Acne: Spot Treatments and How to Remove Blackheads and Whiteheads

Topical treatments for acne, whiteheads, and blackheads

Acne can have a significant impact on quality of life, affecting both self- esteem and psychological development. Pimples, whiteheads, and blackheads can be very a distressing result of acne.

Luckily, there are many different treatment options that target the different pathways that are responsible for the formation of inflammatory and non-inflammatory acne lesions. The variety of treatments can be confusing. It is important to identify the type of acne lesion and the cause to be able to treat it effectively.

 

What is Acne?

Acne is one of the most prevalent skin conditions affecting many teenagers and young adults.[1] It can also affect adults as well. This condition is characterized by the appearance of comedones (whiteheads and blackheads), inflammatory papules, pustules, nodules, and cysts on the face, back, or chest.[2] The problem with acne is that it can lead to scarring and skin pigmentation changes.

The cause of acne is multifactorial and includes a variety of processes. These include:

  • Overproduction of oil from the skin’s oil glands
  • Overgrowth of acne-causing bacteria (Propionibacteriumacnes)
  • Increased and uneven skin protein (keratin) proliferation
  • Inflammation
  • Hormones

The severity of acne can vary. It can be divided into subcategories of mild, moderate and severe. Acne can also be characterized as inflammatory, or non-inflammatory. When pores become clogged with bacteria, the body sends white blood cells to help fight the infection. This results in the area becoming red and swollen or inflamed. This classically presents with papules and pustules, also referred to as zits, pimples, or spots. In contrast, non-inflammatory acne does not present as reddened pimples, but instead with comedones. Comedones, also known as blackheads and whiteheads, are clogged pores in the skin. These can form when dead skin cells and sebum (oil) block the pore. When a comedone is “closed” it is referred to as a whitehead. Conversely, when it is “open” it is exposed to air, which causes an oxidation reaction that turns it black and is therefore referred to as a blackhead.

Table 1. Pimples vs. comedones

Inflammatory Pimples

Non-inflammatory Comedones

Local overgrowth of Cutibacteriumacnes in the pore of the skin

Clogged pores with bacteria, dead skin cells, and oil

Papules and pustules

Redness and inflammation

Normal colonization, no overgrowth

Clogged pores with dead skin cells and oils

Comedones: whiteheads and blackheads

No redness or inflammation

 

Topical Treatments for Acne

Acne presents on the body in many different patterns. Some might experience acne breakouts all over the face, chest, or back, others may just get a few pimples. Regardless of the distribution, there are many different treatment options that help to decrease the appearance and reoccurrence of inflammatory pimples and comedones. Common topical acne treatments may contain either benzoyl peroxide, salicylic acid, azelaic acid, antibiotics or retinoids.

Benzoyl peroxide

Benzoyl peroxide (BPO) is one of the most common and popularly used treatments for acne. BPO can be found in many various acne-specific face washes, gels, creams, lotions, toners, and spot treatments. It is available by prescription or can be purchased over the counter. It usually comes in strengths ranging from 2.5-10%. The higher the strength, the more likely it is to cause side effects such as dryness and irritation. This powerful antiseptic is directly toxic to Propionibacterium acnes, the bacteria responsible for causing acne.[3] In addition to killing bacteria, it also helps to reduce both acne lesions and oil on the skin. Unlike antibiotics, bacteria are unable to develop resistance to BPO, which makes the ingredient an ideal option for combination therapy.[4] Prescription benzoyl peroxide is often combined with other acne-fighting medications. Benzoyl peroxide should not be applied at the same time as topical tretinoin (a topical retinoid), because BPO can deactivate it.

Antibiotics

One component of the formation of acne is through the proliferation of bacteria, namely Propionibacteriumacnes. This bacterium is present on everyone’s skin, but when overproduced it can cause acne. Many acne treatments target these bacteria. Erythromycin and clindamycin are the most commonly prescribed topical antibiotics for acne. However, bacteria can develop resistance to these medications over time.[4] Meaning that the antibiotics are no longer effective in killing the bacteria. For this reason, topical antibiotics are commonly combined with other agents to help reduce the rate of resistance. Antibiotic combination medications are often combined with benzoyl peroxide since bacteria are unable to develop resistance against BPO.

