Blackheads: What are they and how do you treat them?

Tony is a 15-year-old male that comes to the office because he feels his pores are getting clogged.  His mom says, “He is washing his face once a day and I don’t think his face is getting clean enough.”  Her son gave her a sideways look after she said that.  He denies being self-conscious, but mom says that he has been avoiding going out with friends the past few weeks.  He is otherwise a healthy teenager and not taking any other medications.  He plays lacrosse and finds it is a little worse during the season.

On examination, I noted around 40 1-2 open comedones (another name for clogged pores or blackheads) on his chin forehead.  I examined his chest and back (the most common areas for acne) and they were free of pimples.  There were no red (inflamed) pimples on any of these areas.  Pimple is a word to describe all types of acne lesions, not just blackheads.

Acne comes in all shapes, sizes and severities.  The type of acne associated with blackheads is called comedonal acne.  Contrary to popular belief, these are not pores with trapped dirt nor do they come from not washing your face often enough. Sorry mom. Blackheads are open pores filled with dead skin cells and sebum, an oily substance.  When the oxygen in the air reacts with the dead skin cells it becomes “oxidized” and turns black.  If the pore is not open, it does not react with air and is a closed comedone (pore) and it appears as a little white bump.  When they get inflamed this can form a pustule or nodule, which are subjects for another blog. 

If blackheads are not a result of poor hygiene, what causes them?  The exact cause is unclear and probably multifactorial.  During puberty there is a spike in hormones which rev up oil gland production and cause overproduction of oil in these glands.  Blocking the pores or practices that open the pores like shaving or friction may aggravate the condition (like lacrosse gear).  High glycemic foods (think sugary and fattening junk foods) as well as dairy has been shown to increase growth factors and inflammatory pathways linked to acne.  

In terms of treatment, there probably won’t be much improvement with over the counter medications.  Over the counter preparations with salicylic acid and benzoyl peroxide have shown to have some effect but it is minimal.  The best treatment is a prescription topical retinoid (also called vitamin A acid) cream.  This topical helps prevent the pores from clogging by gently getting rid of dead skin cells. It creates new skin cells to form and push out the old skin cells and oil from the pores.  There are different strengths and preparations that your dermatology provider will tailor to your skin type.

For Tony it was recommended he use a gently cleanser twice a day, because hygiene is still important and helps get rid of dead skin cells.  So maybe mom was right after all.  At night he was asked to apply his retinoid cream.  The effects are not immediate but after 4-6 weeks, he should see less blackheads and improvement.  Part of the treatment plan was healthy diet of fruit veggies, whole grains and legumes while eliminating dairy and junk food as much as possible.  This got a thumbs up from mom.  Last but not least Tony was feeling more empowered to have a diagnosis and treatment plan and was going to call his buddies to hang out this weekend.  

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