Acne vulgaris is the most common chronic skin disorder in the United States, affecting
approximately 80% of persons at some point between 11 and 30 years of age. In
1996 in the United States, the National Health Interview Survey reported the
prevalence of acne was 26/1000 in persons <45 years of age.
In addition to the economic costs of physician visits, medications, and over-the-
counter treatments, the disfigurement and permanent scarring from acne can also
have an adverse impact on psychosocial development and the quality of life of those
who suffer from it.
Acne, the major disorder of the pilosebaceous unit, presents as noninflammatory
(closed and open comedones) and inflammatory (papules, pustules, nodules) lesions.
Several factors contribute to the pathogenesis of acne including androgens
(testosterone and DHEA-S), increased sebum production, P. acnes-driven
inflammation, and abnormal follicular epithelial differentiation. Desquamated cornified
cells of the upper canal of the follicle become abnormally adherent. Instead of
undergoing normal shedding and discharge through the follicular opening, the cells
form a microscopic hyperkeratotic plug (the microcomedo) in the follicular canal, which
enlarges and becomes a visible comedo.
Inflammation (and subsequently, inflammatory acne) is a direct or indirect result of
the proliferation of P. acnes. Overgrowth of this anaerobic organism, which is
otherwise a normal constituent of the skin flora, occurs in the lipid-rich environment of
the pilosebaceous units containing microcomedones. The host inflammatory response
to P. acnes causes damage to and rupture of the follicular wall which extends the
inflammatory process into the surrounding dermis, resulting in the formation of the
inflammatory lesions (papules, pustules, and nodules) and ultimately, destruction of
the collagen matrix in the skin and cyst formation.
Acne comes in many shapes and forms and its disease path is simple, but
unfortunately its treatment can be complex, extended, expensive, and cumbersome.
Acne is known by several names that describe its clinical appearance.
Comedones occur when the hair shaft is dilated with sebaceous oil and/or debris
from dead skin cells, bacteria, or dirt. Typically comedones are inflamed and tender.
A closed comedone occurs when the pore is closed over by normal skin. This
occlusion results in a “white” raised lesion with inflammatory tension until the
superficial skin is disrupted either spontaneously or through trauma.
Papular acne is limited to closed pore whiteheads without an active inflammatory
zone. Simple open comedone (blackhead) acne will be included if white head,
pustular, nodular, or vulgaris acne is present.
Pustular acne is defined as cystic acne with within the epidermis. Pustular acne is
evident due to the “pus head” and zone of inflammation. These lesions typically
appear red, raised, and are tender to the touch.
Nodular acne is defined as mid-dermis hair follicle with significant dilation of the hair
shaft and follicle. This lesion is typically raised, indurated, red, and painful at rest.
Cystic or inflammatory acne is defined as deep dermis inflammation. This type
typically results in scarring.
Eighty percent of Americans describe acne as the number one traumatic life event
with either physical or emotional scarring.
The severity of acne is graded using the Burton Scale:
TABLE 1 – Acne Grading According to Burton Scale
Grade 0 - Total absence of lesions
Grade I - Sub Clinical Acne – few comedones visible only in close examination
Grade II - Comedonal Acne – comedones with slight inflammation.
Grade III - Mild Acne – inflamed papules with erythema.
Grade IV - Moderate Acne – many inflamed papules and pustules
Grade V - Severe Nodular Acne - inflamed papulesand pustules with several deep
Grade VI - Severe Cystic Acne – many modular cystic lesions with scarring.
Acne treatment should include a combination of the following resulting in the ability to
maintain the achieved acne skin improvement over a twelve month period:
• an integrated methodology of patient education
• topical skin care
• topical acids
• 1319 nm Nd:YAG laser
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