Salicylic acid

Salicylic acid is a subtype of beta-hydroxy acid (BHA) which is a common ingredient in many over the counter acne medications. This ingredient helps treat acne by exfoliating the skin and dislodging dead skin cells that can clog pores. Over the counter salicylic acid products are available in concentrations ranging from 0.05%-5%, with higher concentrations reserved for prescription medications and chemical peels.[1] Some studies suggest that salicylic acid is as effective, if not more effective than benzoyl peroxide in the treatment of comedonal acne.[5,6]

Azelaic acid

Azelaic acid is a dicarboxylic acid that has both antimicrobial and comedolytic properties.[4] This means that this ingredient helps to fight acne-causing bacteria and decreases the formation of comedones. Therefore, it is effective in treating both comedonal and inflammatory acne.[7] Azelaic acid is also used to treat rosacea and hyperpigmentation.

Retinoids

Topical retinoids are another popular spot treatment used for acne. Retinoids are a family of compounds derived from Vitamin A. When applied topically, it evens out the way skin cells grow and divide.[8] This loosens up skin cells and keratins and helps to unclog pores, and therefore reduces comedone formation. Retinoids have also been shown to reduce inflammatory responses, which helps to reduce redness of the skin, although it can cause redness and irritation as well.[2]

Typically, these retinoids require a prescription by a provider. However, adapalene has become the first and only topical retinoid medication that is now sold over the counter under the brand name Differin. In addition to improving acne, topical retinoids can also boost collagen production, reduce the appearance of fine wrinkles, and even out skin pigmentation, making it popular as an anti-aging treatment as well. Topical retinoids should not be used during pregnancy or breastfeeding.

Table 2. Acne medications

Acne Ingredient

Prescription Brand Name Medications

BPO

Acanya® (benzoyl peroxide/ clindamycin topical)

Benzac® (benzoyl peroxide topical)

Benzaclin® (benzoyl peroxide/ clindamycin topical)

Duac® (benzoyl peroxide/ clindamycin topical)

Epiduo® (adapalene/ benzoyl peroxide topical)

Onexton® (benzoyl peroxide/ clindamycin topical)

Antibiotics

Acanya® (benzoyl peroxide/ clindamycin topical)

Benzaclin® (benzoyl peroxide/ clindamycin topical)

Cleocin T® (clindamycin phosphate)

Clindagel® (clindamycin phosphate)

Duac® (benzoyl peroxide/ clindamycin topical)

Onexton® (benzoyl peroxide/ clindamycin topical)

Staticin® (erythromycin)

Azelaic Acid

Azelex® (azelaic acid)

Finacea® (azelaic acid)

Retinoids

Atralin® (tretinoin)

Avita® (tretinoin)

Retin-A® (tretinoin)

Retin-A Micro® (tretinoin micro)

Differn® (adapalene)

Tazorac® (tazarotene)

 

Comedone (Blackhead and Whitehead) Removal

The presence of blackheads can be a cosmetic nuisance. Fortunately, there are a variety of treatment options that aim to eliminate them. Treatments can either be through the use of topical preparations, chemical peels or manually extracted by a provider.

Topical treatments

When it comes to getting rid of blackheads, there are many comedolytic agents that can be used. These can be bought over the counter or prescribed by a provider.

Although benzoyl peroxide is an effective acne treatment, it is not as effective in treating comedones. BPO works by killing the bacteria that cause pimples and helps to reduce inflammation. Blackheads are not caused by bacteria or considered to be an inflammatory lesion. Instead, the use of a salicylic acid cleanser or spot treatment may be more effective in treating comedones.[5] Salicylic acid is preferred over BPO for comedones because it helps to breakdown the components that form comedones: dead skin cells and excess oil. If the addition of a salicylic acid based cleanser or spot treatment is not effective enough, topical retinoids can be added. Retinoids are considered to be the most effective treatment option for blackheads and whiteheads.[2,5] Topical retinoids help to normalize the shedding of the dead skin cells responsible for clogging pores and forming blackheads.

