Most acne advice focuses on what appears on the surface of the skin. Basically, the spots, congestion, pigmentation redness and oiliness. Treatment then centres around the fastest way to improve these visible features. Whilst this of course makes total sense, it misses one really important fact about acne. By the time acne becomes visible, the disease process has already been active for some time and treatment may in fact be too late. There is actually an earlier stage of acne that determines how acne behaves, treatment success and relapse. This stage is the microcomedone but there is rarely any discussion of it outside of dermatology circles. In this article we’ll review what is the microcomedone and how it affects acne formation, treatment and recurrence.
What are Microcomedones?
The microcomedone is the earliest detectable acne lesion. It forms deep in the follicles beneath the pores of the skin before anything is visible on the surface of the skin. There is no redness, no pain and no obvious blockage that you can see or feel. In fact, the skin can appear completely normal at this stage. What is happening instead is a subtle change in how the follicles behave.
Skin cells inside the follicle do not shed as efficiently as they should. They begin to accumulate and stick together. Sebum (oil) becomes trapped alongside them, gradually narrowing the canal that connects the follicle to the pores on the surface of the skin. This creates a microscopic blockage. The microcomedone at this point is just a structural change within the follicle. If left to progress, it can cause open (blackheads) or closed (white heads) comedones. If these become inflamed or infected the they can form papules, pustules or cysts.
Why am I Just Hearing About Them?
Microcomedones are rarely a topic of discussion because they are literally invisble. You cannot see them on the skin, extract them from pores or clearly illustrate them in photographs. This makes them difficult to explain in lay terms. Most acne education, both clinical and commercial, focuses on what you can observe, measure or improve quickly. As a result, the earliest stage of acne is often skipped in favour of later obvious features because they:
- Are microscopic: Educational material and marketing rely heavily on visual examples but you can only see microcomedones under the microscope. That means they aren’t part of routine assessments and patient-facing discussions.
- Do not cause symptoms: At this stage there is no pain, redness or discomfort, so neither patients nor doctors are aware of them as an underlying problem.
- Complicate the narrative: Acknowledging microcomedones challenges the idea that acne begins with visible spots and management can be purely about reacting to what appears on the surface.
Why Do Microcomedones Matter?
Acne formation is less about individual spots and far more about whether microcomedone formation is being adequately controlled over time. Blackheads, whiteheads and inflammatory spots do not come out of nowhere. They represent later stages of a process that began weeks or even months earlier with microcomedones. By the time acne becomes visible on the surface of the skin, the underlying changes within the follicle have often already been present for some time. As such, the opportunity to intervene early may have already passed. Due to this, microcomedones matter in acne formation because they help explain a few things:
- Why acne can seem to appear suddenly or worsen without an obvious immediate trigger.
- The reason treatment can take a long time to work.
- Maintenance is important and without it recurrence often occurs.
- Why treatment that focuses only on visible spots often leads to disappointing or short-lived results.
Treating the surface lesions only addresses the end of the acne process when what you really need for effect control is to to tackle the stage at which acne actually develops. If you don’t take into account this early microcomedone stage, then acne will always feel unpredictable and random. The good news though is if you treat microcomedones early enough then they may never progress to acne.
How Do Microcomedones Affect Acne Treatment?
Understanding microcomedones holds the key to finding best way to properly treat and control acne. The best treatments usually do not work by rapidly improving the appearance of the skin. Instead, they act by gradually normalising follicular behaviour and reducing the formation of new microcomedones. That is to say, they act at the initial stage of acne formation and resolve the acne before it becomes visible. This process is slow and largely invisible at first which has several important implications for acne treatment:
- Treatment assessment: Acne treatments are often judged too early based on surface appearance alone. At this stage, microcomedone activity may already be reducing, even though visible improvement has not yet caught up.
- Purging: Treatments that act on follicular turnover can change the timing of lesions that were already forming microscopically. Without considering microcomedones, it is common to misinterpret this as treatment failure rather than a predictable part of how these treatments work.
- Inconsistent progress: Different areas of the skin may respond at different speeds. This reflects variation in microcomedone burden between follicles, not random or unreliable treatment effects.
- Stopping too soon: When you stop treatment as soon as the skin looks better, microcomedone formation can quietly resume. This then leads to relapse of breakouts as the underlying process was never fully under control.
