Acne is an incredibly complex disease and has a number of different types. Effective treatment relies on correctly identifying which type of acne you have so you can better target it. Very often even when acne is responding well it can suddenly persist and get worse. This might actually be because you’re dealing with a different type of acne rather than your existing one becoming resistant to treatment. Nowhere is this better illustrated than the fact that closed comedones and inflammatory acne lesions like papules and pustules are frequently lumped together. However, these types of acne behave very differently. Blurring them can result in under treatment or even make the acne worse. In this article, we look at the difference between closed comedones vs inflammatory acne lesions like papules, pustules or cysts. We also review how to properly treat and prevent them as well as avoid treatment failure
What are Closed Comedones?
Closed comedones (aka whiteheads), form when dead skin cells, keratin and sebum (oil) accumulate and block pores beneath the skin surface. Unlike open comedones (aka blackheads), there is no visible opening to the air. Instead, whiteheads appear as small skin-coloured bumps on the skin. They are usually neither painful nor red. They usually appear and remain for long periods before resolving by themselves. Usually, they don’t leave behind dark marks or scars. However, their appearance does make the skin look textured and if they are left untreated then they can become inflamed. The key thing is that closed comedones are not driven primarily by inflammation. As such, they don’t tend to respond to acne treatments that target inflammation or bacteria.
What is Inflammatory Acne?
Inflammatory acne usually develops when a blocked pore or closed comedone becomes inflamed. If the dead skin cells and oil trapped within in the pore sit there for too long, it leads to over growth of certain strains of bacteria in the skin which thrive in this environment. This triggers an immune response which produces inflammation. As a result, the skin becomes red, swollen and tender. Once this happens, a closed comedone progresses to an inflammatory acne stage turning into a papule, pustule or deeper inflamed spots like cysts or nodules. At this point, anti-inflammatory or antibacterial products are usually necessary to reduce redness, kill the bacteria and make spots look less angry. However, they do not clear the original blockage and oil production. If these are not targeted then they remain under the surface to continue inflammatory breakouts.
Difference Between Closed Comedones vs Inflammatory Acne
The key thing to understand is that closed comedones and inflammatory acne are not separate acne types. They are different stages of the same process. A closed comedone (whitehead) is a blocked pore that remains contained beneath the skin. Inflammatory acne develops when this blockage builds up as more dead cells and oil accumulate in the pore. This triggers an immune response leading to inflammation. Here are the key differences between closed comedones vs inflammatory acne lesions like papules, pustules and cysts:
- Origins: Closed comedones form due to abnormal shedding of dead skin cells within the follicle. These cells mix with sebum and create a plug that seals the pore. Inflammatory acne develops when this blocked environment triggers bacterial activity and inflammatory signalling, causing the follicle wall to become irritated and swollen.
- Drivers: Closed comedones are driven by dead skin cells, keratin and oil building up in pores. Inflammatory acne is driven by immune activation. Once inflammation is present, the acne is no longer just a blockage problem.
- Appearance: Normally, closed comedones sit beneath the skin surface and may only be visible as texture or small uniform bumps. Inflammatory acne becomes obvious due to redness, swelling and sometimes pus formation if bacteria starts to over grow in the pore.
- Stability: In general, closed comedones can remain unchanged for long periods if not disturbed. Inflammatory lesions are unstable and often progress quickly by rupturing. This often leaves behind irritation and bacteria which can drive more inflammation. Individual lesions can take days or weeks to resolve but the process continues by creating new pimple.
- Treatment: Closed comedones require treatments like retinoids and exfoliating acids which correct cell turnover and prevent ongoing blockage. Inflammatory acne requires inflammation control alongside bacterial suppression which may involve things like benzoyl peroxide, hypochlorous acid, antibiotics and azelaic acid. Treating inflammation alone allows comedones to persist, while treating comedones alone once inflammation is established is usually insufficient.
How to tell if You Have Closed Comedones vs Inflammatory Acne?
