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| {{DiseaseDisorder infobox |
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| Name = Acne |
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| Image = Akne-jugend.jpg |
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| Caption = Acne of a 14 year old boy during [[puberty]] |
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| DiseasesDB = 10765|
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| ICD10 = {{ICD10|L|70|0|l|60}} |
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| ICD9 = {{ICD9|706.1}} |
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| MedlinePlus = 000873|
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| }}
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| {{Acne Vulgaris}} | | {{Acne Vulgaris}} |
| | {{CMG}}; {{HQ}} {{JH}} {{TAM}} |
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
| | {{SK}} Common acne |
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| {{CMG}}
| | ==[[Acne vulgaris overview|Overview]]== |
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| {{SK}} Acne
| | ==[[Acne vulgaris historical perspective|Historical Perspective]]== |
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| ==Overview== | | ==[[Acne vulgaris classification|Classification]]== |
| '''Acne Vulgaris''' (commonly called Acne) is a [[skin]] disease, caused by changes in the pilosebaceous units (skin structures consisting of a [[hair follicle]] and its associated [[sebaceous gland]]). Severe acne is [[inflammation|inflammatory]], but acne can also manifest in noninflammatory forms.<ref>http://www.emedicine.com/DERM/topic2.htm</ref> Acne lesions are commonly referred to as [[pimples]], spots, or zits.
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| In the United States, acne affects 17 million people. It is most common during [[adolescence]], affecting more than 85% of teenagers, and frequently continues into adulthood. <ref>{{cite journal |author=James WD |year=2005 |title=Clinical practice. Acne |journal=[[New England Journal of Medicine|N Engl J Med]] |volume=352 |issue=14 |pages=1463-72 |id=PMID 15814882}}</ref>
| | ==[[Acne vulgaris pathophysiology|Pathophysiology]]== |
| For most people, acne diminishes over time and tends to disappear, or at least decrease, after one reaches his or her early twenties. There is, however, no way to predict how long it will take for it to disappear entirely, and some individuals will continue to suffer from acne decades later, into their thirties and forties and even beyond.<ref> Anderson, Laurence. 2006. ''Looking Good, the Australian guide to skin care, cosmetic medicine and cosmetic surgery''. AMPCo. Sydney. ISBN 0 85557 044 X. </ref>
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| The term ''acne'' comes from a corruption of the [[Greek language|Greek]] ''άκμή'' (acme in the sense of a skin eruption) in the writings of [[Aëtius Amidenus]]. The vernacular term ''bacne'' or ''backne'' is often used to indicate acne found specifically on one's back.<ref>[http://www.cureforacnes.com Cure forAcne]</ref> or ''backne'' is often used to indicate acne found specifically on one's back.<ref>[http://www.cureforacnes.com Cure forAcne]</ref>
| | ==[[Acne vulgaris causes|Causes]]== |
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| == Diagnosis == | | ==[[Acne vulgaris differential diagnosis|Differentiating Acne Vulgaris from other Diseases]]== |
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| === Common Causes === | | ==[[Acne vulgaris epidemiology and demographics|Epidemiology and Demographics]]== |
| Acne develops as a result of blockages in follicles. [[Hyperkeratinization]] and formation of a plug of [[keratin]] and [[sebaceous gland#sebum|sebum]] (a microcomedo) is the earliest change. Enlargement of sebaceous glands and an increase in sebum production occur with increased [[androgen]] ([[Dehydroepiandrosterone|DHEA-S]]) production at [[adrenarche]]. The microcomedo may enlarge to form an open comedo ([[blackhead]]) or closed comedo ([[whitehead acne|whitehead]]). Increased sebum production provides an environment for the overgrowth of ''[[Propionibacterium acnes]]''.
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| Bacterial overgrowth of ''Propionibacterium acnes'' can cause [[inflammation]], leading to inflammatory lesions ([[papule]]s, pustules, or nodules) in the [[dermis]] around the microcomedo or comedo, which may result in [[scar]]ring or [[hyperpigmentation]].<!--
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| --><ref name="Simpson 2004">{{cite book |author=Simpson, Nicholas B.; Cunliffe, William J. |year=2004 |chapter=Disorders of the sebaceous glands |editor=Burns, Tony; Breathnach, Stephen; Cox, Neil; Griffiths, Christopher |title=Rook's textbook of dermatology |edition=7th ed. |location=Malden, Mass. |publisher=Blackwell Science |isbn=0-632-06429-3 |pages=pp. 43.1-75}}</ref>
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| There are many misconceptions and myths about acne.
| | ==[[Acne vulgaris risk factors|Risk Factors]]== |
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| ====Primary causes==== | | ==[[Acne vulgaris natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| Exactly why some people get acne and some do not is not fully known. It is known to be partly hereditary. Several factors are known to be linked to acne:
| | ==Diagnosis== |
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| * Family/Genetic history. The tendency to develop acne runs in families. For example, school-age boys with acne have other members of their family with acne. A family history of acne is associated with an earlier occurrence of acne and an increased number of retentional acne lesions. <ref>F. Ballangera, P. Baudrya, J.M. N'Guyenb, A. Khammaria, B. Dréno [http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ArtikelNr=90655&ProduktNr=224164&Ausgabe=231609&filename=90655.pdf Heredity: A Prognostic Factor for Acne] 5/2/2005</ref>
| | [[Acne vulgaris history and symptoms|History and Symptoms]] | [[Acne vulgaris physical examination|Physical Examination]] | [[Acne vulgaris laboratory findings|Laboratory Findings]] | [[Acne vulgaris other diagnostic studies|Other Diagnostic Studies]] |
| * Hormonal activity, such as [[menstruation|menstrual cycles]] and [[puberty]]. During puberty, an increase in male sex hormones called androgens cause the glands to get larger and make more sebum. <ref>[http://www.4women.gov/faq/acne.htm US Dept Health and Human Services] January 2005</ref>
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| * [[Stress]], through increased output of hormones from the [[adrenal gland|adrenal (stress) glands]].
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| * Hyperactive [[sebaceous glands]], secondary to the three hormone sources above.
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| * Accumulation of dead skin cells.
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| * [[Bacteria]] in the [[Sebaceous gland|pores]], to which the body becomes 'allergic'. Propionibacterium acnes (P. acnes) is the anaerobic bacterium that causes acne. In-vitro resistance of P. acnes to commonly used antibiotics has been increasing. <ref>[http://www.guideline.gov/summary/summary.aspx?doc_id=9367&nbr=005014&string=Acne+AND+management National Guideline Clearinghouse] 11/12/2007</ref>
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| * Skin irritation or scratching of any sort will activate inflammation.
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| * Use of [[anabolic steroid]]s.
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| * Any medication containing halogens (iodides, chlorides, bromides), [[lithium]], [[barbiturate]]s, or [[androgen]]s.
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| * Exposure to high levels of chlorine compounds, particularly chlorinated [[dioxin]]s, can cause severe, long-lasting acne, known as ''[[Chloracne]]''.
