> ## Documentation Index > Fetch the complete documentation index at: https://docs.hi-doctor.ai/llms.txt > Use this file to discover all available pages before exploring further. # Acne — how a doctor grades it and treats it > What acne is, why it happens, how a doctor grades severity from photos, and the topical treatments considered in an online dermatology consultation. Acne is a disorder of the pilosebaceous unit — the hair follicle and the oil gland attached to it. It is the most common skin condition seen in general practice, and most of it is mild to moderate and responds to a topical medicine. A registered doctor reviews the questionnaire and the photos, grades what is there, and decides whether a topical treatment is appropriate. ## What acne is Every hair follicle on the face, chest and upper back opens into a sebaceous gland. When the lining of that follicle sheds cells faster than it clears them, and the gland is producing more sebum than usual, the opening plugs. That plug is a comedone — open (a blackhead, dark because the keratin oxidises, not because it is dirt) or closed (a whitehead). Inflammation on top of a plugged follicle produces a papule, a pustule, and in the more severe forms a nodule or a cyst. Acne is not an infection and it is not caused by poor hygiene. Washing harder makes it worse, because stripping the barrier drives more irritation into an already inflamed follicle. ## Why it happens The cells lining the follicle stick together and shed abnormally, forming the microcomedone that every other acne lesion grows out of. Retinoids act here, which is why they are the backbone of comedonal acne treatment. Androgens enlarge the sebaceous gland and increase sebum output. This is why acne clusters around puberty, and why a flare that starts in adult women is worth a hormonal question or two. A commensal organism that thrives in the sebum-rich, low-oxygen environment of a plugged follicle. It does not cause acne on its own — it amplifies the inflammation once the follicle is already blocked. Innate immune activation around the follicle produces the redness, swelling and tenderness. Inflammation is present even in lesions that look purely comedonal, which is why an anti-inflammatory agent often helps a face that looks "just blackheads". ## How a doctor grades it Grading is what decides whether the case is treatable online at all. The reviewing doctor is looking at three things. **Lesion type.** Comedonal (blackheads and whiteheads only), inflammatory (papules and pustules), or nodulocystic (deep, tender, larger lesions). The mix changes which agent is chosen first. **Severity.** Most clinical work uses a five-point Investigator's Global Assessment running from clear, through almost clear, mild and moderate, to severe. Mild and moderate acne is the range a topical medicine is expected to help. Severe inflammatory disease is not. **Sequelae.** Scarring — ice-pick, boxcar or rolling — and post-inflammatory hyperpigmentation or erythema. Scarring is the single finding that changes the answer most, because active scarring means the window for preventing permanent damage is closing and a topical medicine alone is not a proportionate response. The acne questionnaire runs to sixteen steps and carries sixteen individual blocking answers. A hard stop is not a rejection of you — it means the answer you gave describes something that should not be managed by an asynchronous review, and the doctor will say so rather than prescribe around it. Because the whole review is asynchronous — there is no video call and no telephone consultation — the photographs carry the weight that an in-person examination normally would. The [dermatology photo guide](/library/guides/dermatology-photos) covers what makes a photo gradeable. ## What a doctor may prescribe All three acne options are topical. A doctor may prescribe one of them after reviewing the case; which one, and whether any is appropriate, is their decision. Anticomedonal, antibacterial and anti-inflammatory in one molecule, and it also fades post-inflammatory pigment. Usually the gentlest of the three, and the one most often considered where pigmentation is part of the complaint. A retinoid paired with an oxidising antibacterial. The retinoid works on the microcomedone, the benzoyl peroxide on inflammation and bacterial load, and the pairing is a mainstay of moderate inflammatory acne. A topical antibiotic combined with benzoyl peroxide at 3% or 5%. The benzoyl peroxide is not optional decoration — it is what suppresses resistance to the antibiotic. Medicines are dispensed and paid for at a pharmacy of your choosing. Hi-Doctor does not sell or ship medicines; the [pricing page](/essentials/pricing) covers what the consultation fee itself includes. ## Oral acne medicines are out of scope This needs saying plainly, because it is the most common reason a case cannot be handled here. Hi-Doctor does not prescribe **any oral dermatology medicine**. That includes isotretinoin, oral antibiotics such as [doxycycline](/library/medicines/doxycycline) or lymecycline when they are being used for acne, hormonal treatments including the combined oral contraceptive pill, and [spironolactone](/library/medicines/spironolactone). Severe, nodular, cystic or scarring acne needs an in-person dermatology assessment, and that is what the doctor will recommend. Isotretinoin in particular requires baseline and repeat blood tests, a