Finding the underlying cause of your acne and the different types of breakouts is helpful in the treatment of acne and prevention of acne scarring.
What is comedonal acne?
Comedonal acne— blackheads and whiteheads—is caused by occlusion or blockage of hair follicles (pores) by the keratinized lining of the upper portion of the hair follicle. Keratin (i.e. skin debris) is normally shed through the follicular opening.
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How does comedonal acne differ from other types of acne?
Sebaceous Filaments
Sebaceous filaments are composed of the natural keratinized lining of the upper portion of the hair follicle and may resemble black heads. A black head is when the pore is clogged by dead skin cells and sebum, whereas a sebaceous filament is the overproduction of sebum (oil) from the hair follicle with no occlusion.
Milia
Milia may resemble a white head; however, these are firm growths that are not typically associated with acne. Milia may occur in areas of trauma, extensive sun exposure, hormonal changes, present shortly after birth in newborns and in aging skin. Milia may require manual removal by a dermatologist with a 11 or 15 blade or needle as they are not easily popped by hand.
How do we tackle comedonal (i.e. blackheads and whiteheads) acne?
Topicals
Retinoids
The best topical treatment for comedonal acne is prescription and/or over-the-counter nighttime topical retinoids. What are retinoids? Retinoids are chemically derived from Vitamin A and greatly contribute to regulating cell growth and proliferation.
- Pros
Retinoids help promote and hasten skin turnover, thus aiding with evening out skin tone, dyspigmentation and non invasively smooth fine lines and wrinkles overtime. There are various types of topical retinoids including tretinoin, tazarotene (Tazorac) and adapalene. Retinoids do not only treat comedonal acne, but also are considered preventative (win-win!).
- Cons
Retinoids may be irritating and drying. When using topical retin-a products, both over-the-counter and prescription, I recommend to all my patients with both oily and dry, sensitive skin to start 2-3 times a week and then increase to nightly as it is very dry and can be irritating.
Salicylic acid
Salicylic acid is a type of beta-hydroxyacid and is used for the treatment of acne. This ingredient is a class of “keratolytics” meaning it opens up the pores and removes excess scale.
- Pros
Salicylic acid cleansers are helpful in the treatment of hyperpigmentation in those with pigmented skin.
- Cons
Though salicylic acid is typically less drying than retinoids and benzoyl peroxide, it may be irritating to those with sensitive skin.
Glycolic Acid
Glycolic acid is a type of alpha-hydroxyacid and is incorporated in serums to help remove skin debris and grease from skin pores.
- Pros
Safe to use during pregnancy. May treat skin hyperpigmentation.
- Cons
May be irritating and drying to those with dry, sensitive skin. Start using glycolic acid 1-2 times weekly and titrate to daily as tolerated to minimize skin irritation and redness.
Benzoyl Peroxide
Benzoyl peroxide reduces inflammation, kills acne-causing bacteria (antibacterial) and helps open up pores (a triple threat!)
- Pros
Benzoyl peroxide may be present in facial cleansers as well as creams and serums. In general, benzoyl peroxide is widely available and affordable.
- Cons
Benzoyl peroxide may bleach clothing, sheets and towels. Benzoyl peroxide may be drying and irritating, especially to those with dry, sensitive skin.
Manual exfoliation
Microdermabrasion
This is a technique used to help with both comedonal acne and acne scars. A dermatologist performs this procedure by using a handheld device that gently removes the excess skin off the top layer of the skin.
- Pros
Minimal downtime and typically painless. The procedure is performed in the office and typically takes about 20-30 minutes. Some may notice results within a few weeks; however, a series of treatments may need to be performed. Discuss realistic expectations with your board-certified dermatologist.
- Cons
Exfoliating may leave your skin feeling refreshed and smooth; however, overexfoliating can exacerbate acne. What may surprise many is that there is a frictional component to acne. The more you try to scrub away your acne, the more red, inflamed and irritated your skin will become.
Prevention is essential
The first and most important preventative step is cleansing. Proper cleansing and hydration of skin is essential to eliminate dirt, oil and skin debris and prevent sebaceous filaments from forming.
The key is to find a face wash that is gentle and maintains hydration while not being too drying or leaving a greasy residue behind. There are numerous facial cleansers that claim to be excellent for acne-prone and oily skin; however, consumers may find these products irritating , drying and contain natural botanicals that may trigger a rash (allergic or irritant dermatitis).
It’s all about the ingredients:
- Zinc pidolate: Cleansers that contain zinc pidolate— an ingredient that effectively cleanses debris and debris on the face while maintaining the skin’s natural pH.
- Hyaluronic acid: Hydrating face washes that contain hyaluronic acid provide that extra boost needed to maintain skin moisturize and integrity of the protective skin barrier while effectively removing excess oils.
- Tea Tree Oil: Cleansers containing tea tree oil may be calming, soothing and help reduce skin redness.
It’s all about the technique:
Dr. Allawh’s Key Steps for Successful Acne Treatment
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Do not be discouraged, it takes time to see results. A majority of topical and oral acne treatments often take at least 6-8 weeks to notice improvement in your acne. So don’t jump ship to a new medication or give up on your current treatment if you aren’t seeing rapid results. There are numerous treatments available for acne (invasive and noninvasive), so if you aren’t pleased with your results, consult with your dermatologist the next step up the ladder.
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Compliance is key! Remembering to take the pills or using the topicals can be tough at times. I recommend setting an alarm on the phone as well as putting your nighttime creams by your toothbrush (brush your teeth, apply your retin-a!).
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Invest in gentle, noncomedogenic facial cleansers and moisturizers. Make sure your moisturizer and cleanser states “facial”, “noncomedogenic” and/or safe for dry, sensitive acne-prone skin. Use of safe ingredients and fragrance-free products is essential in maintaining hydration with minimal irritation.
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