Types of Acne and How to Treat Them

Acne types

You may hear the term “breakout” used to describe all forms of acne, but this isn’t always an accurate description. Not all types of acne spread across the skin.

Clogged pores cause acne itself. These may be attributed to:

• •excess production of oil (sebum)
• •bacteria
• •hormones
• •dead skin cells
• •ingrown hairs

Acne is usually associated with hormonal fluctuations experienced during your teenage years, but adults can experience acne, too. About 17 million Americans have acne, making it one of the most common skin conditions among both children and adults.

Identifying which type of acne you’re experiencing is key to successful treatment. Acne may be noninflammatory or inflammatory. Subtypes of acne within these two categories include:

• •blackheads
• •whiteheads
• •papules
• •pustules
• •nodules
• •cysts

It’s possible to have multiple types of acne at once — some cases may even be severe enough to warrant a visit to the dermatologist.'Types of Acne and How to Treat Them'

Read on to learn more about the subtypes of acne and how you can treat them.

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PICTURES

Acne pictures

Types of Acne

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Blackheads

NONINFLAMMATORY ACNE

Noninflammatory acne

Noninflammatory acne includes blackheads and whiteheads. These normally don’t cause swelling. They also respond relatively well to over-the-counter (OTC) treatments.‘Types of Acne and How to Treat Them'

Salicylic acid is often marketed for acne in general, but it usually works best on noninflammatory acne. It naturally exfoliates the skin, removing dead skin cells that can lead to blackheads and whiteheads. Look for it in cleansers, toners, and moisturizers.'Types of Acne and How to Treat Them'

Blackheads (open comedones)

Blackheads occur when a pore is clogged by a combination of sebum and dead skin cells. The top of the pore stays open, despite the rest of it being clogged. This results in the characteristic black color seen on the surface.'Types of Acne and How to Treat Them'

Whiteheads (closed comedones)

Whiteheads can also form when a pore gets clogged by sebum and dead skin cells. But unlike with blackheads, the top of the pore closes up. It looks like a small bump protruding from the skin.

Whiteheads are more difficult to treat because the pores are already closed. Products containing salicylic acid can be helpful. Topical retinoids give the best results for comedonal acne. Currently, adapalene (Differin) is available over the counter as a retinoid. If it does not work for you, stronger topical retinoids are available by prescription from your dermatologist.

Read more: Acne: Causes, treatment, and tips

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INFLAMMATORY ACNE

Inflammatory acne

Pimples that are red and swollen are referred to as inflammatory acne.

Although sebum and dead skin cells contribute to inflammatory acne, bacteria can also play a role in clogging up pores. Bacteria can cause an infection deep beneath the skin’s surface. This may result in painful acne spots that are hard to get rid of.

Products containing benzoyl-peroxide may help reduce swelling and get rid of bacteria within the skin. These can also remove excess sebum. Your doctor may prescribe either an oral or topical antibiotic along with the benzoyl-peroxide to treat your inflammatory acne. Topical retionoids are also an important part of combatting inflammatory papules and pustules.'Types of Acne and How to Treat Them'

Papules

Papules occur when the walls surrounding your pores break down from severe inflammation. This results in hard, clogged pores that are tender to the touch. The skin around these pores is usually pink.

Pustules

Pustules can also form when the walls around your pores break down. Unlike papules, pustules are filled with pus. These bumps come out from the skin and are usually red in color. They often have yellow or white heads on top.

Nodules

Nodules occur when clogged, swollen pores endure further irritation and grow larger. Unlike pustules and papules, nodules are deeper underneath the skin.

Because nodules are so deep within the skin, you can’t typically treat them at home. Prescription medication is necessary to help clear these up.

Your doctor or dermatologist will likely prescribe the oral medication isotretinoin (Sotret). This is made from a form of vitamin A and is taken daily for four to six months. It can treat and prevent nodules by decreasing oil gland size within the pores.