How Do They Affect Acne Recurrence?
Microcomedones help explain why acne so often comes back after periods of improvement. When visible spots settle, it is easy to assume the acne has resolved. In reality, the follicles involved may still be behaving abnormally. Microcomedones can persist beneath skin that looks calm, maintaining the conditions for acne to re-emerge once treatment is reduced or stopped. This influences acne recurrence in several key ways:
- Location: Acne commonly returns to familiar locations because the same follicles tend to harbour persistent microcomedones. These follicles are more likely to reactivate, even when surrounding skin appears clear.
- False sense of security: Improvement in visible acne does not necessarily mean the underlying process has settled. Microcomedones can remain active despite surface clearance, which is why relapse is common when stopping treatment too soon.
- Timing: Acne does not always come back immediately. Microcomedones may take weeks or months to progress to visible lesions. This gives the impression that acne has returned unexpectedly or without a clear cause.
- Misleading treatment failure: Recurrence is often described as resistance, rebound or a new trigger. More often, it reflects incomplete control of microcomedone formation rather than true treatment failure.
Seen this way, acne recurrence is not a new problem but a continuation of the same process. Microcomedones sit at the centre of this pattern, linking periods of improvement and relapse in a way that visible acne alone does not explain.
Best Way to Treat Microcomedones
Treating microcomedones requires a different mindset to treating visible acne. Because microcomedones are microscopic and non-inflammatory, you can’t target them by spot treatments or short-term interventions. Effective treatment focuses on normalising follicular behaviour over time, reducing the formation of new microcomedones rather than reacting to lesions once they appear. This is why treatments that seem slow or unimpressive early on are often the ones that matter most at this stage. Several principles are particularly important when treating microcomedones:
- Focus on follicular normalisation: The primary aim is to correct abnormal shedding of skin cells within the follicle. Topical retinoids remain the most effective way to do this, as they directly influence keratinocyte turnover and reduce the formation of new microcomedones. Prescription retinoids such as tretinoin and adapalene have the strongest evidence, whilst milder over-the-counter options like retinol may offer some benefit in less acne-prone skin or as maintenance. Other ingredients, such as azelaic, salicylic and other exfoliating acids can also support follicular turnover but are generally less effective at suppressing microcomedone formation on their own.
- Tackle excess oil production: Sebum does not cause microcomedones by itself, but excess oil creates an environment in which abnormal cell shedding is more likely to persist. Reducing sebum production can therefore support microcomedone control. Prescription treatments that influence androgen activity or sebaceous gland output, including sotretinoin and spironolactone can directly affect the oil producing glands. Topical retinoids, zinc and niacinamide can also help regulate oil production.
- Consistency over intensity: Microcomedones form gradually and resolve gradually. Irregular use or frequent switching between treatments allows microcomedone formation to continue quietly, even if visible acne appears temporarily improved.
- Be patient: Because microcomedones sit beneath the surface, improvements are not immediately obvious. Early visible changes are a poor indicator of whether microcomedone formation is being adequately controlled.
- Avoid over-reacting to early flares: Treatments that act at a follicular level can alter the timing of lesions that were already forming microscopically. This does not mean new acne is being created, but that existing microcomedones are progressing more quickly.
- Play the long game: Microcomedones are closely linked to relapse. Ongoing suppression is often needed even when the skin looks clear, particularly if you’re prone to recurrent acne.
Microcomedones sit quietly in the background of acne care, despite playing a central role in how acne forms and behaves. They help explain why acne often feels unpredictable, why treatment can seem slow or inconsistent and why relapse is so common once visible improvement is achieved. Its crucial to understand that acne does not begin when a spot appears and it does not resolve simply because the surface looks clear. By tackling microcomedones correctly and consistently, it is possible to reduce acne breakouts and maintain long term control.
At City Skin clinic, we are super passionate about personalised skincare. Our virtual skin clinic offers safe and effective custom skin treatments. Where appropriate our doctors use ingredients such as Tretinoin, Hydroquinone and Spironolactone to treat skin conditions like acne, hyperpigmentation, melasma and skin ageing. Start your online consultation today. The journey towards great skin starts here.
This article is intended for general informational purposes only and is not a substitute for medical advice, diagnosis or treatment. Always consult a qualified medical provider for any medical concerns or questions you might have.
