Papules (Regular pimples)

These are classic pimples that form when excess oil, dead skin cells, and bacteria become trapped in the deeper layers of the skin, causing inflammation which can later lead to swelling and redness.

Pustules (Large pimples)

Pustules are a type of acne that occur when papules (the mild type of acne) get worse. The initial pimple becomes larger, filled and enlarged with more oil and fluid because the skin attempts to deal with the problem on its own.

Most teens with acne have a mixture of papules and pustules.

Nodular Acne (Deep Pimples)

Large and painful breakouts are called acne nodules which are caused by severe inflammation.

Acne nodules are larger than standard pimples, and they affect deeper layers of the pores and skin.

Blackheads (Open Comedones)

One of the most common forms of comedonal acne is blackheads (a.k.a open comedones). Comedones form when the cells lining the sebaceous duct multiply (cornification) and sebum production increases. A blackhead appears when the debris blocks the sebaceous duct and hair follicle.

Whiteheads (Closed Comedones)

Tiny white bumps that appear on the skin are another type of clogged pore, called white heads. They’re occasionally referred to as closed comedones because, unlike blackheads, the head of the white bump is protected by a thin layer of skin. As the pore is not exposed to the air, it doesn’t oxidize or turn black.

Acne additionally is available in various severity and it affects everyone differently. The most widely used classification of acne is simple: mild, moderate, and severe. Your skin can move between these grades because acne tends to increase and decrease on its own.

Based on the severity, you can determine the best course of action.

Mild acne: Whiteheads and blackheads, with a few papules and pustules, are called mild acne. It can usually be treated with over-the-counter acne medications. However, if it is not treated immediately, it can develop into more serious forms.

Moderate acne: Both papules and pustules in multiples covering less than half of your face are called moderate acne.

Moderately severe acne: Numerous papules and pustules with occasionally inflamed nodules on more than half of your face are categorised as moderately severely acne.

Topical retinoids and topical antibiotics (for non-inflammatory acne) individually or a combination of both are the most commonly used topical acne treatments for moderate acne.

Severe Acne: Numerous painful, large and inflamed pustules, nodules, or cysts, usually affecting most of your face are categorised as severe acne. It’s difficult to get severe acne under control, and hence, dermatologist consultation is required.

Sources

1. InformedHealth, Acne: Overview
2. Newman MD, Bowe WP, Heughebaert C, Shalita AR. Therapeutic considerations for severe nodular acne. Am J Clin Dermatol. 2011;12(1):7-14. doi:10.2165/11532280-000000000-00000
3. https://www.aad.org/public/diseases/acne/diy/types-breakouts
4. https://www.nm.org/locations/central-dupage-hospital
5. https://dermnetnz.org/topics/comedonal-acne

1. Comedonal acne (clogged pores)

Comedonal acne is considered “non-inflammatory,” meaning the skin isn’t inflamed. This type of acne happens because the pores in the skin are clogged. Clogged pores can happen when there’s too much oil or bacteria. It can also happen when dead skin cells don’t shed properly or because of hormonal changes. Clogged pores can cause pimples called whiteheads and blackheads.

Whiteheads are also known as “closed comedones.” These happen when your pores become clogged all the way through, creating a little white or flesh-colored bump on top of your skin.

You can’t remove or fix whiteheads by squeezing them. So don’t try to pop them on your own. This can lead to scarring.

Blackheads

Unlike whiteheads, blackheads look black on the skin’s surface (the color is not from dirt, but from melanin pigment and exposure to air). They’re known as “open comedones.” This is because the head of the pore stays open, while the rest of the pore is clogged. You can remove blackheads by squeezing them. But again, this isn’t recommended because it can cause scarring.

Treatment for comedonal acne

Getting rid of blackheads and whiteheads begins with proper skin care. The products you use on your skin and in your hair can clog your pores. Choose products that are labeled “non-comedogenic,” meaning they’re less likely to make you breakout. And try to avoid using pore strips on blackheads because they are abrasive and can damage your skin, making acne worse.

You can treat comedonal acne with over-the-counter (OTC) treatments, but sometimes stronger prescription medications are needed.

