Acne vulgaris

Last updated: September 13, 2023

Summarytoggle arrow icon

Acne vulgaris is a chronic skin condition that most commonly affects adolescents and young adults, but it can occur at any age. The etiology of acne is multifactorial: genetic predisposition, hormonal effects on sebum production, bacterial colonization with Cutibacterium acnes, and/or keratin plugs from follicular hyperkeratosis. Acne manifests as noninflammatory comedonal acne and/or inflammatory acne, e.g., papules and/or nodules that are often located on the face, shoulders, upper chest, and back. History and physical examination are usually sufficient for diagnosis. Diagnostic studies are only indicated for differential diagnosis or if an underlying medical condition is suspected, e.g., polycystic ovary syndrome (PCOS). Prompt pharmacological treatment is recommended to prevent complications of acne. Treatment is based on the severity of acne and the type of lesion; options include topical and systemic medications.

Epidemiologytoggle arrow icon

  • Prevalence: the most prevalent chronic skin condition in the US, affecting ∼ 50 million people [1][2]
  • Age of onset: typically by 11–12 years, with symptoms usually disappearing around 20–30 years of age [3]
  • Sex: more common in male individuals during adolescence; , but more common in women during adulthood

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Causes of acne vulgaris

Risk factors for acne vulgaris

Clinical featurestoggle arrow icon

Patients with inflammatory acne are at risk for scarring. [8]


Subtypes and variantstoggle arrow icon

Acne fulminans [10][11]

Acne fulminans is a rare, severe form of acne that is characterized by painful ulcerative skin lesions and systemic inflammatory symptoms.


  • Rare disease (approx. 200 documented cases)
  • Age of onset: 13–22 years
  • > (3:1)
  • Mainly individuals of northern European descent


Clinical features


Treatment [10][12]

Diagnosticstoggle arrow icon

Routine testing for C. acnes is not recommended because it does not alter management. [1]

Initial managementtoggle arrow icon

Approach [1][2][13]

Early pharmacological treatment is recommended to prevent acne complications. [13]

Supportive care [1][2][13]

  • Provide general skin care instructions. [13]
    • Use a gentle facial cleanser and avoid excessive cleaning and scrubbing (e.g., with exfoliants). [1]
    • Avoid skin care products (e.g., moisturizers, cosmetics) that are comedogenic.
    • Do not pick at acne lesions.
  • For individuals with endocrine-related acne (e.g., due to PCOS, obesity), recommend maintaining a healthy BMI.
  • Dietary restrictions and supplements (e.g., fish oil) are not supported by current evidence. [1]

Overview of pharmacological therapy [1][2]

The preferred initial treatment regimen is based on the lesion type and severity of acne.

Overview of initial acne treatment by severity [1][2][13]
First-line Second-line
Mild acne
  • Change to a different preferred medication.
  • Try either of the following topical treatments:
Moderate acne
Severe acne

Isotretinoin and oral tetracycline antibiotics should not be prescribed concurrently as both can cause medication-induced intracranial hypertension. [1][2]

Procedural interventions [1][2]

Although there is insufficient evidence on the efficacy of procedural interventions, they may be considered by a dermatologist.

Topical pharmacotherapytoggle arrow icon

General principles

  • Topical treatments are used to treat all stages of acne.
  • A mixture of topical therapies is often required; use of fixed combination products may improve adherence.
  • When prescribing, consider the following to optimize therapy : [1][13][15]
    • Medication concentration
    • Type of topical formulation (e.g., gel, lotion)
    • Duration of skin contact

Topical retinoids [1][2]

  • Retinoids are vitamin A derivatives with an anti-inflammatory and comedolytic effect.
  • Used as monotherapy for comedonal acne or adjunctive therapy for acne of any severity
  • Applied at night as some preparations are not photostable and all retinoids can cause photosensitivity

Commonly used agents [1]

Benzoyl peroxide can inactivate tretinoin; advise patients not to apply both products at the same time unless using a fixed combination product. [1]

Topical retinoids are contraindicated during pregnancy. [1][2]

Topical antibiotics for acne [1][2]

  • Help manage acne through both a bactericidal and anti-inflammatory effect
  • Used as an adjunctive therapy for acne

Commonly used agents

Avoid using topical antibiotics as monotherapy and limit the length of therapy to 12 weeks to prevent the development of drug-resistant bacteria.

