Teenage Acne: What It Is and How It Differs from Folliculitis (including Malassezia folliculitis)

What is Teenage Acne?

In front of the mirror there are small, grainy bumps that can be felt across the forehead and around the nose, and before long red swollen spots or pustules start to appear among them. These changes, arriving with puberty, are called teenage acne, also termed adolescent acne.

Acne is common in adolescents and preadolescents aged 9 and over, and prevalence estimates in adolescents range widely between studies, from 35% to figures above 90%. Onset can begin as early as 7 to 12 years of age (preadolescent acne). This is an area where the data have not converged enough to be narrowed to a single figure, and prevalence data on Korean adolescents specifically were not located for this page.

Why it happens is a little different from what is commonly assumed. With puberty, DHEAS, the precursor of adrenal androgens, rises, and androgens stimulate the growth and secretory function of the sebaceous glands, leading to seborrhoea and acne. What the textbooks state, however, is that acne arises not because hormone levels are high, but because the sebaceous glands respond excessively to circulating androgens at normal levels. Acne severity has also been reported to correlate with pubertal maturation.

Younger adolescents are reported to begin with comedones on the forehead, nose and chin (the T-zone), and as it progresses, inflammatory lesions appear in addition to the comedones.

Picking or manipulating lesions is one of the four risk factors identified by a tool developed to assess the risk of atrophic acne scarring (the other three are the severity of acne at its worst, the duration of acne, and a family history of atrophic acne scarring). That tool was developed in young adults and its specificity was low at 43%, so having a risk factor does not mean scarring will follow.

Acne does not end with the lesions themselves. Suicidal ideation has been reported as more common in severe acne than in mild acne. This is an association and not causation, and it does not mean that acne produces depression. Still, the factors affecting quality of life in adolescents have been reported to differ from those in adults, so judgement is not made from the lesions alone.

How is it treated?

The standard of care for acne is benzoyl peroxide, topical retinoids, topical antibiotics and oral doxycycline, all strongly recommended by international guidelines. For acne that is severe, that carries a psychosocial burden or causes scarring, or that has failed standard oral and topical treatment, oral isotretinoin is strongly recommended.

The same guidelines list, as good practice, combining topical treatments with different mechanisms of action and limiting the use of systemic antibiotics. And because paediatric and adolescent acne is handled as a field separate from adult acne, treatment differs according to age and pubertal status. When The Other considers procedures alongside this, it is not to replace that standard, but to have them available to choose from according to what is found at the visit.

Some of these medicines carry clear age limits. Tetracycline-class antibiotics such as doxycycline, if used during tooth development (the latter half of pregnancy, infancy, and childhood up to the age of 8), can cause permanent discolouration of the teeth (yellow-grey-brown) and enamel hypoplasia, so the labelling restricts their use in children aged 8 and under to severe or life-threatening situations where the benefit outweighs the risk, particularly when no alternative therapy is available. Most middle and high school students are past that age, but the fact that there are ages at which these drugs cannot be used is checked before any prescription.

Isotretinoin is used for severe recalcitrant nodular acne in non-pregnant patients aged 12 and over. If pregnancy occurs while taking it — at any dose, even for a short period — there is an extremely high risk of life-threatening birth defects, and there is no accurate means of determining before birth whether a fetus has been affected. Patients who can become pregnant use two forms of contraception simultaneously (at least one a primary method), from at least 1 month before treatment begins, throughout treatment, and until 1 month after stopping, with a pregnancy test for each prescription. Hypersensitivity to isotretinoin or to vitamin A is also listed as a contraindication.

On matters relating to growth, spontaneous reports in the literature of premature epiphyseal closure at recommended doses have appeared, and in an open-label extension trial with 10 participants that included ages 13 to 17, 2 had a decrease in lumbar spine bone mineral density of up to 3.3%. Spontaneous reports are not an established causal incidence rate, and the bone density figures come from 10 people without a control group — but because this is the item closest to readers who are still growing, the denominator is given here as it stands.

On mood, the evidence runs in two directions at once. The labelling maintains warnings about depression, psychosis and, rarely, suicidal ideation, suicide attempts and aggressive behaviour, while a meta-analysis pooling 25 studies and 1,625,891 people found no increase in the risk of suicide or psychiatric disorders at the population level (all psychiatric disorders RR 1.08, 95% CI 0.99–1.19). Causation has not been established, and monitoring for mood changes during treatment is recommended. This is not something to begin knowing only one side of.

For lesions that repeatedly fill with pus, insulated microneedle radiofrequency (Agnes) is considered. It uses a single fine needle insulated along its upper shaft to deliver energy selectively to the sebaceous gland. In a randomised controlled trial of this method, the number of inflammatory lesions at week 12, after three treatments at 4-week intervals, was significantly lower than in the control group (P=0.03). However, the control group was not an untreated group but one that received microneedling and extraction, and the ages of the participants and the list of adverse events could not be confirmed from the abstract. The authors themselves note that theirs was the first randomised controlled trial of this method, which is how thinly the evidence is stacked in this area.