Effective OTC treatments and active ingredients for comedonal acne include:

• Sulfur

• Salicylic acid

• Benzoyl peroxide

• Low-strength adapalene (Differin)

These treatments help remove dead skin cells and excess oil. Sulfur, salicylic acid, and benzoyl peroxide can be applied directly to the acne spots or used as an entire facial treatment.  Benzoyl peroxide is the most effective option, while sulfur is the mildest on your skin. Salicylic acid may help prevent comedonal acne from returning in the future.

Adapalene is a type of retinoid, the most effective treatment for all types of acne. It should be applied to the entire affected area (not spot treatment) and can take 3 or 4 weeks to start working. If an OTC option isn’t working, you may need a prescription-strength retinoid like tretinoin (Retin-A) or trifarotene (Akleif).

2. Inflammatory acne (pimples)

Inflammatory acne is the medical name for pimples. There are two types of pimples — papules and pustules.

Papules

Papules are small red bumps. They form when oil or excess skin cells blocking a pore mix with bacteria on your skin. The infected contents of the blocked pore spill out into the surrounding skin tissue, causing an inflamed lesion.

Pustules

Pustules are papules that contain pus. They are bulging bumps with a white center and red, violet, or brown inflamed skin surrounding them. They usually occur in clusters on the chest, face, or back.

Like papules, pustules can form when a blocked pore gets infected. But they can also be caused by hormonal changes in the body.

What do papules and pustules look like?

Papules look like a smooth red, violet, or brown skin bump. Unlike pustules, papules do not contain pus. Their exact appearance can vary based on the color of your skin.

Treatment for inflammatory acne

Inflammatory acne is treated with the same OTC medications used for comedonal acne, along with some additional treatments, including:

• Prescription-strength retinoids help with overall inflammation.

• Antibiotics help get rid of C. acnes and lower inflammation. Benzoyl peroxide is combined with antibiotics to help prevent bacteria from becoming resistant.

• Birth control pills help lower androgen hormone levels (like testosterone), which contribute to acne.

• Spironolactone (Aldactone) is a blood-pressure medication used “off-label” to treat acne by lowering androgen hormone levels.

And like with comedonal acne, popping pimples may worsen breakouts and cause scarring, so don’t try to squeeze them. Only your doctor can safely drain pustules.

3. Nodulocystic acne

Nodulocystic acne is when severe breakouts happen much deeper in the skin. This type of acne  can be painful and leave permanent scars. It can affect the face, chest, back, and buttocks.

Nodules

Nodular acne consists of flesh-colored, brown, or red bumps. They’re larger than papules and located deep under the skin’s surface. These occur when papules get more inflamed and grow bigger and deeper. A nodule is different from a cyst in that it doesn’t have any pus, so it feels hard to the touch.

Cysts

Acne cysts are pus-filled bumps that are red or violet in color. They’re larger than pustules and located deep under the skin’s surface. They’re more inflamed and can be quite painful. Cysts are usually the same size as nodules, but they’re softer. This is because cysts are pus-filled and can burst, infecting the surrounding skin.

What does nodulocystic acne look like?

Nodulocystic acne occurs deep under the skin, so it can cause a lot of inflammation that’s painful to touch. Beyond how nodules and cysts feel, there are some visual clues to look for.

Treatment for nodulocystic acne

Since OTC treatments work on the surface level of your skin, they aren’t as effective for this type of acne. If you think you have nodulocystic acne, it’s best to see a dermatologist right away.

Early, aggressive treatment can save you from painful breakouts, permanent scarring, and possible emotional distress. Your dermatologist can help you treat nodulocystic acne with medications like:

• Isotretinoin, an oral retinoid also sold under the brands Claravis, Myorisan, Zenatane, and others

• Antibiotics

• Topical retinoids

• Birth control pills

• Spironolactone (Aldactone)

You might even need multiple medications to get rid of nodulocystic acne. Your provider may suggest injecting stubborn nodules and cysts with steroids to treat them directly and get rid of the inflammation.

How do you know what type of acne you have?

A good way to tell what type of acne you have is through the presence (or absence) of breakouts that leave scars:

• Comedonal acne (blackheads and whiteheads) typically heals without leaving a mark.

• Papules and pustules can leave red or dark marks that fade with time.

• Nodulocystic acne is more likely to leave textural scarring, dents, and pits.