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| * Exposure to certain drugs and chemical compounds, including narcotics (opiates and opioids), especially when taken intravenously
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| Several [[hormone]]s have been linked to acne: the androgens [[testosterone]], [[dihydrotestosterone]] (DHT) and [[Dehydroepiandrosterone|dehydroepiandrosterone sulfate]] (DHEAS), [[17-Hydroxyprogesterone|17-hydroxyprogesterone]], as well as [[insulin-like growth factor 1]] (IGF-I). In addition, acne-prone skin has been shown to be [[insulin]] resistant.
| | ==Treatment== |
| | [[Acne vulgaris medical therapy|Medical Therapy]] | [[Acne vulgaris surgery|Surgery]] | [[Acne vulgaris primary prevention|Primary Prevention]] | [[Acne vulgaris secondary prevention|Secondary Prevention]] | [[Acne vulgaris cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Acne vulgaris future or investigational therapies|Future or Investigational Therapies]] |
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| Development of [[acne vulgaris]] in later years is uncommon, although this is the age group for [[Rosacea]] which may have similar appearances. True acne vulgaris in adults may be a feature of an underlying condition such as pregnancy and disorders such as [[polycystic ovary syndrome]] or the rare [[Cushing's syndrome]]. Menopause-associated acne occurs as production of the natural anti-acne ovarian hormone estradiol fails at menopause. The lack of [[estradiol]] also causes thinning hair, hot flashes, thin skin, wrinkles, vaginal dryness, and predisposes to osteopenia and osteoporosis as well as triggering acne (known as acne climacterica in this situation).
| | ==Case Studies== |
| | [[Acne vulgaris case study one|Case #1]] |
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| ====Diet==== | | ==Related Chapters== |
| =====Milk=====
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| A recent study, based on a survey of 47,335 women, did find a positive epidemiological association between acne and consumption of partially skimmed [[milk]], instant breakfast drink, sherbet, cottage cheese and cream cheese.<ref name="JAmAcadDermatol52">{{cite journal | author=Adebamowo CA, Spiegelman D, Danby FW, Frazier AL, Willett WC, Holmes MD | title=High school dietary dairy intake and teenage acne | journal=J Am Acad Dermatol | year=2005 | pages=207-14 | volume=52 | issue=2|id=PMID 15692464}}</ref> The researchers hypothesize that the association may be caused by hormones (such as several sex hormones and bovine [[insulin-like growth factor 1|IGF-I]]) present in cow milk. Though there is evidence of an association between milk and acne, the exact cause is unclear. Most dermatologists are awaiting confirmatory research linking diet and acne but some support the idea that acne sufferers should experiment with their diets, and refrain from consuming such fare if they find such food affects the severity of their acne.<ref name="AnnAllergy">{{cite journal | author=Fries JH | title=Chocolate: a review of published reports of allergic and other deleterious effects, real or presumed | journal=Ann Allergy | year=1978 | pages=195-207 | volume=41 | issue=4 | id=PMID 152075}}</ref>
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| =====Seafood=====
| | *[[Blackhead]] |
| [[Seafood]] often contains relatively high levels of [[iodine]]. Iodine is known to make existing acne worse but there is probably not enough to cause an acne outbreak.<ref name="JAmAcadDermatol56">{{cite journal | author=Danby FW | title=Acne and iodine: Reply | journal=J Am Acad Dermatol | year=2007 | pages=164-5 | volume=56 | issue=1|id=PMID 17190637}}</ref> Still, people who are prone to acne may want to avoid ''excessive'' consumption of foods high in iodine. | | *[[Keratosis pilaris]] |
| | *[[Pimple]] |
| | *[[Rosacea]] |
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| =====High carbohydrates/High GI===== | | ==External Links== |
| It has also been suggested that there is a link between a diet high in refined sugars and other processed foods and acne. The theory is that rapidly digested carbohydrate food such as white bread and refined sugars produces an overload in metabolic glucose that is rapidly converted into the types of fat that can build up in sebaceous glands. According to this hypothesis, the startling absence of acne in non-westernized societies could be explained by the low [[glycemic index]] of these cultures' diets. Others have cited possible genetic reasons for there being no acne in these populations, but similar populations shifting to these diets do develop acne. Note also that the populations studied consumed no milk or other dairy products.<ref name="ArchDermatol-Cordain">Loren Cordain, et al. "Acne Vulgaris - A Disease of Western Civilization" Arch Dermatol. 2002;138:1584-1590. [http://archderm.ama-assn.org/cgi/content/abstract/138/12/1584 Observation]</ref> Further research is necessary to establish whether a reduced consumption of high-glycemic foods (such as soft drinks, sweets, white bread) can significantly alleviate acne, though consumption of high-glycemic foods should in any case be kept to a minimum, for general health reasons.<ref name="AsiaPacJClinNutr-Smith">{{cite journal | author=Smith R, Mann N, Makelainen H, Braue A, Varigos G | title=The effect of short-term altered macronutrient status on acne vulgaris and biochemical markers of insulin sensitivity | journal=Asia Pac J Clin Nutr | year=2004 | pages=S67 | volume=13 | issue=Suppl | id=PMID 15294556}}</ref> Avoidance of 'junk food' with its high fat and sugar content is also recommended.<ref> Anderson, Laurence. 2006. ''Looking Good, the Australian guide to skin care, cosmetic medicine and cosmetic surgery''. AMPCo. Sydney. ISBN 0-85557-044-X. </ref> On the other hand there is no evidence that fat alone makes skin oilier or acne worse.
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| The University of Pennsylvania and the US Naval Academy conducted experiments that fed subjects chocolate or a bar with similar amounts of macronutrients (fat, sugar etc.) and found that consumption of chocolate, frequent or not, had no effect on the developing of acne. <ref>{{cite web| last =| first = | authorlink =| coauthors =| title =Sweet news about chocolate| work =| publisher =usaweekend.com|date=1998-06-05| url =http://www.usaweekend.com/98_issues/980607/980607eat_smart_chocolate.html| format =| doi =| accessdate=2007-05-27 }} </ref>
| | *{{cite web | title=Acne Questions and Answers |url=http://www.niams.nih.gov/hi/topics/acne/acne.htm| publisher= From the National Institute of Health}} |
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| A 2005 [[systematic review]] found "surprisingly little evidence exists for the efficacy or lack of efficacy of dietary factors, face-washing and sunlight exposure in the management of acne."<ref name="FamPrac">{{cite journal | author=Magin P, Pond D, Smith W, Watson A | title=A systematic review of the evidence for 'myths and misconceptions' in acne management: diet, face-washing and sunlight | journal=Fam Pract | year=2005 | pages=62-70 | volume=22 | issue=1 | id=PMID 15644386}}</ref> A study in November 2006 in Australia gave a 50% reduction in 12 weeks in mild-moderate facial acne by introducing its subjects to a high protein, low GI diet. <ref>[http://www.rmit.edu.au/browse/News%20and%20Events%2FNews%2FResearch%2FHealth%2F;ID=a1n77d16ry1r;STATUS=A RMIT acne study]</ref>
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| The American Medical Association says chocolate does not contribute to acne. <ref>[http://jama.ama-assn.org/cgi/reprint/292/6/764.pdf JAMA Patient Page - Acne]</ref>
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| A recent study<ref>[http://www.physorg.com/news113902673.html]</ref> shows that a diet high enough in sugars triggers the liver to convert these sugars into lipid; as a side-effect this stops production of [[Sex hormone binding globulin]]- a chemical which reduces the level of testosterone in the blood. Since high testosterone levels generally trigger acne, the researchers believe that this can be a cause.
