Acne Vulgaris Associated with Metabolic Syndrome: A Three-Case Series Highlighting Pathophysiological Links and Therapeutic Challenges

<b>Background and Clinical Significance</b>: As a common inflammatory skin disorder, acne vulgaris is classically associated with sebum overproduction, follicular hyper keratinization, and <i>Cutibacterium acnes</i> proliferation. Emerging evidence suggests a link between severe or treatment-resistant acne and metabolic syndrome, characterized by central obesity, insulin resistance, dyslipidemia, and hypertension. This case series aims to explore the clinical overlap between acne and metabolic dysfunction and highlight the relevance of multidisciplinary evaluation. <b>Case Presentation</b>: Three patients with severe acne vulgaris and coexisting metabolic abnormalities were evaluated at a dermatology clinic in Oradea, Romania, between 2023 and 2024. Each patient underwent dermatologic examination, laboratory testing for metabolic and hormonal parameters, and individualized treatment. Management strategies included topical/systemic acne therapies combined with metabolic interventions (lifestyle modifications, metformin (in two cases), and lipid-lowering agents). Case 1 (female, 23) had obesity, insulin resistance, dyslipidemia, and polycystic ovary syndrome (PCOS). Case 2 (male, 19) presented with central obesity and atherogenic dyslipidemia. Case 3 (male, 18) showed insulin resistance, overweight status, and elevated inflammatory markers. All three showed suboptimal response to standard acne treatment. Adjunct metabolic management resulted in partial improvement within 3 months. One patient required isotretinoin after metabolic stabilization. <b>Conclusions</b>: These cases underscore the interplay between acne and metabolic dysfunction. Insulin resistance and systemic inflammation may contribute to therapeutic resistance in acne. Early recognition of metabolic syndrome features in patients with severe acne may improve treatment outcomes. Dermatologists should consider metabolic screening to guide comprehensive, multidisciplinary care.