Introduction¹ ²

Acne is a common dermatological condition affecting the pilosebaceous units, structures composed of hair follicles (the tiny “Sacs” in the skin from which hairs grow) and sebaceous glands. It is characterized by the formation of comedones (blackheads and whiteheads), papules, pustules, and, in more severe cases, cysts and nodules.

Facial involvement is the most typical, but acne can also affect the neck, chest and back.
 

Causes of Facial Acne^{1 2} 

Mechanisms of Formation

Acne arises from excessive sebum production by the sebaceous glands, often driven by androgen hormones. This overproduction of sebum is accompanied by abnormal shedding of skin cells that block the pilosebaceous follicles, leading to comedones. The mixture of sebum and cell debris creates an ideal environment for the proliferation of bacteria, particularly Cutibacterium acnes, which triggers inflammation and the characteristic acne lesions.

Causes and Predisposing Factors

• Several factors contribute to the development of acne:
• Genetics: A family history can increase susceptibility.
• Hormones: Fluctuations during puberty, pregnancy or specific endocrine disorders can boost sebum production.
• Diet: High-glycaemic foods and dairy products are discussed as potential exacerbators, though evidence remains debated.
• Stress: Stress may worsen acne by altering hormonal levels, increasing inflammation and encouraging skin-picking.
• Cosmetic products: Using inappropriate skincare or makeup can clog pores and aggravate acne.
• Sun exposure: While sunlight may temporarily improve acne, excessive exposure can promote inflammation and increase the severity of lesions.
• Lesion manipulation: Squeezing or popping pimples can spread bacteria, worsen lesions, and increase the risk of scarring.

Locations of Facial Acne^{1 2}

Facial acne typically affects areas rich in sebaceous glands because these glands play a major role in acne formation. Common locations of facial acne are:
 

• The T-zone (forehead, nose and chin): Highly prone to acne due to its dense concentration of sebaceous glands.
   
• The cheeks: Though slightly less gland-dense than the T-zone, the cheeks are a common site, especially in adults, with deeper, inflammatory lesions often aggravated by friction (e.g. from mobile phones or pillowcases).
   
• The jawline and neck: More frequent in adults, often linked to hormonal imbalances and characterized by deeper inflammatorylesions such as cysts and nodules.
   
• In severe cases, acne may spread beyond these typical zones to the temples and hairline, eventually involving the entire face.
   

Distinguishing Cold Sores (Herpes labialis) from Lip Acne Lesions^{1 2 3}

Herpes labialis, commonly known as cold sores, is a viral infection caused by herpes simplex virus type 1 (HSV-1). It presents as clusters of small, painful, fluid-filled vesicles at the junction of the lip’s skin and mucous membrane. These vesicles cluster together on a red base and evolve into crusts. The prodromal symptoms include tingling, burning and localized redness. Unlike acne, cold sores are highly contagious while blisters are present, and until they have crusted over.

By contrast, acne lesions on or near the lips appear as comedones (blackheads or whiteheads), papules or pustules without clustered vesicle formation. Acne stems from follicular blockage, excess sebum and local inflammation, and does not follow the vesicle-to-crust evolution of herpes labialis.

Psychological Impacts of Facial Acne^{4 5}

Acne on the face can lead to a profound psychological effect. Research shows that individuals with acne may experience depression, anxiety, low self-esteem, negative body image and reduced quality of life. These impacts are especially acute during adolescence, when peer acceptance and physical appearance play a pivotal role in self-worth.

Emotional Impact of Acne

Even mild acne can cause significant emotional distress, particularly among teenagers, leading to feelings of shame and social withdrawal.

Bullying and Stigmatization

Adolescents may face teasing or bullying at school, exacerbating loneliness and anxiety and making social interactions more challenging.

Long-Term Consequences

Without appropriate treatment, the psychological effects of acne can extend into adulthood, affecting academic performance, career choices and personal relationships. Severe, persistent acne increases the risk of permanent scarring, further compounding its psychological burden and potentially leading to depressive or anxiety disorders that require specialist care.

Treatments for Facial Acne^{1 6}

The treatment strategy depends on the severity of acne and may involve topical, oral, or a combination of therapies.

Topical Treatments

Often first-line for mild to moderate acne, topical options include benzoyl peroxide, topical retinoids, azelaic acid, and topical antibiotics.

Oral Treatments

For moderate to very severe acne, oral medications may be indicated:

• Antibiotics (e.g. tetracyclines): Effective against inflammatory lesions but can cause photosensitivity.
• Zinc: Prescribed for its anti-inflammatory- properties.
• Some contraceptive pills: Used in women of reproductive age requiring both acne control and contraception.
• Isotretinoin: Reserved for severe acne; requires strict medical supervision due to significant side effects and teratogenic risk. Women of childbearing potential must use effective contraception throughout treatment.

Combined Strategies

A combination of topical and oral treatments often yields the best results, maximizing therapeutic efficacy while minimizing acne side effects on quality of life. Treatment continuity and adaptability are crucial, with adjustments made based on the patient's response and tolerance. The choice of therapy is guided by a general practitioner or dermatologist, taking into account the patient's age, medical history, the severity of their acne, and any previous treatments.

Preventive Advice to Avoid Acne Flare-ups^{1 7 8}

Preventing acne involves personal care measures and lifestyle habits that can substantially reduce the frequency and severity of breakouts: ( Here are some recommendations to effectively control and prevent acne)

Skin Hygiene and Care

• Gentle cleansing: Wash your face up to twice a day with a mild, non-abrasive cleanser, especially after activities that cause sweating.
• Product selection: Use gentle, non-comedogenic products; avoid those containing alcohol or harsh exfoliants.
• Hair hygiene: Shampoo regularly, especially if your hair is oily, to prevent breakouts on your forehead and face.

Environmental Factors and Lifestyle Habits

• Avoid touching your face: Transferring bacteria by touching or picking at lesions can aggravate acne and increase the risk of scarring.
• Sun protection: UV exposure can worsen acne. Medications like tetracyclines heighten photosensitivity, so use a broad-spectrum sunscreen.
• Stress management: Stress can exacerbate acne, so adopt effective stress-reduction techniques.
• Smoking cessation: Smoking impairs skin health and may worsen acne.
• Diet: While the role of high-glycaemic foods and dairy in acne aggravation remains debated, a balanced diet rich in fruits and vegetables supports overall skin health.