Acne is an incredibly complex disease with a number of different types. Effective treatment relies on correctly identifying which type you have, so you can target it better. 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 clearer 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 lead to under-treatment or even make the acne worse. In this article, we look at the difference between closed comedones and inflammatory acne lesions like papules, pustules or cysts. We also review how to properly treat and prevent them, and how to avoid treatment failure.
What are Closed Comedones?
Closed comedones (aka whiteheads) form when dead skin cells, keratin and sebum (oil) build up 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. They are usually neither painful nor red. They tend to appear and stay 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 left untreated they can become inflamed. The key thing is that closed comedones are not driven mainly 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 the pore sit there for too long, it leads to overgrowth of certain strains of bacteria that 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 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 you don’t target these, then they remain under the surface and continue to fuel inflammatory breakouts.
What’s the Difference Between Closed Comedones and 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 stays contained beneath the skin. Inflammatory acne develops when this blockage builds up, as more dead cells and oil collect in the pore. This triggers an immune response, leading to inflammation. Here are the key differences between closed comedones and 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 show as texture or small uniform bumps. Inflammatory acne becomes obvious through redness, swelling and sometimes pus, if bacteria start to overgrow in the pore.
- Stability: In general, closed comedones can stay unchanged for long periods if not disturbed. Inflammatory lesions are unstable and often progress quickly by rupturing. This tends to leave 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 pimples.
- Treatment: Closed comedones need treatments like retinoids and exfoliating acids, which correct cell turnover and prevent ongoing blockage. Inflammatory acne needs inflammation control alongside bacterial suppression, which may involve things like benzoyl peroxide, hypochlorous acid, antibiotics and azelaic acid. Treating inflammation alone lets comedones persist, while treating comedones alone once inflammation is established is usually not enough.
How Can You Tell if You Have Closed Comedones or Inflammatory Acne?
It’s important to tell closed comedones and inflammatory acne apart, because this affects treatment. It is possible to have only closed comedones, by themselves or with open comedones (blackheads, which are also a type of non-inflammatory acne). However, most people with inflammatory acne tend to have closed comedones at the same time too. The easiest ways to tell whether you have closed comedones or 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 is more 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.
- Response: Usually, measures like exfoliants and retinoids are enough to clear closed comedones. These are also needed for inflammatory acne, but there is usually a need for extra anti-inflammatory and anti-bacterial ingredients like benzoyl peroxide, or even antibiotics. Closed comedones also change slowly, because they reflect altered follicular behaviour. Inflammatory acne often appears to respond faster, 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 disappointing results. Approaches that reduce blockage can worsen inflammation, while those that calm inflammation may leave the underlying pore blockage untouched. It is also possible to go too far by intensifying everything at once to “cover all bases”. This usually leads to irritation and worse inflammation. So managing mixed acne takes 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 to 4 times a week to help keep pores clear, which prevents and treats closed comedones.
- Avoid Treating Every Lesion the Same Way: Closed comedones and inflamed spots need different though complementary approaches. Use retinoids, exfoliants and oil-absorbing ingredients like zinc all over the face, as they help prevent any type of acne forming in the first place. Spot treat individual inflammatory spots with anti-inflammatories and anti-bacterial agents.
- Separate Treatment Timing: Use retinoids at night and exfoliating acids or spot treatments during the day to minimise irritation.
- Support the Skin Barrier: Consistent moisturising reduces inflammation and lets acne treatments work more effectively.
- Adjust to Pattern Shifts: Mixed acne is not static. Sometimes you might have more closed comedones, other times inflammatory lesions dominate, so adjust your skincare routine accordingly.
What Pitfalls Should You Avoid When Treating Both?
When acne does not improve, it is really tempting to just escalate treatment. For most people, this means adding stronger actives and routines becoming more and more complex. However, escalating without first identifying whether closed comedones, inflammatory acne or both are driving the problem leads to treatment failure. The main pitfalls to avoid when treating closed comedones or inflammatory spots like papules, pustules and cysts include:
- Escalating: Adding multiple actives or increasing strength across your whole routine will most likely just increase irritation, cause 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 treatments like retinoids and exfoliants that normalise keratinisation and oil production. Inflammatory acne needs stabilising 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 stopping early.
- Impatience: It is tempting to discard treatments if they don’t seem to work. However, acne can take weeks or months to respond, so you may be robbing yourself of the right solution.
- Inconsistency: Constantly switching products or frequency stops the skin adapting. This is especially a problem for comedonal acne, which improves gradually. As long as your skin is tolerating your routine, give it time.
Closed comedones and inflammatory acne need a thoughtful approach that targets each type specifically. Where you have both, treatment should aim to prevent closed comedones by modifying the drivers of acne, while using anti-inflammatory agents that quickly suppress inflammatory lesions like pustules or cysts. The key to any successful treatment is to tackle your acne pattern with a consistent, targeted skincare routine.
At City Skin Clinic, we believe that skincare is personal and should always centre around your needs. Our doctors offer custom topical skin treatments for acne using ingredients like tretinoin, azelaic acid, clindamycin and spironolactone where appropriate. If you are interested in a personalised skincare treatment please use our online skin consultation form or book a video consultation. Start your treatment journey today and take your first step towards great skin.
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 professional with any concerns about your skin or treatment options.
