The Different Types of Acne: From Blackheads to Cystic Acne

Acne is the most common skin condition in the United States, affecting up to 50 million Americans and driving over 5 million people to seek medical care each year (37). There is an extensive range of treatment options available, and the economic impact of acne is significant, with costs exceeding $1 billion annually (37).

Alarmingly, 10-15% of patients struggle to achieve satisfactory results from their prescribed therapies. This persistent challenge may partly stem from the varied nature of acne itself. Acne manifests in several distinct forms, each requiring tailored therapeutic approaches for effective management.

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Understanding Acne: What Causes It?

Acne develops through a combination of factors that create an environment conducive to the formation of pimples. The following are universally recognized as the main four factors responsible for acne pathogenesis: 

• Excess sebum (oil) production by sebaceous glands
• Follicular hyperkeratinization: a process in which skin cells within hair follicles shed abnormally and accumulate
• Proliferation of bacteria, particularly Cutibacterium acnes, within the clogged pore
• Inflammation 

However, these factors do not act in isolation; both internal and external variables significantly influence them.

• Hormones strongly influence acne development. Androgens, in particular, stimulate the sebaceous glands and contribute to sebum excess. This is why acne is often a hallmark symptom of androgen-excess states, such as polycystic ovary syndrome (PCOS). (21) 
• Genetics also contribute to acne susceptibility. If acne is prevalent in a family, individuals may be more likely to develop it themselves, suggesting a hereditary component that affects skin characteristics, oil production, and inflammation levels.
• Diet, particularly high-glycemic foods and dairy, can impact inflammation and oil production. 
• Stress is another factor that can exacerbate acne, as it can increase the production of stress hormones that stimulate oil production. 
• Exposure to environmental pollutants and the use of certain skincare products can contribute to pore clogging and skin inflammation.

Non-Inflammatory Acne

Non-inflammatory acne is characterized by lesions that do not involve significant redness or swelling. The primary lesions in non-inflammatory acne are comedones.

Blackheads (Open Comedones)

Open comedones, commonly known as blackheads, are characterized by small, dark spots on the skin, especially the forehead, nose, and chin. The open nature of these comedones means that the pore remains open at the surface, allowing air to interact with the clogged material. The dark color of these lesions is not caused by dirt but by the oxidation of melanin and sebum at the pore's surface. 

Tips for Treating Blackheads

Regular exfoliation can remove dead skin cells and oils that can lead to clogged pores and existing blackheads. To prevent excessively irritating the skin, dermatologists recommend using alpha- and beta-hydroxy acids, such as glycolic and salicylic acids. 

Pore strips are adhesive strips designed to remove blackheads and impurities from the skin, primarily from the nose or other areas prone to blackhead formation. They work by adhering to the surface of the skin and pulling out debris from clogged pores when removed. While pore strips can provide temporary relief from blackheads, overuse can potentially irritate the skin, especially for sensitive skin types.

Whiteheads (Closed Comedones)

Closed comedones, or whiteheads, are small, flesh-colored or white bumps on the skin. They commonly appear on the face, neck, back, chest, and upper arms but can occur anywhere on the body. 

Tips for Treating Whiteheads

Whiteheads can be treated similarly to blackheads. Dermatologists often recommend topical retinoids with or without benzoyl peroxide to treat comedonal acne. 

• Retinoids are vitamin A derivatives that can decrease comedonal numbers by slowing the shedding of skin cells. 
• Benzoyl peroxide increases skin cell turnover and shedding of dead skin cells to reduce the buildup that can clog pores. Additionally, it has strong antibacterial properties against C. acnes.

Inflammatory Acne

Inflammatory acne involves redness, swelling, and discomfort caused by the immune system's response to the overgrowth of C. acnes within clogged pores. When a hair follicle becomes damaged and ruptures, it releases bacteria, proteins, and proinflammatory fats into the surrounding skin tissue, triggering further inflammation and promoting the formation of additional lesions.

The appearance of papules and pustules is a sign that acne has progressed to an inflammatory type. 

• Papules are solid, inflamed bumps on the skin that aren't filled with pus. They're usually smaller than one centimeter in diameter and can be skin-colored, red, brown, or purple.
• Pustules are similar to papules but contain pus, giving them a white or yellow color. 

Tips for Treating Inflammatory Acne

Treating inflammatory acne requires a combination of approaches that address all four of its pathological factors. For mild-to-moderate inflammatory acne, dermatologists often recommend/prescribe: 

• Topical retinoid with benzoyl peroxide
• Topical or oral antibiotics 

These should be combined with a consistent skincare routine that incorporates a gentle cleanser and non-comedogenic moisturizer to wash the face of oil and debris and prevent excessive skin irritation. 

