Acne Pustular (ICD-10: L70) ⚠️

Acne Pustular: A Chronic Inflammatory Skin Condition with Predominant Pustules

Acne pustular is a chronic inflammatory skin disorder that predominantly affects the sebaceous glands and hair follicles. It is characterized by the development of a wide range of dermatological elements, including comedones (blackheads and whiteheads), papules, pustules, and occasionally nodules or cysts. The most commonly affected areas are the face—particularly the forehead, cheeks, and chin—as well as the upper back, chest, and shoulders, where sebaceous gland activity is most pronounced.

This specific form of acne is distinguished by the dominance of inflammatory lesions—primarily papules and pustules—superimposed on a background of comedonal activity. While comedones may still be present, it is the red, inflamed bumps (papules) and pus-filled lesions (pustules) that define the clinical appearance and progression of pustular acne.

The onset of acne pustular is most frequently observed during adolescence, typically beginning between the ages of 11 and 13. While girls may show earlier signs of breakouts, boys tend to develop more severe and persistent forms of acne. In males, the initial presentation often occurs later—around 18 to 20 years of age—but the intensity and spread are generally greater due to hormonal activity.

Acne pustular affects an estimated 80% of the population at some point in their lives, making it one of the most widespread dermatological issues worldwide. Despite this prevalence, many individuals perceive acne as a purely cosmetic concern and do not seek medical treatment. This delay or neglect can worsen outcomes, leading to complications such as scarring, persistent pigmentation changes, and psychological distress.

The condition is rooted in two primary physiological disturbances: overproduction of sebum by the sebaceous glands, and obstruction of the glandular ducts by dead skin cells and keratin. These two factors contribute to the formation of comedones. Once these clogged follicles become colonized by skin-residing bacteria such as Cutibacterium acnes, a local immune response is triggered, resulting in inflammation and the formation of pustular lesions.

Predisposing Factors: What Contributes to the Development of Pustular Acne?

Acne pustular does not stem from a single identifiable cause. Rather, it is a multifactorial disease influenced by a complex interplay of genetic, hormonal, environmental, and behavioral elements. Understanding these risk factors is essential for both prevention and effective long-term management.

• Genetic predisposition: Family history plays a significant role. Studies of twins and families have demonstrated that genetic inheritance heavily influences the onset and severity of acne. Several genes linked to sebaceous gland activity and immune response have been identified as risk enhancers.
• Hormonal imbalances: Hormonal changes, especially during puberty, lead to elevated levels of androgens—male sex hormones that stimulate sebaceous gland growth and sebum production. This explains why acne is most prevalent during adolescence and why males typically experience more severe cases.
• Microbial activity: Although Cutibacterium acnes is a part of the skin’s normal flora, under certain conditions it can trigger an exaggerated immune response, causing inflammation. Additional pathogenic bacteria and parasites like Demodex mites can exacerbate the inflammatory reaction.
• Poor skincare and hygiene: The use of comedogenic products, irregular facial cleansing, and external irritants (such as tight clothing, masks, or occupational tools) can impair the skin barrier, clog pores, and promote lesion formation.
• Environmental and lifestyle factors: Stress, lack of sleep, air pollution, smoking, and deficiencies in essential nutrients (like zinc, vitamin A, or omega-3 fatty acids) can weaken the skin’s natural defense mechanisms and make it more prone to inflammation.
• Dietary habits: Although direct causal links are still debated, observational data suggest that high-glycemic diets rich in sugar, processed food, chocolate, coffee, and dairy products may aggravate acne in susceptible individuals. Reducing or eliminating these foods can often lead to notable improvements.

Diagnostics: How Acne Pustular Is Diagnosed

The diagnosis of acne pustular is primarily clinical, based on a detailed patient history and a visual examination of the skin. During the consultation, the dermatologist gathers information about the onset, progression, triggers, lifestyle factors, and any previous treatments the patient may have tried. This information helps to determine the type and severity of the acne, as well as to identify potential contributing factors.

During physical examination, the clinician assesses the presence, type, and distribution of lesions—whether comedones, papules, pustules, or nodules. In cases where the clinical picture is not fully clear—such as when lesions are minimal or atypical—dermatoscopy can be used for further clarification. This tool magnifies skin structures and allows for better visualization of patterns, aiding in differential diagnosis.

A thorough assessment is crucial not only for proper classification of acne severity (mild, moderate, severe) but also to rule out other skin conditions that may resemble acne. Accurate diagnosis forms the basis for personalized and effective treatment planning.

Symptoms: Visual Signs of Pustular Acne

Acne pustular is identified by a combination of non-inflammatory and inflammatory lesions, with papules and pustules being the dominant features. The following elements are typically present:

• Comedones: These may be open (blackheads) or closed (whiteheads). Closed comedones are small, skin-colored, and slightly raised; open comedones are larger with visible black centers resulting from oxidized sebum. They often appear on the back and shoulders.
• Papules: Red or pink inflamed bumps that are tender to touch. They lack visible pus and usually measure 1–3 mm at the base. In severe inflammation, papules become denser and surrounded by hyperemic skin zones.
• Pustules: These lesions are similar in size to papules but contain visible yellowish or whitish pus. Pustules are tender and denser than surrounding tissue. When ruptured or squeezed, they exude white, structureless contents. Hyperemic halos up to 10 mm are common.
• Nodules: Less frequent in typical pustular acne but may be present in advanced or untreated cases. These are deeper, larger, painful lesions with a high risk of scarring.
• Scars: Typically occur after the healing of deep or repeated lesions. Atrophic scars are the most common and appear as shallow depressions with clear edges. Hypertrophic scars, although less frequent, are thickened, elevated, and rough.
• Post-inflammatory hyperpigmentation (PIH): Brownish patches that remain after lesion healing. These can exist alone or with scars and are more common in darker skin types.