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| =====Vitamins A and E=====
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| Studies have shown that newly diagnosed acne patients tend to have lower levels of [[vitamin A]] circulating in their bloodstream than those that are acne free.<ref>{{cite web |author=Naweko San-Joyz |title=How Does Vitamin A Prevent Acne Outbreaks? |publisher=American Chronical |date=April 11, 2007 |url=http://www.americanchronicle.com/articles/viewArticle.asp?articleID=24129 |accessdate=2007-09-17}}</ref> In addition people with severe acne also tend to have lower blood levels of [[vitamin E]].<ref>{{cite journal |author=El-Akawi Z, Abdel-Latif N, Abdul-Razzak K |title=Does the plasma level of vitamins A and E affect acne condition? |journal=Clin. Exp. Dermatol. |volume=31 |issue=3 |pages=430–4 |year=2006 |pmid=16681594 |doi=10.1111/j.1365-2230.2006.02106.x}}</ref>
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| ====Hygiene====
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| Acne is not caused by dirt. This misconception probably comes from the fact that [[blackhead]]s look like dirt stuck in the openings of pores. The black color is simply not dirt but compact keratin. In fact, the blockages of [[keratin]] that cause acne occur deep within the narrow follicle channel, where it is impossible to wash them away. These plugs are formed by the failure of the cells lining the duct to separate and flow to the surface in the sebum created there by the body.
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| ====Sex====
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| Common myths state that [[masturbation]] causes acne and, conversely, that celibacy or [[sexual intercourse]] can cure it. Acne has not been linked to any type of sexual activity.
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| === Complete Differential Diagnosis ===
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| * [[Acne conglobata]]
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| * [[Acne fulminans]]
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| * [[Acne vulgaris]]
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| * [[Gram-negative]] [[folliculitis]]
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| * [[Hidradenitis suppurativa]]
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| * ''Malassezia'' [[folliculitis]]
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| * [[Miliaria]] ("heat rash")
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| * [[Pyoderma faciale]]
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| * [[Rosacea]]
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| === History and Symptoms ===
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| [[Image:Acne face.jpg|thumb|200px|left|Acne of an older teenager.]]
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| The most common form of acne is known as "acne vulgaris", meaning "common acne." Many teenagers get this type of acne.
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| The [[face]] and upper neck are the most commonly affected, but the [[chest]], [[human back|back]] and [[shoulder]]s may have acne as well. The upper [[arm]]s can also have acne, but lesions found there are often [[keratosis pilaris]], not acne. The typical acne lesions are comedones and inflammatory papules, pustules, and nodules. Some of the large nodules were previously called "[[cyst]]s" and the term ''nodulocystic'' has been used to describe severe cases of inflammatory acne. True [[cysts]] are rarely found in acne, and the term should be abandoned and the term ''severe nodular acne'' used instead.<!--
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| --><ref name="Thiboutot 2003">{{cite book |author=Thiboutot, Diane M.; Strauss, John S. |year=2003 |chapter=Diseases of the sebaceous glands |editor=Burns, Tony; Breathnach, Stephen; Cox, Neil; Griffiths, Christopher |title=Fitzpatrick's dermatology in general medicine |edition=6th ed. |location=New York |publisher=McGraw-Hill |isbn=0-07-138076-0 |pages=pp. 672-87}}</ref>
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| Aside from scarring, its main effects are psychological, such as reduced [[self-esteem]]<ref name="Goodman">{{cite journal |author=Goodman G |title=Acne and acne scarring - the case for active and early intervention |journal=Aust Fam Physician |volume=35 |issue=7 |pages=503-4 |year=2006 |id=PMID 16820822 | url=http://www.racgp.org.au/Content/NavigationMenu/Publications/AustralianFamilyPhys/2006issues/afp200607/20060705goodman.pdf | format=PDF}}</ref> and, according to at least one study, [[clinical depression|depression]] or [[suicide]].<ref>{{cite journal |author=Purvis D, Robinson E, Merry S, Watson P |title=Acne, anxiety, depression and suicide in teenagers: a cross-sectional survey of New Zealand secondary school students |journal=J Paediatr Child Health |volume=42 |issue=12 |pages=793-6 |year=2006 |id=PMID 17096715}}<br>One study has estimated the incidence of suicidal ideation in patients with acne as 7.1% :</br>* {{cite journal |author=Picardi A, Mazzotti E, Pasquini P |title=Prevalence and correlates of suicidal ideation among patients with skin disease |journal=J Am Acad Dermatol |volume=54 |issue=3 |pages=420-6 |year=2006 |id=PMID 16488292}}</ref> Acne usually appears during [[adolescence]], when people already tend to be most socially insecure. Early and aggressive treatment is therefore advocated to lessen the overall impact to individuals.<ref name="Goodman"/>
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| === Physical Examination ===
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| ====Skin====
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| [[Image:AcneVulgarisUSMIL.jpg|thumb|200px|left|Different types of Acne Vulgaris: A: Cystic acne on the face, B: Subsiding tropical acne of trunk, C: Extensive acne on chest and shoulders.<ref>http://picasaweb.google.com/mcmumbi/USMLEIIImages/photo#5089143049752456450</ref>]]
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| ==Treatments==
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| Treatment ranges from knowledge of proper skin-care procedure to use of treatment products and diet control.
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| ===Acne skincare===
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| Proper clinical skincare of acne involves gentle hygiene and minimal and restrained interaction with pimples so that the skin ([[epidermis]] and [[dermis]]) is never bruised due to coarse crushing, which worsens infection and may lead to scarring. [[Clinical lancing]] with a sterilised needle evacuates matured pustules so that when they are pressed the fluids end up outside the [[dermis]] rather than further underneath.
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| Without restrained use of clinical lancing, it is harder for someone with serious acne to avoid causing damage to the [[dermis]], increased infection due to ruptured skin cells, and scarring.
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| ===Available treatment products===
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| There are many products sold for the treatment of acne, many of them without any scientifically-proven effects. Generally speaking successful treatments give little improvement within the first week or two; and then the acne decreases over approximately 3 months, after which the improvement starts to flatten out. Many treatments that promise big improvements within 2 weeks are likely to be largely disappointing. However short bursts of cortisone can give very quick results, and other treatments can rapidly improve some active spots, but not usually all active spots.