Cysts

Cysts can develop when pores are clogged by a combination of bacteria, sebum, and dead skin cells. The clogs occur deep within the skin and are further below the surface than nodules.

These large red or white bumps are often painful to the touch. Cysts are the largest form of acne, and their formation usually results from a severe infection. This type of acne is also the most likely to scar.

The prescription medication isotretinoin (Sotret) is commonly used to treat cysts. In severe cases, your dermatologist may surgically remove a cyst.

SEVERITY

How severe is each type of acne?

Blackheads and whiteheads are the mildest forms of acne. These can sometimes be cleared up with OTC topical medications, such as salicylic acid-based toners or benzoyl-peroxide spot treatments. If they don’t respond to OTC medications, comedones are easily treated with topical retinoids. There is even one type of retinoid, known as adapalene, which is now available over the counter. It’s very effective in clearing blackheads and whiteheads.

Pustules and papules are more moderate forms of acne. These may or may not clear up with OTC meds. Widespread moderate acne may require an oral or topical prescription from a dermatologist.

Nodules and cysts are the most severe form of acne. You have to see a dermatologist to clear up severe acne. Picking or popping nodules and cysts can lead to scars.

NEXT STEPS

What you can do now

It’s important to be patient with your acne treatment. While some treatments may work immediately, you may not see widespread improvement for several months You should also use caution in using too many acne products at once — this can cause dry skin. In response, your pores can create more sebum, then leading to more acne issues.

You should also confirm whether any bumps or swelling are actually the result of acne. There are several skin conditions that cause symptoms similar to those with acne, though they are something entirely different. These include:

• •folliculitis
• •keratosis pilaris
• •milia
• •rosacea
• •sebaceous filaments
• •sebaceous hyperplasia

Seeing a dermatologist is the only way you can receive a full and accurate diagnosis. In some cases, expert treatment may be the only way to fully clear and control your acne.

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Acne: Causes, treatment, and tips

Practice Essentials

Acne vulgaris is a common chronic skin disease involving blockage and/or inflammation of pilosebaceous units (hair follicles and their accompanying sebaceous gland). Acne can present as noninflammatory lesions, inflammatory lesions, or a mixture of both, affecting mostly the face but also the back and chest. ^[1] See the image below.

^{Acne: Causes, treatment, and tips}

Acne vulgaris has a multifactorial pathogenesis, of which the key factor is genetics. ^[2] Acne develops as a result of an interplay of the following four factors: (1) follicular epidermal hyperproliferation with subsequent plugging of the follicle, (2) excess sebum production, (3) the presence and activity of the commensal bacteria Propionibacterium acnes, and (4) inflammation. ^[3]

Signs and symptoms

Acne vulgaris is characterized by noninflammatory, open or closed comedones and by inflammatory papules, pustules, and nodules. Acne vulgaris typically affects the areas of skin with the densest population of sebaceous follicles (eg, face, upper chest, back). Local symptoms of acne vulgaris may include pain, tenderness, or erythema.

Systemic symptoms are most often absent in acne vulgaris. Severe acne with associated systemic signs and symptoms, such as fever, is referred to as acne fulminans. Severe acne, characterized by multiple comedones, without the presence of systemic  Acne vulgaris symptoms, is known as acne conglobata. This severe form of acne frequently heals with disfiguring scars. Additionally, acne vulgaris may have a psychological impact on any patient, regardless of the severity or the grade of the disease. ^[4]

See Clinical Presentation for more detail.

