All You Need to Know About the 4 Stages of Acne & Treatment

While a pimple-filled face is often associated with adolescents and puberty – adult acne is quickly becoming to be just as common – no thanks to the unhealthy lifestyle habits that we have adopted living in today’s fast-paced world.

Despite being present for centuries – acne is still the most commonly diagnosed and treated skin conditions seen in clinics today.

The most common type of adult acne seen in Singapore is post-adolescent acne in women – which is largely hormones related. The data suggests that up to 12% of women over the age of 35 continue to have acne, with that percentage dropping to just 3% in men.

Many causes can leave you more susceptible to having a breakout – including genetics, hormonal changes, unsuitable skincare products and cosmetics, taking certain medications, and even underlying health problems like thyroid issues and polycystic ovary syndrome (PCOS).

If you want to know how to get rid of acne for good, the first step is to ascertain the causes of your acne and identify the type of acne that you have. Traditionally, there are 4 stages of acne that differ in their key characteristics and severity – thus changing the best treatment options available to each patient.

A quick recap: why acne occurs

Acne is caused by a combination of factors: excess sebum production, dirt and dead skin trapped in pores, and the proliferation of the P.acnes bacteria that leads to intense inflammation.

The inflammation that occurs then ruptures the sides of the pore and leaks bacteria into the surrounding skin; resulting in a breakout. While sebum in healthy levels help to keep our skin soft and supple – a surge in production increases the chances of developing acne vulgaris – the most common manifestation of acne that often appears on the face, back, and shoulders.

In fact, scientific evidence shows that the average rates of sebum production is much higher in persons with acne than those without.

While acne often starts off mild, it can quickly progress to more severe forms such as cystic acne – one of the hardest acne types to treat that is characterized by red, inflamed, and painful lesions that have a greater likelihood of leaving scars and post-inflammatory hyperpigmentation (PIH) behind.

Acne types

Acne can be broken down into two types: inflammatory and non-inflammatory acne. Below are the various types of acne (from mild to most severe):

  • Whiteheads (non-inflammatory – otherwise known as closed plugged pores, occurs when oil and skin cells prevent a clogged hair follicle from opening)
  • Blackheads (non-inflammatory – otherwise known as open plugged pores, occurs when the pores are filled with excess oil and dead skin and stay open)
  • Papules (tiny red, inflamed, and tender bumps)
  • Pustules (aka pimples – they are essentially papules with pus that comes out when squeezed due to an accumulation of skin debris, white blood cells, and bacteria)
  • Nodules (large, firm, and hard lesions that can be painful. They do not contain pus and occur deep within the skin)
  • Cysts (painful, pus-filled lesions occurring deep under the skin that are roughly half a centimeter in diameter – have the highest chance of causing scars)

The 4 stages of acne

Dermatologists often conduct a visual assessment to determine the type and severity of a patient’s acne. In general, acne can be classified into one of these four stages:

Grade 1: Non-inflammatory acne – primarily consists of microcomedones, comedones, and the occasional papules and pustules.

Grade 2: Greater number of comedones, papules, and a few pustules present – mostly confined to the face.

Grade 3: Inflammatory acne – more papules, pustules, nodules, and a few cysts present. Progressing to a more severe form that can also appear on the neck and upper part of the body. A greater amount of redness and inflammation present.

Grade 4: Inflammatory acne that is severe – nodules and cysts are common; pus, pronounced inflammation, and scarring are also present at multiple areas such as the face, upper chest, and back. Lesions are firm to the touch and can sometimes look like a big blister. Timely intervention by a dermatologist is key.

In general, the grades are diagnosed based on evaluating the presence or absence of inflammation, observing the number and type of dominant lesions, and how widespread lesions are in order to come up with a verdict.

Although the classifications available are considered to be overly simple and the best treatment plans should take into account a multitude of factors – including the causes of acne and your age – they are still helpful in helping both patients and doctors get a better picture of what is required to tackle acne head-on.

The 4 stages of acne: best treatment options

Most acne medications and treatments often target only one or two of the key factors that cause acne: working to either decrease and block sebum production, kill bacteria and exfoliate away dead skin cells, or alleviate inflammation.

Topical medications include products containing benzoyl peroxide, salicylic acid, or sulphur – all of which are FDA-approved and known to be active-acne fighters. Used primarily for their drying properties and working as an exfoliant to kill acne-causing bacteria – they are often combined with more potent forms of medications such as antibiotics to help with penetration and decrease the chances of harmful side effects.

While many of these can be found over-the-counter, there are several topical medications that require a prescription from a doctor. These include azelaic acid, retinoids, and antibiotics.

Retinoids (vitamin A derivatives) are often the first-line of therapy for treating acne vulgaris as they help to speed up and regulate the process of healthy cell turnover, unclog pores, destroy bacteria, and help with inflammation. In fact, studies have shown that retinoids can help decrease the number of comedones and inflammatory lesions by as much as 40% to 70%!

Antibiotics such as doxycycline and minocycline are also commonly prescribed by dermatologists to kill off the bacteria that is involved with inflammation. The only problem is that antibiotics aren’t recommended for long-term use as it can make you more resistant to other strains of healthy bacteria.

