Types of Acne

Acne is a skin condition that blemishes the skin. All types of acne are caused by changes to the sebaceous glands.

Therefore, acne mostly affects the area of the skin with the highest concentration of sebaceous follicles. These areas include the face and upper parts of the chest and back.

Androgens, such as testosterone and its metabolites, are the major endogenous compounds that initiate these changes in the skin. They essentially increase the production of sebum and when excess sebum gets to the skin, it encourages the growth of acne-causing bacteria such as Propionibacterium acnes.

There are different forms of acne; the 6 types of acne are discussed below.

Acne Vulgaris

Acne vulgaris is the most common skin disease.

It usually starts during the adolescent years when the levels of androgens rise in the body. These hormones stimulate increased production of sebum from the sebaceous glands. This is why the skin becomes oilier during the adolescent years.

Acne vulgaris can be classified by severity. Depending on the lesions that appear on the skin, acne vulgaris can be mild, moderate or severe.

The lesions seen with mild to moderate acne include comedones (whiteheads and blackheads), papules and pustules.

Whiteheads: Whiteheads are non-inflammatory acne lesions. They are formed in narrow or closed pores which prevent the expulsion of sebum, bacteria and dead skin cells to the skin surface. Therefore, they are also referred to as closed comedonal acne.

Whiteheads show on the skin as tiny white spots. They do not last as long as blackheads.

A related acne lesion is called milia. Milia is formed in the same way as whiteheads but only from dead skin cells trapped in skin pores.

Blackheads: Blackheads are also non-inflammatory acne comedones. They are referred to as open comedones because the pores are not completely blocked. Because the pores are partially blocked, the trapped sebum, bacteria and dead skin cells are slowly pushed to the skin surface.

Blackheads are identified by the black spots they leave on the skin.

However, this black top is not dirt or hardened sebum as previously believed. Rather, the black spot is due to the oxidation of melanin, the skin’s own pigment, when exposed to air.

Blackheads are stable structures and they are harder to eliminate than whiteheads.

Papules: Papules are inflammatory acne lesions. They can be observed as red, tender and inflamed spots on the skin.

Papules are formed when whiteheads accumulate too much sebum and bacteria almost to the point of rupturing inside the dermis and close to the epidermis. To prevent this rupturing, dermatologists advise acne sufferers not to squeeze their pimples.

Pustules: Pustules are related to papules. They are also inflammatory acne lesions formed from closed comedones.

On the skin, papules are seen as red circles with white or yellow centers. Papules are mostly already ruptured whiteheads. When the bacteria trapped in whiteheads are released, they infect the surrounding dermis.

The body responds to this local damage by sending white blood cells to repair the cells of dermis and contain the infection. These white blood cells then cause local inflammations at those points. The pus formed from the rupture gets to the surface and are seen as the inflamed spots commonly called zits.

Severe acne vulgaris includes two more acne bodies: cysts and nodules. These are formed from deep rupture of acne comedones. Unlike the superficial acne lesions described above, these acne bodies can cause long-term damage to the skin.

Nodules: Nodules are hard, large bumps underneath the skin surface. They bulge out and stretch the epidermis. They are more painful than superficial acne lesions and can last for months. Nodules should not be squeezed because aggravating them will only cause deeper and more extensive damage to the skin.

Cysts: Cysts form in the same way as nodules but they do contain pus. They are also painful and since they still contain pockets of bacteria-filled pus, aggravating them will only cause even deeper infection of the dermis.

Acne Conglobata

Acne conglobata is the most severe form of acne vulgaris. It is mostly affects men between the ages of 18 – 30 and can persist for many years.

Many large lesions including blackheads are the major presentation of this form of acne. These large lesions connect to each other to form large swaths of acne covering the skin.

Acne conglobata can affect the usual sites of acne breakouts such as the face, chest, back and upper arm. Furthermore, it can also affect the buttocks and thighs. At these sites, acne conglobata can cause severe and permanent damage to the skin.

Acne conglobata is sometimes resistant to the usually effective drugs used in treating acne vulgaris. Therefore, it requires aggressive treatment with multiple anti-acne medications including isotretinoin.

Acne Fulminans

Acne fulminans refers to the sudden breakout of conglobata-like acne lesions. It usually affects young, white males and it can produces severe and painful acne nodules and cysts. Acne fulminans can also cause ulcerating acne lesions on the skin.

Just like conglobata, fulminans can cause extensive and permanent acne scars.

Other defining symptoms of acne fulminans are fevers and joint pain. These strange symptoms may require a few weeks of hospitalization for acne fulminans sufferers.

This form of acne does not respond to antibiotics. Rather, it is treated with isotretinoin and oral steroids.

Acne Rosacea

Acne rosacea is often confused with acne vulgaris and that is because the two types of acne share most of the same presentations.

All of the lesions of acne vulgaris except blackheads are seen with acne rosacea. However, acne rosacea presents with distinctive red rash on the cheeks, chin, nose and forehead. Another way to distinguish acne rosacea from acne vulgaris is the visibility of blood vessels on the skin.

