An Overview of Comedonal Acne

Differentiating Whiteheads and Blackhead From Classic Acne

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Comedonal acne is a common but often-misunderstood form of acne. Rather than the inflamed pimples and pustules characteristic of acne vulgaris (the most common form of acne), comedonal acne causes bumpy skin, blackheads, and non-inflamed blemishes.

Comedonal acne occurs when a hair follicle is blocked by sebum (a waxy skin oil) and dead skin cells. A single bump is referred to as a comedo, while multiple bumps are called comedones.

Tips for treating comedonal acne
Verywell / JR Bee

Comedonal Acne Symptoms

Comedonal acne doesn't look like typical acne. In fact, many people with comedonal acne don't consider themselves to have acne. This is because comedones are not red or inflamed like a typical pimple, nor do they tend to swell to excessive proportions or render pus. Instead, they develop as smaller, non-inflamed bumps (papules) that can either be closed or open.

Comedones are most common on the forehead, chin, and jawline but can develop elsewhere on the face, neck, shoulders, back, or chest. Symptoms can range from mild (with just a few odd blemishes) to severe (covering large areas of skin). Comedones can develop on their own or alongside acne vulgaris.

Comedones can sometimes become acne pimples if you try to pop them, allowing bacteria easy access to broken tissue.

Types

There are several types of comedonal acne blemishes:

Closed Comedones

Closed comedones, commonly referred to as whiteheads, range in color from creamy white to flesh-toned. They occur when the oil plug develops well beneath the opening (pore) of the hair follicle and appear most often on the forehead, chin, and cheeks. Whiteheads are not painful and they cannot be "popped" since they do not contain pus or an underlying infection.

Open Comedones

Open comedones, or blackheads, occur when the oil plug is situated near the opening of a pore. The dark color isn't caused by dirt but rather a chemical reaction in melanin, the pigment responsible for the color of skin. When exposed to oxygen, the melanin in dead skin cells oxidizes and turns a dark-brown color, resulting in a blackhead.

If you were to extract a blackhead, you would see the top portion of the plug is dark, while the lower portion remains a creamy white to yellow color. Blackheads typically form on the sides and bridge of the nose as well as the chin, shoulders, and back.

Microcomedones

Microcomedones are the smallest of all acne blemishes. These comedones, invisible to the naked eye, are the "seeds" from which larger comedones emerge. Every comedone and inflamed pimple begins its life as a microcomedo.

Macrocomedones and Giant Comedones

Macrocomedones are either closed or open comedones that are larger than usual. They can range from 1 millimeter (0.04 inches) to 3 millimeters (0.12 inches) in diameter. More often than not, a macrocomedo will be open, since it will be large enough to push to the opening of a pore.

Giant comedones are blackheads that range in size from several millimeters to 2 centimeters (0.78 inches) in diameter. They typically occur as single blackheads and mainly affect older adults.

Solar Comedones

Solar comedones, also called senile comedones, are caused by excessive sun exposure over a long period of time. They may be small or large, open or closed.

Chronic exposure to the ultraviolet (UV) radiation from the sun can cause the skin to thicken and papules to develop in swollen skin pores (especially around the eyes and on the nose, cheeks, or forehead).

Solar comedones most often occur in people over 60 but can begin to develop by as early as one's 40s with extreme sun exposure.

Favre-Racouchot syndrome is a sun-related disorder characterized by clusters of blackheads on sun-damaged skin, especially under the eyes and around the temples.

Causes

Comedones are associated with the pilosebaceous unit, which includes a hair follicle and sebaceous gland. These units are densely clustered on the face, neck, upper chest, shoulders, and back. Excess amounts of keratin (a protein found in skin, nails, and hair) combined with sebum can plug the opening of the follicle pore.

Sebaceous glands are responsible for producing sebum, the waxy oil that coats, moisturizes, and protects the skin. When a hair follicle becomes dilated, debris from the skin (called keratin sequelae) can mix with sebum to form the plug.

Risk Factors

Like most types of acne, comedonal acne is especially common during the preteen and teen years. However, it can occur at nearly every age, including adulthood.

Comedonal acne can sometimes be a harbinger of acne vulgaris to come, especially when it appears during puberty. With that said, having comedones doesn't necessarily mean you'll get pimples; other factors (including genetics) appear to contribute.

Comedonal acne tends to run in families. If your parents or siblings had it, you are more likely to have it as well.

Puberty also can contribute as the increased production of androgens (male hormones) can put the sebaceous glands into overdrive. The same can occur prior to the onset of a woman's period when hormone levels spike.

Comedonal acne can sometimes be caused or exacerbated by things you put on your face or skin, including oily skincare products or hair pomades. High humidity and air pollution can also contribute.

Diagnosis

Comedonal acne can usually be diagnosed by appearance alone. If a case of whiteheads does not improve with topical treatment, a doctor may check to see if some other condition is causing the tiny, uninflamed bumps on the skin. Examples include:

Treatment

As with other forms of acne, comedonal breakouts aren't caused by a lack of hygiene. Scrubbing or washing your face more frequently is unlikely to clear up an outbreak. As important as daily skincare is, it cannot on its own cure or prevent comedonal acne.

However, there are over-the-counter (OTC) and prescription medications that can help. These include:

If your acne is mild, you may be able to treat it with a topical OTC drug. For more severe or persistent acne, see a dermatologist.

Whether you use an OTC or prescription product, it may take up to 12 weeks before you see any improvement. Stick with it, even if there are no immediate changes.

If you don't see results within three to four months, ask your doctor if there are other, more potent therapies to consider.

Prevention

Minor comedone outbreaks can be prevented or minimized by adjusting the way you care for your skin. Here are a few simple tips that may help prevent pore blockage:

  • Wash only twice daily. Cleansing acne-prone skin more often can cause irritation and leave skin dried and inflamed. Inflamed skin is more vulnerable to infection, increasing the risk of acne pimples.
  • Use non-comedogenic skin products. These are non-oily moisturizers, cleansers, and cosmetics designed to prevent pore blockage. Some are labeled non-comedogenic, while others advertise themselves as anti-acnegenic.
  • Keep your makeup brushes and applicators clean. Sebum and dead skin cells can accumulate on bristles and pads. You can usually remove them with warm, soapy water. Rinse thoroughly and allow to air-dry.
  • Remove your makeup before bedtime. Sleeping with makeup residue contributes to pore blockage. Use a fragrance-free, non-alcohol makeup remover to avoid irritation. Some are infused with glycerin or aloe vera to help moisturize skin.
  • Wash after strenuous activity. Don’t let perspiration and oil stay on your skin. Take a shower and immediately rehydrate with a light, oil-free moisturizer.

If you do get a blackhead or whitehead, do not squeeze it. You are more likely to damage your skin and cause a blemish. Adhesive pore strips and clay masks can help extract tiny blackheads. Whitehead should be left alone and treated topically.

A Word From Verywell

While comedonal acne may not be as apparent or bothersome as other types of acne, you may still be concerned about it. That's completely understandable and why it's best to get it under control while it's still relatively mild.

In the end, you will want to treat your acne appropriately; overtreatment can be just as bad for your skin as undertreatment.

If left untreated, comedonal acne can develop into a more severe breakout and become more difficult to manage. It may take time to realize the benefits of treatments, so be patient and speak with your doctor or dermatologist if you have any questions or concerns.

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