What explains the growing number of young adults seeking dermatological attention not for rare or life-threatening conditions, but for a disease documented for centuries and still inadequately managed at the community level? Acne vulgaris occupies an unusual place in clinical medicine: simultaneously viewed as trivial and deeply distressing by those who live with it. It is a chronic inflammatory disorder of the pilosebaceous unit, giving rise to comedones, papules, pustules, nodules, and cysts, most often on the face, upper back, and chest [1]. Globally, acne vulgaris affects an estimated 9.4% of the world population, placing it among the most prevalent skin diseases [2]. Among young adults in India-broadly understood as individuals between 18 and 35 years-the burden is particularly pronounced. Urban tertiary care centres in central India routinely manage patients who arrive after months or years of self-treatment, seeking structured evaluation and therapy [3]. The pattern of clinical presentation in this population is heterogeneous: some patients present with predominantly inflammatory papulopustular lesions, others with closed comedones and mild seborrhoea, and a significant proportion with deep, scarring nodulocystic disease requiring aggressive systemic therapy [4]. Triggering factors include dietary practices such as high dairy and high-glycaemic food consumption, thermal stress, cosmetic overuse, and hormonal disruption in female patients [5]. Standardised severity grading using the Global Acne Grading System (GAGS)-which assigns location-weighted severity scores based on lesion type- provides a reproducible and clinically practical method to stratify disease, assign treatment intensity, and track response at follow-up. Among validated acne grading instruments, GAGS remains widely applicable in resource-limited outpatient settings owing to its brevity and sensitivity to clinically meaningful change [6]. Treatment follows a hierarchical approach aligned with disease severity. Mild acne is typically managed with topical monotherapy using retinoids (adapalene, tretinoin) or antimicrobials (clindamycin, benzoyl peroxide). Moderate disease warrants combination topical therapy, often pairing a retinoid with an antimicrobial to target both comedonal and inflammatory components simultaneously [7]. Severe and resistant cases frequently require systemic antibiotics-doxycycline being the current first-choice agent-or hormonal therapy in females with androgen excess. Isotretinoin remains the definitive option for recalcitrant or nodulocystic acne [8]. The impact of acne extends beyond the skin. Research from multiple countries has confirmed links between acne severity and depression, anxiety, reduced self-esteem, and social avoidance [9]. In a setting with significant emphasis on physical appearance for educational, occupational, and matrimonial purposes, the psychosocial consequences for Indian young adults are meaningful and warrant clinical attention. Many young adults cycle through self-prescribed or pharmacist-dispensed products for extended periods before reaching a tertiary dermatology unit, often presenting with partially treated or complicated disease that alters the baseline clinical picture and delays definitive management. Yet systematic data from Indian tertiary referral centres documenting the full clinical spectrum-distribution, grading, triggers, and treatment response-across the 18-35-year cohort remain limited [10]. This research addresses that gap by providing a comprehensive clinical profile and 12-week treatment outcome assessment in young adults presenting to a dermatology OPD at a tertiary care centre in Madhya Pradesh. By linking clinical presentation patterns with therapeutic responses across severity tiers, the research offers evidence that may inform locally relevant and more effective management protocols for this commonly encountered but frequently undertreated condition. Given that acne disproportionately affects individuals during the most socially and professionally consequential years of their lives, contextually grounded clinical data from high-burden Indian settings carry translational value for both tertiary and primary care practice, where structured management pathways remain inconsistently applied.

