Acne Treatment Guide: What Each Type of Acne Needs and What to Use at Each Stage

The Four Types of Acne

Type 1: Comedonal Acne (Blackheads and Whiteheads)

Blackhead (open comedo): A pore blocked with oxidised sebum and dead skin cells. The dark colour is oxidation, not dirt.

Whitehead (closed comedo): A pore blocked with sebum and cells but with a closed surface. The contents cannot oxidise.

Cause: Excess sebum production and incomplete skin cell shedding inside the pore. Not caused by bacteria.

Correct treatment: BHA (salicylic acid 0.5% to 2%). Salicylic acid is oil-soluble and penetrates inside the pore where it dissolves the sebum-cell blockage. Applied as a leave-on toner, serum or spot treatment.

What does not work: Benzoyl peroxide addresses bacteria; comedones have no bacterial cause. Topical antibiotics are ineffective for non-bacterial blockage.

Expected timeline: 4 to 8 weeks of consistent BHA use reduces blackhead size and frequency. Maintenance is required; comedonal acne recurs without ongoing BHA use.

Type 2: Inflammatory Acne (Papules and Pustules)

Papule: A red, raised lesion without visible pus. Inflammation around a blocked pore without the characteristic white centre.

Pustule: The same as a papule but with a visible white or yellow pus-filled centre. The pus is dead neutrophils (immune cells that have attacked the bacteria inside the pore).

Cause: Propionibacterium acnes (now reclassified as Cutibacterium acnes) bacteria inside a blocked pore triggering an immune response.

Correct treatment:

• Benzoyl peroxide (2.5% to 5%): Kills acne bacteria by releasing oxygen inside the pore. 2.5% is as effective as 5% and causes less irritation.
• Azelaic acid (10% to 20%): Anti-inflammatory and antibacterial without the drying effect of benzoyl peroxide; more suitable for sensitive and darker skin types
• Topical retinoids: Reduce cell build-up that creates pore blockage; address the underlying cause

What does not work: Salicylic acid alone does not kill bacteria; it addresses the comedonal blockage that precedes the bacterial infection.

Type 3: Hormonal Acne (Cystic and Deep)

Characteristics: Deep, painful, hard nodules or cysts along the jawline, chin and lower cheeks. No visible head. Often cyclical in pattern (worsening in the week before menstruation).

Cause: Androgen hormones (testosterone and dihydrotestosterone) stimulate sebaceous glands to increase sebum production and cause abnormal skin cell shedding inside pores. Topical treatments address surface symptoms but not the hormonal driver.

The topical limitation: No topical treatment fully resolves hormonal acne because the cause is systemic, not surface-level. Topicals reduce the appearance and frequency of individual lesions but do not address the hormonal trigger.

Effective approaches for hormonal acne:

Topical treatments that help alongside medical management:

• Topical retinoids (tretinoin 0.025% to 0.05%): Normalize skin cell turnover in pores
• Niacinamide (5%): Reduces sebum production and inflammation
• Azelaic acid (15% to 20%): Anti-inflammatory; well-tolerated on sensitive skin

Medical treatments that address the hormonal driver:

• Oral contraceptives containing anti-androgenic progestins (drospirenone, cyproterone acetate): Reduce androgen levels systemically
• Spironolactone (prescribed as off-label acne treatment in many countries): Anti-androgen
• Low-dose isotretinoin: For severe or treatment-resistant hormonal acne

If your breakouts are cyclical and concentrated along the jaw: see a GP or dermatologist to discuss hormonal management alongside topical treatment.

Type 4: Fungal Acne (Malassezia Folliculitis)

Characteristics: Small, uniform, itchy bumps typically on the forehead, chest and back. Often mistaken for bacterial acne but does not respond to standard acne treatments.

Cause: Overgrowth of Malassezia yeast in hair follicles, triggered by occlusion, sweating, antibiotic use (which disrupts skin bacteria balance), or humid climates.

Correct treatment:

• Antifungal treatments (ketoconazole 1% or 2% shampoo used as a face or body wash): Used 2 to 3 times weekly
• Avoid fatty acids (lauric acid, oleic acid) in skincare, which feed Malassezia
• Avoid occlusive products that trap heat and moisture at the follicle

What makes it worse: Standard acne treatments (benzoyl peroxide, salicylic acid) have no effect on fungal acne. Heavy oil-based moisturisers worsen the condition by providing Malassezia with additional food.

The Anti-Acne Skincare Routine

Morning:

1. Gentle gel cleanser
2. Niacinamide serum (5%)
3. Oil-free gel moisturiser
4. SPF 50 (non-comedogenic formula)

Evening:

1. Gentle gel cleanser
2. BHA toner (salicylic acid 0.5% to 2%) on congested areas
3. Benzoyl peroxide 2.5% spot treatment on active pustules (let dry 5 minutes)
4. Retinoid (start 0.025% retinol; build to 0.05% or prescription retinoid over 12 weeks)
5. Oil-free moisturiser

What to stop immediately: Harsh physical scrubs, alcohol-based toners, heavy occlusive creams, and any product labelled "pore-minimising" that uses high concentrations of silicone or oil. These worsen congestion and compromise the barrier.