Acne mimics: what else could it be?

Not all that is red and bumpy is acne! Acne can sometimes be tricky to tell apart from other conditions, including (although not limited to):

Demodex folliculitis:

• May be suspected if treatment for facial acne is failing to improve symptoms
• More common if you have a weakened immune system

Demodex folliculitis producing a rosacea-like rash on the face 

Folliculitis barbae

• Distribution/location: folliculitis barbae comes up in areas prone to shaving eg, beard area

A bacterial infection of the beard area follicles - folliculitis barbae 

Gram-negative folliculitis

• Often occurs in patients with pre-existing acne and looks like an acne flare-up
• Can result from long-term management of acne with antibiotics; consider if symptoms don’t get better with usual acne treatment

Gram negative folliculitis 

Malassezia folliculitis

• Comedones (eg, blackheads) are not seen in Malassezia folliculitis
• Usually very itchy
• Distribution: commonly affects chest, upper back

Malassezia folliculitis on the chest 

Rosacea

• Look for other symptoms of rosacea e.g. facial flushing, eye irritation, and telangiectasia (small red lines from visible blood vessels) — these are not typical of acne

Papulopustular rosacea - usually in an older age group than acne 

Keratosis pilaris

• Skin tends to be dry and rough in KP (sometimes called ‘strawberry skin’), rather than oily as in acne
• Distribution: KP is commonly seen on arms and legs

Red cheeks and small rough areas 

Hidradenitis suppurativa (HS)

• Distribution/location: HS tends to be found in skin folds such as the armpits and groin

Hurley Stage II hidradenitis suppurativa 

Pseudofolliculitis barbae (shaving bumps)

• Distribution/location: PFB is often seen in the beard area and is related to shaving.

Pseudofolliculitis - “shaving bumps” often seen in those with black skin 

Perioral dermatitis

• Distribution: limited to around the mouth (or around the eyes in periocular dermatitis; perioral and periocular dermatitis can also occur together).
• Perioral dermatitis sometimes burns or feels itchy.

Small spots that surround the mouth 

Angiofibroma

• Seen in a condition called tuberous sclerosis.

Small blood vessel tumours 

Medications (such as steroids) and other medical conditions (such as polycystic ovarian syndrome) can also cause acne.

If your acne is stubborn, severe, or widespread, it is a good idea to see your doctor to discuss whether something else could be going on, and to review your current treatment.

For more information about acne and its treatment, see:

• Acne (overview)
• How to get rid of acne
• How to get rid of back acne
• Acne scars and how to get rid of them