Diagnosis

Examination in patients with acne vulgaris includes the following features:

• Comedonal acne: Presence of open and closed comedones but usually no inflammatory papules or nodules"Acne vulgaris"
• Mild acne: Presence of comedones and a few papulopustules "Acne vulgaris"
• Moderate acne: Presence of comedones, inflammatory papules, and pustules; a greater number of lesions are present than in milder inflammatory acne
• Nodulocystic acne: Presence of comedones, inflammatory lesions, and large nodules greater than 5 mm in diameter; scarring is often evident"Acne vulgaris"

Laboratory tests

Acne vulgaris is a clinical diagnosis. However, laboratory testing may be indicated in the following situations:

• Female patients with dysmenorrhea or hirsutism: Consider a hormonal evaluation with levels of total and/or free testosterone, dehydroepiandrosterone sulfate, luteinizing hormone, and follicle-stimulating hormone
• Cases refractory to treatment or when improvement is not maintained: Culture skin lesions to rule out gram-negative folliculitis

See Workup for more detail.

Management

Treatment of acne vulgaris should be directed toward the known pathogenic factors, including follicular hyperproliferation, excess sebum, P acnes, and inflammation. The most appropriate treatment is based on the grade and severity of the acne.

Pharmacotherapy

The following medications are used in the treatment of Propionibacterium acne vulgaris:

• Retinoid-like agents (eg, topical tretinoin, adapalene, tazarotene, isotretinoin)
• Antibiotics (eg, tetracycline, minocycline, doxycycline, trimethoprim/sulfamethoxazole, clindamycin, topical clindamycin, topical erythromycin, daptomycin)
• Selective aldosterone antagonists (eg, spironolactone)
• Estrogen/progestin combination oral contraceptive pills (eg, ethinyl estradiol, drospirenone, and levomefolate; ethinyl estradiol and norethindrone; ethinyl estradiol and norgestimate; ethinyl estradiol and drospirenone)
• Acne products (eg, erythromycin and benzoyl peroxide, clindamycin and tretinoin, clindamycin and benzoyl peroxide, azelaic acid, benzoyl peroxide)

When a topical or systemic antibiotic is used, it should be used in conjunction with benzoyl peroxide or topical retinoid to reduce the emergence of resistance.

Nonpharmacotherapy

Diet therapy, such as a low-glycemic diet and avoidance of “junk foods,” has been suggested as a nonpharmacologic measure to manage acne vulgaris.

Procedures

Procedural treatments for acne vulgaris include the following:

• Manual extraction of comedones
• Intralesional steroid injections
• Superficial peels that use glycolic or salicylic acid

Background

Acne vulgaris is characterized by noninflammatory, open or closed comedones and by inflammatory papules, pustules, and nodules. Acne vulgaris typically affects the areas of skin with the densest population of sebaceous follicles; these areas include the face, the upper part of the chest, and the back.

Acne vulgaris is the most common skin disease in the United States; it affects an estimated 80% of Americans at some time during their lives. ^[5] Twenty percent have severe acne, which can result in permanent physical and mental scarring.

Medscape Reference articles on acne include Acne Conglobata,Acne Fulminans,Acne Keloidalis Nuchae, and Acneiform Eruptions.Also see the Medscape Acne Resource Center.

Pathophysiology

The pathogenesis of acne vulgaris is multifactorial. The key factor is genetics. ^[2]Acne develops as a result of an interplay of the following four factors ^[3] :

• Release of inflammatory mediators into the skin
• Follicular hyperkeratinization with subsequent plugging of the follicle
• Propionibacterium acnes follicular colonization
• Excess sebum production

Research has shown that inflammatory responses actually occur before hyperkeratinization. Cytokines produced by CD4⁺ T cells and macrophages activate local endothelial cells to up-regulate inflammatory mediators such as vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), and human leukocyte antigen (HLA)–DR in the vessels around the pilosebaceous follicle. ^[6]

Follicular hyperkeratinization involves increased keratinocyte proliferation and decreased desquamation, leading to sebum- and keratin-filled microcomedones. ^[7]

P acnes is an anaerobic organism present in acne lesions. The presence of P acnespromotes inflammation through a variety of mechanisms. P acnes stimulates inflammation by producing proinflammatory mediators that diffuse through the follicle wall. Studies have shown that P acnes activates the toll-like receptor 2 on monocytes and neutrophils. ^[8]Activation of the toll-like receptor 2 then leads to the production of multiple proinflammatory cytokines, including interleukins 12 and 8 and tumor necrosis factor. Hypersensitivity to P acnes may also explain why some individuals develop inflammatory acne vulgaris while others do not. ^[9]