However, the definitive presentation of acne rosacea is the nose swelling it causes. This is one of the signs of a medical condition called rhinophyma.

Acne rosacea mostly affects adults over 30 years of age. Although it is more commonly seen in women, it is more severe when it affects men. It must not be left untreated.

Acne rosacea should not be treated at home. Consultation with a dermatologist is important.

Rosacea Fulminans or Pyoderma Faciale

Rosacea fulminans is a restricted form of severe rosacea. It only affects 30 – 40 year old women. Also this rosacea only affects the face.

Rosacea fulminans is characterized by large, painful nodules, pustules and sores which can form extensive scars. It usually begins suddenly and lasts for a year. This form of rosacea is treated with isotretinoin and oral corticosteroids.

Gram-Negative Folliculitis

Gram-negative folliculitis is a complication of treating acne vulgaris with long-term course of antibiotics.

This form of acne is characterized by pustules and cysts filled with pus infected by bacteria. This is a form of opportunistic infection that occurs when the long-term broad spectrum antibiotics used in acne treatment wipe out the beneficial, protective bacteria on the skin.

Some of the broad spectrum antibiotics used for treating acne are tetracycline antibiotics such as tetracycline, doxycycline and minocycline as well as other antibiotics such as erythromycin and clindamycin.

These broad spectrum antibiotics are useful for removing many types of bacteria from the skin. However, because they remove both good and bad bacteria, they leave the skin open to attack to whatever bacteria are resistant to them.

Gram-negative folliculitis is rare but when it occurs, it responds well to isotretinoin.

Acne By Grades

Dermatologists often classify acne by grades. There are 4 grades of acne by this classification.

To grade your acne, dermatologists make a physical examination of the area of the skin affected by the acne. 

When the grade of your acne is determined, dermatologists can then know which drugs and natural acne remedies can provide the most benefits.

Grade I: Grade I acne is mild acne. It is usually the start of adolescent acne and sometimes the presentation of adult acne.

Grade I acne is characterized by blackheads, whiteheads and very few, small pimples. These acne lesions are mostly seen around the nose and forehead although milia may occur on the chin.

Another defining feature of Grade I acne is that there are no local inflammations on the skin.

Grade I acne can be successfully treated by over-the-counter (OTC) acne medications and natural acne products. If left untreated, Grade I acne can quickly turn into Grade II acne.

Grade II: Grade II acne is also called moderate acne. It is characterized by more blackheads and whiteheads than what is observed in Grade I acne. In addition, pustules and papules will start to appear at this stage.

The rate of appearance of acne lesions is accelerated in Grade II acne. Also, some local inflammations can be observed on the skin.

At this stage, acne may spread further from the face and affect the chest, shoulders and back especially in males. In females, acne at this stage, affects the chin, cheeks and jaw and the lesions break out in greater numbers a few days before and during the menstrual cycle.

Grade II acne can also be treated at home with OTC acne medications and natural remedies. If left untreated, Grade II acne will progress to Grade III acne especially if the zits are aggravated.

Grade III: Grade III acne is severe acne and it should be treated under the care and supervision of a dermatologist.

All the acne lesions of Grade II acne are seen in Grade III acne but they are more severe and found in greater numbers. In addition, skin inflammation becomes pronounced at this stage and acne nodules will start to appear.

In Grade III acne, the lesions would have spread beyond the face to the neck, chest, shoulders and back. At this stage, acne cannot be managed only by topical medications. The treatment must involve a combination of both topical and oral acne medications.

Grade IV: Grade IV acne is also called nodulocystic or cystic acne. It is the most severe form of the skin condition.

Cystic acne is painful and it involves all the inflammatory and non-inflammatory acne lesions along with nodules and cysts. At this stage, the acne breakout may actually extend all the way to the upper arms.

Grade IV acne involves deep infection of the dermis and almost always cause extensive scarring.

It requires aggressive treatment with powerful anti-acne medications such as isotretinoin.

Types of Acne Scars

Acne scars are caused by the body trying to heal the wounds caused by deep inflammation within the dermis. The 4 types of acne scars are discussed below.

Box Car Scars: These are acne scars caused by the loss of tissue due to inflammatory damage to the dermis.

Box car scars appear on the skin as round or oval depressions with raised sides. These scars are similar to chickenpox scars in appearance. They can be deep or superficial and are mostly found on the temples and cheeks.

Hypertrophic Scars: Hypertrophic scars are also called keloid scars.

While box car scars are caused by tissue loss, hypertrophic scars are caused by overproduction of collagen as the skin tries to heal itself.

These scars are raised above the skin surface in thickened skin folds which cover an area even greater than the wound they try to heal.

Ice Pick Scars: Ice pick scars are the most common acne scars. They occur as deep pits with narrow funnel-like depression extending all the way to the dermis.

Ice pick scars are also formed from tissue loss in the skin.

Rolling Scars: Rolling scars appear as wave-like patterns on the skin. They are caused by partial tissue repair. As the tissues develop under the wound on the skin, it pulls down the epidermis to create the slight depressions that appear as waves.