Cutibacterium acnes and Acne Vulgaris: A Narrative Review of Epidemiology, Pathogenesis, Diagnosis, Management, and Future Perspectives

Abstract

Background and Aims: Acne vulgaris is among the most prevalent inflammatory skin disorders worldwide and represents a substantial source of dermatologic morbidity and psychosocial distress, particularly among adolescents and young adults. This narrative review aimed to synthesize contemporary evidence on the epidemiology, molecular microbiology, pathogenesis, clinical diagnosis, management, prevention, and psychosocial burden of acne vulgaris, while also examining unresolved questions and emerging concepts that may inform future therapeutic strategies.

Methods: The review was conducted in accordance with the principles of the SANRA (Scale for the Assessment of Narrative Review Articles). A structured literature search was performed in PubMed/ MEDLINE to identify the relevant publications addressing the microbiology of Cutibacterium acnes, the pathogenesis, epidemiology, diagnosis, management, prevention, and psychosocial impact of acne vulgaris with the search concluding on 1 March 2026.

Results: Acne vulgaris arises from a multifactorial disruption of the pilosebaceous unit involving increased sebum production, follicular hyper-keratinization, microbiome alterations, and dysregulated immune responses. Disease expression reflects bacterial overgrowth in addition to the relative abundance and strain-level heterogeneity of Cutibacterium acnes, alongside functional shifts in the cutaneous microbiota. These changes activate inflammatory pathways that drive lesion formation and clinical heterogeneity. Molecular studies identified key virulence factors including lipases, porphyrins, and biofilm formation that interact with host immunity to sustain inflammation. Diagnosis remains primarily morphological, with severity grading guiding therapy. Management targets multiple pathogenic pathways using combination regimens that include topical retinoids, benzoyl peroxide, antimicrobials, hormonal therapies, and systemic agents. Oral isotretinoin remains the most effective treatment for severe acne due to its pleiotropic effects, although it requires careful monitoring because of adverse effects and teratogenicity. Increasing antimicrobial resistance highlights the importance of antibiotic stewardship. Emerging management and prevention strategies include microbiome-modulating approaches (e.g., bacteriophages and targeted peptides), vaccines against C. acnes virulence factors, and artificial intelligence–assisted diagnostic tools. The substantial psychosocial burden, including anxiety and depression, is increasingly recognized.

Conclusions: Acne vulgaris is best conceptualized as a complex disorder of the pilosebaceous unit that reflects the convergence of dermatologic, microbiologic, endocrine, immunologic, and psychosocial processes. Advances in microbiome research, immunology, and sebaceous gland biology are redefining the conceptual framework of acne pathogenesis and may enable future therapies that specifically modulate microbial and inflammatory pathways. Such innovations hold promise for transformative strategies for acne vulgaris prevention and management.

Keywords: Acne Vulgaris; Cutibacterium acnes; Skin Microbiome; Pilosebaceous Unit; Acne Pathogenesis; Acne Diagnosis; Acne Management; Dermatologic Inflammation

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