Comedones and Comedonal Acne

Comedones are small flesh-colored, white, or dark bumps on your skin. They are a type of acne blemish caused by plugs of oil and dead skin that become stuck in the openings (follicles) that enclose the roots of your hair. A single bump is called a comedo.

A closed comedo is not open to the skin's surface and is commonly known as a whitehead. An open comedo typically has a dark appearance where air has oxidized the melanin pigment in it, and it is known as a blackhead.

Comedonal acne is a common type of acne that consists of comedones rather than inflamed pimples.

This article will discuss types of comedones and the prevention and treatment of comedones and comedonal acne.

Symptoms of Comedones

Comedonal acne doesn't look like typical acne. Many people with comedonal acne don't realize those bumps and blemishes are, in fact, a type of acne.

Comedonal acne causes few if any, inflammatory breakouts. Instead, symptoms of acne include:

• Skin that looks and feels bumpy
• Blackheads

The bumps of comedonal acne aren't red like a typical pimple; instead, they're whitish or skin-colored. These bumps and blackheads are a type of non-inflamed acne blemishes called comedones. You may know comedones by the more common term, pore blockage.

Comedonal acne can range from mild (with just a few occasional blemishes) to more severe, with many blemishes happening over large areas of skin. It can develop on your face, back, neck, shoulders, and chest.

Comedones can appear on their own or alongside inflamed acne.

Types of Comedones

Comedones are caused by two things: skin-cell growth and increased oil production. A comedo forms when dead skin cells and oil form a plug that blocks your hair follicle. There are several types of comedones.

Open Comedones

An open comedo is what is commonly call a blackhead. It occurs when the plug of oil becomes trapped within the hair follicle near the pore opening. The top of the plug is at the surface of the skin and is exposed to air.

The air oxidizes the oil and darkens it, like when an apple is cut and left exposed to air. The top of the plug takes on the dark brown color typical of blackheads.

If you were to extract the blackhead gently, you could see the dark top portion of the plug is dark while the lower portion not exposed to air is creamy white to yellow.

These blackheads typically form on the sides and bridge of the nose, the chin, shoulders, inside the ear, and back.

Closed Comedones

Closed comedones develop when the pore opening is obstructed, and the plug of oil and skin cells is not exposed to air. The hair follicle is completely blocked.

The plug doesn't turn black; instead, a whitish or flesh-colored bump appears on the skin. The bump isn't red or inflamed, and it doesn't hurt.

These whiteheads most often appear on the forehead, chin, and cheeks.

Microcomedones

Microcomedones are the smallest of all acne blemishes. These comedones, invisible to the naked eye, are the "seeds" of the growth of visible comedones. Every pimple and blackhead begins as a microcomedo.

Macrocomedones

Macrocomedones are open (more common) or closed comedones that are larger than average. They typically range in size from 1 millimeter (0.04 inches) to 3 millimeters (0.12 inches ) in diameter.

Giant Comedones

These are huge blackheads, from several millimeters to 2 centimeters (0.78 inches) in diameter. They typically occur singly and in older adults.

Solar Comedones

Also called senile comedones, these lesions are caused by excessive sun exposure over time. They can also be found as part of Favre-Racouchot syndrome. They may be small or large, open or closed. Solar comedones most often occur in people aged 60 to 80 years, but they can occur in people in their 40s with extreme sun exposure.

What Causes Comedones?

All comedones begin as a plug of sebum, skin oil, and dead skin cells trapped in the follicle. This plug blocks the follicle opening.

The sebaceous glands continue to pump oil into the pore, and as it fills with oil, it pushes up on the skin's surface. This is what creates the bump that you can feel and see.

Comedones aren't typically painful, just annoying. Think of them as pre-pimples because all inflamed pimples get their start as a comedo.

Comedonal acne can be a harbinger of inflammatory acne vulgaris, especially when it appears during puberty. However, comedones don't always progress to inflamed pimples and can stay as a non-inflamed blocked pore just under the skin's surface.

Comedonal acne tends to run in families. If your parents or siblings had it, you're more likely to have it, too. People with oily skin are more prone to comedonal acne as well.

What Makes Acne Worse?

