How should comedonal acne be treated and removed?

How to Remove Comedones

For comedonal acne, topical retinoids (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) combined with benzoyl peroxide 2.5-5% are the definitive first-line treatment, with salicylic acid 0.5-2% as an effective alternative or adjunctive exfoliator. 1, 2

Primary Medical Treatment Approach

First-Line Topical Therapy

• Start with adapalene 0.1-0.3% gel combined with benzoyl peroxide 2.5-5% applied once daily in the evening as the foundation for comedone treatment, as this addresses both existing comedones and prevents new microcomedone formation. 1, 2
• Topical retinoids work by normalizing follicular keratinization and preventing comedone formation through their comedolytic properties. 3, 1
• Apply after washing face and waiting 20-30 minutes for skin to completely dry to minimize irritation. 4
• Use a pea-sized amount for the entire face, avoiding corners of nose, mouth, eyes, and open wounds. 4

Salicylic Acid as Alternative or Adjunct

• Salicylic acid 0.5-2% is the most effective over-the-counter exfoliator specifically for comedonal acne and can be used as an alternative to retinoids or as an adjunct. 1
• Start with once-daily application and gradually increase to 2-3 times daily if tolerated, reducing frequency if excessive dryness or irritation occurs. 1
• Available in washes, leave-on products, and chemical peels, with higher concentration peels (20-30%) providing more intensive treatment for resistant comedones. 1, 2

Second-Line Options

• Azelaic acid 20% cream applied twice daily provides mild comedolytic effects and is particularly beneficial for patients with sensitive skin or darker skin types due to its effect on post-inflammatory hyperpigmentation. 1, 5
• Azelaic acid is pregnancy category B, making it suitable for pregnant patients requiring comedone treatment. 1, 5

Physical Removal Techniques

Manual Comedone Extraction

• Physical comedone extraction is helpful for comedones resistant to medical therapy, though peer-reviewed evidence is limited despite long-standing clinical use. 3
• This should be reserved for comedones that have not responded adequately to 6-8 weeks of appropriate topical therapy. 3, 6
• For closed macrocomedones larger than 3mm, a specialized technique using cautery to puncture the center followed by extraction with dissecting forceps has shown very good cosmetic results. 7

Chemical Peels

• Glycolic acid and salicylic acid chemical peels may provide mild improvement in comedonal acne, though multiple treatments are needed and results are not long-lasting. 3
• Salicylic acid peels at 20-30% concentration applied for 2-4 minutes offer more intensive treatment for resistant comedonal acne. 1

Critical Implementation Strategy

Starting Treatment

• Begin with lower concentrations (adapalene 0.1% or salicylic acid 0.5%) and gradually increase frequency to minimize irritation. 1
• For sensitive skin, start retinoid application every other night initially. 4
• Apply moisturizer or non-comedogenic moisturizer with sunscreen every morning, as retinoids cause photosensitivity. 4

Expected Timeline and Adjustment

• Allow 6-8 weeks minimum before altering the regimen, as improvement typically becomes evident at 3 months with many patients seeing results by 12 weeks. 4, 6
• Initial worsening with appearance of new blemishes at 3-6 weeks is normal—continue treatment through this phase. 4
• Common side effects include dryness, irritation, and erythema; reduce frequency if these become excessive. 1

Combination Therapy Considerations

• Combination therapy is often more effective than monotherapy for comedonal acne. 1
• Fixed-combination products (adapalene 0.1%/benzoyl peroxide 2.5% or clindamycin 1.2%/benzoyl peroxide 3.75%) enhance compliance and may provide superior efficacy. 2, 8
• When using multiple topical agents, apply them at different times of day to minimize cumulative irritation. 5

Important Caveats

Resistant Comedonal Acne

• Closed comedonal acne is a predictive factor for resistance to isotretinoin (adjusted OR = 2.7), so these patients may require more aggressive topical management or physical extraction. 9
• If comedones persist after 12 weeks of appropriate topical therapy, consider adding chemical peels or manual extraction. 3, 1

Safety Precautions

• Avoid tretinoin during pregnancy; use azelaic acid (category B) instead. 5, 4
• Do not apply retinoids to broken skin or active wounds. 1
• Use caution with salicylic acid in children under 12 years due to risk of salicylate toxicity with prolonged, excessive use. 1
• Avoid excessive washing or harsh scrubbing, as this may worsen acne—wash gently 2-3 times daily with mild soap. 4

Maintenance After Clearance

• Continue topical retinoid monotherapy indefinitely after achieving clearance to prevent comedone recurrence. 2