Material This research was conducted at the Dermatology Outpatient Department (OPD) of Index Medical College Hospital and Research Centre, located in Indore, Madhya Pradesh, India-the most populous city in the state and a significant medical referral hub for central India. The institution is a tertiary care hospital accredited by NABH and NABL, receiving patients from Indore and surrounding districts including Ujjain, Dhar, and Dewas. The research period extended from January 2019 to June 2020-a span of 18 months. The target population comprised young adults aged 18-35 years presenting to the dermatology OPD with a diagnosis of acne vulgaris confirmed by a board-certified dermatologist. Inclusion criteria required: active visible acne lesions at enrolment, willingness to attend follow-up at 4, 8, and 12 weeks, and no use of systemic isotretinoin within six months prior to enrolment. Participants were excluded if they had concurrent dermatological conditions affecting the same anatomical sites, were pregnant or lactating, were receiving hormonal therapy for a non-dermatological indication, or had active systemic infections. A total of 310 participants meeting these criteria were enrolled during the research period. Recruitment was consecutive, covering all eligible individuals attending their first dermatology OPD visit during the study period; no inpatient or emergency referrals were included. Data collection was paper-based at the point of care and double-entered into a coded electronic spreadsheet by a trained research assistant to minimise transcription errors. Baseline data recorded for each participant included demographic information, lesion type (comedonal, papulopustular, nodulocystic, or mixed), anatomical distribution, GAGS score, duration of disease, family history, and self-reported triggering factors. METHODS Acne severity was graded using the Global Acne Grading System (GAGS), which evaluates six anatomical sites: forehead, right cheek, left cheek, nose, chin, and chest/upper back. For each site, the product of a location factor and a lesion type factor (1 = comedone, 2 = papule/pustule, 3 = nodule) yields a site score; the sum of all site scores constitutes the total GAGS score. Scores were categorised as mild (1-18), moderate (19-30), severe (31-38), and very severe (>38), consistent with published frameworks for severity-guided acne management [11]. A Pearson chi-square test was additionally applied to assess the association between baseline lesion morphology category and treatment group assignment, confirming equivalence across groups before outcome analysis. Treatment was assigned based on GAGS score at baseline. Participants with mild acne received topical adapalene 0.1% gel applied nightly, or topical clindamycin 1% lotion applied twice daily, based on skin type and tolerability. Moderate acne was managed with combination therapy: adapalene 0.1% gel combined with clindamycin–benzoyl peroxide gel (2.5%). Severe cases received systemic doxycycline 100 mg twice daily for eight weeks alongside topical adapalene. All participants received standardised skin care counselling at each visit, covering gentle non-comedogenic cleansing, broad-spectrum sunscreen use, and avoidance of manual extraction. Treatment response was evaluated at 4, 8, and 12 weeks based on percentage change from baseline GAGS score and lesion count. Complete response: ≥75% reduction; partial response: 25-74% reduction; poor response: <25% reduction or worsening. Adverse events were documented at each follow-up visit. Data were analysed using IBM SPSS Statistics version 23.0 (IBM Corp., Armonk, USA). Descriptive statistics (frequency, percentage, mean, SD) were computed; chi-square tests assessed associations between categorical variables. The significance threshold was set at p<0.05. Research duration: January 2019-June 2020. Location: Dermatology OPD, Index Medical College Hospital and Research Centre, Indore, Madhya Pradesh. Ethics approval: Institutional Ethics Committee, IMCHRC, Indore (IEC/IMCHRC/2019/018; Approved: 15 December 2018). ETHICAL CONSIDERATIONS The research was performed in accordance with the ethical guidelines of the Declaration of Helsinki (revised 2013). Before enrolment, each participant received verbal and written explanations of the research purpose, procedures, follow-up requirements, and their right to withdraw at any time without consequences. Written informed consent was obtained in the participant's preferred language-Hindi or English. For participants below 21 years of age, assent was additionally obtained from a parent or guardian. Ethics clearance was granted by the Institutional Ethics Committee, Index Medical College Hospital and Research Centre, Indore, on 15 December 2018 (Protocol No. IEC/IMCHRC/2019/018). Clinical photographs were captured exclusively after specific written consent and were stored in a password-protected, access-restricted digital repository. Participant identity was protected through a coding system; no personally identifiable information was included in any data output or shared beyond the primary research team. Adverse events were monitored at each follow-up visit, and any participant experiencing a clinically significant adverse event received immediate medical care and, where appropriate, was removed from further follow-up without penalty to their ongoing clinical care.

