Types of Acne & How They Form: A Complete Guide

Many teenagers and adults struggle with acne. A good proportion of our patients are teens and young adults. They experience changes in their skin and hair as they undergo hormonal changes associated with puberty. This also associates with the start of acne. In this article, we explain the different types of acne, and how they form, including excerpts from Acne Care Bible: Dermatologist’s Tips For Acne Treatment & Prevention by Dr. Teo Wan Lin, dermatologist at TWL Specialist Skin & Laser Centre.

How does acne form? 

When you enter into puberty, the first thing that happens is the production of sex hormones which we call androgens. Androgens specifically for males – testosterone and in females – estrogen. Females have both testosterone and estrogen. The levels of this testosterone in both boys and girls during the onset of puberty stimulates the oil glands also known as the sebaceous glands. When these become active, you will find that certain parts of your skin get greasier. These areas include the T-Zone of your face, namely your forehead, nose, and chin. In addition, the chest and the back are also areas which will get greasier.

The process of different types of acne begins the same way, that is with inflammation. Not everyone will develop acne at puberty. The reason is that one requires the specific genetic makeup for the androgens to bind to certain receptors in the skin. When there is a family history of acne, one is much more likely to develop it during the onset of puberty. This causes inflammation to start underneath the skin in the deeper layers. They are formed as “micro” whiteheads specifically known as micro-comedones. These micro-comedones then rise to the top of the skin in two weeks to a month. This is before it appears on your skin as either a visible whitehead or blackhead. 

Is it true that your pores are getting blocked in the process?

The answer is both yes and no. Yes because you have to be first genetically predisposed to the development of acne to have your “pores blocked”. This process is that of inflammation which causes the skin to trap bits of dead skin. Dead skin accumulates as debris, combining with excess oil and grime to form whiteheads and blackheads. At the same time, the answer to this question is also a “no” because there are individuals who produce oil during the onset of puberty, but lack the genetic tendency to develop the different types of acne. Hence, they do not find their pores getting blockage at all.

Does bacteria cause acne? Is acne contagious?

Amongst those who suffer from acne and those who don’t, all have a type of bacteria on their skin known as Propionibacterium acnes. However, individuals who develop acne are colonised with this bacteria. This means that they have far greater amounts of P. acnes on their skin than those who do not. That being said, acne itself is not contagious and the very root cause of it is your genetic makeup. 

My friend does not have acne, that’s so unfair.

There is nothing to be ashamed about because it is the same genetic makeup that you have which makes you an individual. Research has shown that individuals who suffer from acne tend to age much better than their counterparts who do not suffer from acne. This is because individuals who suffer from acne tend to have greasier skin. As a result, the overall oil of the skin helps to preserve the skin’s elasticity and increased sense of facial fullness when they grow older. Besides, the purpose of this article is to let you know that acne and the different types of acne are all 100% treatable. So read on!

What are the factors that trigger acne?

1. Genetics

To put it simply, the root cause of your acne is your genetics. However, many other factors go towards triggering acne. 

2. Excessive oily complexion 

An excessive oily complexion is the result of a condition which we call seborrhea. Sometimes, this may be due to the use of inappropriate cleansers. Many cleansers formulated for oily skin contain strong lathering agents or astringents. These completely strip the skin of its natural moisture barrier. 

If your cleanser leaves your skin feeling “squeaky clean”, it likely is too drying. This may result in a condition known as reactive seborrhea, causing your skin to produce even more oil instead. You may also find it helpful to switch to a lotion or serum-based moisturiser, rather than a cream formula, which contains much more oil. Remember, the key here is to maintain a healthy skin barrier, not to dehydrate it!

3. Watch your diet

Current research shows that consuming dairy, chocolate, foods high in saturated fat as well as foods with a high glycemic index can increase the body’s tendency to inflammation. In contrast, a diet rich in plant-based antioxidants and olive oil is beneficial for healthy skin.

Now, in the following segment, we are delving specifically into the different types of acne pimples that you may see. With this, you may better recognize them when you see it and know what to do about them. We have spoken briefly in the previous chapter about whiteheads and blackheads. Now I shall take you right into the details!

Types of Acne: What are whiteheads?

You may notice whiteheads forming. Before you try to understand what whiteheads are, I’m sure you would have heard of closed pimples or blind pimples. Blind pimples are pimples without a head. Individuals who are just starting to develop acne may notice that they have predominantly whiteheads and blackheads. The medical term for whiteheads is closed comedones and blackheads would be open comedones. These are both different types of acne. The reason for the “open” and “closed” terminology is simple. When they are open, this signifies that there is a tract that leads to the surface of the skin. This explains why you may be able to see the blackhead at the surface of your skin. Conversely, when they are closed, there is no visible tract to the surface or an obvious opening to the surface of your skin. Consequently, the pimple may feel “hidden”.

