Comedonal Acne: Causes, Treatments, Extraction and More

• Comedonal acne is characterized by pores blocked with oily residue, grime and dead skin cells
• These blockages are referred to as blackheads and whiteheads 
• Effective topical treatments for mild symptoms include azelaic acid, benzoyl peroxide, and salicylic acid 
• Prescription options such as retinoids and oral contraceptives are reserved for more severe symptoms or difficult to treat cases 

Comedones are small bumps called blackheads and whiteheads that develop in oilier areas of the face such as the cheeks, chin and nose, commonly referred to as the T-zone. Comedonal acne is usually associated with puberty as this is when sebaceous (oil) glands are most active. However, this condition is very common and can affect any age group due to a host of reasons. 

Early onset of comedonal acne can precede more severe forms of acne including inflammatory acne. Prompt, effective and consistent treatment is required to clear pores and prevent worsening symptoms. 

What Is Comedonal Acne?

When pores (hair follicles) become blocked with sebum, dead skin cells, grime and debris they form hard plugs just beneath the skin’s surface. While unsightly, they are not painful nor inflamed.

These plugs are referred to as whiteheads (closed comedones) and blackheads (open comedones); the latter being dark in color due to the pore’s contents oxidizing when exposed to the air.

Comedonal acne can be minor, moderate or severe depending on the lesion count; it can also present alongside inflammatory acne lesions such as pus-filled papules, pustules and cysts. 

If left untreated, comedonal acne can degrade and become inflamed and pustular.

Where is it likely to develop?

Blackheads and whiteheads typically form in those areas that have a high concentration of  sebaceous glands. These areas include the face as well as the chest, upper back and shoulders.  

What does it look like? 

Comedonal acne develops in hair follicles and presents as small flesh-colored or black bumps that give skin a rough texture.

What Causes It? 

Comedonal acne develops when dead skin cells and oil become trapped within pores. Excess sebum production is the primary driver of comedonal acne and can be triggered by a number of causes. 

Genetics and environment

Science has long established that a strong family history is typically found among acne patients. This genetic component has also been linked to earlier development of acne, higher counts of comedones and therapeutic challenges.  

A large study of female twins demonstrated that 81% of acne was due to genetic factors with the remaining 19% attributed to unrelated environmental factors. These factors include temperature and sun exposure, as both have a drying effect on skin which can prompt sebaceous glands to trigger oil production as compensation.

High levels of air pollution have also been linked to acne development.

Hormones

Fluctuating sex hormones, primarily androgens, can have a strong impact on the development of comedonal acne. During puberty, higher levels of androgens are secreted which spurs overproduction of sebum and leads to acne lesions.

These fluctuations in hormones are also present during other life stages such as adolescence, pregnancy and menopause; these elevate the risk of blocked pores.

Comedogenic products

Heavy or too-rich moisturizers such as cocoa or coconut butter and wheat germ oil can form a layer over the skin that traps dirt, sebum and bacteria. As well, a number of ingredients added to skin care products and cosmetics can irritate skin and clog pores including:

• Acetylated lanolin
• Algae extract
• Laureth-4
• Myristyl myristate
• Isopropyl isostearate
• Isopropyl palmitate
• Cetyl acetate 
• Lauric acid

Diet

Some research has shown a positive correlation between dairy consumption and acne. One theory is that the hormones in dairy milk stimulate insulin-like growth factor 1 (IGF-1), a hormone, which leads to inflammation and increased oil production. 

However, since the 1960s there have been multiple studies to determine if there is a link between diet and acne and these studies have produced conflicting results: some conclude that there is insufficient evidence to link certain foods and acne and others say there is a link between diet and acne.

Who is most likely to get comedonal acne? 

Adolescents are most likely to develop comedonal acne, and it can last into their 20s and 30s in about 64% and 43% of people, respectively.

Among adult women, 12%–22% are affected by acne compared to 3% of adult men. This can be attributed to women experiencing hormone fluctuations during menstruation, pregnancy and menopause. 

Comedonal Acne Treatments

Comedonal acne is typically treated with over-the-counter (OTC) topicals with the goal of regulating sebum levels and treating existing comedones by promoting skin cell turnover to achieve smooth and clear skin.

Over-the-counter topicals 

Effective OTC medications include topical treatments such as azelaic acid, benzoyl peroxide and salicylic acid. 

Azelaic acid

Azelaic acid is a comedolytic which means it can effectively break down existing comedones, and as a keratolytic it can gently break apart the outer layers of skin allowing skin to slough off. This also helps prevent new blockages from forming.

This acid has antimicrobial and anti-inflammatory properties to prevent bacteria from colonizing resulting in infection; it also helps heal skin. 

In controlled studies, azelaic acid has demonstrated comparable efficacy to topical tretinoin, benzoyl peroxide, erythromycin and oral tetracycline – all well established and effective acne medications that typically target inflammatory acne.