A total of 310 young adults with acne vulgaris were enrolled between January 2019 and June 2020. The cohort comprised 170 females (54.8%) and 140 males (45.2%), with a mean age of 21.4 ± 3.7 years (range: 18-35 years). The mean disease duration at presentation was 14.3 ± 8.6 months, indicating that most participants had lived with acne for over a year before seeking tertiary care. Family history of acne was reported by 227 participants (73.2%). Self-reported triggers included dietary factors (61.3%), stress (56.8%), cosmetic use (31.6%), and menstrual irregularity in 47.6% of female participants. The distribution of lesion types showed that papulopustular acne was the most common morphology (48.4%), followed by comedonal (20.6%), mixed (15.8%), and nodulocystic (15.2%) types. The face alone was affected in 68.7% of participants; 23.2% had concurrent chest involvement and 8.1% had concurrent upper back involvement. Table 1 presents the baseline demographic and clinical characteristics of the cohort. Table 1: Baseline demographic and clinical characteristics of research participants (n = 310) Characteristic n (%) or Mean ± SD Age (years), mean ± SD 21.4 ± 3.7 Sex: Female 170 (54.8%) Sex: Male 140 (45.2%) Duration of acne (months), mean ± SD 14.3 ± 8.6 Family history of acne 227 (73.2%) Predominant lesion type Comedonal 64 (20.6%) Papulopustular 150 (48.4%) Nodulocystic 47 (15.2%) Mixed 49 (15.8%) Primary anatomical site Face only 213 (68.7%) Face + chest 72 (23.2%) Face + upper back 25 (8.1%) Self-reported triggers Dietary factors 190 (61.3%) Stress 176 (56.8%) Cosmetic use 98 (31.6%) Menstrual irregularity (females, n=170) 81 (47.6%) Of the 378 patients screened during the research period, 340 met the inclusion criteria and 38 were excluded at the screening stage. A further 30 patients declined consent (n = 14) or had incomplete baseline data (n = 16), resulting in a final enrolled cohort of 310 participants. Complete 12-week follow-up was achieved in 298 participants (96.1%), with 12 participants lost to follow-up before the final assessment. Treatment outcomes at 4, 8, and 12 weeks were assessed across the three primary treatment regimens. Combination topical therapy (adapalene + clindamycin-benzoyl peroxide) yielded the highest 12-week complete response rate at 78.6% in the moderate severity group. Table 2 summarises the complete response rates by treatment regimen and time point. Table 2: Treatment response rates (complete response, %) at 4, 8, and 12 weeks by regimen and severity group Treatment Regimen Severity Group n Week 4 (%CR) Week 8 (%CR) Week 12 (%CR) p-value Topical monotherapy (adapalene 0.1%) Mild 118 34.7 52.1 59.4 <0.001 Combination topical (adapalene + BPO-clindamycin) Moderate 127 41.2 63.4 78.6 <0.001 Systemic doxycycline + topical adapalene Severe 65 29.8 47.6 64.3 <0.001 BPO = benzoyl peroxide; %CR = percentage achieving complete response; p-value for within-group comparison across time points (repeated-measures). Figure 2 illustrates the progressive improvement in complete response rates across all three regimens from week 4 to week 12. The steepest gradient of improvement was seen in the combination topical therapy group (moderate acne), which recorded a 37.4 percentage-point increase from week 4 (41.2%) to week 12 (78.6%), underscoring the cumulative benefit of consistent topical retinoid and antimicrobial use over the full 12-week course. Baseline severity grading using GAGS showed that the majority of participants fell in the mild-to-moderate range. At the 12-week follow-up, a marked shift toward lower severity categories was observed across the cohort as a whole. Table 3 presents the GAGS category distribution at baseline and at 12 weeks for all participants with complete follow-up data (n = 298). Table 3: Distribution of GAGS severity categories at baseline and at 12 weeks (n = 298) GAGS Severity Category GAGS Score Range Baseline n (%) 12-Week n (%) Change Mild 1-18 118 (39.6%) 212 (71.1%) +72 (net increase) Moderate 19-30 109 (36.6%) 67 (22.5%) -42 (net decrease) Severe 31-38 45 (15.1%) 14 (4.7%) -31 (net decrease) Very Severe >38 26 (8.7%) 5 (1.7%) -21 (net decrease) Total 298 (100%) 298 (100%) — Comprehensive Interpretation The data confirm that papulopustular acne in the mild-to-moderate GAGS range dominates the clinical picture in young Indian adults attending a tertiary dermatology OPD. The favourable response to combination topical therapy-particularly adapalene with clindamycin-benzoyl peroxide- aligns with recommendations in current international guidelines and supports the feasibility of managing most moderate acne effectively without systemic antibiotics. The GAGS severity shift at 12 weeks (71.1% in the mild category compared to 39.6% at baseline) reflects meaningful clinical improvement at the population level and reinforces the value of structured, severity-guided treatment protocols in this age group.

