Different Types of Acne

Read on to learn about different types of acne. Several different types, or variations, of acne exist; some are common while others are very rare. The acne most people have is also known as acne vulgaris (meaning common). Other types of acne are given different names to distinguish them from each other.

The treatments vary according to the type of acne a person has. Types of acne can be divided into severity, while others are only ever severe by nature. Some doctors, when classifying acne, may wish to literally count spots in order to grade it.

Doctors will usually divide acne into four different grades - mild, moderate, severe  and cystic- there are also a few other common types. However these descriptions are a helpful start to getting acne correctly diagnosed and, most importantly, treated. Put simply:

  1. Grade 1: Open comedones
  2. Grade 2: Open and closed comedones and some papulopustules 
  3. Grade 3: Pustular Acne
  4. Grade 4: Nodulocystic Acne

Acne can also be classified by the type of lesion—comedonal, papulopustular, and nodulocystic. Pustules and cysts are considered inflammatory acne.

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Mild acne

This describes skin that is beginning to show the typical first signs of acne: greasiness, open blackheads sometimes in large numbers and a few spots. There is no inflammation. Mild acne might be widespread or confined to one area. Grade 1 acne often occurs in early adolescence, particularly on the the nose and forehead. A lot of adults also have mild acne, which is present as blackheads on the forehead and nose. Milia are often present in the chin and eye region.

This type of acne is generally fairly easy to keep under control and will not be scarring.  It can usually be successfully treated with over-the-counter (OTC) products containing salicylic acid with rapid results. If you treat acne when it is in this early stage it can help to prevent it worsening to moderate acne. this is particularly important in teenagers. Mild acne may progress to moderate acne if not treated.

Although it is less noticeable than any other type, this does not mean that someone feels their acne is only a mild problem, nor that it shouldn’t be distressing. The severity of acne does not always correlate with how it affects a person.

different types of acne - mild acne picture- on chin

Above: picture of mild acne. Acne falls into the "mild" category if you have fewer than 20 whiteheads or blackheads, fewer than 15 inflamed bumps, or fewer than 30 total lesions. Mild acne is usually treated with over-the-counter topical medicine. It may take up to eight weeks to see a significant improvement.

Moderate acne

As the description suggests, the acne will be more than mild. Again, it can be concentrated in one area or may be widespread. Comedones (blackheads) and milia will be present in greater numbers. In Grade 2 acne however, any spots may be larger, usually red and/or filled with pus with signs of open and closed comedones. There is now slight inflammation of the skin visible. Papules and pustules will appear with greater frequency and breakout activity is more apparent. The spots may start to appear on other areas of the face, not just the nose and forehead. The shoulders and chest may also develop acne spots, with occasional spots on the back, particularly in men. Adult women often develop spots and breakouts on the chin, cheeks, and jaw-line, particularly when immediately pre-menstrual and during periods. Another factor that may distinguish this from mild acne would be spots showing various stages of the acne process, from newly formed spots, to healing spots and/or some scarring.

Moderate acne can still be treated with OTC preparations at home. In addition to salicylic acid, a benzoyl peroxide lotion should be used daily or twice daily in order to kill the Propionibacterium acnes bacteria that produce the inflammation and lead to red papules and pustules. However, if after applying OTC products at home for a few weeks the acne does not significantly improve, then it is time to consult a doctor, either your family doctor, GP or a dermatologist (skin specialist). Moderate acne can progress to severe acne, especially if the acne spots or pimples are frequently squeezed or picked. 

types of acne - picture of moderate acne on face

Above: picture of moderate acne. If you have 20 to 100 whiteheads or blackheads, 15 to 50 inflamed bumps, or 30 to 125 total lesions, your acne is considered moderate. Dermatologists usually recommend prescription medication for moderate to severe acne. It may take several weeks to notice an improvement, and your acne may appear to get worse before it gets better.

Severe acne

Grade 3 acne is considered severe. The main difference between moderate or Grade 2 acne and severe or Grade 3 acne is the degree of inflammation present. The skin is now obviously inflamed and reddened. The usual signs of acne, such as red and yellow spots and comedones will be present, but far more widespread and very angry looking. Papules and pustules appear in larger numbers. Severe acne usually affects other regions, such as the neck, chest, shoulders, and/or upper back, in addition to the face.