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| Modes of improvement are not necessarily fully understood but in general treatments are believed to work in at least 4 different ways (with many of the best treatments providing multiple simultaneous effects):
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| *normalising shedding into the pore to prevent blockage
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| *killing [[P. acnes]]
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| *antinflammatory effects
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| *hormonal manipulation
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| A combination of treatments can greatly reduce the amount and severity of acne in many cases. Those treatments that are most effective tend to have greater potential for side effects and need a greater degree of monitoring, so a step-wise approach is often taken. Many people consult with doctors when deciding which treatments to use, especially when considering using any treatments in combination. There are a number of treatments that have been proven effective:
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| [[Image:Benzoyl peroxide gel.jpg|thumb|right|250px|Benzoyl peroxide cream.]]
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| ====Topical bactericidals====
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| Widely available [[over-the-counter drug|OTC]] bactericidal products containing [[benzoyl peroxide]] may be used in mild to moderate acne. The gel or cream containing benzoyl peroxide is rubbed, twice daily, into the pores over the affected region. Bar soaps or washes may also be used and vary from 2 to 10% in strength. In addition to its therapeutic effect as a keratolytic (a chemical that dissolves the keratin plugging the pores) benzoyl peroxide also prevents new lesions by killing ''[[Propionibacterium acnes|P.acnes]]''. In one study, roughly 70% of participants using a 10% benzoyl peroxide solution experienced a reduction in acne lesions after 6 weeks.<ref>[http://www.ijdvl.com/article.asp?issn=0378-6323;year=1993;volume=59;issue=5;spage=243;epage=246;aulast=Dogra Comparative evaluation of retinoic acid, benzoyl peroxide and erythromycin lotion in acne vulgarils]</ref>Unlike antibiotics, benzoyl peroxide has the advantage of being a strong oxidizer (essentially a mild bleach) and thus does not appear to generate bacterial resistance. However, it routinely causes dryness, local irritation and redness. A sensible regimen may include the daily use of low-concentration (2.5%) benzoyl peroxide preparations, combined with suitable non-comedogenic moisturisers to help avoid overdrying the skin.<ref name"AcneOrg">Kern, Daniel W. "Clear skin regimen: A free, step by step program." Acne.org. [http://www.acne.org/regimen.html Instructions]</ref>
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| Care must be taken when using benzoyl peroxide, as it can very easily bleach any fabric or hair it comes in contact with.
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| Other antibacterials that have been used include [[triclosan]], or [[chlorhexidine gluconate]] but these are often less effective.
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| Prescription-strength benzoyl peroxide preparations do not necessarily differ with regard to the maximum concentration of the active ingredient (10%), but the drug is made available dissolved in a vehicle that more deeply penetrates the pores of the skin.
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| ====Topical antibiotics====
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| Externally applied antibiotics such as [[erythromycin]], [[clindamycin]], Stiemycin or [[tetracycline]] aim to kill the bacteria that are harbored in the blocked follicles. Whilst topical use of antibiotics is equally as effective as oral, this method avoids possible side effects of stomach upset or drug interactions (e.g. it will not affect the oral contraceptive pill), but may prove awkward to apply over larger areas than just the face alone.
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| ====Oral antibiotics====
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| Oral antibiotics used to treat acne include erythromycin or one of the [[tetracycline antibiotics]] ([[tetracycline]], the better absorbed [[oxytetracycline]], or one of the once daily [[doxycycline]], [[minocycline]] or [[lymecycline]]). [[Trimethoprim]] is also sometimes used ([[off-label use]] in UK). However, reducing the ''P. acnes'' bacteria will not, in itself, do anything to reduce the oil secretion and abnormal cell behaviour that is the initial cause of the blocked follicles. Additionally the antibiotics are becoming less and less useful as resistant ''P. acnes'' are becoming more common. Acne will generally reappear quite soon after the end of treatment—days later in the case of [[topical]] applications, and weeks later in the case of oral antibiotics.
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| It has been found that sub-antimicrobial doses of antibiotics such as minocycline also improve acne. It is believed that minocycline's anti-inflammatory effect also prevents acne. These low doses do not kill bacteria and hence cannot induce resistance. Oral antibiotics such as Doxycycline have better results on the treatment of acne.<ref name=Thiboutot >{{cite journal
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| | author=Thiboutot, D, | title= Prescription Medications for Treating Acne.| journal=Acne Net. | year=2000 | pages=179-187 | volume=9 | issue=7-8 | id=PMID 15636181}}</ref> and generally will work better if started with at a higher dose.
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| ====Hormonal treatments====
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| In females, acne can be improved with [[Hormone|hormonal]] treatments. The common combined [[Estrogen|oestrogen]]/[[Progestagen|progestogen]] methods of [[hormonal contraception]] have some effect, but the anti-[[testosterone]], [[Cyproterone]], in combination with an oestrogen (''Diane 35'') is particularly effective at reducing androgenic hormone levels. Diane-35 is not available in the USA, but a newer oral contraceptive containing the progestin [[drospirenone]] is now available with fewer side effects than Diane 35 / Dianette. Both can be used where blood tests show abnormally high levels of [[androgen]]s, but are effective even when this is not the case. Along with this, treatment with low dose spironolactone can have anti-androgenetic properties, especially in patients with polycystic ovarian syndrome.
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| If a pimple is large and/or does not seem to be affected by other treatments, a dermatologist may administer an injection of [[cortisone]] directly into it, which will usually reduce redness and inflammation almost immediately. This has the effect of flattening the pimple, thereby making it easier to cover up with makeup, and can also aid in the healing process. Side effects are minimal, but may include a temporary whitening of the skin around the injection point. This method also carries a much smaller risk of scarring than surgical removal.
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| ====Topical retinoids====
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| A group of medications for normalizing the follicle cell lifecycle are [[topical]] [[retinoids]] such as [[tretinoin]] (brand name Retin-A), [[adapalene]] (brand name Differin) and [[tazarotene]] (brand name Tazorac). Like isotretinoin, they are related to [[vitamin A]], but they are administered as topicals and generally have much milder side effects. They can, however, cause significant irritation of the skin. The retinoids appear to influence the cell creation and death lifecycle of cells in the follicle lining. This helps prevent the [[hyperkeratinization]] of these cells that can create a blockage. [[Retinol]], a form of vitamin A, has similar but milder effects and is used in many over-the-counter moisturizers and other topical products. Effective topical retinoids have been in use over 30 years but are available only on prescription so are not as widely used as the other topical treatments. Topical retinoids often cause an initial flare up of acne and facial [[flushing (physiology)]].
