Acne : What type do you have?
Types of acne
There are two ways to break down acne. One is by type to help guide treatment and the other is by popular terms that seem break acne down by location and age.
If we break down acne by type used by dermatologists to guide treatment, then the types are as follows:
1. Comedonal acne. Comedones are clogged pores. Commonly referred to as whiteheads and blackheads. This is caused by a build up of keratin, dead skin cells, oil and sebum in our pores. This stage of acne is the earliest stage and often treated with topical therapy. Over counter ingredients include salicylic acid, benzoyl peroxide and now adapalene. These products work by exfoliating or removing build up of oil, dead skin cells and sebum to prevent them from building up in the pores. If over the counter treatments do not seem to work well for osme skin types, then the prescription tretinoin or tazarotene can be added in to be a bit more aggressive to remove the clogged pores. This stage does not tend to be scarring.
2. Inflammatory acne. The next stage is considered inflammatory acne as these clogged pores become pink, pustular and scabby. This is a result of bacteria, P acnes, finding its way into the clogged pores. The bacteria triggers inflammation. This next stage of acne if early can be treated by adding in a topical antibiotic such as Clindamycin. However, if the inflammation is severe or persistent, an antibiotic by mouth will often be needed. This stage of acne is does not necessarily lead to long term scars but will, for the short term, leave behind pink or discolored areas wherever the acne was most inflamed. It can take a few months to fade.
3. Nodulocystic acne. This deeper, often painful, stage of acne is often associated with scarring. Although many parents will ask me to tell their kids that their acne scars are because they picked at their acne, the reality is that much scarring from acne is more likely from how deep the acne was in the first place. Whether or not we pick at this type of acne, it will scar regardless. Although antibiotics by mouth may help along with topical acne therapies, often times isotretinoin is needed to treat this type of acne and prevent scarring.
If we break down acne by how the popular press and the average person thinks of acne, then the most common types would be :
1. “Hormonal acne”. Many women will refer to hormonal acne as acne that occurs a week before their cycle. It’s not a medical term for acne as by definition most acne does have some hormonal component. This type of acne is most likely from fluctuations in hormones our body experiences during the course of our cycles that leads to a flare of acne. It can be particularly frustrating when the acne from one cycle fails to clear before the next cycle begins! In this category of acne sometimes oral contraceptives or a medication called spironolactone can be helpful to regulate the hormonal “surges” that trigger flares.
2. “Menopausal acne”. This is frustrating for women to experience! It’s also a misnomer because often this is not true acne. It is more often a form of rosacea that is worsened by traditional acne products. It is important to see your dermatologist to avoid using the wrong products here as this can lead to worsening of your flares. The most common description that patients will give for this is that the acne is deep, sensitive or sore, doesn’t come to a head, and if they try to squeeze these just clear fluid comes out and the pimple actually gets worse!
3. “Beard acne”. This is also technically not acne but a form of folliculitis or inflamed hair follicles from bacteria that finds its way into the hair follicles or pores. It often requires topical or oral antibiotics to clear along with a razor change.
4. “Body acne”
Body acne can be really frustrating to manage! The most important first step is accurately diagnosing it. Many patients referred to me for persistent body acne have often been misdiagnosed.
To be truly acne, you should be able to find a background of clogged pores or comedones, also known as whiteheads and blackheads. Acne will start with clogged pores that then become inflamed. On the body, the common triggers are physical blockage of the pores. Body gear for sports such as football and lacrosse can physically block the pores. Thicker products such as oil based moisturizers or hair gels can also directly clog pores. If this is severe it may require oral antibiotics or Accutane to clear. At the very least a topical retinoid is important to minimize scarring.
