Is acne ever just skin deep?

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Acne manifests primarily as lesions on various parts of the body, including the face, neck, back, and chest. Acne presents as comedones, papules, pustules, nodules, and sometimes cysts, macular erythema, excoriation, and pigmentation changes, often leading to chronic scarring.1 

Close-up of a woman's face with acne under a magnifying glass
Psychologically, acne impacts emotional functioning, social interactions, relationships, leisure activities, daily routines, sleep patterns, academic performance, and work productivity. [Source: Shutterstock]

Psychologically, acne impacts emotional functioning, social interactions, relationships, leisure activities, daily routines, sleep patterns, academic performance, and work productivity. Studies show that the impact of acne on health-related quality of life (QoL) is similar to that of chronic conditions like asthma, psoriasis, and arthritis.1,2 

According to Hughes and Bewley, the psychological impact of acne is largely due to unrealistic beauty standards perpetuated by the media, which can fuel feelings of inadequacy and social exclusion, exacerbating the emotional toll of living with acne.1  

Adolescents navigating the challenges of acne face self-image and social acceptance challenges, which have long-term effects. Patients report decreased confidence, verbal abuse, and bullying, which contribute to the development of comorbid major depressive (18.5% versus 12% in the general public), anxiety (>68%) and body dysmorphic disorders (9%-15%).1,3 

Suicidal ideation is a significant concern among patients living with acne, with increased risks observed across various age groups. A meta-analysis examining suicidality among adolescents living with various skin conditions found a high prevalence range of suicide attempts, spanning from 0.08% for psoriasis to 21.9% for acne. The odds of suicide attempts were substantially higher among adolescents living with acne.1 

Furthermore, a multi-centre investigation showed that 40.6% of adults living with acne were concerned about their appearance, 12.3% experienced suicidal ideation with 4% directly attributing their suicidal thoughts to acne.1 

When it comes to seeking treatment for acne, Patients feel disregarded and marginalised by healthcare professionals due to conflicting perceptions of acne severity and that their concerns were viewed as trivial.2 

Therefore, it is extremely important to establish a strategy that fosters synergy between healthcare professionals and affected Patients to effectively manage acne, according to the American Academy of Dermatology (AAD). An extremely important aspect of acne management is developing a strong patient-provider relationship. This involves actively listening to the patient’s perspective and discussing all aspects of treatment to ensure adherence to treatment.2,4  

To better understand an individual’s perspective, it is essential to identify the specific aspects of acne that are most bothersome. This information can inform treatment approaches and help set realistic long-term treatment goals. Common concerns include hyperpigmentation, scarring, active lesions, and overall appearance.4 

Another key component of a strong patient-provider relationship is shared-decision making. Individualising acne care based on the potential treatment benefits and risks, the severity, extent, and region of acne involvement, treatment costs, and patient preferences, is essential because it improves long-term outcomes.2 

One of the first steps when developing individualised acne care, is grading the severity of the condition. Three main approaches are used to assess acne severity: Global acne severity grading, acne lesion counting, and multimodal digital imaging. One of the most widely used tool is the Investigator Global Assessment (see Table 1).4,5 

What are the most affective acne treatments available? 

According to the 2024 AAD acne guidelines, topical therapies are the cornerstone of treatment and can be used as initial or maintenance therapy, either as monotherapy or in combination with other topical or oral agents.2  

Commonly used topical therapies include retinoids, benzoyl peroxide (BPO), antibiotics, clascoterone, salicylic acid, and azelaic acid. Multi-modal therapy combining multiple mechanisms of action is recommended to optimise efficacy. Topical retinoids, which are vitamin A derivatives, are considered essential for acne treatment due to their comedolytic and anti-inflammatory properties.2  

Topical antibiotics, such as erythromycin and clindamycin, can be used for their antibacterial and anti-inflammatory effects but are not recommended as monotherapy due to concerns about antibiotic resistance (see Box 1).2,4  

Fixed-dose combinations of topical agents, including BPO with retinoids or antibiotics, improve treatment adherence.2,4 

Azelaic acid, with its comedolytic, antibacterial, and anti-inflammatory properties, is particularly beneficial for patients with sensitive or darker skin types.2  