Birth control pills and spironolactone are especially useful for women experiencing acne due to hormonal changes. They can also be used in combination with other medications such as retinoids, which have been suggested to have a superior response in treating adult female acne as compared to just using retinoids alone.

The most common side effects from taking topical medications range from mild irritation, dry skin, to more severe ones like fetal abnormalities in pregnant women. Ideally, you should talk to your doctor about the possible side effects of your treatment and tell them about any concerns that you may have.

Other types of treatment include facials, microdermabrasion, chemical peels, and acne laser treatment – all of which can be used in combination with topical and systemic medications for more synergistic effects.

Typically, over-the-counter medications and creams are enough to treat and clear mild to moderate (grades 1 and 2) types of acne. For moderate to severe types (grades 3 and 4) – systemic medications and laser treatments can be much more valuable.

A general rule of thumb is to wait 6 weeks into any medication to make any evaluations – if there are no visible improvements or you aren’t seeing satisfactory results, consider taking a visit to the dermatologist to get assessed and treated.

What about those with recurrent acne?

Many patients find that acne often occurs in the same few spots on their face – also known as chronic recurrent acne, this happens because of damaged pores on your skin, which are repeatedly getting clogged and inflamed when excess oil is produced.

Thankfully, there are treatments available today that aim to treat acne at its root – directly treating the pores to control and manage sebum production – this includes the unique AGNES acne treatment!

Our clinic is the first to bring in AGNES into Singapore as part of our comprehensive acne treatment program. A tiny insulated wire is used to deliver electrical currents of monopolar and radiofrequency (RF) energy into the pores to destroy the sebaceous glands; effectively shrinking it without causing any thermal injury to the epidermis.

Overtime, less oil is produced, pores are healthy, and no inflammation and infection can occur. In fact, less than 10% of acne recurs within a year of the final treatment session – with up to 90% clearance of both non-inflammatory and inflammatory acne after the third session!

Another treatment that our clinic has recently brought in is Gold Photothermal Therapy (Gold PTT) – a powerful procedure that also aims to treat acne at its root. By delivering gold nanoparticles into the pores and heating them with a laser – this activates the nanoparticles to create a focused photo-thermal effect in the pores that decreases the activity levels of the sebaceous glands. The FDA has also approved Gold PTT in the treatment of acne vulgaris.

There are plenty of studies demonstrating the effectiveness of gold PTT as an effective treatment for recurrent acne patients. A 2019 study showed that 3 sessions of PTT prevented the development of new lesions during a follow-up period of 3 – 4 months in Asian patients.

If you don’t wish to deal with acne anymore and forgo the use of oral medications that causes undesirable side effects – both AGNES and Gold PTT are a much safer, more effective, and “permanent” solution to your breakouts!

Treating all acne types and stages

Our doctors enjoy utilizing a combination approach of topical and systemic treatments, chemical peels, laser treatments, and recommending a post-treatment aftercare and maintenance routine. We have noticed that this provides the best results that brings long-lasting benefits for acne sufferers – even for those with persistent cystic acne!

Using a combination treatment approach has been shown to have a greater efficacy than simply using a single modality. The best combination treatments are those that target the different factors of acne – not only reducing its severity and recurrence, but also helping to improve your skin’s overall appearance for healthy and more flawless skin!

We have created a proprietary and highly-personalized acne treatment program that has been meticulously developed in our 20 years of experience treating the condition. Starting with facial treatments, it is followed by laser treatments using the Q-switch or Vbeam laser, then selective follicle treatment using either AGNES or Gold PTT. We then end the treatment with topical and oral therapy for maintenance.

We also offer skin rejuvenation treatments such as Rejuran Healer that can help with accelerating the wound healing process and stimulating collagen synthesis after aa breakout, and subcision for acne scars!

Acne can be a persistent problem that can leave you feeling depressed, socially withdrawn, and negatively impact both your personal and professional life. If you are not responding to over-the-counter medications and are experiencing painful and widespread acne lesions that is causing a lot of emotional distress – book an appointment with us to tap into our wide range of solutions and get the best acne spot treatment in Singapore today!


  • Is it possible to self-diagnose my acne?

Although it may seem easy to diagnose acne, the truth is that it is difficult to determine the causes of acne and distinguish it between other similar skin conditions such as psoriasis and rosacea.

In addition, you may be experiencing different types of acne at any one time, and since getting an accurate diagnosis is vital if you want the best results – you are better off consulting an experienced and knowledgeable doctor who has a wide experience treating all types of acne.

  • Why am I experiencing a flareup during my treatment?

Sometimes, acne needs to get worse before it gets better. Often, flareups can occur during the initial phases of treatment due to the skin working hard to drain and remove the dirt and bacteria.

A good example is isotretinoin – where patients often report acne worsening during the first 7 – 10 days after they begin treatment. However, it generally settles and a single course is enough to clear acne in 85% of patients!

  • What other tips do you have for those suffering from acne?

Adhering to a good skincare routine and being consistent with it is your best bet to preventing a flareup and ensuring lasting results with any treatment.

Always refrain from doing any extraction on your own and remember to pick cleansers that contain ingredients such as glycolic and salicylic acid to help exfoliate dead skin cells and promote skin renewal, while unclogging your pores and reducing sebum levels.

When it comes to your diet, you should also avoid high-glycemic and sugary foods that can mess with your hormones and have been found to be linked to acne flareups.

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