GPAtlas🧭 When to suspect
Acne vulgaris is a chronic inflammatory disorder of the pilosebaceous unit, driven by four processes acting together:
• Increased sebum production.
• Abnormal follicular keratinisation.
• Colonisation with Cutibacterium acnes (formerly Propionibacterium acnes).
• Inflammation.
Acne usually begins around puberty (from about age 12) and most often affects the face, though the chest, shoulders and upper back are commonly involved.
Lesions are characteristically polymorphic – a mixture of non-inflammatory comedones (blackheads and whiteheads) and inflammatory papules, pustules, nodules and cysts.
Suspect acne in any adolescent or young adult with this pattern, and ask about oily skin, a family history of acne, and aggravating factors.
The two skills that matter most in primary care:
• Grade severity accurately, because management is driven almost entirely by severity.
• Recognise the impact on mental health, which does not track the appearance of the skin.
| Lesion pattern | NICE classification | First-line approach |
|---|---|---|
| Predominantly comedones with few papules/pustules | Mild to moderate (≤34 inflammatory lesions, ≤2 nodules) | 12-week course of a topical fixed-combination |
| Widespread papules and pustules, ± a few nodules | Mild-to-moderate or moderate-to-severe by lesion count | Topical fixed-combination, ± oral antibiotic if moderate-to-severe |
| Numerous inflammatory lesions, ≥3 nodules, cysts or scarring | Moderate to severe (≥35 inflammatory lesions or ≥3 nodules) | • Topical + oral antibiotic • Consider referral and isotretinoin |
| Sudden ulcerating/crusting nodules with systemic upset | Acne fulminans | Same-day on-call dermatology (within 24 hours) |
Most acne settles by the early-to-mid twenties, but it can persist into the thirties and forties. A first presentation, or treatment-resistant acne, in an adult woman should prompt thought about hyperandrogenism and polycystic ovary syndrome (PCOS).
|
🧠 Clinical pearl • Comedones are the diagnostic hallmark of acne. • If a patient has inflammatory papules and pustules but no comedones, question the diagnosis. • Rosacea brings flushing and telangiectasia (and no comedones). • Perioral dermatitis characteristically spares the skin immediately around the lips. • Monomorphic pustules in someone on long-term antibiotics suggest Gram-negative folliculitis. |
Source: NICE NG198
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