Acne Classification and Disease Burden

  • Gerd Plewig
  • Bodo Melnik
  • WenChieh Chen


Nosology does not rank high among the interests of acne researchers. Yet the lack of a common international standard for classifying and grading the severity of acne has been a distressing source of confusion and controversy. The result is that epidemiological data and classifications from different sources cannot be compared because the criteria are different. This adversely affects every field of investigation, for example, surveys concerning the prevalence of acne in different countries. At present we have no definite information about whether acne is more prevalent in meat eaters than in vegetarians, in cold climates compared with warm ones, in different ethnic groups, etc. What dermatologists may classify as severe acne in Japan might be considered mild by American dermatologists.


Acne Classification and Grading

  1. Allen BS, Smith JG Jr. Various parameters for grading acne vulgaris. Arch Dermatol. 1982;118:23–5.CrossRefGoogle Scholar
  2. Burke BM, Cunliffe WJ. The assessment of acne vulgaris – the Leeds technique. Br J Dermatol. 1984;111:83–92.CrossRefGoogle Scholar
  3. Cook CH, Centner RL, Michaels SE. An acne grading method using photographic standards. Arch Dermatol. 1979;115:571–5.CrossRefGoogle Scholar
  4. Doshi A, Zaheer A, Stiller MJ. A comparison of acne grading systems and proposal of a novel system. Int J Dermatol. 1997;36:416–8.CrossRefGoogle Scholar
  5. Dréno B. Assessing quality of life in patients with acne vulgaris: implications for treatment. Am J Clin Dermatol. 2006a;7:99–106.CrossRefGoogle Scholar
  6. Kang S, Lozada VT, Bettoli V, et al. New atrophic acne scar classification: reliability of assessments based on size, shape, and number. J Drugs Dermatol. 2016;15:693–702.Google Scholar
  7. Lucky AW, Barber BL, Girman CJ, et al. A multirated validation study to assess the reliability of acne lesion counting. J Am Acad Dermatol. 1996;35:559–65.CrossRefGoogle Scholar
  8. Motley RJ, Finlay AY. How much disability is caused by acne? Clin Exp Dermatol. 1989;14:194–8.CrossRefGoogle Scholar
  9. O’Brien SC, Lewis JB, Cunliffe WJ. The Leeds revised acne grading system. J Dermatol Treat. 1998;9:215–20.CrossRefGoogle Scholar
  10. Parish LC, Witkowski JA. The acne scoreboard. Int J Dermatol. 1978;17:490–1.CrossRefGoogle Scholar
  11. Petit L, Zugaj D, Bettoli V, et al. Validation of 3D skin imaging for objective repeatable quantification of severity of atrophic acne scarring. Skin Res Technol. 2018;24:542–50.CrossRefGoogle Scholar
  12. Petukhova TA, Foolad N, Prakash N, et al. Objective volumetric grading of postacne scarring. J Am Acad Dermatol. 2016;75:229–31.CrossRefGoogle Scholar
  13. Report of the Consensus Conference on Acne Classification. Washington, DC, March 24 and 25, 1990. J Am Acad Dermatol. 1991;24:495–500.Google Scholar
  14. Samuelson JS. An accurate photographic method for grading acne: initial use in a double-blind clinical comparison of minocycline and tetracycline. J Am Acad Dermatol. 1985;12:461–7.CrossRefGoogle Scholar
  15. Shalita AR, Leyden JJ, Kligman AM. Reliability of acne lesion counting. J Am Acad Dermatol. 1997;37:672.CrossRefGoogle Scholar
  16. Tan JK, Jones E, Allen E, et al. Evaluation of essential clinical components and features of current acne global grading scales. J Am Acad Dermatol. 2013;69:754–61.CrossRefGoogle Scholar
  17. Tan J, Frey MP, Knezevic S, et al. The relationship between dermatologist- and patient-reported acne severity measures and treatment recommendations. J Cutan Med Surg. 2015;19:464–9.CrossRefGoogle Scholar
  18. Witkowski JA, Parish LC, Guin JD. Acne grading methods. Int J Dermatol. 1980;116:517–118.Google Scholar

Disease Burden of Acne and Quality of Life

  1. Barnes LE, Levender MM, Fleischer AB Jr, Feldman SR. Quality of life measures for acne patients. Dermatol Clin. 2012;30:293–300.CrossRefGoogle Scholar
  2. Dréno B. Assessing quality of life in patients with acne vulgaris: implications for treatment. Am J Clin Dermatol. 2006b;7:99–106.CrossRefGoogle Scholar
  3. GBD 2013 DALYs and HALE Collaborators, Murray CJ, Barber RM, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition. Lancet. 2015;386:2145–91.CrossRefGoogle Scholar
  4. Hayashi N, Miyachi Y, Kawashima M. Prevalence of scars and “mini-scars”, and their impact on quality of life in Japanese patients with acne. J Dermatol. 2015;42:690–6.CrossRefGoogle Scholar
  5. Karimkhani C, Dellavalle RP, Coffeng LE, et al. Global skin disease morbidity and mortality: an update from the global burden of disease study 2013. JAMA Dermatol. 2017;153:406–12.CrossRefGoogle Scholar
  6. Md ZAL. Psychosocial issues in acne management: disease burden, treatment adherence, and patient support. Semin Cutan Med Surg. 2015;34(5 Suppl):S92–4.Google Scholar

Excoriations in Acne

  1. Bach M, Bach D. Psychiatric and psychometric issues in acne excoriée. Psychother Psychosom. 1993;60:207–10.CrossRefGoogle Scholar
  2. Fruensgaard K. Psychotherapeutic strategy and neurotic excoriations. Int J Dermatol. 1991;30:198–203.CrossRefGoogle Scholar
  3. Gieler U, Consoli SG, Tomás-Aragones L, et al. Self-inflicted lesions in dermatology: terminology and classification–a position paper from the European Society for Dermatology and Psychiatry (ESDaP). Acta Derm Venereol. 2013;93:4–12.CrossRefGoogle Scholar
  4. Gupta MA, Gupta AK, Schork NJ. Psychosomatic study of self-excoriative behavior among male acne patients: preliminary observations. Int J Dermatol. 1994;33:846–8.CrossRefGoogle Scholar
  5. Gupta MA, Gupta AK, Schork NJ. Psychosomatic correlates of self-excoriative behavior among women with mild to moderate facial acne vulgaris. Psychosomatics. 1996;37:127–30.CrossRefGoogle Scholar
  6. Gupta MA, Vujcic B, Gupta AK. Dissociation and conversion symptoms in dermatology. Clin Dermatol. 2017;35:267–72.CrossRefGoogle Scholar
  7. Kenyon FE. Psychosomatic aspects of acne. Br J Dermatol. 1966;78:344–51.CrossRefGoogle Scholar
  8. Khumalo NP, Shaboodien G, Hemmings SM, et al. Pathologic grooming (acne excoriee, trichotillomania, and nail biting) in 4 generations of a single family. JAAD Case Rep. 2016;2:51–3.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Gerd Plewig
    • 1
  • Bodo Melnik
    • 2
  • WenChieh Chen
    • 3
  1. 1.Department of Dermatology and AllergyLudwig-Maximilian-University MunichMunichGermany
  2. 2.Department of Dermatology, Environmental Medicine and Health TheoryUniversity of OsnabrückOsnabrückGermany
  3. 3.Department of Dermatology and AllergyTechnical University of MunichMunichGermany

Personalised recommendations