The difference between blackheads, whiteheads, papules, and pustules
When you think about acne, you generally consider it to be a pus-filled pimple, but that is just one phase of the acne process.
Acne isn’t a monolith. It’s a complex series of conditions ranging from cases so mild, you may not be able to see them in the mirror up through cases so severe they can leave permanent scars on your face.
What are the different types of acne, and how are they distinguished?
There are three tiers of acne: mild acne, moderate, and severe. As it worsens, acne moves through the tiers from one type of acne to another. Going from least severe to most severe these are the main types of acne:
Mild types of acne - blackheads and whiteheads
At its mildest form, acne can be so small that you don’t even notice it is there. There is a type called microcomedones that are not visible to the naked eye.
The most common forms of mild acne are blackheads and whiteheads.
What is the difference between blackheads and whiteheads?
For starters, blackheads and whiteheads look different from each other. Blackheads are dark brown to black dots on your skin that seem flat against your skin or slightly raised. Whiteheads are white and more noticeably elevated, with a white cap at the pointiest spot. While many people may think the white stuff in whiteheads is pus, it’s actually just a combination of the body’s natural oil (sebum) and dead skin cells. Pus doesn’t occur in acne until the acne is infected in the more severe pustule phase.
Though they look quite different, blackheads and whiteheads are actually formed by similar processes. Both are clogged hair follicles, both known as comedones. The difference between them is where the clog occurs.
For blackheads the clog occurs on the surface of the follicle and sebum from the sebaceous gland is still able to escape (they are also known as open comedones). For whiteheads the escape is closed off (they are also known as closed comedones) and pressure builds up under the skin until they form a raised skin-colored bump.
The reason blackheads are black is because of a substance known as sebum. This oily substance can clog the pores and turn darker with oxidation. Your melanin will become oxidized and when it does it turns dark. Since whiteheads are closed off from air, they don’t get exposed to oxygen and remain a lighter color.
Blackheads can vary in size from hard to see to several millimeters across in extreme cases. Whiteheads are usually the size of a pinhead.
While it was once believed that blackheads and whiteheads did not involve inflammation, there is some evidence that even the mildest forms of acne involve some inflammation.
In addition to the acne form of whiteheads, there is another skin condition, milia that is also referred to as whiteheads that looks similar but is actually caused by small cysts. In our discussion of whiteheads, we are referring to the acne version, not milia.
Moderate types of acne - papules and pustules
The main difference between mild forms of acne and more severe forms is that severe forms of acne involve a bacterial infection. The bacteria involved isn’t anything particularly rare or special. The Cutibactrium acnes (usually referred to as P. acnes) bacterium responsible for making acne worse is normally present, slowly growing on your skin.
As acne worsens, this bacteria invades the hair follicles/pores that have been physically clogged and your body’s immune system will begin to respond. As it does, the whitehead bumps that may have been skin colored become red and noticeably inflamed.
The uniform red bumps that form in this phase are known as papules. You can’t pop them. They can hurt.
As your body’s immune system fights off the bacteria, pus is formed and papules turn into pustules. With pus comes a raised light-colored bump. While you technically could pop pimples in this phase it isn’t recommended because it can draw more bacteria deeper into the skin and worsen the infection.
Severe types of acne - cystic and nodular
As acne gets severe, the size of acne increases and it can start to inflict serious damage on your skin. The acne can get hard, inflamed, and your infection can worsen. It gets bigger, penetrates deeper into the skin and has greater risk of causing permanent damage in the form of scars.
There's two types of severe acne: cystic acne and nodular acne. They can also occur independently of each other or together at the same time. Cystic acne is characterized by cysts which are softer and filled with fluid. Nodular acne involves nodules which are hard and solid. Because they are hard, Nodules are typically more painful.
For cystic and nodular acne, seek out help from dermatologists.
How do you treat different types of acne?
For starters you can help reduce most types of acne by treating your skin right - cleansing it twice daily and using non-clogging moisturizer.
Most people that experience acne tend to be resistant to using moisturizers and hydrators because of the oiliness of their skin. Using a non-clogging (non-comedogenic) moisturizer for a couple weeks can help reduce oil production.
Treatment of whiteheads and blackheads can be done by a dermatologist or trained skin care professional. They will use specialized tools and techniques that reduce the transferring bacteria when extracting.
As bacteria starts invading in cases of moderate severity, it’s a sign that it’s time to use topical antibiotics to fight it. You can treat papules or pustules by applying salicylic acid and benzoyl peroxide to your skin.
You can also start helping your skin recover by applying topical retinoids which help your body heal, decrease inflammation and redness, unclog pores by stimulating skin cell turnover and regulate oil production.
If your acne is getting worse and starts causing cysts and nodules to develop, it’s time to see a dermatologist. They may give you topical or oral antibiotics, corticosteroid injections to help your treatment. If you have cysts, they may drain your cysts using a sterile lancet.
RESOURCES:
1. Cleveland Clinic. Blackheads. https://my.clevelandclinic.org/health/diseases/22038-blackheads
2. DermNet.Comedonal acne. https://dermnetnz.org/topics/comedonal-acne
3. Medscape. Cutibacterium (Propionibacterium) Infections. https://emedicine.medscape.com/article/226337-overview?form=fpf