Excess sebum is another key factor in the development of acne vulgaris. Sebum production and excretion are regulated by a number of different hormones and mediators. In particular, androgen hormones promote sebum production and release. ^[10] The degree of comedonal acne in prepubertal girls correlates with circulating levels of the adrenal androgen dehydroepiandrosterone sulfate (DHEA-S). ^[11]

Numerous other mediators and receptors, including growth hormone and insulinlike growth factor, as well as peroxisome proliferator-activated receptors also regulate the sebaceous gland and may contribute to the development of acne. ^[12, 13] Furthermore, the sebaceous gland acts a neuroendocrine-inflammatory organ that is activated via corticotrophin-releasing hormones in response to stress and normal functions. ^[14]

Epidemiology"Acne vulgaris"

United States

Acne vulgaris affects 80% of Americans at some time during their lives. ^[5] Twenty percent have severe acne, which can result in permanent physical and mental scarring.

International

Persons of some races are affected more than others. Cystic acne is prevalent in the Mediterranean region from Spain to Iran.[15]

Race

Acne is common in North American whites. African Americans have a higher prevalence of pomade acne, likely stemming from the use of hair pomades. Ethnicities with darker skin are also more prone to postinflammatory hyperpigmentation. ^{[16]Acne vulgaris}

Sex

During adolescence, acne vulgaris is more common in males than in females. In adulthood, acne vulgaris is more common in women than in men. ^{[17]Acne vulgaris}

Age

Acne or acneform lesions, such as in neonatal cephalic pustulosis, may be present in the first few weeks and months of life, when a newborn is still under the influence of maternal hormones and when the androgen-producing portion of the adrenal gland is disproportionately large. ^[18] This neonatal acne tends to resolve spontaneously. However, some neonates may require therapy (eg, topical retinoids). ^{[18]Acne vulgaris}

Adolescent acne usually begins with the onset of puberty, when the gonads begin to produce and release more androgen hormone.

Acne is not limited to adolescence. Twelve percent of women and 5% of men at aged 25 years have acne. By age 45 years, 5% of both men and women still have acne. ^[19]

Prognosis

Acne may cause long-lasting and detrimental psychosocial and physical effects. It is associated with depression and anxiety, regardless of disease severity, although the psychological effects usually improve with treatment. Furthermore, acne may cause permanent scarring that is difficult to correct

In male patients, acne generally clears by early adulthood. Five percent of men still have acne at age 25 years. Female patients frequently have adult acne. Twelve percent of women still have acne at age 25 years. Five percent of women still have acne at age 45 years. ^[19]

The overall prognosis for persons with acne is good.

Patient Education

Patients should be instructed on their morning and evening treatment programs. Retinoid dermatitis may develop at approximately day 10 of therapy. Patients must be informed of this in advance so they will not consider this exfoliation an allergy. By skipping a day or 2 and restarting the program slowly, the skin can adapt to this irritation."Acne vulgaris"

Prescriptions should be accompanied by a discussion of the potential adverse effects.Acne vulgaris,

For patient education resources, see the Skin Conditions and Beauty Center as well as the patient education article Acne. Also see the Medscape Acne Resource Center., "Acne vulgaris"Acne vulgaris,Acne vulgaris#Acne vulgaris#Acne vulgaris#Acne vulgaris

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Acne: Causes, treatment, and tips

Acne is a skin condition that causes spots and pimples,especially on the face, shoulders, back, neck, chest, and upper arms.

It is the most common skin condition in the United States (U.S.), affecting up to 50 millionAcne: Causes, treatment, and tips Americans yearly.

It commonly occurs during puberty, when the sebaceous glands activate, but it can occur at any age.

The glands produce oil and are stimulated by male hormones produced by the adrenal glands in both males and females.