Can’t I just squeeze my whiteheads out?

Many individuals think of squeezing, pricking, or extracting to remove the whiteheads. However, from a dermatologist’s perspective, this is not a good idea as it introduces bacterial infection and can cause inflammatory scarring.

Why is that so?

You may temporarily remove the underlying debris in the whitehead that you are squeezing or pricking. However, this will cause scarring and introduce bacteria which may cause a deeper cyst to form. Also, this does not solve the underlying cause – your genetics causing inflammation which is responsible for acne development. While we cannot change one’s genetics, a much better plan is to remove the whitehead without physical trauma to the skin. This is because traumatising your skin in any way will increase the risk of getting skin infections. As you have heard before, acne can trigger off from bacteria. Consequently, this is a definite way to cause your acne to get worse and it will also develop scarring when you do that. 

What are the approved methods to get rid of whiteheads?

First of all, if you have just one or two or even up to five whiteheads, using a gentle cleanser that is formulated with antibacterial properties, maintaining good hygiene as well as over-the-counter use of pimple cream may help in removing the whiteheads. Some of these over-the-counter preparations may contain salicylic acid, benzoyl peroxide, or sulfur. These may work for mild acne. However if you should develop skin irritation, do know that you have to stop the cream. The reason is that these medications work by drying up your skin. Prescription retinoid creams will also be available via your dermatologist, these are effective against whiteheads and blackheads.

Also, when you are using benzoyl peroxide formulations, be aware that they are formulated in different concentrations – 2.5%, 5% and 10% are commonly used. Some formulations have even up to 40% benzoyl peroxide. My personal experience with patients who have used benzoyl peroxide is that it is extremely drying for their skin. It can even give rise to the issue of “oily dehydrated skin” common in acne sufferers who also use drying topicals like benzoyl peroxide for spot treatment.

Non-Drying Anti-Acne Formulations

My personal preference for anti-acne formulas are those derived from botanical extracts. Rather than just drying the surface of your skin with chemicals such as salicylic acid and benzoyl peroxide or even sulfur, newer acne cream formulations utilise anti-inflammatory plant extracts. The Blemish Spot Cream which I formulate as a spot acne treatment incorporates an algae extract, Chlorella Vulgaris. Chlorella has been shown to inhibit P. acnes and its inflammatory mediators in studies. The ingredient works with amino acids, which also function as natural moisturising factors, to heal acne blemishes. 

It is important to note that you want your pimple to heal well and with minimal scars. For that, you should consider applying a serum or a light moisturizer that also contains natural moisturizing factors such as amino acids, polyglutamic acid, and hyaluronic acid. These are moisturisers that are formulated without grease and it will help your skin to heal well. If you find that these methods don’t work for you, you may have to visit a dermatologist. 

What happens if I am visiting a dermatologist for whiteheads?`

Firstly, an evaluation would be done to determine if you have comedonal acne. If you have “fungal acne”, an acne-like eruption affecting the hairline, chest and back which really is due to a yeast known as Malessezia furfur that causes a condition known as Pityosporum Folliculitis.

For instance, your dermatologist will prescribe antifungal shampoos and creams with or without anti-acne medication. Examples of treatments that are very effective for whiteheads, closed comedones would be retinoids. Retinoids are derivatives from vitamin A and they work by regulating the rate of cell turnover. With that, your skin will have less dead skin cells to work with to produce debris.

Types of Acne: What exactly are blackheads? 

Those black dots you see on your nose aren’t due to dirt, they are actually a form of the different types of acne. Blackheads are due to the presence of dead skin, oil and dirt mixed together and exposed to oxygen in the air, the process of oxidation causes it to turn “black”. This is similar to what happens to an apple after you peel it and leave it outside. The same process of oxidation is responsible for the appearance of blackheads. The key difference between a blackhead and whitehead is that for blackheads, there is an obvious tract which leads to the surface of the skin. So if you apply pressure, you may find some yellowish whitish material extruding. 

Is squeezing your blackheads a good idea?

In my opinion, some individuals do experience improvement in their skin when they extract blackheads. Usage of vacuum-assisted methods such as home devices as well as pore packs may be of limited use in individuals who suffer from blackheads. However, one thing to note is that these blackheads do not go away. After you remove them with various physical methods, they almost always recur. 

Can we treat blackheads definitively?

