Severe Acne Scales - How Severe is Your Acne?


Lesson 8

Is your acne bad? Is your acne severe? How severe is your acne – is it severe in each location?

Isn’t all acne severe?

Doctors have created different scales to measure how just how severe acne is for each case  – but no scale is standard.

Regardless, it is very important for you to know how bad your acne is (or your client’s if you are a skin care professional) so it can be properly treated.

Acne can be measured using such terms as light, mild, medium or severe.

In this lesson you will learn how acne is classified or graded by doctors.

You can use their acne severity scales to determine the severity level of your acne.How-severe-is-your-acne-scales

This will help you in two ways:

1. It will help determine what kind of treatment to start with, and –

2. It will allow you to monitor the improvement of  your skin once you begin treatment.

If you acne is light – then don’t start your treatment as if it were severe.

On the other hand, if your acne is severe then you want to move up the strength of your treatment expeditiously as you skin adapts to the medicines and treatment skills that are offered.

If your acne is not improving when it should during your treatment then you’ll know to notify your doctor right away, then most likely jump to a higher stage of treatment under your doctor’s supervision.

Nothing is more horrifying than reading forum comments from a young people who are devastated by acne that does not improve for months and months – without ever changing their treatment program.

Sadly, this happens all to often!

If your acne does not improve in a few weeks – then the treatment is not working and it needs to be changed.

In other words – your acne needs to be moving down the “Acne Severity Scale”…


Unbelievably, there are in existence today over 25 different scales from around the world that grade the severity of acne.

And, amazingly – doctors do not yet agree on which scale should be the standard.

One of the several important questions to ask your doctor is,  “what is the severity of my acne – and which scale is being used?”.

You want to know the scale of your acne so you can have a starting point for treatment.

You want to know where you are starting – so you can know where you are going to end up (which will always be acne-free with clear skin).

You will want to monitor the your skin’s healing process week by week – as you progress  DOWN the scale – to clear skin!

The scale you or your doctor is using really does not matter too much – it’s the PROGRESS down the scale over a CERTAIN amount of time that is important

Movement down the scale is the acne healing process.

Let’s go over a few of the more popular acne grading scales now – so you have some idea what they are and how they work so you can use them yourself, and understand what your doctor may be talking about.

First it is important to understand that acne severity can be graded in several different ways:

  • Type of lesions – grading technique
  • Number of lesions – counting technique
  • Distribution on the face – chin, cheeks, nose, forehead
  • Location on the body – neck, arms, back, chest
  • Gender – women can experience a very specific hormonal induced acne
  • Affect on your quality of life – don’t care to devastated and socially isolated
  • A combination of each of these

These are the names of some of the acne grading scales you may come across:How-severe-is-your-acne-vintage-scales

  • Leeds scale
  • Burton scale
  • Cook’s scale
  • Pillsbury scale
  • European scale
  • Global Acne Grading System (GAGS)
  • US FDA scale

Here is a brief description of how these different acne scales grade acne:

Leeds scale –

Counts and categorizes acne sores into inflammatory and non-inflammatory types in to a range of 0 to 10, can be compared to photographs.

Burton scale –

Uses grades from 1 – 6 using the type of lesions, their numbers and location on the body, acne may be classified as mild, moderate or severe.

Comedones and inflammatory lesions are usually considered separately:

Grade I – sub-clinical acne (home treatment or no treatment), a few closed comedones (whiteheads), and open comedones, (blackheads).

Grade II – comedonal acne, areas of papules, that are small, solid red bumps on the skin surface.

Grade III – mild acne, when the papules are inflamed with some as pustules, containing pus, which is the result of rapid bacterial expansion.

Grade IV – moderate acne,  many inflamed papules & pustules

Grade V – severe nodular acne, inflamed papules & pustules with several deep nodular lesions, which can cause permanent damage to the dermis – which means acne scars.

Grade VI – severe cystic acne, or severe back acne, many nodular cystic lesions and scaring, permanent alteration of the dermis.

Pillsbury scale –How-Severe-is-Your-Acne-women

Classifies the severity of the acne from 1, least severe,  to 4, most severe.

Grade 1: Comedones and occasional small cysts confined to the face.

Grade 2: Comedones with occasional pustules and small cysts confined to the face.

Grade 3: Many comedones and small and large inflammatory papules and pustules, more extensive but confined to the face.

Grade 4: Many comedones and deep lesions tending to join together into a continuous area and involving the face and the upper of the trunk, such as the chest, neck, arms, & back.

Cook’s scale –

Uses photographs to grade and compare the patient’s severe acne using severity from 0 to 8,  0 being the least severe and 8 being the most severe.

