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Grade 4 acne typically includes:

  1. many open and closed comedones

  2. cystic acne, inflammation, and scar formation from tissue damage

  3. black or dark patches on the skin

  4. open sores, reddish patches

The correct answer is: cystic acne, inflammation, and scar formation from tissue damage

Grade 4 acne is the most severe form of acne and is characterized by cystic acne, inflammation, and scar formation from tissue damage. This level of acne involves deep-rooted cysts, which can be painful, inflamed, and lead to significant scarring if not treated properly. This contrasts with options A, C, and D, which describe characteristics of different types or severities of acne, but do not align with the specific features of Grade 4 acne.