Azelaic acid can be found in store as a foam, gel or cream or peel formulas.

Benzoyl peroxide

Benzoyl peroxide is the gold standard for treating inflammatory acne as it can effectively kill acne-causing bacteria. It can also be used to successfully treat noninflammatory acne, because like azelaic acid, it too is an effective keratolytic agent that breaks down deep-seated plugs. 

Contrary to popular thought, benzoyl peroxide has not been shown to regulate sebaceous gland activity but it can dry up excess oils from the skin’s surface. 

Benzoyl peroxide can be found in cleansers, toners, gels, creams and moisturizers; it is frequently used in combination with other topicals such as retinoids for greater results. 

Salicylic acid

Salicylic acid is a desmolytic agent, and as such, can deeply exfoliate by dissolving the bonds that hold dead cells together on the skin’s surface. With continued use, comedonal plugs dissolve and pores can remain clear.

This acid also has mild antimicrobial and anti-inflammatory properties to help in healing and infection prevention. It can also reduce the look of enlarged pores and smooth rough texture.

Salicylic acid can be found in cleansers, toners, gels, moisturizers and peels. Clinical studies have demonstrated that a superficial salicylic acid peel is well tolerated and can show significant results in treating comedonal lesions.  

Prescription medications

Topical treatments are considered first-line therapy for treating comedonal acne. However, should OTC products not provide satisfactory results, your dermatologist can prescribe stronger topicals, combine several treatments, or add on another medication to achieve greater results. 

Antibiotics are not typically prescribed as these treat symptoms of inflammatory acne. 

Retinoids

Adapalene and tazarotene are two powerful retinoids that provide measurable results. 

Topical retinoids are vitamin-A derivatives that treat and prevent comedones by exfoliating dead skin cells, clearing blocked pores and boosting skin cell turnover. Most importantly, they are able to reduce sebum production to prevent comedones from forming in the first place.

Adapalene and tazarotene have been shown to be superior to tretinoin for comedonal acne with several studies showing improvements of 33%–64%.

Isotretinoin is an oral retinoid that has demonstrated the greatest results in reducing levels of sebum with decreases of 90% achieved while on this therapy. 

When retinoids are used alongside benzoyl peroxide, greater results can be achieved.

Oral contraceptives

Oral contraceptives that contain both estrogen and progesterone are prescribed for girls over the age of 15 and women to balance hormone levels which in turn regulates sebum production and helps maintain clear pores.

Currently there are three FDA-approved brands for acne treatment: Estrostep, Ortho Tri-Cyclen and YAZ.

Home remedies

Several home remedies can be considered to treat mild-to-moderate comedonal acne including the following:   

Tea tree oil is a popular essential oil that offers an abundance of skin-healing benefits. In the case of comedones, it can help dry oil skin to prevent comedo formation and protect from progressing to inflammatory acne due to its strong anti-inflammatory properties.

Clay masks can absorb excess oils from the skin, and lift out dead skin cells and debris that build up on the skin’s surface. The warm temperature of the clay/water mixture combined with  the mask helps release the clogged matter from within the follicles.

Witch hazel is a natural plant extract that has astringent qualities to dry up whiteheads and blackheads. The tannins found within remove excess oils without drying skin, constrict tissue to tighten pores and balances pH levels of skin. 

Comedonal Acne Extraction

Topical treatment of whiteheads and blackheads is the most recommended method to remove these blemishes. However, a comedone extractor tool can also be used to express the contents from the pore using gentle pressure. 

Before doing so, wash both the extractor tool and your hands well; afterward apply an antibiotic ointment to aid in healing and prevent infection.

For widespread or persistent cases, or if you develop microcomedones, extraction is best left in the hands of a dermatologist.

Tips to Prevent Comedonal Acne

The most impactful preventative you can take is to cleanse your face daily to maintain fresh, clean skin.

A pH balanced facial wash can remove the daily accumulation of oils and debris while maintaining the balance of the skin’s outer layer. Opt for a product that includes active exfoliating agents such as cleansers containing salicylic acid to remove dead skin cells, brighten skin and prevent acne formation.  

Replace comedogenic moisturizers with light-weight, oil-free products alternatives. Hyaluronic acid moisturizers are ideal as they effectively hydrate skin without clogging pores. 

Takeaway

Comedonal acne is a noninflammatory skin condition that is characterized by whiteheads and blackheads that develop on the face, chest, upper back and shoulders. These occur due to the accumulation of excess oils and dead skin cells.  

While some triggers are unavoidable, there are steps you can take to reduce your risk of developing this form of acne. This would include daily use of a gentle facial cleanser to remove grime, oil and dead skin cells. Regularly exfoliating your skin with an azelaic or salicylic acid- based product will ensure your skin is free of pore-clogging debris.  

Home remedies and OTC products are usually successful but prescription medications such as retinoids and birth control pills can be effective options for more severe or recalcitrant comedonal acne.