Many things can make acne progress and worsen. They include:

• Changing hormone levels during puberty, or in females the week before their periods
• Skin pressure or friction from, for example, tight collars, backpacks, helmets, or other sporting equipment (causing a specific type of acne called acne mechanica)
• Oily cosmetic products such as moisturizers and hair pomades
• Air pollution
• High humidity
• Squeezing pimples or picking at them
• Scrubbing skin too hard

How to Treat Comedones

Like other types of acne, comedonal breakouts aren't caused by a lack of hygiene. Scrubbing your skin or washing your face more often isn't enough to clear up your skin.

While a consistent daily skincare routine is essential to healthy skin, know that good skincare alone probably won't clear your skin. There are plenty of treatments that will, though, available both over the counter and by prescription.

Some common treatments for comedonal acne include:

• Salicylic acid
• Benzoyl peroxide
• Differin (adapalene)
• Topical retinoids
• Azelaic acid

If your acne is mild, you may be able to treat it with over-the-counter (OTC) treatments. For more severe and persistent acne, it's a good idea to see your healthcare provider to discuss treatment options.

Any treatment can take up to 12 weeks to see an improvement. Stick with it, even if you don't notice any immediate signs that it's working. Treatments in the retinoid category might seem to worsen symptoms initially, sometimes referred to as a purge or flare. However, this is a sign that the medication is working, increasing cell turnover, which will lead to clearer skin.

Talk to a dermatologist if you're not seeing good results after three months of treatment.

Prescription Medication

The most common prescription medications for skin conditions involving the sebaceous glands are antibiotics, birth control pills, spironolactone,isotretinoin, and topical retinoids like tretinoin.

Antibiotics: Antibiotics, usually doxycycline, minocycline, azithromycin, and trimethoprim-sulfamethoxazole, are most often prescribed for inflammatory forms of acne, although reduction of open and closed comedones can be seen when used for inflamed acne.

Birth Control Pills: People who menstruate may have skin flare-ups during specific times of the monthly menstrual cycle. Birth control pills can mediate the hormones that lead to these flare-ups.

Spironolactone: This medication is given to females to help prevent severe acne breakouts. It may also be prescribed with birth control pills for increased effectiveness in treating acne. It is also often prescribed with birth control pills because spironolactone can cause severe congenital disabilities.

Isotretinoin: This medication is typically used for severe acne in males and females. People with macrocomedones are more likely to experience a relapse of their symptoms on isotretinoin than those with other types of comedonal acne.

Surgical Procedures

Procedures to extract comedones can be performed in a healthcare provider's office. However, this is not usually done unless other forms of topical therapy have been tried first. Large comedones are most likely to need surgical removal.

Healthcare providers can use a small blade or needle to make a small hole in the middle of the comedo. A comedone extractor is pressed against the skin, and the material inside the pore is pushed outward.

Some comedones respond to cryotherapy, which involves freezing the lesion with liquid nitrogen, but this is not a common form of treatment. For small lesions, most surgical procedures can be performed with topical lidocaine or even without anesthesia at all.

Preventing Comedones

In many cases, minor comedones can be prevented (or at the least reduced). There are a few steps you can take to keep pore blockages away:

• Wash the right amount: Wash acne-prone skin areas only twice a day. Additional washing may irritate your skin.
• Use the right products. Washing, moisturizing, and applying makeup should be done with oil-free and non-comedogenic skin products, as these are less likely to clog your pores.
• Maintain clean implements: Keep all your makeup brushes and applicators clean.
• Wash before bed: Gently remove all makeup before you go to bed.
• Don't let sweat stick around: Don’t let perspiration and oil stay on your skin. Take a shower after a workout or other strenuous physical activity. If a shower or sink are not available, consider using a gentle skin cleansing cloth.

Outlook

Dealing with comedones can be frustrating, but most cases can be managed with a combination of medications and prevention.

How long it takes to see progress depends on the treatment. Surgical treatment is apparent on the same day. Oral treatments can take six weeks to a few months before noticeable clearing.

See a healthcare provider if you are still experiencing troublesome symptoms after trying over-the-counter remedies. Persistent comedones can be treated more aggressively.

Summary

As with all types of acne, treating comedonal acne as soon as possible is best. For minor blemishes, OTC products are often enough. More severe, widespread, or long-lasting cases can be effectively treated with prescription medications.

It will take time to notice the benefits of new treatments, so be patient and talk to your healthcare provider if you have any concerns or questions.