Chemical peels

Chemical peels are a common procedure performed by a licensed professional in the management of acne and acne scars. They cause controlled destruction of the epidermis, leading to exfoliation and removal of superficial lesions, and promote skin regeneration. Common peeling agents used are salicylic acid, glycolic acid, and lactic acid. For the treatment of comedones, salicylic acid is the most effective peeling agent.[9] Salicylic acid used in chemical peels is the same as the over the counter formulation but at a much higher strength. When applied to the skin for peeling purposes, salicylic acid reduces oil production, has both antibacterial and anti-inflammatory effects, and breaks down comedones.[9] In addition to treating blackheads, salicylic acid peels can help to treat inflammatory acne (papules and pustules) acne scars, and acne prone oily skin.[9] It is important to find a professional who has experience doing peels to avoid adverse side effects such as scarring or hyperpigmentation.

Extraction

In addition to topical treatments, manual extraction of blackheads is another alternative treatment option. However, this option is generally reserved for comedones that do not respond to topical retinoid treatment.[4] While blackhead extraction tools are available to purchase over the counter, it is recommended to have them professionally extracted. Inaccurate placement or technique can actually make the comedone worse if the pore ruptures. Rupturing can cause an inflammatory response, leading to increased redness and inflammation at the comedone site.[4] If opting for the extraction method of blackhead removal, concurrent use of topical retinoids has shown to help facilitate an easier removal with less trauma.[4]

 

Tips to Avoid Acne, Blackheads, and Whiteheads

  • Wash face with benzoyl peroxide or salicylic acid based cleanser
  • Use non-comedogenic facial products
  • Do not sleep in makeup
  • Regularly clean makeup brushes
  • Consult with a dermatologist for an acne treatment regime to determine which topical or oral treatments are best for you

* This Website is for general skin beauty, wellness, and health information only. This Website is not to be used as a substitute for medical advice, diagnosis or treatment of any health condition or problem. The information provided on this Website should never be used to disregard, delay, or refuse treatment or advice from a physician or a qualified health provider.

References

  1. Decker A, Graber EM. Over-the-counter Acne Treatments: A Review. J Clin Aesthet Dermatol.2012;5(5):32-40; PMID: 22808307 Link to research.
  2. Kraft J, Freiman A. Management of acne. CMAJ.2011;183(7):E430-435; PMID: 21398228 Link to research.
  3. What is the Role of Benzoyl Peroxide Cleansers in Acne Management?: Do they Decrease Propionibacterium acnes Counts? Do they Reduce Acne Lesions? J Clin Aesthet Dermatol.2008;1(4):48-51; PMID: 21218192 Link to research.
  4. Lowell A Goldsmith SIK, Barbara A. Gilchrest, Amy Paller, David J. Leffell, Klaus Wolff. Fitzpatrick's Dermatology in General Medicine. Vol Volume 2. Eighth Edition ed: McGraw Hill Professional; Feb 22, 2012.
  5. Russell JJ. Topical therapy for acne. Am Fam Physician.2000;61(2):357-366; PMID: 10670502 Link to research.
  6. Zander E, Weisman S. Treatment of acne vulgaris with salicylic acid pads. Clin Ther.1992;14(2):247-253; PMID: 1535287 Link to research.
  7. Fitton A, Goa KL. Azelaic acid. A review of its pharmacological properties and therapeutic efficacy in acne and hyperpigmentary skin disorders. Drugs.1991;41(5):780-798; PMID: 1712709 Link to research.
  8. Buchanan PJ, Gilman RH. Retinoids: Literature Review and Suggested Algorithm for Use Prior to Facial Resurfacing Procedures. J Cutan Aesthet Surg.2016;9(3):139-144; PMID: 27761082 Link to research.
  9. Kontochristopoulos G, Platsidaki E. Chemical peels in active acne and acne scars. Clin Dermatol.2017;35(2):179-182; PMID: 28274356 Link to research.