Acne and its severity

Acne (also called Acne Vulgaris in medical terms) is a common inflammatory skin condition that frequently affects almost 85% adolescents and young adults. The average age of persons seeking treatment is therefore 24 years of age. Although the exact mechanism behind acne formation is not known, it is thought that acne develops due to the over secretion of sebum and increase in size of the glands secondary to stimulation by androgens. Whilst the face is commonly affected, it can also occur in other sebaceous gland dense areas such as the neck, chest and back.

While acne is not life threatening in the clinical sense, it can damage the emotional and psychological framework of the affected person leading to depression, anxiety and social withdrawal. With the latest techniques, therapies and treatments available, acne can indeed be treated effectively. However in order to do this, the disease needs to be graded according to severity and type. There are more than 25 methods for judging the severity of acne and about 19 methods for counting lesions. How severe the acne is, is determined by the number, type and distribution of the lesions.

Severity of acne

Acne can be broadly divided into two major types based on type of lesions: A) Inflammatory acne: characterized by the presence of nodules, papules or pustules (having “pus” cells). B) Non-inflammatory acne: characterized by open or closed comedones (blackheads or whiteheads).

Acne can also be classified by severity of skin lesions:

a) Mild Acne

This consists of a condition where the lesions are mainly non-inflammatory with very few inflammatory lesions, usually less than ten in number. Mild acne can further be classified into two types, the mild comedonal acne where comedones are the main lesions and generally non inflammatory; and the mild papopustular acne where papules or pustules maybe present, but are very few in number (less than ten). Topical retinoid therapy is usually enough for treating first type while the second type is usually 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.

b) Moderate acne
In moderate 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 these lesions are usually found on the face, shoulders, back and chest. This is usually treated with oral antibiotics and retinoids as well as hormone therapy in women.

c) Moderately severe acne
Here erythematous papsules, pustules and nodules are present in moderate distribution on the face and some scarring may be present. Treatment remains the same as moderate acne, with an increased dependence on systemic therapy.

d) Severe Acne
In these cases, many painful and inflammatory nodules are present all over the body. There may be the presence of innumerable papopustules (i.e. small collections or pockets of pus). This usually results in scarring. For these patients the use of a combination of topical and oral antimicrobial agents is appropriate.

e) Very severe acne
There are some patients whose acne does not clear even with the combination of oral and topical therapy. Sinus tracts (i.e. blind ended tunnels in the skin occurring from recurrent infections), comedone clusters, innumerable nodules, inflammation and severe scarring, usually accompany very severe acne. This mostly occurs in patients with excessive seborrhea and who have a gram-negative infection of hair follicles and sebaceous glands. Excessively severe acne can be treated with isotretinoin when other methods fail.

Treatment of severe acne

Severe forms of acne can be disfiguring and require years of treatment. It is important for patients and their families to know that several treatment options exist. This may require trial and error to find a treatment that works for an individual. Hence treatment failures are possible and it is therefore important that family and friends understand this and be supportive of individuals undergoing the treatment.