Believe it or not, most cases of persistent body acne sent to me are actually a form of folliculitis or infected hair follicles. Hair follicles can be infected by bacteria or yeast or other causes. When people talk about “sweat acne” they are usually mislabeling their breakouts as acne when they are actually folliculitis. The key difference is that folliculitis tends to be more extensive- extends down the length of the back- and it tends to have pus bumps based around hair follicles. Sweating can allow bacteria to dive into pores and trigger this type of folliculitis. Many people harbor staphylococcus on their skin- in their noses, under their arms or in the fold between the hip and the groin. When they sweat a lot the bacteria spreads from these areas and triggers flares. Its important to know this because antibiotics by mouth for an extended period of time may be more helpful. Another persistent cause is yeast that gets into our pores- pityrosporum folliculitis. I have seen people flare with this after sunburns or sweating as well. This is treated with a different antibiotic or antiyeast agent.
5. Neonatal acne or acne neonatorum
Baby acne or neonatal acne can be present at birth or develop over the first 4 weeks of life. It usually appears as clogged pores or closed comedones and I occasionally pustules over the forehead, nose and cheeks.
There are lots of factors that can contribute to this developing. It is thought to be the result of maternal hormones and neonatal hormones that stimulate the oil glands on the face and increase oil production. Maternal hormones or androgens can transfer to the baby. Also, neonatal adrenal glands produce high levels of androgens called Dehydroepiandrosterone until about the age of 1 when the neonatal adrenal gland naturally shrinks. These hormones stimulate the sebaceous or oil glands resulting in increased oil production and the acne as a result of this. There are some studies that show that neonatal acne could also be a response to a yeast called malassezia but this is not seen in all cases.
This is mild and self limited. It does not require treatment and spontaneously resolved usually by the age of 3 months with your scarring.
However, if it is severe, persistent or doesn’t respond to topical treatment with anti acne medications, it is important to consider a workio for a condition called congenital adrenal hyperplasia, an underlying endocrine disorder, or a tumor that could be secreting excess hormones.
In routine cases, there is no scarring. It is superficial and not deep and cystic. However if there are severe and inflammatory lesions it is important to have these evaluated to intervene early with treatment and consider further workup if warranted.
Due to its hormonal nature it really cannot be prevented. Meaning this is not the result of something the parents are doing.
If interested in treating, traditional acne therapies do work. I tend to prefer azaleic acid cream - there is a 20% that is prescription and a 10% that is OTC. It’s not as drying or harsh as some of our other acne preps. Tretinoin cream can also be used but I tend to recommend using only 2-3 nights a week as it can cause a lot of dryness. If areas are inflamed or there are pustules you can also use either benzoyl peroxide gel (i would stick with a 1% or 2.5%) or a topical antibiotic called clindamycin.
Most often this self resolved and does not require treatment and does not scar unless severe. If parents do not wish to treat it, this is ok:) it does not require treatment in most cases. If it’s unclear if treatment should be tried it is a good idea to see your dermatologist to assess the risk of scarring.
6. ‘Acne’ under the arms, buttocks, or in the groin area
I think of this as such an important topic because I have seen countless instances of misdiagnosis which results in not only delays in treatment but also significant emotional and psychological distress over implications of a wrong diagnosis. For example, I have had patients told they had herpes by their obgyns that has often turned out to be contact dermatitis to the blue dye in panty liners and tampons. I have seen women lose relationships after trusting the initial misdiagnosis assuming that their partners were not being faithful only to find out later the diagnosis was just a contact dermatitis. I’ve seen patients routinely misdiagnosed as ‘acne’ for years upon years when in fact they have a staphylococcus carrier state resulting in bacterial folliculitis that can be successfully treated within a month.
The most common cause is actually a bacterial folliculitis. Staphylococcus aureus is a bacteria that is commonly found in the environment. It can take up residence on the skin- inside the nose, under the arms or in the fold between hip and groin. When it lives in the fold between hip and groin you may not always see signs of it. However, after shaving or sweating or periods of stress there will be ‘breakouts’ that develop in the hair follicles. Most people think they just get ‘ingrown hairs’. Although this can occur, it often develops in pus bumps, boils and cysts that can be recurrent, persistent and scarring for years.
