;16:500–6.CrossRefPubMedGoogle Scholar
  51. 51.
    Sobral Filho JF, Silva CNA, Rodrigues JC, Rodrigues JLTD, Aboui-Azouz M. Avaliação da herdabilidade e concordância da acne vulgar em gêmeos. An Bras Dermatol. 1997;72(5):225–8.Google Scholar
  52. 52.
    Rathi SK. Acne vulgaris treatment: the current scenario. Indian J Dermatol. 2011;56(1):7–13.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Del Rosso JQ. Topical therapy for acne in women: is there a role for clindamycin phosphate-benzoyl peroxide gel? Cutis. 2014 Oct;94(4):177–82.PubMedGoogle Scholar
  54. 54.
    Sieber MA, Hegel JK. Azelaic acid: properties and mode of action. Skin Pharmacol Physiol. 2014;27(1):9–17.CrossRefPubMedGoogle Scholar
  55. 55.
    Zeichner J. Evaluating and treating the adult female patient with acne. J Drugs Dermatol. 2013;12(12):1418–27.Google Scholar
  56. 56.
    Ebede TL, Emily LA, Berson D. Hormonal treatment of acne in women. J Clin Aesthetic Dermatol. 2009;2(12):16–22.Google Scholar
  57. 57.
    Katsambas AD, Dessinioti C. Hormonal therapy for acne. Why not as first therapy? Facts and controversies. Clin Dermatol. 2010;28(1):17–23.CrossRefPubMedGoogle Scholar
  58. 58.
    Kim GK, Del Rosso JQ. Oral spironolactone in post-teenage female patients with acne vulgaris. Practical considerations for the clinician based on current data and clinical experience. J Clin Aesthet Dermatol. 2012;6(3):37–50.Google Scholar
  59. 59.
    Salvaggio HL, Zaenglein AL. Examining the use of oral contraceptives in the management of acne. Int J Women Health. 2010;2:69–76.Google Scholar
  60. 60.
    Barr NG. Managing adverse effects of hormonal contraceptives. Am Fam Physician. 2010;82(12):1499–506.Google Scholar
  61. 61.
    Johnson NP. Metformin use in women with polycystic ovary syndrome. Ann Transl Med. 2014;2(6):56.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Kim W, Mancini AJ. Acne in childhood: an update. Pediatr Ann. 2013;42(10):418–27.CrossRefPubMedGoogle Scholar
  63. 63.
    Yeo L, Ormerod AD. Treatment of acne in children. Am J Clin Dermatol. 2014;15(2):77–86.CrossRefPubMedGoogle Scholar
  64. 64.
    Barbareschi M, Benardon S, Guanziroli E, et al. Classification and grading. In: Schwartz RA, Micali G, editors. Acne. Gurgaon: Nature Publishing Group; 2013. p. 67–75.Google Scholar
  65. 65.
    Kuiri-Hänninen T, Haanpää M, Turpeinen U, Hämäläinen E, Dunkel L, Sankilampi U. Transient postnatal secretion of androgen hormones is associated with acne and sebaceous gland hypertrophy in early infancy. J Clin Endocrinol Metab. 2013 Jan;98(1):199–206.CrossRefPubMedGoogle Scholar
  66. 66.
    Eichenfield LF, Krakowski AC, Piggott C, Del Rosso J, Baldwin H, Friedlander SF, Levy M, Lucky A, Mancini AJ, Orlow SJ, Yan AC, Vaux KK, Webster G, Zaenglein AL, Thiboutot DM, American Acne and Rosacea Society. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics. 2013 May;131(Suppl 3):S163–86.CrossRefPubMedGoogle Scholar
  67. 67.
    Serna-Tamayo C, Janniger CK, Micali G, Schwartz RA. Neonatal and infantile acne vulgaris: an update. Cutis. 2014;94(1):13–6.PubMedGoogle Scholar
  68. 68.
    Admani S, Barrio VR. Evaluation and treatment of acne from infancy to preadolescence. Dermatol Ther. 2013;26(6):462–6.CrossRefPubMedGoogle Scholar
  69. 69.
