Acne vulgaris, and acne fulminans

acne · acne vulgaris · spots · acne fulminans · pomade acne · acne conglobata

Extremely common and rarely urgent - except acne fulminans, and except the scarring that is entirely preventable by treating early.

GPBand D

Red flags

Acne fulminans - abrupt severe ulcerating and crusted acne with fever, arthralgia and systemic upset; needs urgent dermatology and is not managed with routine acne treatment
Scarring of any degree - a reason for prompt effective treatment and referral, not reassurance
Severe psychological distress or suicidal ideation - ask directly, and treat this as the urgent problem it is
Sudden severe acne with virilisation, or in a young child - consider an endocrine cause
Acne that has worsened abruptly after starting isotretinoin - a recognised trigger for fulminans, needing specialist advice

Recognise

On light skin

Comedones with inflammatory red papules and pustules, and nodules or cysts in severe disease, with erythematous macules and scarring after lesions resolve.

On brown and black skin

Inflammatory lesions appear darker, violaceous or hyperpigmented rather than red, so severity is routinely under-scored. Two consequences dominate practice here. First, post-inflammatory hyperpigmentation is often the patient's main complaint and is frequently more distressing and longer-lasting than the acne itself - dismissing it as cosmetic is a common way to lose a patient's trust, and treating the acne promptly is what prevents it. Second, keloid and hypertrophic scarring is substantially more likely - pooled odds ratio 6.14 (95% CI 3.75 to 10.07) in Black compared with White individuals, and 3.70 in Asian individuals, in a 2026 network meta-analysis - especially on the chest, back and jawline, which raises the urgency of effective early treatment rather than watchful waiting. Pomade acne along the hairline and forehead, from oil-based hair products, is a specific and easily missed pattern, and is listed among the disorders commoner in Black patients.

In any skin tone

Comedones - blackheads and whiteheads - distinguish acne from other papulopustular rashes
Distribution on face, chest and upper back
Grade by the presence of nodules, cysts and scarring, not by how red it looks
Any scarring means treat actively now - scarring is permanent and preventable
Ask about mood; the psychological impact is substantial and under-asked
Acne fulminans: sudden severe ulcerating acne with fever, joint pain and malaise - an emergency

Distribution

Face, chest and upper back - the sebaceous areas.

Photographs

Nodulocystic acne along the jawline on brown skin. Deep inflamed nodules and pustules at the angle of the jaw, and across the cheek the flatter **dark marks of post-inflammatory hyperpigmentation** left by lesions that have already settled. Those marks are the reason acne matters more in skin of colour: they last months to years, they are what the patient is usually most distressed by, and they are made worse by picking and by delayed treatment. Treat the active acne promptly and say so.
Fitzpatrick IV (Fitzpatrick type estimated from the photograph, not stated by the source) · Sedef94 · Wikimedia Commons - Üzdə düyünlü və kistik sızanaqlar (Acne Vulgaris) 01.jpg · CC BY-SA 4.0

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Rosacea — Rosacea has no comedones, spares nothing in the central face, and features flushing and telangiectasia
Skin abscess, boils and folliculitis — Folliculitis is follicular pustules without comedones, often on the trunk or thighs
Hidradenitis suppurativa — Nodules in the flexures with sinus tracts are hidradenitis, not acne, though they coexist
Seborrhoeic dermatitis — Both affect sebaceous areas, but seborrhoeic disease scales and has no comedones

What to do in the ED

Recognise that most acne is not an ED problem - but that a patient who has come to the ED about it is usually distressed, and dismissing them is the wrong response
Treat acne fulminans as urgent: NG198 1.4.1 asks for same-day referral to the on-call hospital dermatology team to be assessed within 24 hours - not simply a standard acne regimen
Signpost to the GP for NICE NG198-guided treatment, and say clearly that effective treatment exists and that scarring is preventable
Ask about mood and about the impact on school, work and social life
Where there is scarring or severe disease, say explicitly that this warrants dermatology referral rather than repeated courses of antibiotics
Know which NG198 referrals are unconditional. 1.4.2 says refer - not consider - for diagnostic uncertainty, acne conglobata or nodulo-cystic acne. 1.4.4 adds acne of any severity causing persistent psychological distress or a mental health disorder
In patients with brown or black skin, address the post-inflammatory hyperpigmentation directly - explain that treating the acne is what treats the marks. And say that it is a referral criterion in its own right: NG198 1.4.3 lists 'acne with persistent pigmentary changes' alongside scarring and treatment failure. The pigmentation is not only a counselling point, it is a route to dermatology
Ask about hair products in hairline acne

Disposition

GP management per NICE NG198. Referral is unconditional (1.4.2) for diagnostic uncertainty, acne conglobata or nodulo-cystic acne, and is considered (1.4.3, 1.4.4) for scarring, persistent pigmentary changes, treatment failure, or acne of any severity causing persistent psychological distress. Acne fulminans is a same-day referral to the on-call dermatology team for assessment within 24 hours (1.4.1).

Safety-netting

Acne is treatable and scarring can be prevented, so please do follow this up rather than waiting it out. Return urgently if spots become suddenly much worse with ulcers, fever or joint pains. The dark marks left after spots heal are not scars and will fade, and treating the acne is what makes them go. If this is affecting your mood, please tell someone - that matters as much as the skin.

Sources

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