Indian Journal of Dermatology, Venereology and Leprology, Vol. 75, No. 7, , 2009, pp. 13-25
Acne in India: Guidelines for management - IAA Consensus Document
Raj Kubba, AK Bajaj, DM Thappa, Rajeev Sharma, Maya Vedamurthy, Sandipan Dhar, S Criton, Rui Fernandez, AJ Kanwar, Uday Khopkar, Malavika Kohli, VP Kuriyipe, Koushik Lahiri, Nina Madnani, Deepak Parikh, Sudhir Pujara, KK Rajababu, S Sacchidanand, VK Sharma, Jayakar Thomas - members Indian Acne Alliance
Correspondence Address: Dr. Raj Kubba, Consultant Dermatologist, Kubba Clinic, 10, Aradhana Enclave, Ring Road, New Delhi - 110066, India. firstname.lastname@example.org
Code Number: dv09035
Acne is the easiest skin condition to diagnose because of its distinctive anatomic distribution, age of occurrence, and polymorphic appearance in which the comedones (blackheads especially) are the most unique and pathognomonic feature [Figure - 9],[Figure - 10],[Figure - 11]. Typically it starts at puberty, in girls between age 12-14 years, and in boys between 14-16 years. Occasionally, it may start at age 7 or 8 years (adrenarche) and when it does, it portends severe acne. Acne waxes and wanes through adolescent years and early adult life, it peaks between 17-21 years. In about 90% of sufferers, acne will spontaneously remit before 30 years of age. In the rest, its course is unpredictable, and it may persist well into the fifth and the sixth decade (persistent acne). Less commonly, acne may make its first appearance in mature adults - after 30 years (adult acne). Adult acne is more common in women and is often a part of cutaneous hyperandrogenism [Figure - 12],[Figure - 13],[Figure - 14]. ,
Face is the theater of action. It is involved in 99% of acne sufferers.  Back is involved in 60% and chest in 15%.  Preadolescent acne and early adolescent acne is largely confined to the forehead [Figure - 9]. With time there is cephalocaudal migration. Typical adolescent acne involves the entire face but shows predilection for cheeks [Figure - 10],[Figure - 11],[Figure - 15],[Figure - 16],[Figure - 17]. In men who have grown beard, it relatively spares the lower face and neck. In severe cases, even external ears are involved. Adult acne is largely confined to the jaw area [Figure - 18]. Acne vulgaris (common acne) shows variable involvement of seborrheic areas of upper torso, namely, upper back, sternal area, shoulders, and upper arms [Figure - 19] and [Figure - 20] [Table - 2]. In some cases, acne is largely confined to the torso with little or no involvement of the face (acne corporis) [Figure - 21] and [Figure - 22]. Acne corporis denotes severe acne and often involves the entire back and in some cases even buttocks and thighs. Acne does not occur on the scalp although folliculitis occasionally co-occurs and is misdiagnosed as acne. Concomitant folliculitis , especially pityrosporum folliculitis, is more common than is recognized [Figure - 23]. 
Acne shows a variable and fluctuating mix of comedones, folliculocentric inflammatory lesions, scars, and pigmentary disturbances. The full spectrum includes many types of comedones [Table - 3] - blackheads (open comedones), whiteheads (closed comedones), missed comedones, macrocomedones, sandpaper comedones, submarine comedones [Figure - 24],[Figure - 25],[Figure - 26];  inflammatory lesions - papules, pustules, nodules, cysts, macules [Figure - 27],[Figure - 28],[Figure - 29],[Figure - 30],[Figure - 31]; atrophic scars - rolling, boxcar, ice-pick; hypertrophic scars and keloids; and acne hyperpigmented macules (AHM) [Figure - 32],[Figure - 33],[Figure - 34],[Figure - 35],[Figure - 36],[Figure - 37],[Figure - 38].  The precursor lesion is a microcomedo which evolves into open or closed comedone and further into papule or nodule. Microcomedo may also directly evolve into papule or nodule [Figure - 2]. The diagnosis of acne is untenable in the absence of comedones. Yet 7% of acne patients do not show comedones at first evaluation.  On the other hand, the presence of a single comedone is enough to diagnose acne! The preadolescent acne and the beginning of adolescent acne is largely comedonal. Acne papules, pustules, and nodules appear later. Acne severity is gauged by the number and types of inflammatory lesions [Table - 4] [Figure - 39].
Acne papules are conical, measure 3 mm or less, and often show a pore at the summit. Pustules are similar in size and represent more intense inflammation; they are sterile on routine cultures. Nodules measure 4 mm or larger and show tenderness that is proportional to size. Nodules sometimes soften and become fluctuant when they are erroneously described as cysts; at best they are pseudocysts [Figure - 40],[Figure - 41]. Such lesions may further evolve into hemorrhagic crusts, abscesses, or sinus tracts [Figure - 42]. Nodules carry high potential for scarring, especially in the genetically prone. Acne macules represent resolved papules/nodules and often precede atrophic scars [Figure - 29]. Acne scars [Table - 5] are invariably atrophic on the cheeks, and hypertrophic/ keloidal over the jaw angles [Figure - 35], shoulders, upper back, and sternal areas. Papular scars are sometimes encountered on the chin [Figure - 37] and nose, perifollicular fibrosis and perifollicular elastolysis on the back, chest, and neck. Macular atrophic scars are large, 5-20 mm, somewhat circular, soft, and erythematous, and occur on the back. Mixed scars and unclassifiable scars are also encountered [Figure - 43]. Scarring is seen in 22% of acne sufferers. Rarely, severe acne scars are complicated with osteoma cutis. 
Acne variants [Figure - 44],[Figure - 45],[Figure - 46],[Figure - 47],[Figure - 48],[Figure - 49],[Figure 50],[Figure 51],[Figure 52],[Figure 53],[Figure 54],[Figure 55]: Acne offers a wide spectrum of clinical subtypes. Some subtypes are aggressive or severe and are associated with constitutional symptoms and systemic involvement. This group includes acne conglobata [Figure - 44], acne fulminans, pyoderma faciale (rosacea fulminans) [Figure - 45], and SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis) [Figure - 46]. SAHA syndrome (seborrhea, acne, hirsutism, alopecia) [Figure - 47],[Figure - 48],[Figure - 49] denotes acne in the context of endocrine abnormality, particularly polycystic ovarian syndrome. Infantile acne is sometimes severe and prolonged and warrants evaluation for adrenal or gonadal tumor. Acne excoriθe [Figure - 29] and [Figure 56] is often a manifestation of dysmorphophobia. Frictional acne, acne mechanica, acne cosmetica, and tropical acne (acne Mallorca) are mild variants or acne look alikes. Drug-induced acne includes drug aggravation of pre-existing acne (androgenic hormones, anabolic steroids, INH, lithium) or a de novo acneiform eruption (oral corticosteroids, halogens) [Table - 1].
Clinical differential diagnosis: Many skin conditions mimic acne [Table - 6]. Some are more acneiform than others. This is a large group and includes: rosacea, perioral dermatitis, folliculitides - namely, Gram-negative folliculitis, other bacterial folliculitides, pityrosporum folliculitis, candida folliculitis, demodex folliculitis, herpetic folliculitis, and HIV-associated eosinophilic pustular folliculitis, lupus miliaris disseminatus facei, adenoma sebaceum, milia, verruca plana, and molluscum contagiosum. All of the above conditions lack comedones and are thus easily distinguished from acne. However, some of these conditions may co-occur with acne and that may pose diagnostic difficulty.
Copyright 2009 - Indian Journal of Dermatology, Venereology and Leprology
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