The risk of scars developing is greater because the infection spreads and affects deeper layers of the skin. It is important to see a dermatologist if you have severe acne in order to obtain the best treatment. Grade 3 acne is usually treated with both topical and systemic (oral medication) therapies available only with a doctor'sprescription. If Grade 3 acne is not treated then it may progress to Grade 4.

different types of acne - severe acne picture- showing inflamed papules and papulopustules on face

Above: picture of severe acne. Inflamed papules and papulopustules are present.

Cystic acne

The most serious form of acne, Grade 4 is often called cystic or nodulocystic acne. Truly severe acne is, luckily, quite rare. The usual signs of acne, such as red and yellow spots and comedones, will be present, but far more widespread and very angry looking. Someone with this type of acne will often have large cysts. A cyst is a pus-filled spot over 5mm in diameter. There are numerous comedones, papules, pustules, and nodules, in addition to cysts. There is a pronounced degree of inflammation and breakouts are severe. Cystic acne is very painful. Acne of this severity usually extends beyond the face, and may affect the entire back, chest, shoulders, and upper arms. The infection is deep and widespread. Unfortunately, most cystic acne sufferers develop scarring. It is vital that Grade 4 acne is treated by a dermatologist. It can be hard to control, and nearly always requires potent systemic drugs (such as isotretinoin  Accutane) in addition to topical medications.

types of acne - picture of nodulocystic acne on chin

Above: picture of nodulocystic acne. People with severe nodulocystic acne have multiple inflamed cysts and nodules. The acne may turn deep red or purple. It often leaves scars. Prompt treatment by a dermatologist can minimize scarring. In some cases, a doctor may inject corticosteroids directly into nodules and cysts to reduce the size and painful inflammation.

This is the type of acne most likely to scar and needs to be treated with appropriate medication as soon as possible.

Nodules are deep-seated, hard, lumpy spots. They may last for up to eight weeks. Some nodules may continue to return as it is difficult to remove all the contents. Squeezing nodules is never recommended as it is likely to cause scarring. Severe acne can have quite a fast onset for some.

To avoid scarring seek immediate help from a doctor if you have severe acne on any part of the body. Expect to return regularly (at least once a month) for close review. This condition will usually require a referral to a dermatologist (skin doctor).

Variations of acne

Acne will usually have a straightforward cause. See: acne what is it (what causes acne). Some types, however, do not fit into the usual categories. Most of these are rare but include the following:

Acne conglobata

This type of acne usually affects more men than women and is most likely to occur between the ages of 18 and 30 years. It may occur on the site of an existing papule, pustule or comedone or on an area of skin previously affected by acne.

This rare and serious type of inflammatory acne requires aggressive treatment. Even with treatment, it may leave the skin scarred and permanently damaged. It is characterised by large cysts that are interconnected beneath the skin, forming ‘tracts’ or visible lumps that join one another. Even after clearing the pus-filled cysts and spots, it is possible that they will again become inflamed, resulting in the problem returning. This will usually occur in one concentrated area of the body, such as the buttocks. It is a painful and disfiguring condition, requiring immediate help from a dermatologist. Usually the strongest acne treatments will be prescribed and, if necessary, a course of steroids will also be prescribed.

different types of acne - picture of acne conglobata on back

Above: picture of acne conglobata on back. Acne conglobata is one of the most severe forms of acne. It involves many inflamed nodules that are connected under the skin to other nodules. It can affect the neck, chest, arms, and buttocks. It often leaves scars. This type of acne is more common in men and is sometimes caused by taking steroids or testosterone. Timely treatment by a dermatologist is essential.

Acne fulminans

This rare type of acne will be aggressive, painful and inflamed in a similar way to acne conglobate. It can start very quickly and in some cases become severe in a matter of weeks. Where it differs is that it may present with painful joints along with aches and pains similar to those experienced in arthritis. It may also be accompanied with a fever. This rare condition is documented in boys, rarely in females, and may be linked to the adrenal glands that release hormones. Its exact cause is not known. Acne fulminans can be treated with steroids, but will not usually respond to antibiotics in the way that other types of acne will.

Hidradenitis suppurativa

This condition is linked to acne but affects only certain sweat producing lands (apocrine glands). Unlike normal sweat glands which are triggered by overheating, the apocrine glands are triggered by stress, hormonal changes such as menstruation or sexual stimulation. Hidradenitis suppurativa occurs in the armpits, nipples and the genitoanal region (the buttocks and genitals). Apocrine glands are stimulated by another hormone called adrenaline. This condition may be connected to acne because it is often present only in people who have acne vulgaris.

