There is plenty of misinformation surrounding acne, and its ubiquitous nature may suggest that it’s a completely harmless condition that will pass on its own. In most cases, that is true, but acne is capable of leaving permanent scars. Beyond that, acne creates a lot of self-esteem issues in patients, particularly in teenagers and young adults. Poor self-esteem can lead to various anxiety or depressive disorders, especially when the acne leaves permanent cosmetic effects behind. And, in rare cases, acne can produce serious complications that warrant immediate treatment. In short, it’s not as harmless as it seems.

The Signs and Symptoms of Acne

When most people talk about acne, they are referring to a particular type of the disorder, known as acne vulgaris. Technically, there are more than 20 varieties in the acne family, but acne vulgaris is by far the most common. In 2015, more than 630 million people were estimated to suffer from acne vulgaris, making it the most prevalent skin condition in the world, and the eighth most common disease, period. The European Journal of Dermatology estimates that between 80 and 90 percent of teenagers in the Western world experience acne, though lower prevalence rates have been reported in rural areas.

Acne is classified by its severity, though all grades of acne are characterized by the presence of non-inflammatory or inflammatory lesions that are immediately apparent. In the U.S., doctors classify acne into four grades, depending on what kinds of lesions are present. Those grades include:

1. Grade 1, or mild acne – Grade 1 acne is the most common, and on its own is not worth worrying about. However, grade 1 acne often progresses to more severe forms of the condition, which means that treatment is still indicated, even for mild cases like these.

Instances of grade 1 acne are defined by clusters of “comedones,” or skin-colored bumps that predominantly appear on the forehead and chin. Whiteheads and blackheads are typically present in patients suffering from grade 1 acne, as well, but inflammatory lesions are extremely rare at this stage.

2. Grade 2, or moderate acne – Grade 2 acne is characterized by a combination of comedones and inflammatory pustules, which most people refer to as pimples. At this stage, the acne is more widespread, and may spread to the trunk. Grade 2 acne is much more visually apparent, as the inflammatory action behind pimples reddens the skin.

One piece of misinformation regarding pimples is that they can be treated by “popping” them. This can actually worsen the acne and cause it to spread further.

3. Grade 3, or severe acne – Grade 3 acne is marked by dense instances of comedones, pimples and inflamed lesions. At this stage, the acne has covered patches of the trunk and may be present on both the front and back of the trunk. In areas where the acne is most apparent, the skin may be generally inflamed, resulting in tenderness or pain. Treatment is necessary at this point to avoid scarring.

4. Grade 4, or severe nodular acne – Until recently, grade 4 acne was referred to as cystic acne, but cysts are rare, even in patients with extreme cases of acne. However, grade 4 still warrants immediate treatment. Protruding nodules and dense patches of pustules are present in patients with severe nodular acne, and more involved methods of treatment, including laser therapy or extended antibiotic use, may be necessary. Treatment is essential to prevent extensive scarring.

There are several considerations the healthcare provider will need to make before devising a treatment plan for a patient, but the most important is the condition’s severity. The worse the acne, the more aggressive and timely the treatment will need to be.

Where does acne come from?

Doctors know how acne forms, but it’s still an open question as to what the underlying risk factors are. Acne forms in hair follicles that have been clogged with a combination of oily sebum, dead skin cells and a particular species of bacteria (Propionibacterium acnes). The dead skin cells clump together in the follicle and the bacteria worsens the situation by creating a biofilm around the follicle’s surface. The clogged follicle becomes inflamed and may rupture.

As to what creates the conditions for increased sebum and excessive production of skin cells, the research isn’t clear. A genetic component is strongly suspected, as twin studies have demonstrated a correlation. Beyond that, hormonal cycles, diet, stress and environmental factors have all been hypothesized to play a role, but what role they play isn’t clear. Mechanical obstruction of skin follicles, like with a helmet, can worsen acne that’s already present.

A study in the Journal of the American Academy of Dermatology has demonstrated that a diet low in simple sugars can improve acne in patients. Although dietary changes should not be relied on alone for treatment, it’s still recommended by most physicians.

Dealing with acne

If acne is not treated, it may eventually progress to more severe forms, until scarring is a real risk. Allowing acne to worsen can also damage a patient’s self-esteem and lead to social anxiety or depression. Several studies have demonstrated a link between severe acne and suicide ideation, so the emotional toll can be considerable. And in rare cases, conditions like pyogenic granulomas and facial edema can develop.

A primary care physician is capable of dealing with most instances of acne. As acne can be diagnosed by visual examination, there are few difficulties in assessing the scope of the condition. In addition to the acne’s severity, the healthcare provider will also consider the patient’s age, sex, skin type (oily or dry) and health status. Pregnant women, in particular, require a specialized and careful treatment plan, as many topical agents are linked to fetal harm.

Standard treatment options include benzoyl peroxide, retinoids (reduce inflammation and sebum production), antibiotics, hormonal agents, azelaic acid and salicylic acid. These have been shown to be effective in most mild and moderate cases of acne. Severe cases usually require a combination of these treatments.

Acne is often dismissed as a minor annoyance, but it’s a real health condition that can have serious consequences for the patient. That’s why it’s best to address it with a physician’s help before it worsens.