ACNE UNCUT: Different Forms of Acne

We've identified what acne is and touched on surface-level topics. Let's take a deeper dive into what different acne forms and how they are classified. 

Acne is broken into two different types: NON- INFLAMMATORY v. INFLAMMATORY. 


Non-inflammatory acne is not red or inflamed. It is known as comedones. It is a noninflamed buildup of dead skin cells, sebum, dirt, debris, or more inside the follicle/pore.

  1. Blackheads - are open comedones. It is a direct result of excess sebum building up in the follicle and large enough to retain all of it. They do not encourage P.acnes growth because the follicle opening is large enough to be exposed to oxygen. Oxygen in the air causes oxidation to occur, resulting in a black or brown color. Blackheads rarely develop into inflammatory forms of acne.

#SkinTea Fun Fact: Sebaceous filaments are often mistaken for blackheads. THEY ARE NOT! They are small, solidified impactions without cell buildup. In plain English, it is an oil build up in the follicle. It's commonly found on the nose and can cause an acne breakout.

Side Note: You'll notice when professionally extracting blackheads, the deeper the blackhead, in the follicle, the lighter it is. The color is directly related to the air (oxygen) exposure.

  1. Whiteheads - are closed comedones. It results from dirt, debris, and cell buildup, similar to a blackhead, but the opening is not as large, or a thin film of skin has grown over the follicle. The small opening / thin film of skin is ideal for bacteria growth because the oxygen is not penetrating the follicle. An overgrowth of P.acnes can result in a buildup of pressure that may cause the follicular wall to rupture. If the follicular wall ruptures, the bacteria can spread, sending the body into overdrive with white blood cells (aka swelling, inflammation in an attempt to heal)Whiteheads can develop into inflammatory acne. 

*Side Note: You should not forcibly extract blackheads or whiteheads. They both need to be pre-softened to reduce the follicular wall's breakdown due to the impaction. There are a few ways to pre-soften the follicular wall: steam, deincrustation solution, enzyme peels, or chemical peels. 



Inflamed acne is characterized by red or inflamed lesions. 

  1. Papules - are red, sore raised elevations on the skin. It does not contain any fluid; therefore, it is NOT a whitehead. They vary in size and don't typically do not come to a head. They are under the skin's surface and sometimes "magically disappear." When they "disappear," the immune system has successfully absorbed, healed, or disposed of it.
  2. Pustules - are papules that have had an influx of white blood cells. The cells form a 'clump' that rises to the surface or comes to "a head". Therefore, relieving pressure from within the follicle.

Side Note: Papules affect the nerve endings because they are deeper in the skin than pustules. Pustules are impactions that have been pushed to the surface. They are easier to extract and less painful than papules because it alleviates pressure on the nerve.

  1. Nodules - are very similar to papules; however they are even deeper in the skin. They are hard and sore to the touch.
  2. Cyst - also called a dermal cyst, is deeper than nodules. It is a massive invasion of white blood cells.

Side Note: Estheticians should not extract nodules nor dermal cyst. They should be referred to a dermatologist for treatment.

Now, you know the difference between inflammatory and non-inflammatory forms of acne and how skin professionals are able to tell the difference. But, you also need to know - they are classified into four different groups:

  1. Grade I - Characterized by open (blackheads) and closed (whiteheads) comedones with an occasional pimple (inflammatory acne) and commonly seen in the early stages of teenage acne and adults with acne-prone skin.
  2. Grade II - Characterized by a larger number of closed comedones with some papules or pustules and commonly seen when comedogenic products are used.
  3. Grade III - Characterized by a substantial amount of open and closed comedones; red, inflamed, and irritated skin; and many papules and pustules. Most commonly associated with 'teenage acne.'
  4. Grade IV - Characterized by nodules and dermal cyst known as cystic acne. 

Side Note: Grade III + Grade IV are typically treated and recommended to a dermatologist. Estheticians and esthetic service can be a great benefits! Regular deep pore facials, LED treatment, or peels (if an ideal candidate) can improve the skin's overall health and appearance

Remember - acne is a skin condition. Therefore, the skin is not healthy and will go to great lengths to heal itself. Acne scarring is one of them. The body will begin to produce high amounts of collagen to compensate for the lack of normal forming tissue - known as hypertrophic scarring. In some cases, the tissues can be destroyed during inflammation/swelling, resulting in acne pits - known hypertrophic scarring. Both forms of scarring can be seen and associated with Cystic Acne (Grade IV).

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