Other topical agents [1][2][13]

There is limited evidence to support the use of certain topical medications such as salicylic acid, niacinamide, and sulfacetamide/sulfur for the treatment of acne. [1][2]

Oral antibiotic therapytoggle arrow icon

General principles [1][2]

Recommended antibiotics [1][2]

Alternative oral antibiotics (e.g., cephalosporins, penicillins, or trimethoprim/sulfamethoxazole) are not recommended for treating acne because of limited evidence, but can be considered if preferred regimens are not tolerated or acceptable (e.g., during pregnancy). [1]

Always combine oral antibiotics with topical therapy and limit treatment duration to < 4 months to prevent antibiotic resistance. [1][2][13]

Hormonal therapytoggle arrow icon

General principles

Combined oral contraceptive pill (COCP) [1][2]


FDA-approved COCPs for the treatment of acne [1][2][13]

Users of progestin-only contraception often report worsening of acne. It is unclear what impact the new progestin-only pill containing drospirenone, an antiandrogenic progestin, has on hormonal acne. [16][17]

Aldosterone antagonists

Contraception is generally recommended for women of reproductive age who are taking spironolactone, which can have antiandrogenic effects on a developing fetus (e.g., feminization of a male fetus). [1]

Glucocorticosteroids [1][2]

Oral glucocorticoid therapy can decrease the risk of acne fulminans-like eruptions in patients starting isotretinoin therapy. [1][2]

Acne can worsen with rapid titration of glucocorticosteroids; avoid long-term treatment to minimize the side effects of glucocorticoid therapy. [1]

Isotretinoin therapytoggle arrow icon

General principles [1][2]

Indications [1][2]

  • Severe; , nodular, recalcitrant acne
  • Moderate acne requiring therapy escalation


Avoid oral isotretinoin during pregnancy and in female individuals of reproductive age not using contraception because of the risk of teratogenesis. [2]

Initiating isotretinoin therapy [1][2][19]

Enrollment in the online iPLEDGE program is required for all patients, prescribers, and pharmacists dealing with isotretinoin to prevent cases of fetal retinoid syndrome. [1][2]

Ongoing management of isotretinoin therapy [1][2][19]

Patients planning to conceive should discontinue treatment at least one month prior to conception.

Cytopenias can occur with isotretinoin use, but there is insufficient evidence to recommend routine monitoring of complete blood counts. [1]

Adverse effects of isotretinoin [1][2]

Fetal retinoid syndrome [24]

Individuals taking oral isotretinoin should be monitored for symptoms of suicidal ideation and inflammatory bowel disease, even though there is insufficient evidence of an association. [1][2]

Ongoing management of acnetoggle arrow icon

Following the initiation of an acne medication regimen, it typically takes 4–6 weeks to notice clinical improvement and at least 2–3 months to see clearing. [14]

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Special patient groupstoggle arrow icon

Acne in infants

Neonatal cephalic pustulosis [26][27][28]

Infantile acne [26][27]

Neonatal cephalic pustulosis resolves without treatment, but infantile acne requires treatment to prevent scarring. [26]

Acne in pregnancy [13][29]

Agents safe to use during pregnancy [13][29][30]

Agents to be used with caution during pregnancy [13][29]

Only use the following medications if the potential benefit outweighs the potential or unknown risks to the fetus.

Agents to avoid during pregnancy [13]

The following agents are contraindicated in women who are pregnant or planning pregnancy.