Yes. However, you should seek medical treatment with retinoids – which are prescription items – or chemical peels as early as possible. Microdermabrasion is also an effective tool. In my practice, I use a vacuum-assisted microdermabrasion technique that gently extracts the blackheads (improving the cosmetic appearance) while simultaneously infusing anti-oxidants and alpha-hydroxy acids to resurface the skin. Generally, once one develops blackheads, it is very hard for them to completely reverse the condition. However, these methods are certainly more effective and sustainable than squeezing out your blackheads one by one.

As emphasized before, any process that involves mechanical trauma or picking with your fingers or using any instruments does carry the risk of introducing bacteria. You may find that after squeezing a blackhead, you develop a red bump there instead. Which leads us to the next part that we are going to discuss. What are these red bumps?

Types of Acne: Papules 

Amongst the different types of acne, the red bumps are what we call papules. A papule is a medical term for the red acne bumps that occur alongside whiteheads and blackheads. In individuals who suffer from acne, this is almost certainly a result of secondary bacterial infection of underlying blackheads and whiteheads.

What are some of the types of bacteria that can cause infection?

We have spoken about P. acnes in the previous part, the bacteria that is responsible for acne. Now, we are going to zoom in on various types of bacteria that may be present on your skin. There is staph aureus, short for staphylococcus aureus. Staphylococcus aureus is what we call a normal commensal or an inhabitant of the skin. However, if you have acne, it means that your skin barrier has a breach, and hence more susceptible to infections. When there is an area of skin breakage due to the acne bump, you are much more likely to get secondary bacterial infections. Papules may or may not come to a head. When papules have come to a head, there is the tip which usually appears to be a yellowish area. There are also gram-negative bacteria which can cause an eruption of pustules over existing areas of whiteheads and blackheads.

How do you manage a papule? 

If your pimple is coming to a head, here’s what to do. Right after a warm shower, when your skin is slightly moist, use a clean wet cotton pad to apply gentle pressure around the tip of the papule.  If the papule is “ripe”, this will cause the contents of the papules to extrude. What we recommend when you have a papule is to apply your blemish spot cream until it resolves. It usually takes on an average of 3 to 5 days for a papule to resolve. Instead of coming to a head, if the papule gets bigger, deeper, and more painful, you may have a cyst.

Types of Acne: What is an acne cyst?

A cyst occurs when the body is not functioning properly to remove the infected dead skin material. Instead, it tries to bury it deeper and deeper. In the end, it forms a little wall around the area of infection, hoping to separate it from the normal tissue. 

However, infection is very much alive and the cyst typically will get deeper, larger, and more painful and may not come to head at all. This is the most important thing to look out if your acne is not undergoing treatment by a dermatologist. Cystic acne is amongst the most severe types of acne and is best to seek treatment from a dermatologist.

How do you manage a cyst? 

When you develop a cyst and it is there for longer than 4-5 days, the recommendation is that you attend a dermatologist office for a steroid injection to help with bringing the inflammation down. If you do not bring the inflammation down, very often you will find that the cyst can develop into a larger area of infection known as an abscess. While this is very rare, it is potentially dangerous as it can cause deep-seated infection and scarring. The abscess has to be treated with drainage, a form of surgery where a cut is made for the pus to be removed. 

Types of Acne: Pustules

Pustules are yellow spots which you may see on your face that appears to be filled with white or yellowish pus. The cause of these types of acne is usually a secondary bacterial infection by gram-negative bacteria. It can be caused by poor hygiene in an individual who is acne-prone. Taking an acne medication such as isotretinoin can also lead to an alteration of skin flora (bacterial balance) in early stages that can lead to gram negative infection.

How do you manage a pustule? 

Pustules can be easily treated and relieved if they are few. If you have two to three pustules, use the same method as you would treat a “ripe papule”. Right after a warm shower, the damp cotton pad method to gently compress around the edges of the pustule is actually a method we call a warm compress. The environment in the warm shower helps to dilate the blood vessels so that any haemoserous fluid, in this case, the pus, can easily release.

However, if you did not manage to successfully drain out the pustule, we recommend that you repeat the process by compressing with a moist cotton pad two to three times a day until the fluid fully drains. On the other hand, if you find yourself having more than three to four pustules, you may have a serious case of gram-negative folliculitis and it is necessary to treat that with oral antibiotics. 

In summary, we have covered the various types of acne which can be broadly classified into the following – whiteheads, blackheads, the red bumps on your skin known as papules, deeper bigger bumps known as cysts and finally, when infection occurs, you can also get a pus-filled bump known as a pustule.