At least 85 percent of people in the U.S. experience acne between the ages of 12 and 24 years.

Contents of this article:

1. What is acne?
2. Causes
3. Types
4. Over-the-counter treatment
5. Treating moderate to severe acne
6. 15 tips for managing acne

Fast facts on acne

Here are some facts about acne. More detail is in the main article.

• Acne is a skin disease involving the oil glands at the base of hair follicles.
• It affects 3 in every 4 people aged 11 to 30 years.
• It is not dangerous, but it can leave skin scars.
• Treatment depends on how severe and persistent it is.
• Risk factors include genetics, the menstrual cycle, anxiety and stress, hot and humid climates, using oil-based makeup, and squeezing pimples.

What is acne?

Acne is a chronic, inflammatory skin disease that results in whiteheads, blackheads, pimples, cysts, and nodules. It is not dangerous, but it can leave skin scars.

Human skin has pores that connect to oil glands under the skin. Follicles connect the glands to the pores. Follicles are small sacs that produce and secrete liquid.

The glands produce an oily liquid called sebum. Sebum carries dead skin cells through the follicles to the surface of the skin. A small hair grows through the follicle out of the skin.

Pimples grow when these follicles get blocked, and oil builds up under the skin.

They tend to appear on the face, back, chest, shoulders, and neck.

Skin cells, sebum, and hair can clump together into a plug. This plug gets infected with bacteria, and swelling results. A pimple starts to develop when the plug begins to break down.

Propionibacterium acnes (P. acnes) is the name of the bacteria that live on the skin and contributes to the infection of pimples.

Research suggests that the severity and frequency of acne depend on the strain of bacteria. Not all acne bacteria trigger pimples. One strain helps to keep the skin pimple-free.

Causes

Stress can be a key trigger of acne in some cases.

A range of factors triggers acne, but the main cause is thought to be a rise in androgen levels.

Androgen is a type of hormone, the levels of which rise when adolescence begins. In women, it gets converted into estrogen.

Rising androgen levels cause the oil glands under the skin to grow. The enlarged gland produces more sebum. Excessive sebum can break down cellular walls in the pores, causing bacteria to grow.

Some studies suggest that genetic factors may increase the risk.

Other causes include:

• some medications that contain androgen and lithium
• greasy cosmetics
• hormonal changes
• emotional stress
• menstruation

Types

Acne pimples vary in size, color, and level of pain.

The following types are possible:

• Whiteheads: These remain under the skin and are small
• Blackheads: Clearly visible, they are black and appear on the surface of the skin
• Papules: Small, usually pink bumps, these are visible on the surface of the skin
• Pustules: Clearly visible on the surface of the skin. They are red at their base and have pus at the top
• Nobules: Clearly visible on the surface of the skin. They are large, solid, painful pimples that are embedded deep in the skin
• Cysts: Clearly visible on the surface of the skin. They are painful and filled with pus. Cysts can cause scars.

Over-the-counter treatment

Treatment depends on how severe and persistent the acne is.

Mild acne

A variety of steroidal and non-steroidal creams and gels are available to treat acne, and many are effective.

Mild acne can be treated with over-the-counter (OTC) medications, such as gels, soaps, pads, creams, and lotions, that are applied to the skin.

Creams and lotions are best for sensitive skin. Alcohol-based gels dry the skin and are better for oily skin.

OTC acne remedies may contain the following active ingredients:

• Resorcinol: helps break down blackheads and whiteheads
• Benzoyl peroxide: kills bacteria, accelerates the replacement of skin, and slows the production of sebum
• Salicylic acid: assists the breakdown of blackheads and whiteheads and helps reduce inflammation and swelling
• Sulfur: exactly how this works is unknown
• Retin-A: helps unblock pores through cell turnover
• Azelaic acid: strengthens cells that line the follicles, stops sebum eruptions, and reduces bacterial growth. There is cream for acne, but other forms are used for rosacea.

