Acne Vulgaris

Acne vulgaris is the most common form of acne, a chronic inflammatory condition of the hair follicle and sebaceous (oil) gland unit that leads to blackheads, whiteheads, pimples, and sometimes deeper nodules or cysts, most often on the face, chest, and back. It typically begins around puberty but can persist into adulthood and may cause physical scarring and significant psychological distress if not managed appropriately.

Acne can often provoke feelings of discomfort, stigma, or anxiety, prompting people to avoid discussing their symptoms with others, even with their healthcare providers. This reluctance can lead to delays in treatment, ultimately affecting both the physical health and emotional well-being of patients. However, many of these issues are common, and effective medications are available.

The American Academy of Dermatology guidelines note that topical retinoids are central to long-term management of mild acne vulgaris. Retinoids are strongly recommended due to their effectiveness in addressing clogged pores and inflammation.

Systemic tetracyclines are typically reserved for moderate-to-severe acne or in cases in which topical treatment fails.

Guideline recommendation

• The AAD’s updated acne guidelines issue a strong recommendation for topical retinoids for patients with acne across severities, including mild disease, reflecting robust evidence for comedonal and mixed acne.​

• For mild acne, topical retinoids are recommended as first‑line and as ongoing maintenance therapy to keep pores clear and reduce new lesion formation over time.​

Role of combinations and benzoyl peroxide

• The guidelines also strongly support fixed‑dose combinations that pair a topical retinoid with benzoyl peroxide, which improves efficacy and helps limit antibiotic use.​

• Benzoyl peroxide can be added to a retinoid regimen long term, but topical antibiotic monotherapy is discouraged because of antibiotic‑resistance concerns, so antibiotics—if used—should be short term and always combined with benzoyl peroxide, not relied on for maintenance.​

• OCULAR MANIFESTATIONS: 

  Acne vulgaris can be associated with several ocular (eye and eyelid) manifestations, mostly through effects on the eyelids’ oil glands and the tear film, and through certain acne treatments. The main issues are dry eye–type symptoms, meibomian gland dysfunction, and treatment‑related surface inflammation.​

  Direct ocular surface changes

  • People with moderate‑to‑severe acne vulgaris show a higher rate of dry eye, with reduced tear film stability and more structural damage and obstruction of the meibomian (eyelid oil) glands than individuals without acne.​

  • These meibomian changes lead to increased tear evaporation, ocular surface discomfort, conjunctival redness, and a higher prevalence of dry‑eye symptoms (burning, grittiness, fluctuating vision) in acne patients.​

  Eyelid and tear film involvement

  • Meibomian gland dysfunction and obstruction, increased meibum viscosity, and partial gland loss are characteristic ocular findings in acne populations and are thought to be linked in part to Cutibacterium (Propionibacterium) acnes activity at the lid margin.​

  • As a result, patients can present with chronic eyelid margin irritation and hyperemia, and in some cases secondary blepharitis‑like complaints, even if the corneal surface staining remains relatively mild.​

  Treatment‑related ocular manifestations

  • Systemic isotretinoin, frequently used for severe acne, is strongly associated with dry eye, blepharitis, blepharoconjunctivitis, conjunctivitis, hordeola/chalazia, and other ocular surface complaints due to its effects on meibomian and lacrimal gland function.​

  • Some topical acne therapies, including retinoid–antibiotic combinations, can also worsen or induce dry‑eye signs and symptoms in susceptible patients by destabilizing the tear film and irritating the ocular surface.​

  Practical implications

  • Any acne patient with persistent burning, dryness, redness, or lid swelling should be evaluated for dry eye and meibomian gland dysfunction, especially if they have moderate‑to‑severe disease or are taking isotretinoin.​

  • Management typically includes preservative‑free lubricant drops, lid hygiene and warm compresses, review or adjustment of acne medications, and referral to Optometry if symptoms are significant or vision is affected.​

   
   

Author

Paddy Kalish OD, JD and B.Arch Author and Blogger