Resisting pimple popping is also important, as this can increase the risk of increased redness and pain, infection, and scarring.

Severe Acne Types

Nodular and cystic acne (often collectively referred to as nodulocystic acne) is the most severe form of inflammatory acne. C. acnes becomes trapped under the skin, perpetuating infection and inflammation. 

Nodules are hard, painful lumps that form deep beneath the skin's surface. Cysts are pus-filled lumps that resemble boils. Both types of lesions can be very painful and range in size from as small as a pea to as large as a dime. Nodules and cysts often take months to heal and frequently leave permanent scars once they disappear.

Tips for Treating Severe Acne

Nodulocystic acne is often resistant to monotherapy with first-line treatment options. Effective treatment often requires a combination of oral antibiotics and prescription-strength topicals. Additionally, your dermatologist may recommend:

• Corticosteroid injections to shrink large, painful nodules and cysts
• Incision and drainage of a lesion to remove its inner contents
• Isotretinoin is an oral retinoid reserved for treating severe inflammatory acne or refractory acne that is causing significant distress or scarring.

Other Forms of Acne

There are also other forms of acne:

Acne Mechanica

Acne mechanica is a type of acne triggered by repeated physical friction, pressure, heat, or irritation on the skin. It often occurs in areas where clothing, sports gear, or equipment like helmets, backpacks, or tight straps continuously rub against the skin. Athletes are commonly affected by acne mechanica wherever their equipment or uniforms rub against the skin. Depending on the severity, this type of acne can appear as small red bumps, pustules, or even deeper nodules. (23) 

Minimizing friction is the most important aspect of treating and preventing this type of acne. This can be done by wearing loose-fitting, breathable clothing, using padding or moisture-wicking fabrics under gear, and showering immediately after sweating. Additionally, using non-comedogenic skincare products and gently cleansing the skin can help reduce the buildup of sweat, dirt, and oils on the skin. (23) 

Hormonal Acne

Hormonal acne is a type of acne driven by fluctuations in hormone levels. It primarily affects women, especially during periods of hormonal change such as puberty, menstruation, pregnancy, menopause, or stress. Hormonal acne commonly appears in the lower part of the face, especially the jawline and chin.

Treatment for hormonal acne focuses on correcting the underlying hormonal imbalances. It may include medications such as oral contraceptive pills (OCPs) and spironolactone, which reduce androgen levels and stabilize hormone fluctuations.

Fungal Acne (Malassezia Folliculitis)

Fungal acne occurs when hair follicles become infected with a fungus called Malassezia yeast. This fungus causes clusters of small, itchy red papules on the skin, which can turn into pustules. 

Treatment of fungal acne involves addressing the overgrowth of yeast on the skin with topical and oral agents, such as: 

• Topical antifungal creams or shampoos containing ketoconazole or selenium sulfide
• Oral antifungal supplements and medications: fluconazole, caprylic acid, oregano oil, garlic, and berberine

How to Identify Your Acne Type

Because the treatment strategy for acne can vary depending on its type, correctly diagnosing acne type is essential for better treatment outcomes and avoiding unnecessary or ineffective treatments.

The location and timing of breakouts, the appearance of lesions, and associated symptoms help to classify acne correctly. When in doubt, it's best to consult a dermatologist. A skincare professional has the clinical expertise to evaluate your skin, review your medical history, and conduct any necessary tests to provide an accurate diagnosis. This ensures you receive the most appropriate and effective treatment for your acne type.

Preventing Acne Breakouts

Following these additional recommendations can help prevent acne breakouts: 

• Maintain a consistent skincare routine that includes cleansing the skin twice daily with a gentle, non-comedogenic cleanser to remove excess oil, dirt, and impurities from the skin. 
• Using non-comedogenic moisturizers and sunscreens helps to keep the skin hydrated and protected without clogging pores.
• Manage stress through techniques such as mindfulness, exercise, or talk therapy.
• Eat a balanced anti-inflammatory diet that supports a well-balanced microbiome and limits consumption of foods known to commonly trigger acne, specifically high-glycemic foods and dairy. 

Sticking to a consistent skincare routine is important because it takes time for therapeutic interventions to show noticeable results. It can take about 6-8 weeks before you begin to see initial improvements in acne and up to 3-4 months for complete acne resolution. (1) 

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Key Takeaways

• Acne manifests in various forms, ranging from mild comedogenic acne to more severe inflammatory conditions.
• Correctly diagnosing the acne type is an essential first step in achieving control over acne, as this guides the selection of appropriate treatments and lifestyle adjustments. 
• Patience and consistency with your skincare regimen, coupled with professional guidance from a dermatologist, are the keys to successfully managing and resolving acne.