pregnancy-prevention programme where relevant, and face-to-face monitoring for mood and other effects. None of that is compatible with an asynchronous topical service, and no responsible online consultation should offer it. ## Realistic timelines Often the worst-looking phase. A retinoid causes dryness, flaking and stinging as the skin adjusts, and lesions that were already forming under the surface come up. This is expected, not a sign the treatment is failing. Irritation settles as tolerance builds. New lesions typically start appearing less often before the existing ones have finished clearing, so counting new spots is a better early signal than looking in the mirror. The point at which a topical treatment can be judged fairly. Twelve weeks of consistent use is the usual minimum before deciding whether an agent is working. Acne is a chronic condition with a natural course. Maintenance — usually a retinoid, at a reduced frequency — is what stops the microcomedone reforming. Stopping entirely when the skin looks clear is the most common cause of relapse. Post-inflammatory marks run on a much slower clock than the acne that caused them. Red marks fade over months; brown marks can take longer still, and both fade faster with daily sun protection. ## What does not work * **Scrubbing and astringents.** Physical exfoliation and alcohol toners damage the barrier and increase inflammation. They make skin feel clean and look worse. * **Spot-treating alone.** By the time a lesion is visible, the microcomedone that produced it formed weeks ago. Treatment is applied to the whole affected area, not to individual spots. * **Toothpaste, lemon juice and household remedies.** These are irritants. On darker skin tones, the irritation they cause is a reliable way to produce post-inflammatory hyperpigmentation that outlasts the spot. * **Assuming diet is the cause.** There is an association between high-glycaemic-load diets and acne, and a weaker one with skimmed milk, but neither is a treatment, and a restrictive diet is a poor substitute for a medicine that acts on the follicle. * **Stopping at the first sign of improvement.** See the maintenance point above. ## When to see someone in person Book a face-to-face appointment rather than an online review if you have deep tender nodules or cysts, any acne that is already leaving scars, acne with sudden severe onset, acne accompanied by marked hair loss, irregular periods or voice change in a woman, or acne that has not responded to two full courses of topical treatment. Sudden severe acne with fever and joint pain is a reason to seek urgent care the same day. ## Common questions Not strictly. The acne questionnaire lets you choose to send photos later, and the case is flagged internally as missing them. But a doctor grading acne without an image is working from your description alone, and the most likely outcome of an ungradeable case is that no prescription is issued. No. Isotretinoin and every other oral dermatology medicine are outside what Hi-Doctor prescribes. If your acne is severe enough to warrant it, the doctor will tell you that and refer you to in-person care. A retinoid commonly causes an initial period of dryness, peeling and an apparent increase in lesions over the first few weeks. It settles. What is not expected is severe burning, swelling or a spreading rash, and those are reasons to stop and message the doctor. Jawline and lower-face distribution in adult women is often described as hormonal in pattern. The topical options are the same, but a doctor may specifically ask about cycle regularity, excess hair growth and other androgenic signs, because those findings point towards an assessment that an online topical service cannot provide. The pregnancy step in the questionnaire exists for exactly this reason. Topical retinoids are not used in pregnancy. Other options may or may not be appropriate, and that decision belongs to the reviewing doctor, who needs to know before prescribing rather than after. Yes, and more than most people expect. Retinoids and azelaic acid both increase how reactive the skin is to ultraviolet light, and sunlight darkens the post-inflammatory marks that acne leaves behind. Daily broad-spectrum protection is part of the treatment, not an optional extra. ## Related reading * [Azelaic acid](/library/medicines/azelaic-acid) · [adapalene](/library/medicines/adapalene) · [benzoyl peroxide](/library/medicines/benzoyl-peroxide) · [topical clindamycin](/library/medicines/clindamycin-topical) * [How to apply a prescription topical](/library/guides/how-to-apply-topicals) * [Side effects of dermatology topicals](/library/guides/side-effects-dermatology) * [Taking your dermatology photos](/library/guides/dermatology-photos) * [Rosacea](/library/conditions/rosacea) — often confused with acne, and treated differently * [Safety and eligibility](/essentials/safety) · [how a consultation works](/essentials/how-it-works) ## Start a consultation Answer the acne questionnaire, upload your photos, and a registered doctor reviews the case. They decide whether a topical treatment is appropriate and which one — and declining is a normal outcome. See [what it costs](/essentials/pricing) and [how the review works](/essentials/how-it-works). This page is reference information, not medical advice and not a prescription. Whether a medicine is appropriate for you is decided by a registered doctor after reviewing your consultation.