The key signs of this condition are deep-seated nodules or lumps around the breasts, armpits or the genitoanal region. These may appear in isolation or in a group and the condition tends to continually relapse.

The lesions are made up of deep cysts and nodules with tract formation similar to acne conglobata. Scarring is again common and secondary infection frequently occurs. This affects more women than men and is common in people who are overweight. If this type of acne fails to respond to aggressive treatments, it may be likely that the blockages will require surgery to help drain them. They will be packed with sterile dressings and allowed to heal. This condition is very distressing and painful. There is a dedicated support group called the British Association for Hidradenitis Suppurativa. Their website is http://www.hstrust.org.

Hidradenitis suppurative - technical article

Dissecting cellulitis of the scalp 

This is similar to acne conglobata (see above) with the presence of cysts, nodules and interconnected tracts. However when it is located on the scalp, it often leads to scarring; this in turn leads to hair loss in those areas, and secondary infection may be common. This may respond quite well to steroid injections directly into the lesions, which can be painful and should be carried out by a specialist.

Acne mechanica

This might also be called ‘friction acne’ as it is often the result of anything that traps heat against the body for a prolonged period of time, or rubs or puts pressure on the skin. Any keen sportsman or woman who is also prone to acne may find that sports equipment pushed or held tightly next to skin, such as baseball caps, helmets and sweatbands, brings on a breakout in these areas.

Until quite recently, anyone with moderate to severe acne was disqualified from joining the armed forces. It was feared that tropical humid weather conditions in war zones or practice areas might worsen existing acne where heavy armour or packs were worn in close contact with the skin. This ruling has changed, but anyone carrying heavy weights or equipment which is in prolonged contact with a sweating body should be aware that it can aggravate existing acne. In tropical areas, this can lead to potentially serious consequences such as the blood infection septicaemia, which can be life-threatening if not treated quickly.

It is not uncommon for acne to develop under tight bra straps, on the inner thighs or around areas of tight clothing that attract sweat. Even excessive phone use could, in theory, cause a similar problem. Maybe this condition could be called ‘mobile phone acne’. This type of acne can be helped by reducing the pressure of tight clothing and carrying wet wipes to regularly remove excess sweat in the affected areas. Removing the sweat helps to reduce the problem.

types of acne - picture of acne mechanica on forehead

Above: picture of acne mechanica. Acne mechanica is caused by heat, friction, and pressure against the skin, often the result of wearing sports gear such as a helmet or baseball cap. It is sometimes called "sports-induced acne" because it occurs frequently in athletes. Preventive measures include wearing an absorbent material under sports equipment and showering immediately after activity.

Acne Majorca

This type of acne was first described in the 1970’s when northern Europeans found that cheap holiday destinations such as Spain offered plenty of sun at affordable prices. Some people believe that sunlight can help their acne; indeed the UV light may well kill off bacteria and sterilise existing acne. However UV exposure also promotes a thickened, horny layer of skin. This layer can more easily obstruct the follicle of the sebaceous glands. The improvement in the skin is usually short term and lasts little longer than the tan itself. The result of obstructing the skin, however, is to make acne worse. In addition to this, oily sun creams and lotions can themselves cause an outbreak of acne. Always use acne-friendly brands that are oil free.

Drug-induced acne

As the title suggests, some types of acne will flare up as a result of drugs taken either for medical conditions or (illegally) for muscle-building effect. One mood stabiliser, lithium, will often trigger acne in patients. For those who need the benefits of a drug such as lithium, any resulting acne should be easy to control by taking anti-acne medication at the same time.

Steroids are used for hormone-related conditions but are also taken illegally by body-builders who will commonly source them to help ‘bulk-up’ their muscles quickly. They will often buy them from the internet or dealers. These might have the effect of building muscles quickly, but the side-effect of acne is common. Frighteningly, many will again turn to illegal sources to obtain powerful acne treatments that may also have serious side-effects. People who get caught in this dangerous loop are risking their health and wellbeing for the sake of a sport and their appearance.

Gram-negative folliculitis

This rare condition can easily be mistaken for acne vulgaris (common acne) because it occurs as a result of using long-term antibiotic medication prescribed to treat the acne vulgaris. If individuals with acne experience a sudden flare up after their skin has been clear for a while, and if they are taking a long-term course of antibiotics, the possibility of gram-negative folliculitis should be considered and investigated.

