A Dermatologist’s Perspective to Understanding Acne Types

Acne is a common disorder of the oil, or sebaceous, glands. Not all acne looks the same or behaves the same. It manifests in various forms. Acne can be mild or severe and there is a spectrum of severity. As a dermatologist, I am here to guide you through the different types of acne and help you identify what treatment might help you.

There are 5 basic types of acne:

Comedonal acne
Hormonal acne
Nodulocystic acne
Rosacea acne
Acne Conglobata

1. Comedonal Acne: Early Signs

Comedonal acne, often considered early acne, is characterized by multiple open and closed comedones, also known as blackheads and whiteheads. This can occur as early as 9 years old and also populates around the nasal tissue, mid-face, and chin. Our hormones turn on during this early phase of puberty and these particular areas of the face have a high density of sebaceous so this is why we get pimples here. Comedonal acne can be just clogged pores like blackhead or these papules can be inflammatory – presenting with red, pink, and tender lesions.

2. Hormonal Acne: Cyclic Flares

Hormonal acne flares cyclically during hormone shifts, especially noticeable in the female menstrual cycle. Although technically all acne is hormonal, this term is reserved for acne worsening before your period or cyclically with your menstrual cycle. These pimples are usually deeper than comedonal acne and are characterized by ‘underground’, inflamed cysts along the jawline or chin. The jawline has several oil glands attached to those hair follicles and more androgen receptors, therefore, during a menstrual cycle, as the androgen profile shifts these follicles “wake up” and tend to produce cysts in this area. Hormonal acne is classically tender, deep, painful and fluctuates with menstrual cycles.

3. Nodulocystic Acne: Complex & Severe

Nodulocystic acne is a combination of open and closed comedones, superficial and deep cysts, potentially causing significant scarring and disfigurement if left untreated. It occurs all over the face, including the mid-cheeks, temples, neck, and posterior scalp. Due to its scarring potential, immediate evaluation and treatment by a dermatologist is crucial.

4. Rosacea Acne: A Unique Intersection

While rosacea and acne are two distinct pathophysiological disorders, they can intersect. Rosacea acne involves mid-facial redness, superficial pustules, visible blood vessels, and increased sensitivity to skin care products. This disorder is characterized by inflammation, and vasodilation (broken or visible blood vessels) with variations in symptoms among individuals. Some people have just rosy cheeks, while others have full face pustules and itchy eyes. Yes, it can affect your eyeballs!

5. Acne Conglobata: Sudden and Severe

Acne Conglobata is a sudden onset of irruptive deep cystic acne, predominantly affecting the chest and back in young men. Disfiguring and extremely painful, this type requires immediate evaluation by a board-certified dermatologist, as typical washes and topical treatments will not be effective. Accutane is recommended and most effective for Acne Conglobata.

Understanding the nuances of each acne type is essential because not all acne is the same, and consequently, treatments vary. Beyond physical implications, the severity of acne can significantly impact mental well-being. Moderate to severe acne of any type can lead to depression, school absence and low self-esteem. A thorough evaluation by an experienced board-certified dermatologist is recommended to determine the specific type of acne and identify the most suitable skin care products and treatments

The BASICS of Acne Skin Care

Simply washing your face or using the latest instagram or tik tok fad does not cure acne. Temporary fads or one-hit-wonder creams rarely improve the underlying cause of acne. The topicals Regardless of the type of acne you have, all acne is characterized mainly by four physiological issues:

1. Clogged pores/hair follicles due to dysregulated skin shedding (keratinization)

** The ingredients that target this factor are creams that increase cell turnover like retinols or glycolic or salicylic acids. Accutane is a powerhouse treatment for comedones and all types of acne. It can be micro-dosed and used creatively to completely abort the acne process and achieve completely clear skin.

2. Hormonal stimulation of oil glands leading to increased oil production

**The ingredients that target this factor are facial products that have a phytoestrogen component like Dr. Zenovia Benzoyl Peroxide Cleanser and other acne products in the line. The Dr. Zenovia products are the only over-the-counter products that address this hormonal component. They are enriched with a proprietary Regulate-360 complex with the powerful genstein molecule that tricks the skin by adding a local dose of plant-based estrogen which in turn lowers the androgen profile at the skin level only. These products target this specific hormonal aspect of acne.

Oral medication like Oral Contraceptives and Spironolactone are therapies that improve acne by targeting the hormonal stimulation of the oil gland.

3. Bacterial overgrowth due to the lack of oxygen in the pore/hair follicle

** This factor is treated with topical antibiotics like sulfur based soaps or Benzoyl Peroxide products. There are a host of prescription level antibiotics that can be prescribed as well.

Oral antibiotic therapies like Doxycycline are also prescribed for the overgrowth of bacteria and also have a powerful anti-inflammatory component.

4. Inflammation – this is not present in all acne but inflammation is when lesions are red and tender. The level of inflammation depends on your acne type and it is your body’s immune response to acne.

** The ingredients that target this factor are sulfur based products (sulfur is both antibacterial and anti-inflammatory), niacinamide-containing products, and devices like therapeutic red light. One of my favorite anti-inflammatory products for all types of acne is the Dr.Zenovia INflammaging Night Repair treatment. This is a light moisturizer that is enriched with resveratrol, caffeine, and antioxidants and works to shut down inflammation and soothe the skin.

In addition, sebum production in the scalp can worsen acne and cause tiny hairline papules or pimples. There are nuances that can improve acne like a dandruff shampoo if you have an oily scalp. Or red light therapy if you have micro-papules and inflamed lesions.

As you can see, acne is a complicated multi-factorial skin disorder that varies widely and the ingredients necessary to improve the features of acne depends on what you’re trying to target. In addition, acne in severe cases can lead to permanent scarring. Scarring is something you do not grow out of…it stays with you forever.

So if you are scarring don’t try to find the latest cream – see a dermatologist and start oral medication based on your doctor’s evaluation.

Acne is definitley one of my favorite subjects because addressing and curing acne goes beyond skin deep; it’s about empowering individuals to feel confident and comfortable in their own skin.