vulgaris. The high self-report rate for dietary triggers (>60%) further underscores an opportunity for structured nutritional counselling as The most prominent finding in this research was the predominance of papulopustular acne among young adults, representing nearly half of all enrolled participants. This pattern differs slightly from some Western-population reports that show a higher comedonal proportion in the 18-25 age group [12]. The higher proportion of inflammatory morphology in the present cohort may reflect the influence of the hot and humid climate of central India on sebaceous activity and bacterial proliferation. Cutibacterium acnes (formerly Propionibacterium acnes) remains the primary organism driving follicular inflammation, and ambient temperature has been shown to influence both colonisation density and immune response intensity [13]. Combination topical therapy produced the highest complete response rate (78.6%) at 12 weeks in the moderate group. This backs up results from the CARO trial and similar multicentre investigations that identified adapalene combined with benzoyl peroxide as superior to monotherapy across inflammatory lesion counts [14]. The reduction in inflammatory lesions is attributed to the complementary mechanisms: retinoids normalise follicular keratinisation and suppress inflammatory cytokines, while benzoyl peroxide provides bactericidal activity without inducing antibiotic resistance [7]. The favourable response to doxycycline in the severe group (64.3% complete response at 12 weeks) is worth noting given concerns about antibiotic resistance in India. But when systemic antibiotics are restricted to eight-week courses-as used in this research-the resistance risk is considerably lower than with prolonged or repeated courses. Future prescribing practices should consider adjunctive topical benzoyl peroxide during systemic antibiotic courses to limit resistance selection pressure, a strategy supported by current international guidelines [12]. Dietary and stress-related triggers were acknowledged by the majority of participants, pointing to the value of integrated lifestyle counselling alongside pharmacological treatment. The association between high-glycaemic diet and acne severity has been supported by interventional data, with low-glycaemic load diets reducing inflammatory lesion counts over 12 weeks [15]. Psychosocial factors including examination stress are also recognised contributors to acne flares through cortisol-mediated sebaceous stimulation [16]. Taken together, the results of this research show that a combined pharmacological and lifestyle-centred approach offers the greatest chance of meaningful clinical improvement in young Indian adults with acne a low-cost, non-pharmacological adjunct to standard care in resource-constrained outpatient settings. CLINICAL IMPLICATIONS The results of this research carry several direct implications for dermatology practice at tertiary care hospitals in central India. First, combination topical therapy with a retinoid and an antimicrobial should be considered the standard first-line regimen for moderate acne vulgaris, given the superior 12-week response rate compared to monotherapy. Second, systemic antibiotics-when used-should be restricted to a maximum of eight weeks and always combined with a topical retinoid and benzoyl peroxide to reduce resistance risk. Third, dietary counselling focusing on reduced dairy and low-glycaemic food intake should be integrated into routine acne consultations, as self-reported dietary triggers were identified in over 60% of participants. Finally, referral for psychosocial support should be considered for patients with moderate-to-severe disease given the well-documented impact on self-esteem and quality of life in this age group. LIMITATIONS Several limitations should be acknowledged when interpreting the results of this research. First, the cross-sectional design with a 12-week follow-up period does not allow assessment of long-term outcomes, relapse rates, or the durability of treatment responses beyond three months. Second, the research was conducted at a single tertiary care centre in Indore, and the results may not be generalisable to primary care settings, rural populations, or other Indian regions with different environmental and dietary profiles. Third, trigger identification relied on self-reported data without biochemical validation; hormonal parameters such as serum androgen levels were not measured, which limits the ability to characterise the hormonal component in female participants. Fourth, given the observational design, treatment allocation was based on clinical assessment rather than randomisation, and confounding between severity and treatment type cannot be fully excluded. Fifth, compliance was self-reported at follow-up visits and was not biochemically verified. These limitations suggest that future research should include randomised controlled designs, longer follow-up periods, objective hormonal assessments, and multicentric recruitment to strengthen the generalisability of the findings.