Combined oral contraceptives (COCs) are widely used for the treatment of acne. COCs work by inhibiting ovulation and reducing androgen levels, subsequently decreasing ovarian androgen production and increasing sex hormone-binding globulin. COCs also exhibit anti-androgenic properties by reducing free testosterone levels and blocking the androgen receptor.2   

COCs have demonstrated efficacy in improving acne severity, with greater reductions in both inflammatory and non-inflammatory lesion counts compared to placebo. COCs can be combined with other oral or topical acne medications, such as tetracycline antibiotics and spironolactone, to enhance treatment efficacy.2  

While COCs are generally well-tolerated, they are associated with certain risks, including venous thromboembolism, myocardial infarction, stroke, and breast cancer. However, the absolute risk of these adverse events (AEs) associated with COCs is relatively small.2 

Another extremely effective option is isotretinoin, which was approved for the treatment of severe, recalcitrant nodular acne since 1982. While its precise mechanism of action is not fully understood, isotretinoin effectively reduces acne symptoms by targeting multiple aspects of the condition.2  

It works by decreasing the size and secretion of sebaceous glands, indirectly reducing levels of sebum-dependent Cutibacterium acnes bacteria, normalising keratinocyte keratinisation to inhibit comedogenesis, and possessing anti-inflammatory properties.2 

Studies have shown significant reductions in lesion counts and acne severity with isotretinoin treatment compared to placebo. Additionally, isotretinoin has been found to be superior to alternative formulations such as lidose-isotretinoin and low-dose isotretinoin.2 

Isotretinoin is associated with various AEs, particularly affecting the mucocutaneous, musculoskeletal, and ophthalmic systems. However, these side effects generally resolve upon discontinuation of the medication. Pregnancy prevention is a critical consideration with isotretinoin due to its potential teratogenic effects.2 

Studies have not identified a significant association between isotretinoin use and neuropsychiatric conditions or inflammatory bowel disease. Available evidence suggests a low risk of AEs such as abnormal liver function, abnormal lipid levels, and mild hematologic abnormalities. Regular laboratory monitoring during treatment is recommended.2 

The evidence for the efficacy of various dermatological procedures in treating acne, including traction, chemical peels, laser and light-based devices, microneedle radiofrequency devices, and photodynamic therapy, remains insufficient to make definitive recommendations, according to the AAD.2  

Management of truncal acne 

The AAD published a guideline specifically aimed at the management of truncal (chest, shoulders, and back) acne in 2023, which they state requires a distinct management approach compared to facial acne. Important considerations include the types of lesions present, the extent of body surface area affected, and the specific location of lesions on the trunk.4  

Apart from efficacy, other important factors to consider include ease of spreadability, potential adverse events, potential to bleach/stain clothing, local tolerability, and patient preference.4 

Certain clinical scenarios may warrant a more aggressive treatment approach, such as the presence of nodules, deep inflammatory lesions, acne-induced scarring, significant impact on quality of life, physical pain, high psychosocial burden, or a large body surface area affected.4 

Systemic therapy may be preferable to topical therapy for acne lesions in hard-to-reach areas of the trunk. Topical formulations considered appropriate for truncal acne include lotions, foams, and gels.3 

Managing the acne sequelae 

The AAD’s The Personalizing Acne: Consensus of Experts (2023) guidelines also include recommendations for the management of the acne sequelae. Recommendations for individualising a management approach for patients with acne sequelae, include:4 

  • Prompt treatment escalation: The presence of acne-induced scarring, acne-induced macular hyperpigmentation, and acne-induced macular erythema may prompt a more rapid escalation in the treatment of active acne lesions. 
  • Addressing existing sequelae: Selecting a treatment that reduces existing acne-induced macular hyperpigmentation and acne-induced macular erythema, along with treating active acne lesions, is important for at-risk patients. 
  • Prevention of future sequelae: It is crucial to select a treatment that mitigates or reduces the risk of developing acne-induced macular hyperpigmentation in the future for at-risk patients. 
  • Combination therapy: Consider combination therapy, involving two different topical treatments or a topical and oral treatment, to target multiple pathways in acne pathophysiology and mitigate the risk of patients developing acne-induced macular hyperpigmentation. 
  • Sunscreen usage: Advise patients on the importance of using sunscreen, particularly when there is a risk of acne-induced macular hyperpigmentation. 
  • Consideration of scarring severity: When selecting treatment for active acne lesions in patients with concomitant acne-induced scarring, consider the severity of scarring present, the size of the affected area, and the morphology of scars present. 


