A Complete Guide to Acne Types and Treatment
Blackheads, whiteheads, inflammatory and pustular acne, severe nodular/cystic acne, then pigmentation and scars — a practical map of what changes with each pattern.
Acne · 7 min read · August 31, 2026
Start by identifying the acne pattern
Acne is not one condition with one universal treatment. I start with lesion type, inflammatory severity, and whether pigmentation or scarring is already developing before choosing therapy.
Blackheads and whiteheads
Blackheads are open comedones; the dark color comes from oxidation rather than dirt. Whiteheads are closed comedones covered by a thin layer of skin.
- Core treatment: adapalene or another topical retinoid.
- Salicylic acid can be added when appropriate and tolerated.
- Extraction alone does not prevent new comedones from forming.
Red and pustular inflammatory acne
Inflammatory acne produces red, tender papules and may develop pustules containing pus. Pus alone does not automatically mean an oral antibiotic is needed.
- A common core combination is benzoyl peroxide plus adapalene.
- More extensive or severe inflammatory acne may need an oral treatment after clinical assessment.
- Antibiotics should not be used as open-ended monotherapy for acne.
Nodular or cystic acne
Deep painful nodules and cystic lesions carry a higher risk of permanent scarring. For severe nodular or cystic acne, isotretinoin (Roaccutane) is the key and most effective systemic drug treatment and requires appropriate medical assessment and monitoring.
When a hormonal pattern may matter
Jawline and chin acne can occur in hormonally influenced adult female acne, but location alone does not establish a hormonal diagnosis. Menstrual pattern, excess hair growth and other clinical clues matter.
- Spironolactone can be considered in suitable female patients.
- Combined oral contraceptives are another option for selected patients when medically appropriate.
Pigmentation and redness after acne
A flat brown mark after a lesion is usually post-inflammatory hyperpigmentation rather than an indented scar. Red or pink residual marks may represent post-inflammatory erythema and follow a different treatment path.
- Azelaic acid and consistent sunscreen are useful options for post-inflammatory pigmentation.
- Controlling active acne comes first because every new lesion can create another mark.
Ice-pick, rolling and boxcar scars
- Ice-pick scars: TCA CROSS with trichloroacetic acid is a common targeted option; selected scars may be suitable for punch excision.
- Rolling scars: subcision is often important when fibrous tethering is the main problem and can be combined with collagen-remodeling procedures such as RF microneedling.
- Boxcar scars: treatment depends on depth and may include fractional CO₂ laser or other targeted techniques.
Control active acne first, then match the procedure to the scar type rather than choosing a device by name.
When to seek an earlier medical assessment
- Deep painful nodules or cystic lesions.
- New or worsening permanent scars.
- Extensive acne that is not improving despite consistent appropriate therapy.
- Associated hormonal features or concern for another medical or medication-related cause.
Medical references
- Guidelines of care for the management of acne vulgaris
- Acne vulgaris: management (NG198)
- The Use of Chemical Reconstruction of Skin Scars (CROSS) Method With Trichloroacetic Acid (TCA) for Atrophic Scars
- Subcision in acne scarring: A review of clinical trials
- Comparative Efficacy and Safety of Fractional CO2 Laser and Gold Microneedling Radiofrequency for Atrophic Acne Scars: A Systematic Review
Medical review
This guide was written and medically reviewed by Dr. Yousef Abo Zarad, a German board-certified specialist in Dermatology and Venereology.