Referencestoggle arrow icon

  1. Oge' LK, Broussard A, Marshall MD. Acne Vulgaris: Diagnosis and Treatment. Am Fam Physician. 2019; 100 (8): p.475-484.
  2. Eichenfield DZ, Sprague J, Eichenfield LF. Management of Acne Vulgaris. JAMA. 2021; 326 (20): p.2055.doi: 10.1001/jama.2021.17633 . | Open in Read by QxMD
  3. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016; 74 (5): p.945-973.doi: 10.1016/ j.jaad.2015.12.037 . | Open in Read by QxMD
  4. Magin P, Adams J, Heading G, Pond D, Smith W. Psychological sequelae of acne vulgaris: results of a qualitative study. Can Fam Physician. 2006; 52 (8): p.978-9.
  5. AMA. Drospirenone (Slynd): A New Progestin-Only Oral Contraceptive. JAMA. 2020; 323 (19): p.1963.doi: 10.1001/jama.2020.1603 . | Open in Read by QxMD
  6. Barbieri JS, Mitra N, Margolis DJ, Harper CC, Mostaghimi A, Abuabara K. Influence of Contraception Class on Incidence and Severity of Acne Vulgaris. Obstet Gynecol. 2020; 135 (6): p.1306-1312.doi: 10.1097/aog.0000000000003880 . | Open in Read by QxMD
  7. Layton AM, Eady EA, Whitehouse H, Del Rosso JQ, Fedorowicz Z, van Zuuren EJ. Oral Spironolactone for Acne Vulgaris in Adult Females: A Hybrid Systematic Review. Am J Clin Dermatol. 2017; 18 (2): p.169-191.doi: 10.1007/s40257-016-0245-x . | Open in Read by QxMD
  8. The iPLEDGE REMS Prescriber Guide. Updated: October 1, 2021. Accessed: September 4, 2023.
  9. Friedman DI. Medication-induced intracranial hypertension in dermatology.. Am J Clin Dermatol. 2005; 6 (1): p.29-37.doi: 10.2165/00128071-200506010-00004 . | Open in Read by QxMD
  10. Xia E, Han J, Faletsky A, et al. Isotretinoin Laboratory Monitoring in Acne Treatment. JAMA Dermatol. 2022.doi: 10.1001/jamadermatol.2022.2044 . | Open in Read by QxMD
  11. Blasiak RC, Stamey CR, Burkhart CN, Lugo-Somolinos A, Morrell DS. High-Dose Isotretinoin Treatment and the Rate of Retrial, Relapse, and Adverse Effects in Patients With Acne Vulgaris. JAMA Dermatol. 2013; 149 (12): p.1392.doi: 10.1001/jamadermatol.2013.6746 . | Open in Read by QxMD
  12. Poulin Y, Sanchez NP, Bucko A, et al. A 6-month maintenance therapy with adapalene-benzoyl peroxide gel prevents relapse and continuously improves efficacy among patients with severe acne vulgaris: results of a randomized controlled trial. Br J Dermatol. 2011; 164 (6): p.1376-1382.doi: 10.1111/j.1365-2133.2011.10344.x . | Open in Read by QxMD
  13. Sladden MJ, Harman KE. What Is the Chance of a Normal Pregnancy in a Woman Whose Fetus Has Been Exposed to Isotretinoin?. Arch Dermatol. 2007; 143 (9).doi: 10.1001/archderm.143.9.1187 . | Open in Read by QxMD
  14. 9 Things to try when your acne won't clear. Updated: November 30, 2021. Accessed: July 25, 2023.
  15. Bhate K, Williams HC. Epidemiology of acne vulgaris. Br J Dermatol. 2013; 168 (3): p.474-485.doi: 10.1111/bjd.12149 . | Open in Read by QxMD
  16. Tuchayi SM, Makrantonaki E, Ganceviciene R, Dessinioti C, Feldman SR, Zouboulis CC. Acne vulgaris. Nature Reviews Disease Primers. 2015; 1 (1).doi: 10.1038/nrdp.2015.29 . | Open in Read by QxMD
  17. Belzer A, Parker ER. Climate Change, Skin Health, and Dermatologic Disease: A Guide for the Dermatologist. Am J Clin Dermatol. 2023; 24 (4): p.577-593.doi: 10.1007/s40257-023-00770-y . | Open in Read by QxMD
  18. Juhl CR, Bergholdt HKM, Miller IM, Jemec GBE, Kanters JK, Ellervik C. Dairy Intake and Acne Vulgaris: A Systematic Review and Meta-Analysis of 78,529 Children, Adolescents, and Young Adults.. Nutrients. 2018; 10 (8).doi: 10.3390/nu10081049 . | Open in Read by QxMD
  19. Bernardis E, Shou H, Barbieri JS, et al. Development and Initial Validation of a Multidimensional Acne Global Grading System Integrating Primary Lesions and Secondary Changes. JAMA. 2020; 156 (3): p.296.doi: 10.1001/jamadermatol.2019.4668 . | Open in Read by QxMD
  20. Feldman S, Careccia RE, Barham KL, Hancox J. Diagnosis and treatment of acne.. Am Fam Physician. 2004; 69 (9): p.2123-30.
  21. James WD, Berger T, Elston D. Andrews' Diseases of the Skin: Clinical Dermatology. Elsevier Health Sciences ; 2015
  22. Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne fulminans and its variants. J Am Acad Dermatol. 2017; 77 (1): p.109-117.doi: 10.1016/j.jaad.2016.11.028 . | Open in Read by QxMD
  23. Bocquet‐Trémoureux S, Corvec S, Khammari A, Dagnelie M ‐A., Boisrobert A, Dreno B. Acne fulminans and Cutibacterium acnes phylotypes. J Eur Acad Dermatol Venereol. 2019; 34 (4): p.827-833.doi: 10.1111/jdv.16064 . | Open in Read by QxMD
  24. Karon A. Experts present first recommendations for treating acne fulminans. MDEdge Dermatology. 2016.
  25. Samycia M, Lam JM. Infantile acne. Can Med Assoc J. 2016; 188 (17-18): p.E540-E540.doi: 10.1503/cmaj.160139 . | Open in Read by QxMD
  26. Eichenfield LF, Frieden IJ, Mathes E, Zaenglein A, Esterly NB. Neonatal Dermatology E-Book. Elsevier Health Sciences ; 2007
  27. Fang WC, Chiu LW. Neonatal Cephalic Pustulosis. N Engl J Med. 2023; 389 (6): p.e10.doi: 10.1056/nejmicm2301685 . | Open in Read by QxMD
  28. Chien AL, Qi J, Rainer B, Sachs DL, Helfrich YR. Treatment of Acne in Pregnancy. J Am Board Fam Med. 2016; 29 (2): p.254-262.doi: 10.3122/jabfm.2016.02.150165 . | Open in Read by QxMD
  29. Ly S, Kamal K, Manjaly P, Barbieri JS, Mostaghimi A. Treatment of Acne Vulgaris During Pregnancy and Lactation: A Narrative Review. Dermatol Ther. 2022; 13 (1): p.115-130.doi: 10.1007/s13555-022-00854-3 . | Open in Read by QxMD
  30. Russell JJ. Topical therapy for acne.. Am Fam Physician. 2000; 61 (2): p.357-66.

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