For the management of Patients living with a high burden of disease, the guidelines recommend regular follow-up appointments to monitor progress and adjust treatment as needed. It may also be beneficial to involve other healthcare providers, such as psychiatrists or primary care physicians, to address comorbid conditions or psychological concerns.4  

Treatments with a faster onset of action can help alleviate symptoms more quickly and improve patient satisfaction. Integrating strategies to mitigate risk factors for sequelae into the treatment plan can prevent long-term complications.4  

Escalate treatment using combination therapy, which involves combining different topical treatments or a combination of topical and oral treatments, can target multiple pathways in acne pathophysiology and enhance treatment efficacy.4 

How do you personalise acne treatment? 

The AAD developed a Personalised Acne Treatment Tool (PATT) and a Personalised Acne Care Pathway (PACP) to aid healthcare professionals to personalise acne treatment. According to the AAD, PATT (see Figure 1) represents a significant departure from conventional acne management strategies by placing patients at the forefront of care.4,6  

While traditional methods rely heavily on clinical assessments of acne severity, PATT adopts a more comprehensive approach, considering a range of patient-specific and disease-related factors such as severity of acne, patient history, specific clinical features, and individual treatment preferences.4  

By incorporating these factors into the decision-making process, PATT fosters a collaborative relationship between patients and providers, empowering patients to actively participate in determining their treatment plans.4 

The PACP (see Figure 2) provides practical recommendations to facilitate the long-term management of acne, which can be used by healthcare professionals to optimise and personalise care throughout the patient journey.6 

It incorporates patient-centred goals, reviewing, assessing, and modifying treatment, a transition from initiation to maintenance therapy, and guidance on how to manage patients in cases of relapse or remission.6 


A one-size-fits-all approach falls short to addressing the multifaceted needs of patients living with acne. Management requires a holistic understanding of the individual's experiences, preferences, and specific manifestations of the condition. 

By embracing a patient-centric model, healthcare professionals can transcend conventional paradigms, engaging in meaningful dialogues that prioritise patient voices and perspectives. 

The recognition of acne as more than just a dermatological concern but a deeply ingrained psychological and emotional burden underscores the need for individualised interventions.  

Box 1: Considerations when prescribing antibiotics 

When using antibiotics for acne treatment, it is essential to be mindful of the potential risks associated with their use. Both topical and oral antibiotics are commonly prescribed alongside topical retinoids for moderate-to-severe acne cases. However, their frequent use has been linked to antibiotic resistance and disruption of the skin microbiome.4 

One of the primary concerns is the development of antibiotic resistance in C. acnes, which can lead to reduced treatment efficacy or acne recurrence. To address this issue, BPO is often incorporated into treatment regimens when long-term antibiotic therapy is necessary. This combination helps mitigate the risk of resistance development.4 

To further minimise the risk of antimicrobial resistance, the AAD advocates for the adoption of combination regimens targeting multiple pathways in acne pathophysiology whenever feasible. This approach aims to optimise treatment efficacy while reducing reliance on antibiotics. Furthermore, when systemic antibiotics are used, it is crucial to limit their duration to mitigate the risk of antimicrobial resistance.4 


  1. Hughes O, Bewley A. Is it really ever ‘just acne’? Considering the psychodermatology of acne, British Journal of Dermatology, 2023. 
  2. Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. JAAD Int, 2024. 
  3. Kobusiewicz A, Tomas-Aragones L, Marron SE, Zalewska-Janowska A. Body dysmorphic disorder in patients with acne: treatment challenges. Postepy Dermatol Alergol, 2022. 
  4. Layton AM, Alexis A, Baldwin H, et al. The Personalized Acne Treatment Tool - Recommendations to facilitate a patient-centered approach to acne management from the Personalizing Acne: Consensus of Experts. JAAD Int, 2023. 
  5. Bae IH, Kwak JH, Na CH, Kim MS, Shin BS, Choi H. A Comprehensive Review of the Acne Grading Scale in 2023. Ann Dermatol, 2024. 
  6. Tan J, Alexis A, Baldwin H, Beissert S, et al. The Personalised Acne Care Pathway-Recommendations to guide longitudinal management from the Personalising Acne: Consensus of Experts. JAAD Int, 2021. 

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