The nature and severity of acne

Acne is a follicular skin disease most frequently occurring during the adolescent or teenage years of a person’s life. It has been found that around 85% of teenagers suffer from this skin disorder worldwide. However, acne is not only restricted to teenagers, but in many cases continues well into adulthood. The average age when therapy is sought by the typical acne sufferer is 24 years.

Acne vulgaris is the most common skin disorder known medically. It is a pleomorphic inflammatory disorder occurring mostly on the face, but it can also extend to the areas of the neck, chest and the back as well depending on the type and severity of the disease.


It is thought that acne develops due to hyper sensitivity to the stimulation of sebocytes and follicular keratinocytes by androgens giving rise to the hyperplasia of sebaceous glands and seborrhea that is seen externally in the form of acne.


Acne is characterized by open or closed comedones (both blackheads and whiteheads), which either occur in isolation or may be found grouped together with papules or pustules, mainly on the face and upper trunk. How severe the acne is, is determined by the number, type and distribution of the lesions.

Acne is not life threatening in the clinical sense, but it can damage the emotional and psychological framework of the sufferer leading to mild or extreme depression, anxiety and social withdrawal. With the latest techniques, therapies and treatments available, acne can indeed be treated effectively. In order to do this, however, the disease needs to be graded according to severity and type, keeping in mind several other factors as well. This skin disorder varies from one person to the other so it needs to be classified accordingly for appropriate treatment.

There are more than 25 methods for judging the severity of acne and about 19 methods for counting lesions.

Severity of acne

Acne vulgaris is easily diagnosed. The presence of comedones confirms its diagnosis. Acne can be broadly divided into two major severity types:

  • Inflammatory acne characterized by the presence of nodules, papules or pustules (having “pus” cells).
  • Non inflammatory lesions characterized by open or closed comedones (blackheads or whiteheads).

Acne can also be divided by its severity as follows:

Mild Acne
This can be of two types. One is mild comedonal acne where comedones are the main lesions and generally non inflammatory. Topical retinoid therapy is usually enough for treating this type of acne. The other is mild papopustular acne where papules or pustules maybe present, but are very few in number (less than ten). Several open and closed comedones present with few inflammatory papsules can also be described as mild acne. As these are slightly inflammatory, they are treated by using topical retinoid drugs as well as antibacterial preparations. Acetic acid may also be used to treat mildly papopustular acne. Mild acne is almost always limited to the face.

Moderate acne
In moderate cases of acne there are many comedones, few or many pustules, few nodules but no significant scarring. There may be excessive pigmentation of the skin in some cases and this type can be found on the face, shoulders, back and chest. This type of acne can be treated with oral antibiotics and retinoids as well as hormone therapy in women.

Moderately severe acne
Here erythematous papsules, pustules and nodules are present in moderate distribution on the face and some scarring may be present.

Severe Acne
In these cases, many painful and inflammatory nodules are present all over the body. There may be the presence of innumerable papopustules as well. There is bound to be scarring. For these patients the use of a combination of topical and oral antimicrobial agents is appropriate.

Very severe acne
There are some patients whose acne does not clear even with the combination of oral and topical therapy. These types are characterized by sinus tracts, comedone clusters, innumerable painful and deep rooted nodules, excessive inflammation and inevitable scarring. This mostly occurs in patients with excessive seborrhea and who have a gram negative folliculitis infection. Excessively severe acne can be treated with isotretinoin when other methods fail.

Thus, sebaceous hyperplasia with seborrhea, heightened cornification of the ducts, colonization of the follicles by the P acnes, bacteria and inflammation, and immune responses are the various factors which lead to different kinds of acne.

Treatment of severe acne

Severer forms of acne can be disfiguring and require years of treatment. Dermatologists have the most experience treating the different types of severe acne. It is important for patients and their families to know that severe, disfiguring forms of acne may require years of treatment and patients can experience one or more treatment failures. During treatment, the support of family and friends can greatly comfort patients.