Acne is more than just pimples. Learn the different types of acne and the best ways to treat them so you can get a step closer to clear skin. It is time to get down to the nitty gritty about acne and decode the different types and the best ways to treat them.

It is important to know the different types of acne because the most effective way you can treat your pimples is by understanding your skin type and what type of acne you are suffering.

Acne vulgaris

This is common acne, and it takes many forms. The disorder starts when the follicular portion of the FPSU is plugged, producing two kinds of plugged pores (comedones), open and closed. Open comedones are the classic blackheads  . Closed comedones are called whiteheads


Acne rosacea

For reasons that are discussed in this article, comedones  are not seen in acne rosacea. The diagnosis is made  based upon the appearance of folliculopapules and folliculopustules   on

the convex surfaces of the central face and chin and forehead. The background skin is a rosy pink color that gives the disorder its name  . It usually onsets after the teen years and may last into the senior years.

There may be accompanying telangiectasia This has led to the definition of a subtype of rosacea called erythematotelangiectatic rosacea  . More on that later (see Appendix A).

There may also be a peculiar thickening of the involved tissues. The nose is most commonly involved, but cheeks and chin and other facial areas may show swelling, thickening, and eventually a woody firmness. This is called phyma (nodule or swelling) formation, and the classic involvement of the nose induces rhinophyma. Finally there may be, for reasons undetermined, involvement of the soft tissues of the eye, which carries the designation ocular rosacea .


Acne inversa (hidradenitis suppurativa)

This variation shows up in areas where the FPSU plugs up and then the follicular wall ruptures deep in the sebofollicular junction area. Most commonly this onsets in the axillae   inguinal creases, perineum, genitals   and perianal areas, but this disorder can appear anywhere FPSUs exist, including the trunk   the face   behind the ears, in the pilonidal sinus (cyst) area   and the scalp .

for the latter, it is termed perifolliculitis capitis abscedens et suffodiens (dissecting folliculitis of the scalp). There are often no visible comedones early in the disorder, and the first sign of trouble is usually a single deep reddish-purple painful nodule, often thought to be a “boil” caused by infection. It may erupt to the surface of the skin and discharge, or the mass may expand sideways, causing the formation ofdeep and then communicating sinuses lined with squamous epithelium.

These may become secondarily infected and drain purulent material for months or years. Secondary scarring can be extensive and complicates therapy . Multiheaded comedones, the follicular remnants of the FPSU, serve as the tombstones of burned-out FPSUs.

A special form of this disorder combines AI/HS, pilonidal sinus (cyst) disease, dissecting folliculitis of the scalp, and acne conglobata. These four disorders are referred to as the follicular occlusion tetrad  , but they are all basically the same disorder with variations dictated by local conditions.

Grading the three acnes Acne vulgaris Acne researchers have been searching for methods of grading the severity of acne for decades, and the search is still on, but the criteria seem now to be set.

A panel of acne experts “concluded that an ideal acne global grading scale would comprise the essential clinical components of primary acne lesions, their quantity, extent, and facial and extrafacial sites of involvement; with features of clinimetric properties, categorization, efficiency, and acceptance” .


There are presently three evaluation systems that recognize the need to include extra-facial sites: the Leeds system  , the Comprehensive Acne Severity Scale (CASS)  , and the Global Acne Grading System (GAGS)  . The Leeds system is complex but has a track record and a separate subcategory for non-inflammatory acne. The CASS is validated but does not discriminate between inflammatory and non-inflammatory lesions. The GAGS is not yet validated. A fourth, the Global Acne Severity Scale (GEA Scale), is designed for France and Europe and could likely be adapted to include extra-facial sites.

Acne rosacea The classification and grading system proposed by an expert committee in 2004 is still in use. Each feature of the disorder, from flushing to phymatous change, is generally graded as absent, mild, moderate, or severe, as are the physicians’ ratings of the severity of the subtypes proposed and the patients’ global assessment  . Although the ratings have the disadvantage of being somewhat subjective, they are reasonably accurate, reproducible, and generally manageable in the clinic. Acne inversa (hidradenitis suppurativa) Each of the two grading systems used in this disorder follows one of the patterns described for the other two acnes.

The original, Hurley’s three-“stage” system, is simple enough to use in the clinic . Its three levels of severity serve as useful clinical shorthand for communicating degree of severity among dermatologists and surgeons. The more refined, more objective, and therefore more complex Sartorius score , and its modifications, is of greater use to the researcher than the clinician.

As befits a complex disease, the scoring system is complicated at first sight but it does provide the reproducible results essential for tracking of physical improvements over time  . Other rating systems are available to quantify quality of life and degree of pain relief, but an overall rating system that would allow global evaluation, including serial follow-up of all aspects of the disorder, has yet to be developed ..

Overall, in evaluating and grading all the acnes in the clinic, it is hard to beat “So, how are you doing?”, “What’s your biggest problem right now?”, and “May I take a look?” when dealing with patients one on one. As my first supervising surgical resident admonished me, “When all else fails, examine the patient.” Those three questions, and their answers, are the best grading system