Welcome to Derm Day, a regular column where we talk with the best dermatologists in the acne biz about all things breakouts - the good (but wait, is there anything good?), the bad and the ugly.
Today’s installment features Dr. Dendy Engelman, MD FACMS FAAD, who is educating us on different types of acne, the causes and what it can signify depending where on your face it pops up (no pun intended).
Can you tell us about all the different types of acne, causes, and characteristics of each?
Whiteheads: commonly found on back, shoulders, face
Whiteheads, or closed comedones, occur when the follicles beneath your skin become filled with bacteria and have a very small opening at the top of your skin. Air isn’t able to enter the follicle. The bacteria inside of it doesn’t undergo a chemical reaction, so it stays white in color.
Blackheads: commonly found on back, shoulders, face
Blackheads, or open comedones, are the skin-colored bumps that form when you have a pimple. In the case of blackheads, these comedones consist of follicles beneath your skin with very large openings, or pores. When you have blackheads, these large pores become clogged with a substance known as sebum. A chemical reaction with the sebum occurs under your skin. Melanin is oxidized and turns the clogged pores a black color.
These are both non-inflammatory.
Papules vs Pustules
A papule is a small red bump. Its diameter is usually less than 5 millimeters (about 1/5 of an inch). Papules don’t have a yellow or white center of pus. When a papule does accumulate pus, it becomes a pustule. Most papules become pustules. This process commonly takes a few days.
This is a type of inflammatory acne.
Cystic acne is the most serious type of acne. It develops when cysts form deep underneath your skin. This can result from a combination of bacteria, oil, and dry skin cells that get trapped in your pores. Although anyone can develop acne, cystic acne tends to occur in people with oily skin. It’s also more common in teens, women, and older adults with hormonal imbalances.
Hormonal acne is exactly what it sounds like — acne tied to fluctuations in your hormones. Although it’s typically associated with hormone fluctuations during puberty, hormonal acne can affect adults of any age. It’s especially common in women. During puberty, hormonal acne often appears in the T-zone. This includes your forehead, nose, and chin. Hormonal adult acne typically forms on the lower part of your face. This includes the bottom of your cheeks and around your jawline. For some people, hormonal acne takes the form of blackheads, whiteheads, and small pimples that come to a head, or cysts. Cysts form deep under the skin and don’t come to a head on the surface.
Phew, that’s a lot of different kinds! What does acne look like on different skin tones and types?
On lighter skin tones, inflammatory acne tends to look more red than on darker skin tones, but you can see a redness on all tones. The main concern is when it comes to acne scarring, which is a concern for all skin tones - in people with lighter skin, acne scars are usually a very dark purple color and can have a slightly thinner appearance. In people with darker skin, scars are often much darker than the rest of their skin.
How do you treat each type of acne?
Whiteheads + Blackheads: This type of acne is typically treated effectively with non-prescription acne treatments, like benzoyl peroxide and salicylic acid.
Papules + Pustules: This type of acne is typically treated effectively with non-prescription acne treatments, like benzoyl peroxide, salicylic acid and/or retinoids.
Cystic Acne: Due to the severity of cystic acne, OTC treatments are typically not effective and often combination therapies are required. Isotretinoin, oral antibiotics, Spironolactone, topical retinoids and oral contraceptives are all common treatment options.
Hormonal Acne: OTC treatments are usually not effective. Oral contraceptives, anti-androgen drugs or retinoids for less severe cases are usually the go to.
What do breakouts in different regions of the face signify? Can you explain each section of the face?
Forehead: Forehead acne is very common. Breakouts can appear in the form of whiteheads, blackheads, pimples, cysts & nodules. Stress, poor hygiene, hair products, makeup and skin irritation can all make forehead acne worse.
Cheeks: Acne on the cheeks is also quite common. I'd recommend regularly cleaning your phone (many don't realize how much bacteria ends up on our phones!) and changing your pillowcase very often to help minimize breakouts.
Nose: The nose is a bit more prone to breakouts because the pores in this location tend to be larger than elsewhere, where sebum can trap dead skin cells and bacteria. Digestive troubles, hormone fluctuations and hair removal/excessive nose blowing can also be underlying factors in breakouts on the nose.
Chin: Pimples on the chin are very common. They are typically the result of fluctuations in hormones. This is particularly the case for females and teenagers.
Jawline: Jawline breakouts are commonly associated with hormonal fluctuations, especially in women. Men can also experience jawline breakouts from using old razors while shaving.
Interested in visiting Dr. Dendy IRL? Check out http://www.drdendyengelman.com/.
About The Expert:
Dr. Dendy Engelman is a board certified dermatologic surgeon. She is currently an associate at Manhattan Dermatology and Cosmetic Surgery.
Dr. Engelman attended Wofford College in South Carolina and was inducted into Phi Beta Kappa and graduated summa cum laude with honors with a double major in psychology and French. She also played on Wofford's varsity volleyball team. Dr. Engelman earned the Presidential Scholar award while a medical student at the Medical University of South Carolina. She was also awarded the Humanism in Medicine Scholarship primarily for establishing and running a free medical care clinic in Charleston and in Haiti where she continues to serve on an annual mission with her family.
Following medical school, Dr. Engelman completed her internship in Internal Medicine at the Mount Sinai Medical Center in Manhattan. In addition to a dermatology residency at the Medical University of South Carolina, Dr. Engelman completed a one-year fellowship in Mohs and dermatologic surgery, lasers, liposuction and vein treatments. She also has extensive training and experience in cosmetic dermatology - including neurotoxins, injectable fillers, and chemical peels.
Most recently, Dr. Engelman was appointed Director of Dermatologic Surgery at New York Medical College where she oversees the training of future Mohs surgeons and dermatologists. She is a fellow of the American Academy of Dermatology, American Society of Dermatologic Surgery and American College of Mohs Surgery.