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| ====Oral retinoids====
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| A daily oral intake of [[vitamin A]] derivatives like [[isotretinoin]] (marketed as [[Accutane]], Sotret, Claravis) over a period of 4-6 months can cause long-term resolution or reduction of acne by reducing the secretion of oils from the glands. It is believed that isotretinoin works primarily by reducing the secretion of oils from the glands, however some studies suggest that it affects other acne-related factors as well. Isotretinoin has been shown to be very effective in treating severe acne and can either improve or clear well over 80% of patients. The drug has a much longer effect than anti-bacterial treatments and will often cure acne for good. The treatment requires close medical supervision by a [[dermatologist]] because the drug has many known [[Adverse effect (medicine)|side effects]] (many of which can be severe). About 25% of patients may relapse after one treatment. In those cases, a second treatment for another 4-6 months may be indicated to obtain desired results. It is often recommended that one lets a few months pass between the two treatments, because the condition can actually improve somewhat in the time after stopping the treatment and waiting a few months also gives the body a chance to recover. Occasionally a third or even a fourth course is used, but the benefits are often less substantial. The most common side effects are dry skin and occasional nosebleeds (secondary to dry nasal mucosa). Oral retinoids also often cause an initial flare up of acne within a month or so, which can be severe. There are reports that the drug has damaged the liver of patients. For this reason, it is recommended that patients have blood samples taken and examined before and during treatment. In some cases, treatment is terminated due to elevated liver enzymes in the blood, which might be related to liver damage. Others claim that the reports of permanent damage to the [[liver]] are unsubstantiated, and routine testing is considered unnecessary by some dermatologists. Blood triglycerides also need to be monitored. However, routine testing are part of the official guidelines for the use of the drug in many countries. Some press reports suggest that isotretinoin may cause [[clinical depression|depression]] but as of September 2005 there is no agreement in the medical literature as to the risk. The drug also causes birth defects if women become pregnant while taking it or take it while pregnant. For this reason, female patients are required to use two separate forms of [[birth control]] or vow [[abstinence]] while on the drug. Because of this, the drug is supposed to be given to females as a last resort after milder treatments have proven insufficient. Restrictive rules (see [[IPLEDGE|iPledge]] Program) for use were put into force in the USA beginning in March 2006 to prevent misuse.<!--
| |
| --><ref name="IPledgeGuide">{{cite web | title=The iPLEDGE Program - Guide to Best Practices for Isotretinoin - "The resource to help the prescriber prepare, plan treatments, and prevent pregnancies during the course of isotretinoin therapy" | year=2005 | url=https://www.ipledgeprogram.com/Documents/Prescribers%20Guide%20v3_0A.pdf | format=PDF}}</ref>
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| This has occasioned widespread editorial comment.<!--
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| --><ref name="USnews-Healy">{{cite news | author=Bernadine Healy | title=Pledging for Accutane | date=[[2005-05-09]] | publisher=US News Best Health | url=http://www.usnews.com/usnews/opinion/articles/050905/5healy.htm}}</ref>
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| ====Phototherapy====
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| ====='Blue' and red light=====
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| It has long been known that short term improvement can be achieved with sunlight. However, studies have shown that sunlight worsens acne long-term. More recently, visible light has been successfully employed to treat acne ([[Phototherapy]]) - in particular intense violet light (405-420nm) generated by purpose-built fluorescent lighting, dichroic bulbs, LEDs or lasers. Used twice weekly, this has been shown to reduce the number of acne lesions by about 64%;<!--
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| --><ref name="JDermatolSci-Kawada">{{cite journal | author=Kawada A, Aragane Y, Kameyama H, Sangen Y, Tezuka T | title=Acne phototherapy with a high-intensity, enhanced, narrow-band, blue light source: an open study and ''in vitro'' investigation | journal=J Dermatol Sci | year=2002 | pages=129-35 | volume=30 | issue=2 | id=PMID 12413768}}</ref>
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| and is even more effective when applied daily. The mechanism appears to be that a [[porphyrin]] (Coproporphyrin III) produced within ''P. acnes'' generates [[free radicals]] when irradiated by 420nm and shorter wavelengths of light.<!--
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| --><ref name="ZNaturforsch-Kjeldstad">{{cite journal | author=Kjeldstad B | title=Photoinactivation of Propionibacterium acnes by near-ultraviolet light | journal=Z Naturforsch [C] | year=1984 | pages=300-2 | volume=39 | issue=3-4 | id=PMID 6730638}}</ref>
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| Particularly when applied over several days, these free radicals ultimately kill the bacteria.<!--
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| --><ref name="FEMSImmunolMedMicrobiol-Ashkenazi">{{cite journal | author=Ashkenazi H, Malik Z, Harth Y, Nitzan Y | title=Eradication of Propionibacterium acnes by its endogenic porphyrins after illumination with high intensity blue light | journal=FEMS Immunol Med Microbiol | year=2003 | pages=17-24 | volume=35 | issue=1|id=PMID 12589953}}</ref>
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| Since porphyrins are not otherwise present in skin, and no UV light is employed, it appears to be safe, and has been licensed by the [[United States|U.S.]] [[Food and Drug Administration|FDA]].<!--
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| --><ref name="FDA-Light">"New Light Therapy for Acne" U.S. [[Food and Drug Administration]], FDA Consumer magazine, November-December 2002 [http://www.fda.gov/fdac/departs/2002/602_upd.html#acne Notice]</ref>
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| The treatment apparently works even better if used with red visible light (660 nanometer) resulting in a 76% reduction of lesions after 3 months of daily treatment for 80% of the patients;<!--
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| --><ref name="BrJDerm-Papageorgiou">{{cite journal | author=Papageorgiou P, Katsambas A, Chu A | title=Phototherapy with blue (415 nm) and red (660 nm) light in the treatment of acne vulgaris. | journal=Br J Dermatol | volume=142 | issue=5 | pages=973-8 | year=2000 | id=PMID 10809858 | url=http://acne-advice.com/products/beautyskin/british-journal.pdf | format=PDF}}</ref>
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| and overall clearance was similar or better than benzoyl peroxide. Unlike most of the other treatments few if any negative side effects are typically experienced, and the development of bacterial resistance to the treatment seems very unlikely. After treatment, clearance can be longer lived than is typical with topical or oral antibiotic treatments; several months is not uncommon. The equipment or treatment, however, is relatively new and reasonably expensive to buy initially, although the total cost of ownership can be similar to many other treatment methods (such as the total cost of benzoyl peroxide, moisturiser, washes) over a couple of years of use.
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| =====Photodynamic therapy=====
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| In addition, basic science and clinical work by dermatologists Yoram Harth and Alan Shalita and others has produced evidence that intense blue/violet light (405-425 nanometer) can decrease the number of inflammatory acne lesion by 60-70% in 4 weeks of therapy, particularly when the ''P.acnes'' is pretreated with [[delta-aminolevulinic acid]] (ALA), which increases the production of porphyrins. However this photodynamic therapy is controversial and apparently not published in a peer reviewed journal.
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| =====Laser treatment=====
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| [[Laser]] surgery has been in use for some time to reduce the scars left behind by acne, but research has been done on lasers for prevention of acne formation itself. The laser is used to produce one of the following effects:
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| * to burn away the follicle sac from which the hair grows
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| * to burn away the sebaceous gland which produces the oil
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| * to induce formation of [[oxygen]] in the bacteria, killing them
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| Since lasers and intense pulsed light sources cause thermal damage to the skin there are concerns that laser or intense pulsed light treatments for acne will induce hyperpigmented macules (spots) or cause long term dryness of the skin.
