The Four Grades of Acne

THE FOUR GRADES OF ACNE
James E Fulton, Jr., M.D., Ph.D.

Dermatologists often divide acne vulgaris (the technical term for common acne) into four major grades using the Pillsbury Classifications originated by a famous Philadelphia dermatologist, Dr. Donald Pillsbury14. The grades help to correlate the types of acne to specific treatment schedules. I have slightly modified the grade definitions to better fit these types of acne to certain treatment methods I use. 14 D Pillsbury, WC Shelley, AM Kligman. Dermatology. Saunders & Co., Philadelphia, PA.

Grade I: This mildest grade consists primarily of blackheads and whiteheads. An older teenager who is not severely affected but merely visited with a transient problem will not develop lesions further than the Grade I stage. Even though this is the least severe form of acne, it could be a bad prognosis for the future if it develops in a very young teenager around the ages of twelve to fourteen. This is especially true if parents or older brothers and sisters suffered a more severe case. In this instance, Grade I acne could signal the first step toward more severe acne. As I outline in the treatment section of this book, slight peeling with the vitamin A conditioning lotions will usually clear this problem.

Grade II: This type of acne is a unique type of acne where the face becomes studded with whiteheads. We call this process maturation arrest acne because the comedones do not go ahead and mature into actual blackheads. The whiteheads just continue to enlarge. The surface opening never dilates. The dead skin cells or keratinocytes become trapped inside. This is the toughest acne to treat because it requires extensive peeling to force the impactions to open up.

Grade III: This type of acne is the form most frequently treated at my medical office. This grade consists of the typical inflamed acne papules or pustules along with the milder stages of acne blackheads and whiteheads.

Grade IV: This cystic form of acne is the heartbreaker. While Grade IV will likely display the whole spectrum of acne lesions such as blackheads, whiteheads, papules, pustules, and nodules, it is characterized by the addition of cysts. Grade IV acne is often accompanied by severe inflammation that becomes very red and even purplish. This is potentially the most scarring type of acne. However, it often responds the most rapidly to treatment when using the stronger acne control regimens.

Not all faces fit neatly into one definite grade. In reality, individual acne cases will fall somewhere in the spectrum of the four grades of acne. Categorizing the disease’s severity makes it easier to understand and also helps in diagnosis and treatment. The treatment schedule selected and followed will be based on the grade of acne.

What determines the acne grade and severity forecast? As we said before, the answer is largely genetic. Some families will have no more than whiteheads and blackheads. Other families develop the more inflammatory acne with papules, pustules, nodules, and cysts. In families with badly scarring acne, the warnings are there to read and heed. Fortunately, we can now stop the effects of the genetic acne cycle.

DETERMINE YOUR GRADE OF ACNE
With the help of your lesion count chart, the photos in Chapter 4, and your mirror, determine your grade of acne. Let’s review the grades.

Grade I acne consists predominantly of whiteheads and blackheads with an occasional inflammatory lesion. Usually the number of lesions (counting just one side of the face) is less than twenty-five.

Grade II acne, also referred to as "maturation arrest" acne, is the most difficult type to evaluate and treat. The face is studded with many whiteheads. The Grade II person’s skin may look clear from a
distance, but up close the skin feels rough. An adamosis lesion count usually reveals from fifty to a hundred whiteheads. You may have to pull the skin tight to see them. There may be an occasional inflammatory lesion, especially if these lesions are picked or manipulated.

Grade III acne is more typical. Many of you will fall into this category. In addition to a mixture of whiteheads and blackheads, there are a constant number of inflammatory lesions, usually around seven to ten papules and pustules at any one particular time.

Grade IV acne is often referred to as cystic acne. The face displays all of the above: lesions, nodules, and cysts. Remember, Grade IV acne often responds to treatment the fastest.

Other considerations: Besides your grade of acne, there are a few other factors that come into play in determining your treatment program; for instance, your age and heredity forecast. If you are young, perhaps twelve or thirteen, and have Grade I acne but an older brother or sister developed a more severe grade of acne, you will need to be realistic and consider yourself a Grade I going on, say, Grade III or IV. Therefore you should start your treatment as if you are Grade I, but rapidly increase to the Grade III regimen to avoid becoming a more severe grade. On the other hand, if you are a Grade I at age seventeen or eighteen, you are not likely to flare up into a higher grade. You are most fortunate. You can stick to the Grade I schedule and it will work well for you.

Other factors that could indicate the need to adjust your treatment are very oil skin, very dry skin, black skin, and adult women’s special skin problems. In the following pages we will tell you how to adjust your treatment schedule for such factors. First decide which of the four grades of acne you fall into. Then fill in your grade at the top of your lesion count chart. Also fill in "skin type," whether oily, normal, or dry. You can determine this from the results of the skin oiliness test.

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