It is advisable to start with the lowest strengths, as some preparations can cause skin irritation, redness, or burning on first use.

These side effects normally subside after continued use. If not, see a doctor.

Treating moderate to severe acne

A skin specialist, or dermatologist, can treat more severe cases.

They may prescribe a gel or cream similar to OTC medications but stronger, or an oral or topical antibiotic.

Corticosteroid injection

If an acne cyst becomes severely inflamed, it may rupture. This can lead to scarring.

A specialist may treat an inflamed cyst by injecting a diluted corticosteroid.

This can help prevent scarring, reduce inflammation, and speed up healing. The cyst will break down within a few days.

Oral antibiotics

Oral antibiotics may be prescribed for up to 6 months for patients with moderate to severe acne.

These aim to lower the population of P. Acnes. The dosage will start high and reduce as the acne clears.

P. acnes can become resistant to the antibiotic in time, and another antibiotic is needed. Acne is more likely to become resistant to topical rather than oral antibiotics.

Antibiotics can combat the growth of bacteria and reduce inflammation.

Erythromycin and tetracycline are commonly prescribed for acne.

Oral contraceptives

Oral contraceptives can help control acne in women by suppressing the overactive gland. They are commonly used as long-term acne treatments.

These may not be suitable for women who:

• have a blood-clotting disorder
• smoke
• have a history of migraines
• are over 35 years old

It is important to check with a gynecologistfirst.

Topical antimicrobials

Topical antimicrobials also aim to reduce P. acnes in patients with moderate to severe acne. Examples are clindamycin and sodium sulfacetamide.

The dermatologist may prescribe a topical retinoid.

Topical retinoids are a derivative of vitaminA. They unclog the pores and prevent whiteheads and blackheads from developing.

Examples of topical retinoids prescribed in the U.S. are adapalene, tazarotene, and tretinoin.

Isotretinoin

This is a strong, oral retinoid, used for the treatment of severe cystic acne and severe acne that has not responded to other medications and treatments.

It is a strictly controlled medication with potentially serious side effects. The patient must sign a consent form to say that they understand the risks.

Adverse effects include dry skin, dry lips, nosebleeds, fetal abnormalities if used during pregnancy, and mood swings.

Patients who take isotretinoin must avoid vitamin A supplements, as these could lead to vitamin A toxicity.

15 tips for managing acne

Here are some tips for looking after skin that has acne or is prone to it.

1. Wash your face no more than twice each day with warm water and mild soap made especially for acne.
2. Do not scrub the skin or burst the pimples, as this may push the infection further down, causing more blocking, swelling, and redness.
3. Avoid popping pimples, as this makes scarring likelier.
4. A specialist can treat a pimple that requires rapid removal for cosmetic reasons.
5. Refrain from touching the face.
6. Hold the telephone away from the face when talking, as it is likely to contain sebum and skin residue.
7. Wash hands frequently, especially before applying lotions, creams, or makeup.
8. Clean spectacles regularly as they collect sebum and skin residue.
9. If acne is on the back, shoulders, or chest, try wearing loose clothing to let the skin breathe. Avoid tight garments, such as headbands, caps, and scarves, or wash them regularly if used.
10. Choose makeup for sensitive skin and avoid oil-based products. Remove makeup before sleeping.
11. Keep hair clean, as it collects sebum and skin residue. Avoid greasy hair products, such as those containing cocoa butter.
12. Avoid excessive sun exposure, as it can cause the skin to produce more sebum. Several acne medications increase the risk of sunburn.
13. Use an electric shaver or sharp safety razors when shaving. Soften the skin and beard with warm soapy water before applying shaving cream.
14. Avoid anxiety and stress, as it can increase production of cortisol and adrenaline, which exacerbate acne.
15. Try to keep cool and dry in hot and humid climates, to prevent sweating.

Acne is a common problem. It can cause severe embarrassment, but treatment is available, and it is effective in many cases.

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