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| The FDA has approved several companies, such as Candela Corp. to use a cosmetic laser for the treatment of acne.<ref>http://www.reflectionscenter.com/sb_acne_press_trade.pdf</ref> However, efficacy studies have used very small sample sizes (fewer than 100 subjects) for periods of six months or less, and have shown contradictory results.<ref>http://news.bbc.co.uk/2/hi/health/3808055.stm</ref><ref>http://www.cosmeticsurgery-news.com/article1053.html</ref> Also, laser treatment being relatively new, protocols remain subject to experimentation and revision,<ref>http://www.dermatologytimes.com/dermatologytimes/article/articleDetail.jsp?id=93752</ref> and treatment can be quite expensive. Also, some Smoothbeam laser devices had to be recalled due to coolant failure, which resulted in painful burn injuries to patients.<ref>http://www.fda.gov/bbs/topics/enforce/2004/ENF00830.html</ref>
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| ====Less widely used treatments====
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| *[[Azelaic acid]] (brand names ''Azelex'', ''Finevin'', ''Skinoren'') is suitable for mild, comedonal acne.<!--
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| --><ref name="MedlinePlus-Azelaic">{{cite web | author=MedlinePlus | title=Azelaic Acid (Topical) | url=http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202783.html | date=2001-07-24}}</ref>
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| * Zinc: Orally administered [[zinc]] gluconate has been shown to be effective in the treatment of inflammatory acne, although less so than [[tetracycline]]s.<!--
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| --><ref name="ActaDermVenereol-Dreno">{{cite journal | author=Dreno B, Amblard P, Agache P, Sirot S, Litoux P | title=Low doses of zinc gluconate for inflammatory acne | journal=Acta Derm Venereol | year=1989 | pages=541-3 | volume=69 | issue=6 | id=PMID 2575335}}</ref><!--
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| --><ref name="Dermatology-Dreno">{{cite journal | author=Dreno B, Moyse D, Alirezai M, Amblard P, Auffret N, Beylot C, Bodokh I, Chivot M, Daniel F, Humbert P, Meynadier J, Poli F | title=Multicenter randomized comparative double-blind controlled clinical trial of the safety and efficacy of zinc gluconate versus minocycline hydrochloride in the treatment of inflammatory acne vulgaris | journal=Dermatology | year=2001 | pages=135-40 | volume=203 | issue=2 | id=PMID 11586012}}</ref>
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| * [[Tea tree oil (melaleuca oil)|Tea Tree Oil (Melaleuca Oil)]] has been used with some success, comparable to benzoyl peroxide but without excessive drying, and has been shown to be an effective anti-inflammatory in skin infections. <!--
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| --><ref name="pmid11482001";>{{cite journal |author=Mantle D, Gok MA, Lennard TW |title=Adverse and beneficial effects of plant extracts on skin and skin disorders |journal=Adverse drug reactions and toxicological reviews |volume=20 |issue=2 |pages=89-103 |year=2001 |pmid=11482001 |doi=}}</ref><!--
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| --><ref name="pmid12452873">{{cite journal |author=Koh KJ, Pearce AL, Marshman G, Finlay-Jones JJ, Hart PH |title=Tea tree oil reduces histamine-induced skin inflammation |journal=Br. J. Dermatol. |volume=147 |issue=6 |pages=1212-7 |year=2002 |pmid=12452873 |doi=}}</ref><!--
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| --><ref name="pmid15373773">{{cite journal |author=Khalil Z, Pearce AL, Satkunanathan N, Storer E, Finlay-Jones JJ, Hart PH |title=Regulation of wheal and flare by tea tree oil: complementary human and rodent studies |journal=J. Invest. Dermatol. |volume=123 |issue=4 |pages=683-90 |year=2004 |pmid=15373773 |doi=10.1111/j.0022-202X.2004.23407.x |url=http://www.nature.com/jid/journal/v123/n4/full/5602507a.html}}</ref>
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| * [[Nicotinamide]], (Vitamin B3) used topically in the form of a gel, has been shown in a 1995 study to be more effective than a topical antibiotic used for comparison, as well as having fewer side effects.<!--
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| --><ref name="Shalita1995">{{cite journal | author = Shalita A, Smith J, Parish L, Sofman M, Chalker D | title = Topical nicotinamide compared with clindamycin gel in the treatment of inflammatory acne vulgaris. | journal = Int J Dermatol | volume = 34 | issue = 6 | pages = 434-7 | year = 1995 | id = PMID 7657446}}</ref> Topical nicotinamide is available both on prescription and [[Over-the-counter drug|over-the-counter]]. The property of topical nicotinamide's benefit in treating acne seems to be its anti-inflammatory nature. It is also purported to result in increased synthesis of collagen, keratin, involucrin and flaggrin.
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| *There are also certain treatments for acne mentioned in Ayurveda using herbs such as [[Aloe vera]],<ref>{{cite web |title=Greenleaf Aloe Vera Gel |url=http://www.brihans.com/products_greenleaf.html |publisher=Brihans}}</ref> Aruna, [[Turmeric|Haldi (Turmeric)]],and [[Papaya]].<ref name="ayushveda">[http://www.ayushveda.com/health/acne.htm Ayurveda Encyclopedia, "Acne Treatment"]</ref> There is limited evidence from conventional medical studies on these products.<ref name="pmid11482001">{{cite journal |author=Mantle D, Gok MA, Lennard TW |title=Adverse and beneficial effects of plant extracts on skin and skin disorders |journal=Adverse drug reactions and toxicological reviews |volume=20 |issue=2 |pages=89-103 |year=2001 |pmid=11482001 |doi=}}</ref> Products from Rubia cordifolia, Curcuma longa (commonly known as Turmeric), [[Hemidesmus indicus]] (known as ananthamoola or anantmula), and Azadirachta indica (Neem) have been shown to have anti-inflammatory effects, but not aloe vera.<ref name="pmid12622461">{{cite journal |author=Jain A, Basal E |title=Inhibition of Propionibacterium acnes-induced mediators of inflammation by Indian herbs |journal=Phytomedicine |volume=10 |issue=1 |pages=34-8 |year=2003 |pmid=12622461 |doi=}}</ref>
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| * [[Rofecoxib]] was shown to improve premenstrual [[acne vulgaris]] in a placebo controlled study.<ref>{{cite journal |author=Tehrani R, Dharmalingam M |title=Management of premenstrual acne with Cox-2 inhibitors: A placebo controlled study |journal=Indian J Dermatol Venereol Leprol [serial online] |year=2004 |volume=70 |pages=345-348 |url=http://www.ijdvl.com/text.asp?2004/70/6/345/13475 |accessdate=2007-06-23}}</ref>
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| * [[Naproxen]] or [[ibuprofen]] are used for some moderate acne for their anti-inflammatory effect.<ref>[http://dermnetnz.org/acne/acne-treatment.html Dermnet NZ-Acne management]</ref>
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| | |
| === History of some acne treatments ===
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| The history of acne reaches back to the dawn of recorded history. In Ancient Egypt, it is recorded that several pharaohs were acne sufferers. From Ancient Greece comes the English word 'acne' (meaning 'point' or 'peak'). Acne treatments are also of considerable antiquity:
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| * Ancient Rome: bathing in hot, and often sulfurous, mineral water was one of the few available acne treatments. One of the earliest texts to mention skin problems is ''De Medicina'' by the Roman writer [[Aulus Cornelius Celsus|Celsus]].