It’s important to distinguish between closed comedones vs inflammatory acne as this affects treatment. It is possible to only have closed comedones by themselves or with open comedones (these are blackheads which are also a type of non-inflammatory acne). However, most people with inflammatory acne tend to also have closed comedones at the same time. The easiest way to tell if you have closed comedones vs inflammatory acne lesions like pustules, papules or cysts include:
- Look: If breakouts feel like small, firm bumps with little colour change, closed comedones are likely. If redness, swelling and visible spots stand out more than texture then it’s likely inflammatory acne. Closed comedones also tend to look similar to one another and appear in clusters. Inflammatory acne is usually more variable, with spots differing in size, redness and depth.
- Feel: Closed comedones are typically non-tender and only noticeable by touch. Inflammatory lesions are often sore, sensitive or painful.
- Responses: Usually measures like exfoliants and retinoids are enough to clear closed comedones. Whilst these are also necessary for inflammatory acne, there’s usually a need for additional ant-inflammatory and anti-bacterial ingredients like benzoyl peroxide or even antibiotics. Additionally, closed comedones change slowly because they reflect altered follicular behaviour. Inflammatory acne often appears to respond faster to treatment because inflammation can be suppressed quickly.
What Do You Do if You Have Both Types?
Treating closed comedones and inflammatory acne the same way usually leads to unsatisfactory outcomes. Approaches that reduce blockage can worsen inflammation, whilst those that calm inflammation may leave the underlying pore blockage untouched. It’s also possible to go too far by intensifying everything at once in an attempt to “cover all bases”. This usually leads to irritation and worsening inflammation. As such, managing mixed acne requires restraint and a thoughtful approach:
- Stabilise Inflammation First: When inflammatory lesions are active, calming the skin takes priority. Reducing irritation and background inflammation improves tolerance and prevents ongoing flare-ups.
- Use Targeted Exfoliation: Use a gentle exfoliant up to 3-4 times a week to help keep pores clear in order to prevent and treat closed comedones.
- Avoid Treating Every Lesion the Same Way: Closed comedones and inflamed spots require different though complimentary approaches. Use retinoids, exfoliants and oil absorbing ingredients like zinc all over the face as they help prevent any type of acne from forming in the first place. Spot treat individual inflammatory acne pimples with anti-inflammatories and anti-bacterial agents.
- Separate Treatment Timing: Use retinoids at night and exfoliating acids as well as spot treatments during the day to minimise irritation.
- Support the Skin Barrier: Consistent moisturisation reduces inflammation and allows acne treatments to work more effectively.
- Adjust to Pattern Shifts: Mixed acne is not static. Some time you might have more closed comedones, tehr time inflammatory lesions dominate so adjust your skincare routine accordingly.
Pitfalls to Avoid When Treating Closed Comedones vs Inflammatory Acne
When acne does not improve, it’s really tempting to just escalate treatment. For most people, this means adding stronger actives and ultimately routines becoming more complex. However, without clearly identifying whether closed comedones, inflammatory acne or both are driving the problem leads to treatment failure. The main pitfalls to avoid if you’re treating closed comedones vs inflammatory pimples like papules, pustules and cysts include:
- Escalating: Adding multiple actives or increasing strength across your entire skincare routine will most likely just increase irritation, produce purging and slow down progress.
- Over Exfoliation: Increasing the strength or frequency of exfoliation often worsens inflammatory acne.
- Oversimplification: Closed comedones need time and consistency using acne modifying drugs like retinoids and exfoliants that can normalise keratinisation and oil production. Inflammatory acne needs stabilisation first through ingredients that dampen inflammation.
- Introducing Retinoids Too Soon: Retinoids are highly effective for all forms of acne but only when the skin barrier is intact. Starting them in already inflamed or over-exfoliated skin often leads to irritation and early discontinuation.
- Impatience: It’s tempting to discard treatments if they don’t appear to work. However, acne can take weeks or months to respond to treatment so you may be robbing yourself of the right solution.
- Inconsistency: Constantly switching products or frequency prevents the skin from adapting. This is especially problematic for comedonal acne, which improves gradually. As long as your skin is tolerating your skincare, give it time.
Closed comedones and inflammatory acne require a thoughtful approach that specifically targets each type of acne. In cases where you have both, treatment should seek to prevent closed comedones through modifying the drivers of acne vs anti-inflammatory agents that immediately suppress inflammatory acne lesions like pustules or cysts. The key to any successful treatment is to tackle your acne pattern using a consistent, targeted skincare routine.
At City Skin Clinic, we are extremely 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.