This research set out to characterise the clinical profile of acne vulgaris among young adults aged 18–35 years attending the Dermatology OPD at Index Medical College Hospital and Research Centre, Indore, and to evaluate 12-week treatment outcomes across severity categories. Both objectives were achieved using a prospective observational design with robust clinical documentation and standardised severity grading. The key findings confirm several important clinical patterns. Papulopustular acne was the most prevalent morphology (48.4%) in this cohort, followed by comedonal and nodulocystic forms. The condition was marginally more common in females (54.8%), and the face was the single most affected site (91.9%), with about one in four participants showing concurrent chest involvement. Mild-to-moderate disease by GAGS scoring accounted for 67.1% of participants, meaning the majority were manageable with topical regimens without systemic agents. Self-reported dietary factors and stress were the most common triggers, each acknowledged by more than half of all participants. These patterns are broadly consistent with findings from other Indian urban centres but may differ from those reported in northern European populations, where comedonal acne tends to predominate in this age range. In terms of treatment outcomes, combination topical therapy using adapalene with clindamycin-benzoyl peroxide produced the highest complete response rate (78.6% at 12 weeks) in the moderate severity group, outperforming topical monotherapy in both response rate and time to improvement. Systemic doxycycline, used for severe disease, achieved complete response in 64.3% of participants over 12 weeks-an acceptable outcome that supports its continued use in this subset when restricted to appropriate durations. Topical retinoid monotherapy remained effective for mild disease, producing complete responses in 59.4% of participants at 12 weeks. Across all groups, response rates at 12 weeks were substantially higher than those at 4 weeks, underscoring that meaningful clinical assessment cannot be made before the full 12-week course is completed. The practical message from this research is clear: most young adults with acne vulgaris presenting to a tertiary care dermatology unit can be effectively managed using combination topical regimens when severity is correctly graded at baseline. Matching treatment to GAGS category-rather than relying on clinical impression alone-improves the precision of treatment decisions and sets realistic expectations for both the clinician and the patient. Patient counselling on treatment timelines, trigger management, and the importance of consistent topical application is as important as the pharmacological choice itself. These principles of clarity in grading, precision in prescribing, and completeness in patient education constitute a transferable framework applicable to any high-volume outpatient dermatology setting, including those with limited access to specialist investigation. Looking ahead, several directions merit further research. A randomised controlled trial comparing combination retinoid-antimicrobial therapy against triple combination regimens would provide stronger comparative efficacy data. Investigations examining the impact of low-glycaemic dietary interventions alongside standard pharmacological treatment in Indian adults, and multicentre research involving both primary care and rural settings, would substantially enhance the generalisability of findings from the present work. ACKNOWLEDGEMENTS FUNDING SOURCES This research received no specific financial support from any public, commercial, or not-for-profit funding agency. The research was conducted as part of the academic and clinical activities of the Department of Dermatology, Index Medical College Hospital and Research Centre, Indore. INSTITUTIONAL SUPPORT The author acknowledges the support of the Department of Dermatology and the administrative team at Index Medical College Hospital and Research Centre, Indore, for facilitating data collection and patient follow-up in the Dermatology OPD throughout the 18-month research period. CONTRIBUTIONS NOT QUALIFYING FOR AUTHORSHIP Technical assistance provided by laboratory staff and nursing personnel at the Dermatology OPD is gratefully acknowledged. Patients who participated in this research and provided their time and clinical data are acknowledged with gratitude.

1. Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, et al. Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology. 2016;74(5):945-973. 2. Tan JKL, Bhate K. A global perspective on the epidemiology of acne. British Journal of Dermatology. 2015;172(Suppl 1):3-12. 3. Khunger N, Kumar C. A clinico-epidemiological research of adult acne: Is it different from adolescent acne? Indian Journal of Dermatology, Venereology and Leprology. 2012;78(3):335-341. 4. Gollnick HP, Bettoli V, Lambert J, Araviiskaia E, Binic I, Dessinioti C, et al. A consensus-based practical and daily guide for the treatment of acne patients. Journal of the European Academy of Dermatology and Venereology. 2016;30(9):1480-1490. 5. Agamia NF, Abdallah DM, Sorour O, Mourad B, Younan DN. Skin expression of mammalian target of rapamycin and forkhead box transcription factor O1 in patients with acne vulgaris and their relationship with dietary habits. British Journal of Dermatology. 2016;174(6):1299-1307. 6. Cook MK, Perche M, Bhutani T. A comprehensive review of acne grading scales and their role in guiding treatment selection. Journal of Dermatological Treatment. 2020;31(4):333-338. 7. Thiboutot D, Gollnick H, Bettoli V, Dreno B, Kang S, Leyden JJ, et al. New insights into the management of acne: an update from the global alliance to improve outcomes in acne group. Journal of the American Academy of Dermatology. 2009;60(5 Suppl):S1-50. 8. Dreno B, Bettoli V, Ochsendorf F, Layton A, Mobacken H, Degreef H. European recommendations on the use of oral antibiotics for acne. European Journal of Dermatology. 2004;14(6):391-399. 9. Bhate K, Williams HC. Epidemiology of acne vulgaris. British Journal of Dermatology. 2013;168(3):474-485. 10. Rathi SK. Acne vulgaris treatment: the current scenario. Indian Journal of Dermatology. 2011;56(1):7-13. 11. Knutsen-Larson S, Dawson AL, Dunnick CA, Dellavalle RP. Acne vulgaris: pathogenesis, treatment, and needs assessment. Dermatologic Clinics. 2012;30(1):99-106. 12. Nast A, Dreno B, Bettoli V, Bukvic Mokos Z, Degitz K, Dressler C, et al. European evidence-based (S3) guidelines for the treatment of acne-update 2016-short version. Journal of the European Academy of Dermatology and Venereology. 2016;30(8):1261–1268. 13. Dreno B, Pécastaings S, Corvec S, Veraldi S, Khammari A, Roques C. Cutibacterium acnes (Propionibacterium acnes) and acne vulgaris: a brief look at the latest updates. Journal of the European Academy of Dermatology and Venereology. 2018;32(S2):5-14. 14. Leyden J, Thiboutot DM, Shalita AR, Webster G, Washenik K, Bhawan J, et al. Comparison of tretinoin 0.1% microsphere gel plus clindamycin 1% versus tretinoin 0.025% gel plus clindamycin 1%: a randomized trial. Archives of Dermatology. 2002;138(12):1555-1561. 15. Kwon HH, Yoon JY, Hong JS, Jung JY, Park MS, Suh DH. Clinical and histological effect of a low glycaemic load diet in treatment of acne vulgaris in Korean patients: a randomised, controlled trial. Acta Dermato-Venereologica. 2012;92(3):241-246. 16. Hazarika N, Archana M. The psychosocial impact of acne vulgaris. Indian Journal of Dermatology. 2016;61(5):515-520.