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| * 1800s: Nineteenth century dermatologists used sulphur in the treatment of acne. It was believed to dry the skin.
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| * 1920s: [[Benzoyl Peroxide]] is used
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| * 1930s: [[Laxative]]s were used as a cure for what were known as 'chastity pimples'. Radiation also was used.
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| * 1950s: When antibiotics became available, it was discovered that they had beneficial effects on acne. They were taken orally to begin with. Much of the benefit was not from killing bacteria but from the anti-inflammatory effects of tetracycline and its relatives. Topical antibiotics became available later.
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| * 1970s: [[Tretinoin]] (original Trade Name Retin A) was found effective for acne.<ref name="pmid4265099">{{cite journal |author= |title=Tretinoin (retinoic acid) in acne |journal=The Medical letter on drugs and therapeutics |volume=15 |issue=1 |pages=3 |year=1973 |pmid=4265099 |doi=}}</ref> This preceded the development of oral [[isotretinoin]] (sold as Accutane and Roaccutane) in 1980.<ref name="pmid6107678">{{cite journal |author=Jones H, Blanc D, Cunliffe WJ |title=13-cis retinoic acid and acne |journal=Lancet |volume=2 |issue=8203 |pages=1048–9 |year=1980 |pmid=6107678 |doi=}}</ref>
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| * 1980s: Accutane is introduced in America
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| * 1990s: Laser treatment introduced
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| * 2000s: Blue/red light therapy
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| ===Future treatments===
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| A 2007 [[microbiology]] article reporting the first [[genome]] [[DNA sequencing|sequencing]] of a ''[[Propionibacterium acnes]]'' [[bacteriophage]] (PA6) said this "should greatly enhance the development of a potential [[phage therapy|bacteriophage therapy]] to treat acne and therefore overcome the significant problems associated with long-term antibiotic therapy and bacterial [[antibiotic resistance|resistance]]."<!--
| |
| --><ref name="Farrar 2007">{{cite journal |author=Farrar MD, Howson KM, Bojar RA, West D, Towler JC, Parry J, Pelton K, Holland KT |year=2007 |title=Genome sequence and analysis of a Propionibacterium acnes bacteriophage |journal=J Bacteriol |volume=189 |issue=11 |pages=4161-7 |id=PMID 17400737 |url=http://jb.asm.org/cgi/reprint/189/11/4161.pdf}}</ref>
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| | |
| === Preferred treatments by types of acne vulgaris ===
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| *Comedonal (non-inflammatory) acne: local treatment with [[azelaic acid]], [[salicylic acid]], topical [[retinoids]], benzoyl peroxide.
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| *Mild [[papule|papulo]]-[[pustule|pustular]] (inflammatory) acne: [[benzoyl peroxide]] or topical retinoids, topical [[antibiotic]]s (such as [[erythromycin]]).
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| *Moderate inflammatory acne: [[benzoyl peroxide]] or topical retinoids combined with oral antibiotics ([[tetracycline]]s). [[Isotretinoin]] is an option.
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| *Severe inflammatory acne, nodular acne, acne resistant to the above treatments: [[isotretinoin]], or contraceptive pills with [[cyproterone]] for females with [[virilization]] or [[drospirenone]].
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| ==Acne scars==
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| ''See [[Acne scarring]].''
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| Severe acne often leaves small [[scar]]s where the skin gets a "volcanic" shape. Acne scars are difficult and expensive to treat, and it is unusual for the scars to be successfully removed completely.<!-- need citation that lists rates of success, rather than a support group just stating thats it is difficult. User:Davidruben, 6 Sept 2006 -->
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| Physical acne scars are often referred to as "Icepick" scars. This is because the scars tend to cause an indentation in the skin's surface. There are a range of treatments available.
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| Although quite rare, the medical condition [[Atrophia Maculosa Varioliformis Cutis]] results in "acne like" depressed scars on the face.
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| [[Image:Acne scars.jpg]]
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| '''Ice pick scars''' - ''Deep pits, that are the most common and a classic sign of acne scarring.''
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| <br />
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| '''Box car scars''' - ''Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to chickenpox scars.''
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| <br />
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| '''Rolling scars''' - ''Scars that give the skin a wave-like appearance.''
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| <br />
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| '''Hypertrophic scars''' - ''Thickened, or keloid scars.''
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| <ref>[http://www.acneguide.ca/acne_scar_treatments/types_acne_scars.html '''Types of Acne Scars''']</ref>
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| <br />
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| ==Pigmentation==
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| Pigmented scars is a slightly misleading term, suggesting a change in the skin's pigmentation, and that they are true scars. Neither is true. Pigmented scars are usually the result of nodular or cystic acne (the painful 'bumps' lying under the skin). They often leave behind an inflamed red mark. Often, the pigmentation scars can be avoided simply by avoiding aggravation of the nodule or cyst. When sufferers try to 'pop' cysts or nodules, pigmentation scarring becomes significantly worse, and may even bruise the affected area. Pigmentation scars nearly always fade with time taking between 3 months to two years to do so, although rarely can persist.
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| On the other hand, some people, particularly people with naturally tanned skin do develop brown [[hyperpigmentation]] scars which is caused by a local increased production of the pigment [[melanin]]. These too typically fade over time.
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| == Grading scale ==
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| There are multiple grading scales for grading the severity of acne vulgaris,<ref>Leeds, Cook's and Pillsbury scales obtained from [http://www.clinicalevidence.com/ceweb/conditions/skd/1714/1714_background.jsp#outcomes here]</ref> three of these being:
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| ''Leeds acne grading technique:'' Counts and categorises lesions into inflammatory and non-inflammatory (ranges from 0-10.0).
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| '''Cook's acne grading scale:'' Uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe).
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| ''Pillsbury scale:'' Simply classifies the severity of the acne from 1 (least severe) to 4 (most severe).