Other causes include hormonal changes, allergic reactions, hidradenitis (consisted autoimmune), etc.
Often those who find that they sweat more, have hormonal fluctuations, people that play contact sports, those that share razors, wear tight clothing, etc.
How can you tell the difference between acne and an STI? This is important to tell apart!
Herpes is exquisitely tender or painful and classically appears as vesicles or blisters grouped together in a patch or plaque. They are not necessarily based around a hair follicle the way folliculitis is. The other key point: herpes will resolve without treatment within a couple of weeks. Folliculitis will persist and recur and need to be treated.
The other sexually transmitted infections such as syphilis (classically painless), chancroid, gonorrhea and chlamydia often have an enlarged lymph node in the area. Always check for ‘lumps’ that can be painful along the fold between the hip fold. I strongly recommend a dermatologist evaluation as sometimes the clearest diagnosis is made by biopsy or culture of the lesions.
- Wash with an antibacterial soap like dial or lever 2000
- use disposable razors or frequently change the blade to avoid reinfecting or spreading
- see your doctor to confirm diagnosis and treatment
- wipe down gym equipment and use hand sanitizers
- if you feel as though you suffer from excess sweating then consider using a stick antiperspirant in the fold between hip and groin to decrease sweating
- don’t wear tight constrictive clothing
- don’t share razors
- see your doctor! You will likely benefit from a slightly longer course of antibiotics along with an antibiotic cream called mupirocin to the fold between hip and groin one week per month for 3 months to treat staph carrier state.
7. Perennial cystic acne. Many women that live in certain climates will talk about how their acne only flares in the fall and winter. Its difficult to say what is triggering this as the reasons can vary widely. However, it may actually be that the reduced sun exposure at these times of the year may trigger more acne or the lack of sun may make it difficult to ‘camouflage’ it. Sometimes it helps to be one step ahead of the game and start consistently using acne preps in August and September to prevent it.
Causes of acne
The cause of acne is essentially anything that leads to clogged pores. Pores can become clogged because of excess oil/sebum production or blockage of the pore. Excess sebum and oil production can be triggered by hormones, stress, medications (such a lithium, steroids, and even some cancer drugs), and potentially some foods although there is a lot of disagreement on this. Blockage of pores can result from dead skin cells accumulating on the surface from poor hygiene, thicker hair products or greases, face gear for sports, and even some cosmetics or products that may be a bit thicker.
Treatment for acne really depends on the type and stage. Early stages and milder acne can often be managed with topical therapy in the form of salicylic acid or benzoyl peroxide. If resistant we move on to prescription topicals such as tretinoin or tazarotene. Inflammatory acne that includes pus bumps and red sensitive or inflamed areas will often require antibiotics. Deeper cystic acne or persistent and resistant acne may require the use of isotretinoin. There is a place for oral contraceptives and spironolactone in the management of hormonal acne. However, these are long term therapies that require further discussion on expectations.
Acne scar treatments
When I evaluate patients for acne scar management the first step is to categorize the scarring.
1. Pink spots or macules with no raised or indented areas. This will fade on its own but can clear faster with the use of topical tretinoin or even the addition of hydroquinone for bleaching or azaleic acid.
2. Raised acne scars, also known as popular acne scars. These can be treated by resurfacing. Laser, cautery or dermabrasion can flatten these areas.
3. Depressed or pitted acne scars. There is a range here from rolling or boxcar scars that are slightly indented to actual pitted scars that run deep. For the rolling or boxcar scars, the treatments range from subcision, microneedling, resurfacing with laser, deep chemical peels, and fillers. The pitted acne scars are the most difficult to manage. Although the above therapies can improve them, often the results are not quick or perfect. These scars can be managed by removing or excising them. Although this runs the risk of developing a raised scar, its much easier to flatten a scar afterwards than to lift it up!