For lesions spread over a wide area, The Other PTT is considered. It uses light energy to suppress the activity of sebaceous glands distributed broadly across the skin. For the approach of delivering particles into the sebaceous glands and then applying an 800 nm laser, 2 randomised controlled trials in patients with moderate to severe facial acne — mean age 21, with a lower enrolment limit of 16 — reported improvement in inflammatory lesions after three treatments. In one of those trials (enrolling ages 16 to 26), inflammatory lesions were significantly reduced against sham treatment at 12 weeks (P=0.015) and 16 weeks (P=0.04). However, a Cochrane systematic review (2016) pooling 71 randomised controlled trials and 4,211 participants on light treatments for acne concluded that none, including studies comparing a gold microparticle suspension against vehicle, showed a clinically meaningful effect, and noted the lack of high-quality evidence for light therapy.

Because the two bodies of evidence point in different directions, this page does not make a definite claim about the effect. In addition, no study designed exclusively in minors was identified on either side, and whether the devices used in the literature above match the conditions of the devices used at this clinic was not verified for this page. Which method is applied, or whether one is applied at all, is decided at an in-person visit after looking at the distribution and severity of the lesions.

Aftercare

Recovery time after a procedure differs from person to person, so no single figure is given here. Which activities to avoid during recovery, and for how long, is explained at the visits before and after the procedure.

The treated area is left alone, not rubbed and not picked at. The same applies to squeezing lesions by hand — picking or manipulating lesions is counted as one of the four risk factors for atrophic acne scarring.

Washing is done gently, without scrubbing. How often to wash and which products to use depend on the state of the skin, so they are decided together at the visit. For what it is worth, there is no evidence that poor hygiene causes acne — it is not a condition that comes from not washing.

Other conditions that look similar

Not every rough bump that appears in adolescence is acne. Keratosis pilaris is red, rough, bumpy skin without pain or itching, appearing mainly on the extensor surfaces of the proximal arms and legs and on the buttocks. It is reported to affect 50% to 80% of adolescents, and it differs from acne in that it arises in childhood and improves with time. Treatment may give a cosmetic benefit, but textbooks note that there are no controlled clinical trials supporting this.

Verruca plana (flat warts) are flesh-coloured elevations 1 to 7 mm in size caused by HPV types 3, 10 and 28, and can number in the hundreds. Lesions that resemble one another in form can call for different directions of treatment, so this should be confirmed in the clinic before anything is started.

Frequently asked questions

This page is general information about a treatment and is not a diagnosis or a recommendation. The right choice differs by skin condition, so treatment is decided after an in-person examination. Individual results vary.

References

1. Guidelines of care for the management of acne vulgaris J Am Acad Dermatol. 2024;90(5):1006.e1-1006.e30 (Reynolds RV et al.)
2. Evidence-based recommendations for the diagnosis and treatment of pediatric acne Pediatrics. 2013;131 Suppl 3:S163-86 (Eichenfield LF et al.)
3. Epidemiology of acne vulgaris Br J Dermatol. 2013;168(3):474-85 (Bhate K, Williams HC)
4. Acne Vulgaris StatPearls (NBK459173)
5. Acne Treatment Based on Selective Photothermolysis of Sebaceous Follicles with Topically Delivered Light-Absorbing Gold Microparticles J Invest Dermatol. 2015;135(7):1727-1734 (Paithankar DY et al.)
6. Light therapies for acne Cochrane Database Syst Rev. 2016;9(9):CD007917 (Barbaric J et al.)
7. Selective Sebaceous Gland Electrothermolysis Using a Single Microneedle Radiofrequency Device for Acne Patients: A Prospective Randomized Controlled Study Lasers Surg Med. 2020;52(5):396-401 (Ahn GR et al.)
8. Treatment of acne vulgaris with fractional radiofrequency microneedling J Dermatol. 2014;41(7):586-91 (Kim ST et al.)
9. A Systematic Review Examining the Potential Adverse Effects of Microneedling J Clin Aesthet Dermatol. 2021;14(1):45-54 (Gowda A et al.)
10. Efficacy and safety of microneedling radiofrequency in acne scars J Cutan Aesthet Surg. 2024;17(4):315-319 (Navyadevi U et al.)
11. Local Anesthetic Toxicity StatPearls (NBK499964)
12. Malassezia Furfur StatPearls (NBK553091)
13. [Malassezia folliculitis] Ugeskr Laeger. 2020;182(47):V08200572 (Henning MA et al.)
14. Keratosis Pilaris StatPearls (NBK546708)
15. Wart StatPearls (NBK431047)
16. DOXYCYCLINE CAPSULE — Labeling DailyMed (REMEDYREPACK INC.)
17. AMNESTEEM (ISOTRETINOIN) CAPSULE — Labeling DailyMed (Mylan)
18. Risk of Suicide and Psychiatric Disorders Among Isotretinoin Users: A Meta-Analysis JAMA Dermatol. 2024;160(1):54-62 (Tan NKW et al.)
19. Systematic review of antibiotic resistance in acne: an increasing topical and oral threat Lancet Infect Dis. 2016;16(3):e23-33 (Walsh TR et al.)
20. A clinical evaluation of acne scarring and its incidence Clin Exp Dermatol. 1994;19(4):303-8 (Layton AM et al.)
21. Development of an atrophic acne scar risk assessment tool J Eur Acad Dermatol Venereol. 2017;31(9):1547-1554 (Tan J et al.)
22. Predictors of Quality of Life in Adults and Adolescents with Acne: A Cross-Sectional Study Indian J Dermatol. 2022;67(3):239-246 (Yıldırım F et al.)