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| == See also ==
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| * [[Blackhead]]
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| * [[Keratosis pilaris]]
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| * [[Pimple]]
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| * [[Rosacea]]
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| ==References==
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| {{Reflist|2}}
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| ==Further reading==
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| * Review articles and guidelines:
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| ** {{cite journal |author=Webster GF |year=2002 |title=Acne vulgaris |journal=[[British Medical Journal|BMJ]] |volume=325 |issue=7362 |pages=475-9 |id=PMID 12202330 |url=http://www.bmj.com/cgi/reprint/325/7362/475.pdf}}
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| ** {{cite journal |author=Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, Shalita AR, Thiboutot D; Global Alliance to Improve Outcomes in Acne |year=2003 |title=Management of acne: a report from a Global Alliance to Improve Outcomes in Acne |journal=J Am Acad Dermatol |volume=49 |issue=1 Suppl |pages=S1-37 |id=PMID 12833004}}
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| ** {{cite journal |author=Feldman S, Careccia RE, Barham KL, Hancox J |year=2004 |title=Diagnosis and treatment of acne |journal=[[American Family Physician|Am Fam Physician]] |volume=69 |issue=9 |pages=2123-30 |id=PMID 15152959 |url=http://www.aafp.org/afp/20040501/2123.pdf}}
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| ** {{cite journal |author=Haider A, Shaw JC |year=2004 |title=Treatment of acne vulgaris |journal=[[Journal of the American Medical Association|JAMA]] |volume=292 |issue=6 |pages=726-35 |id=PMID 15304471 |url=http://jama.ama-assn.org/cgi/reprint/292/6/726.pdf}}
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| ** {{cite journal |author=Katsambas AD, Cunliffe WJ (eds.) |year=2004 |title=Acne and its treatment |journal=Clin Dermatol |volume=22 |issue=5 |pages=359-447 |url=http://www.sciencedirect.com/science?_ob=PublicationURL&_tockey=%23TOC%235002%232004%23999779994%23529140%23FLA%23&_cdi=5002&_pubType=J&view=c&_auth=y&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=a2a2432972cd2c1acdb5c3c588325276}}
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| ** {{cite journal |author=James WD |year=2005 |title= Clinical practice. Acne |journal=[[New England Journal of Medicine|N Engl J Med]] |volume=352 |issue=14 |pages=1463-72 |id=PMID 15814882}}
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| ** {{cite journal |author= |year=2005 |title=Drugs for acne, rosacea and psoriasis |journal=[[Treatment Guidelines from The Medical Letter|Treat Guidel Med Lett]] |volume=3 |issue=35 |pages=49-56 |id=PMID 15961971}}
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| ** {{cite journal |author=Sinclair W, Jordaan HF; Global Alliance to Improve Outcomes in Acne |year=2005 |title=Acne guideline 2005 update |journal=S Afr Med J |volume=95 |issue=11 Pt 2 |pages=881-92 |id=PMID 16344888 |url=http://blues.sabinet.co.za/WebZ/Authorize?sessionid=0:autho=pubmed:password=pubmed2004&/AdvancedQuery?&format=F&next=images/ejour/m_samj/m_samj_v95_n11_a21.pdf}}
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| ** {{cite journal |author=Zaenglein AL, Thiboutot DM |year=2006 |title=Expert committee recommendations for acne management |journal=[[Pediatrics (journal)|Pediatrics]] |volume=118 |issue=3 |pages=1188-99 |id=PMID 16951015 |url=http://pediatrics.aappublications.org/cgi/reprint/118/3/1188.pdf}}
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| ** {{cite journal |author=Purdy S, de Berker D |year=2006 |title=Acne |journal=[[British Medical Journal|BMJ]] |volume=333 |issue=7575 |pages=949-53 |id=PMID 17082546}}
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| ** {{cite journal |author=Strauss JS, Krowchuk DP, Leyden JJ, Lucky AW, Shalita AR, Siegfried EC, Thiboutot DM, Van Voorhees AS, Beutner KA, Sieck CK, Bhushan R; [[American Academy of Dermatology]]/American Academy of Dermatology Association |year=2007 |title= Guidelines of care for acne vulgaris management |journal=J Am Acad Dermatol |volume=56 |issue=4 |pages=651-63 |id=PMID 17276540}}
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| * Reference books and chapters:
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| ** {{cite book |author=Plewig, Gerd; Kligman, Albert M. |year=2000 |title=Acne and rosacea |edition=3rd ed. |location=New York |publisher=Springer-Verlag |isbn=3-540-66751-2}}
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| ** {{cite book |author=Cunliffe, William J.; Gollnick, Harald P. M. |year=2001 |title=Acne : diagnosis and management |location=London |publisher=Martin Dunitz |isbn=1-85317-206-5}}
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| ** {{cite book |author=Thiboutot, Diane M.; Strauss, John S. |year=2003 |chapter=Diseases of the sebaceous glands |editor=Burns, Tony; Breathnach, Stephen; Cox, Neil; Griffiths, Christopher |title=Fitzpatrick's dermatology in general medicine |edition=6th ed. |location=New York |publisher=McGraw-Hill |isbn=0-07-138076-0 |pages=pp. 672-87}}
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| ** {{cite book |author=Zaenglein, Andrea L.; Thiboutot, Diane M. |year=2003 |chapter=Acne vulgaris |editor=Bolognia, Jean L.; Jorizzo, Joseph L.; Rapini, Ronald P. (eds.) |title=Dermatology |location=London |publisher=Mosby |isbn=0-32302-4092 |pages=pp. 531-44}}
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| ** {{cite book |author=Habif, Thomas P. |year=2004 |chapter=Acne, rosacea, and related disorders |title=Clinical dermatology : a color guide to diagnosis and therapy |edition=4th ed. |location=Edinburgh |publisher=Mosby |isbn=0-323-01319-8 |pages=pp. 162-208}}
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| ** {{cite book |author=Simpson, Nicholas B.; Cunliffe, William J. |year=2004 |chapter=Disorders of the sebaceous glands |editor=Burns, Tony; Breathnach, Stephen; Cox, Neil; Griffiths, Christopher |title=Rook's textbook of dermatology |edition=7th ed. |location=Malden, Mass. |publisher=Blackwell Science |isbn=0-632-06429-3 |pages=pp. 43.1-75}}
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| ** {{cite book |author=James, William D.; Berger, Timothy G.; Elston, Dirk M. |year=2006 |chapter=Acne |title=Andrews' diseases of the skin : clinical dermatology |edition=10th ed. |location=Philadelphia |publisher=Saunders Elsevier |isbn=0-7216-2921-0 |pages=pp. 231-50}}
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| ==External links==
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| * {{cite web | title=Acne Questions and Answers |url=http://www.niams.nih.gov/hi/topics/acne/acne.htm| publisher= From the National Institute of Health}} | |
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| {{Diseases of the skin and subcutaneous tissue}} | | {{Diseases of the skin and subcutaneous tissue}} |
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| [[es:Acné]] | | [[es:Acné]] |
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| [[tr:Akne]] | | [[tr:Akne]] |
| [[zh:粉刺]] | | [[zh:粉刺]] |
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| [[Category:Signs and symptoms]]
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| [[Category:Skin diseases]] | | [[Category:Skin diseases]] |
| [[Category:Dermatology]] | | [[Category:Dermatology]] |
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