Global assessment scale

0 – Normal, clear skin with no evidence of acne vulgaris

1 – Skin is almost clear, some non-inflammatory lesions present, with some non-inflamed papules, papules must be developing and may be showing color, although not yet pink-red

2 – Some non-inflammatory lesions are present, with a few inflammatory lesions, papules/pustules only, but no nodulo-cystic lesions

3 – Non-inflammatory lesions predominate, with multiple inflammatory lesions evident,  several to many comedones and papules/pustules, and there may or may not be one small nodulo-cystic lesion in a certain area

4 – Inflammatory lesions are more apparent,  many comedones and papules pustules, there may or may not be a few nodulo-cystic lesions

5 – Highly inflammatory lesions predominate the area with a variable number of comedones, many papules/pustules and nodulo-cystic lesions

EU Guidelines (European Union) –How-Severe-is-Your-Acne-men

Simple clinical classification:

Comedonal acne – non-inflammatory whiteheads and blackheads.

Mild – moderate papulopustular acne

Severe papulopustular acne – moderate nodular acne

Severe nodular acne – conglobate acne

The Global Acne Grading System (GAGS)  –

Uses math to calculate a severity number:

First each area is assigned a number or a factor based on how many pilosebaceous     units are in that area:

-forehead and each cheek is 2
-chin and nose is 1
-chest and upper back is 3

Then, each of the above factors are multiplied against a number for the type of sores in that region:

1 for ≥ one comedo
2 for ≥ one papule
3 for ≥ one pustule
4 for ≥ one nodule

US FDA (United State Food and Drug Administration) –How-Severe-is-Your-Acne-surveyor

Uses a five-category descriptive scale:

  • Clear – indicating no inflammatory or noninflammatory lesions
  • Almost clear – rare noninflammatory lesions with no more than one papules/pustule
  • Mild – some noninflammatory lesions, no more than a few papules/pustules but no nodules
  • Moderate – up to many noninflammatory lesions, may have some inflammatory lesions, but no more than one small nodule
  • Severe – up to many noninflammatory and inflammatory lesions, but no more than a few nodules


It does not really matter which scale you use, the key point is that you understand the stage of your acne and what is going on under your skin.

If you have only white heads and blackheads then you have plugged up pores.

If you are showing some bumps and redness then the bacteria has entered the exponential stage and are damaging the walls of your follicles.

If you have pus filled sores then the you have an advanced bacterial infection in your pores at the dermis level and above.

The bacteria are well in to the exponential stage of growth as evidenced by the pus which is the waste products of bacteria, and other species such as staph and p. acnes sub-species may be further damaging your skin tissue.

If you have wide connected areas of cysts and nodules then you have a severe multi-level, multi-stage bacterial infection of the skin with with all the stages of acne occurring at the same time, and all the stages of bacterial growth occurring throughout all of your skin layers.

You should be under the care of a qualified, and fully engaged doctor if you have mild acne or worse and if your have any type of acne other than common acne vulgaris.

You should begin a step-by-step treatment program to determine which products, medications and applications will solve your case of acne.

You should be moving down the acne severity scale certainly after two to three weeks of proper treatment.

You can prove your acne is changing or not changing with this very simple technique…

Take a picture of your acne.How-Severe-is-Your-Acne-George-Clooney

Take a “right now” photo.

Then take a photo in a couple of weeks after treatment.

The Acne Project treatment checklist and calendar that you can download from the right sidebar guides through this.

Put the photos side by side and judge for yourself – what grade is your acne in each photo?

Do you see a significant change in your acne severity?

If you don’t – you should see a doctor, and change your treatment.

If you see a significant change – you should likely continue treatment until you are clear, then enter the clear skin maintenance stage.

Now – let’s see if you can pass this test…

Severe Acne Knowledge test

1. What are the various ways acne can be graded?

2. What are some of the names of a few acne grading scales?

3. What might be a description of acne on the following made-up scale?

  • Clear or 0
  • Mild, non-inflammatory or 1-ish to 2-ish
  • Moderate, inflammatory or 3-ish to 4-ish
  • Severe, nodular or cystic acne, 5-ish to 6-ish

4. What grade is your acne?

5. What grade of acne do other people have that you can observe?

6. What is your acne treatment goal? (hint – it is to be clear or scale number 0)

Did you pass the test?

Of course you did! Great job! You are progressing well through these lessons – but keep it going…

You need to start your treatment plan very soon!

See you in the next lesson…Lesson 9!

Brendon and The Acne Project Research Team

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More Resources

US National Library of Medicine – National Institutes of Health – Acne Grading Scales

YouTube Videos – Acne Severity



  1. Brendon Amundson says:

    Did you doctor tell you what scale he or she is using and what grade your acne is?

    Did he or she look at you with a dumbfounded or surprised look?

    Tell us your experiences!

    (We’ve heard lots of funny stories)

Talk To US!