    Hester C, Park C, Chung J, Balkrishnan R, Feldman S, Chang J. Medication adherence in children and adolescents with acne vulgaris in medicaid: a retrospective study analysis. Pediatr Dermatol. 2016;33(1):49–55.CrossRefPubMedGoogle Scholar
  70. 70.
    Alchorne AOA, Alchorne MMA, Silva MM. Occupational dermatosis. An Bras Dermatol. 2010;85(2):137–47.CrossRefPubMedGoogle Scholar
  71. 71.
    Valgas N, Salaro CP, Bornhausen-Demarch E, Bonora CJ, Broce AA. Elaioconiosis – case report. An Bras Dermatol. 2011 Jul-Aug;86(4 Suppl 1):S53.CrossRefPubMedGoogle Scholar
  72. 72.
    Svendsen K, Hilt B. Skin disorders in ship’s engineers exposed to oils and solvents. Contact Dermatitis. 1997;36:216–20.CrossRefPubMedGoogle Scholar
  73. 73.
    Fabbrocini G, Kaya G, Caseiro Silverio P, De Vita V, Kaya A, Fontao F, Sorg O, Saurat JH. Aryl hydrocarbon receptor activation in acne vulgaris skin: a case series from the Region of Naples. Italy Dermatol. 2015;231(4):334–8.CrossRefGoogle Scholar
  74. 74.
    Ju Q, Zouboulis CC, Xia L. Environmental pollution and acne: chloracne. Dermatoendocrinol. 2009;1(3):125–8.CrossRefPubMedPubMedCentralGoogle Scholar
  75. 75.
    Passarini B, Infusino SD, Kasapi E. Chloracne: still cause for concern. Dermatology. 2010;221(1):63–70.CrossRefPubMedGoogle Scholar
  76. 76.
    Patterson AT, Kaffenberger BH, Keller RA, Elston DM. Skin diseases associated with Agent Orange and other organochlorine exposures. J Am Acad Dermatol. 2016;74(1):143–70.CrossRefPubMedGoogle Scholar
  77. 77.
    Redgrave TG, Wallace P, Jandacek RJ, Tso P. Treatment with a dietary fat substitute decreased Arochlor 1254 contamination in an obese diabetic male. J Nutr Biochem. 2005;16:383–4.CrossRefPubMedGoogle Scholar
  78. 78.
    Du-Thanh A, Kluger N, Bensalleh H, Guillot B. Drug-induced acneiform eruption. Am J Clin Dermatol. 2011;12(4):233–45.CrossRefPubMedGoogle Scholar
  79. 79.
    Momin SB, Peterson A, Del Rosso JQ. A status report on drug-associated acne and acneiform eruptions. J Drugs Dermatol. 2010;9(6):627–36.PubMedGoogle Scholar
  80. 80.
    Balta I, Ozuguz P. Vitamin B12-induced acneiform eruption. Cutan Ocul Toxicol. 2014;33(2):94–5.CrossRefPubMedGoogle Scholar
  81. 81.
    Rosa DJ, Matias Fde A, Cedrim SD, Machado RF, Sá AA, Silva VC. Acute acneiform eruption induced by interferon beta-1b during treatment for multiple sclerosis. An Bras Dermatol. 2011;86(2):336–8.CrossRefPubMedGoogle Scholar
  82. 82.
    Seneschal J, Kubica E, Boursault L, Stokkermans J, Labreze C, Milpied B, Ezzedine K, Taïeb A. Exogenous inflammatory acne due to combined application of cosmetic and facial rubbing. Dermatology. 2012;224(3):221–3.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2018

Authors and Affiliations

  • Marina de Almeida Delatti
    • 1
  • Renan Lage
    • 2
  • Elisa Moraes
    • 1
  • Beatrice Abdalla
    • 3
  • Marcel dos Santos
    • 1
  • Adilson Costa
    • 4
    Email author
  1. 1.Service of Dermatology of the Pontifical CatholicUniversity of Campinas (PUC-Campinas)CampinasBrazil
  2. 2.Hospital e Maternidade Celso Pierro – PUC CampinasCampinasBrazil
  3. 3.ABC School of MedicineSanto AndreBrazil
  4. 4.State Public Workers Welfare InstituteSão PauloBrazil

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