There are two types of gram-negative folliculitis. In 80% of people, there will be superficial pustules without comedones that extend from the nose area to the chin and cheeks. In 20% of cases, deep nodular and cystic spots will be seen (large, hard-feeling spots or softer red lumps, both of which are over 5 mm in diameter).

Treating this successfully can be very challenging, although some improvement is seen with isotretinoin (Roaccutane). Clues as to whether you might have gram-negative folliculitis include:

  • You have used systemic antibiotics (antibiotics taken by mouth) for prolonged periods.
  • You have a flare up of pustular or cystic type spots that are resistant to the usual treatments.

Gram-negative organisms tend to be harboured in the nose, so testing for this condition will usually require a painless swab from inside the nostril. Sebum on the skin (the oiliness responsible for acne) provides an ideal moist environment for the bacteria to thrive. Antibiotics often fail to solve the problem, possibly because they may kill the bacteria, but have no effect on the sebum.

Unusual types of acne (acne variants)

Acne excoriée

This occurs frequently in adolescent girls and young women. Patients pick their skin leading to inflammatory lesions. Treatment can be difficult, psychological problems should be investigated, and underlying acne lesions managed with standard acne treatment. Successful treatment with habit reversal has been reported.

Dysmorphophobia

This occurs in a small number of acne patients. The patient’s perception of their acne is disproportionate to their physical signs. There is often associated depression and/or obsessional neurosis. The acne should be treated in the standard fashion and psychiatric collaboration is important.

Drug-induced acne

This is well recognized. Corticosteroids are the most common offenders. Steroid acne has a monomorphic appearance and consists of noninflammatory and inflammatory lesions. Other drugs implicated include anticonvulsants, lithium, and the novel epidermal growth factor receptor (EGFR) inhibitors currently used for solid tumours.

Cosmetic acne

Various cosmetic ingredients induce comedones, in particular lanolins, petrolatum, and certain vegetable oils. Hair pomades can produce a monomorphic, low-grade acne.

Infantile acne

This is rare but may result in scarring if left untreated. Patients develop inflammatory lesions, particularly on the cheeks, usually after 3 months of age. These can evolve into deep-seated nodules and sinus tracts. Treatment is similar to adult acne, but tetracyclines should be avoided due to the risk of discoloured teeth. Topical therapies and/or oral erythromycin (125 mg twice daily) or trimethoprim (100 mg twice daily) can be used safely.

Gram-negative folliculitis

This occurs as a complication of any long-term topical or oral antibiotic therapy. It is characterized by sudden onset of multiple pustules, often localized periorally and perinasally. This results from overgrowth of Gram-negative organisms including Escherichia coli, proteus, pseudomonas, and klebsiella. The offending antibiotic should be stopped and changed to oral trimethoprim or ampicillin. Oral isotretinoin generally produces a more rapid and permanent response.

Acne conglobata

This is an uncommon severe form of acne characterized by acne nodules, interconnecting sinuses, grouped comedones, and extensive scarring. Treatment is difficult and the problem usually runs a chronic course. Isotretinoin is usually the preferred therapy. Concomitant short courses of antibiotics and oral steroids may be required to control acute exacerbations.

Acne fulminans

This is rare, most frequently affecting adolescent boys. Acute erosive inflammatory lesions occur predominantly on the trunk. Associated systemic symptoms including fever, weight loss, arthralgia, and myalgia are evident. The aetiology is uncertain, but the presence of microscopic haematuria, erythema nodosum, increased response to P. acnes antigen on skin tests, and depressed response to intradermal purified protein derivatives are in favour of an abnormal immunological response. Oral prednisolone is the treatment of choice followed by the cautious introduction of systemic isotretinoin. A number of cases of acne fulminans have been triggered by anabolic steroids and testosterone.

Pyoderma faciale

This disorder is more common in adult women and often occurs in the context of emotional stress. These patients are not systemically unwell but the appearance of the disorder often adds considerably to the stress. Treatment with prednisolone reducing over 4 to 6 weeks and the daily application of moderate to potent topical steroid for 1 week will help. Isotretinoin should be introduced after 1 week, and, if tolerated, can be gradually increased.

SAPHO

This is the acronym for synovitis, acne, pustulosis, hyperostosis, and osteitis in which a group of overlapping joint diseases occur in conjunction with palmoplantar pustulosis and, less frequently, with psoriasis, acne, and inflammatory bowel disease.

As you can see there are many types of acne, but they can all be successfully treated.

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