The preferred areas for pustular acne include the face (forehead, cheeks, chin), the upper back (particularly the scapular region), the chest, and the shoulder girdle. Acne in other body areas is uncommon and typically indicates another dermatologic or systemic issue.

Differential Diagnosis: Conditions That Mimic Acne Pustular

Accurate diagnosis requires ruling out several other dermatologic conditions that can present with similar signs. Conditions to differentiate from include:

• Rosacea: A chronic inflammatory condition resembling acne but lacking comedones and often associated with facial flushing.
• Isolated comedones and milia: Superficial keratin plugs or small white cysts that resemble closed comedones.
• Dermatitis: Inflammatory conditions like seborrheic or perioral dermatitis may cause red papules or pustules.
• Acneiform eruptions: Acne-like rashes induced by medications, topical irritants, or occupational exposures.
• Skin cancers: Nodular basal cell carcinoma or amelanotic melanoma may mimic adult acne and must be considered in resistant or unusual presentations.

Risks: Why Acne Pustular Should Not Be Ignored

Though acne pustular is not life-threatening, it serves as a visible marker of internal processes—some of which may be hormonal, metabolic, or immunological. Neglecting the skin’s condition may result in overlooking deeper, more systemic imbalances.

Moreover, acne pustular has a profound impact on a person’s psychological well-being. Adolescents and adults with moderate to severe acne often suffer from social withdrawal, low self-esteem, and even anxiety or depression. Scarring and hyperpigmentation further compound these challenges.

If left untreated, severe or repeated pustular lesions may rupture, become secondarily infected, and even lead to localized skin abscesses. Therefore, timely intervention is not only about aesthetics—it is about preserving skin integrity and overall health.

Tactics: Best Practices for Managing Acne Pustular

At the first signs of persistent or worsening pustular acne, it is critical to consult a dermatologist. Early evaluation helps prevent scarring and identify potential underlying triggers.

Patients should seek medical help when:

• Lesions persist or worsen despite self-care or over-the-counter treatments.
• New symptoms appear—such as nodules, pain, or increased redness.
• There is a history of scarring, or hyperpigmentation is increasing.
• There has been a mechanical injury to acne-prone skin (e.g., picking or pressure).

Ongoing monitoring and skin care adjustments are necessary throughout the course of the disease. Life transitions—diet changes, climate shifts, new cosmetics, or hormonal treatments—can all trigger flare-ups and should be discussed with a medical provider.

Treatment: A Multimodal and Individualized Approach

Treating acne pustular requires a comprehensive strategy tailored to the individual. Treatment modalities include:

• Topical therapies: Such as benzoyl peroxide, salicylic acid, topical retinoids, and antibiotics. These reduce inflammation, normalize keratinization, and reduce microbial growth.
• Systemic medications: Oral antibiotics or hormonal therapy (e.g., oral contraceptives, anti-androgens) may be used for moderate to severe cases when topical therapy is insufficient.
• Cosmetic procedures: Manual or device-assisted comedone extraction, chemical peels, and non-ablative laser treatments can enhance skin clarity.
• Phototherapy and physiotherapy: Light- and heat-based therapies reduce inflammation and bacterial colonization.
• Scar revision treatments: Including laser resurfacing, microneedling, and dermabrasion for post-acne scars.

Patients must avoid interrupting their treatment or using unapproved topical agents. Acne treatment requires time, discipline, and often several months to yield results. Open dialogue with a healthcare provider allows for treatment adjustment and realistic expectations.

Prevention: Skin Care and Lifestyle for Long-Term Control

While not all cases of acne pustular can be prevented, proactive measures can reduce the likelihood and severity of flare-ups. Key recommendations include:

• Use non-comedogenic skin products: Select cleansers, moisturizers, and makeup that do not clog pores.
• Practice consistent hygiene: Cleanse the skin twice daily with gentle, pH-balanced products—avoid over-scrubbing.
• Limit UV exposure: Use SPF daily and avoid prolonged sun or tanning bed exposure, which may worsen inflammation or PIH.
• Follow a balanced diet: Reduce high-glycemic foods, excessive dairy, and processed sugars; increase fruits, vegetables, and water intake.
• Manage stress: Psychological stress affects hormone levels and immune function—use techniques such as meditation, exercise, or counseling.
• Schedule regular dermatology checkups: Professional monitoring ensures early detection of complications and supports treatment compliance.

By combining clinical care, proper skin maintenance, and lifestyle awareness, most cases of acne pustular can be effectively controlled—helping patients regain confidence and maintain long-term skin health.