Under-the-Skin Acne: Causes and Effective Treatments Without Scarring

Closed comedones (under-the-skin acne) are small bumps that form when pores are clogged with dead skin cells and sebum, sitting beneath the skin's surface. They are not swollen or red, and they do not form a head, which is why typical topical products often fail to work. From a distance, the skin might look fine, but touching it reveals a bumpy, rough texture across the entire area.

Those are closed comedones. And the reason they are so frustrating is that you can apply one product after another, yet your skin remains exactly the same.

What exactly are closed comedones?

Simply put, closed comedones form when pores become clogged. Dead skin cells fail to shed properly and, combined with sebum, create a plug beneath the skin's surface. Because there is no inflammatory response yet, they are not red, swollen, or painful—they just sit there, making the skin's surface rough and uneven.

This is a key difference from inflammatory acne. Inflammatory acne involves inflammation and bacteria, requiring a completely different treatment approach. Although both are called "acne," they require distinct management—which is why using a single cream for all types of acne rarely yields results.

Additionally, closed comedones have a noteworthy characteristic: if left untreated for too long, some bumps can turn into inflammatory acne.

Why do you get closed comedones?

There is no single cause. In clinical practice, commonly encountered factors include:

• Abnormal desquamation (the skin's natural shedding process), causing dead cells to accumulate and clog pores.
• Skincare or cosmetic products that are unsuitable for your skin type, especially comedogenic products.

• Inadequate or excessive cleansing. Both cause issues. Washing your face too often with harsh cleansers strips the skin's protective barrier, causing it to react by producing more oil.
• Hormonal factors, which affect sebum production.
• Lifestyle and environmental factors—staying up late, chronic stress, wearing tight face masks for extended periods, and dusty environments.

An important note: you should not self-diagnose the cause based on online information. Determining your specific triggers is the doctor's job during a consultation, as the success of your treatment plan depends entirely on this step.

What you should not do: pop them at home

This is the most important part of this article.

Closed comedones lie deep beneath the skin and have no head. When you try to squeeze them, you are actually applying heavy pressure to clogged tissue. The common results include:

• The plug is pushed deeper into the skin instead of coming out.
• The area transitions from non-inflammatory closed comedones to red, swollen inflammatory acne.
• Damage spreads to surrounding tissue, leaving long-lasting dark spots.

• If the damage is deep enough, atrophic scars (pitted scars) form—and pitted scars are much harder to treat than acne itself.

Many cases of dark spots and pitted scars seen in our clinic are not caused by the acne itself, but by improper handling. If you have already squeezed them and the area is swollen and painful, seek medical advice early instead of continuing to self-treat at home.

The correct treatment approach

Since acne is a medical skin condition, it requires a structured treatment plan rather than a miracle product. The process at BonBoz is as follows:

1. 1Examination and classification. A dermatologist directly examines and assesses your skin to determine the type of acne, its severity, and any co-existing skin conditions.
2. 2Identifying the cause. The doctor asks about your skincare habits, current cosmetics and medications, menstrual cycle, lifestyle, and previous treatments. This step is crucial for tailoring an effective regimen.
3. 3Customizing the treatment plan. The doctor designs a personalized regimen for your specific condition, explaining what to use, why to use it, the expected timeline for re-evaluation, and the associated costs.
4. 4In-clinic treatments when indicated. If necessary, procedures are performed in strict accordance with the treatment plan and aseptic techniques—not a one-session "clear-the-whole-face" extraction.
5. 5Home care. You will receive detailed instructions on your routine, product order, and equally important: what to stop using because it is worsening your skin.
6. 6Follow-up and adjustment. Everyone's skin responds differently, so the doctor schedules follow-up visits to monitor progress and make adjustments. This is a mandatory step, not an option. If inflammatory acne worsens after 2 weeks of treatment, or if your skin experiences severe irritation from the products, you should contact your doctor immediately rather than waiting for your scheduled appointment.

1. 1Addressing remaining dark spots and scars. Only when the acne is under control will the doctor evaluate and treat dark spots and scars—as treating scars and hyperpigmentation while the skin is still inflamed is generally ineffective.

How long does it take for the skin to clear up?

This is a question everyone wants a specific number for, but giving a general timeline would be overpromising.

The rate of improvement depends on the type of acne, its severity, the underlying causes, and how strictly you adhere to the treatment plan. One thing to keep in mind: with certain regimens, your skin may go through a purging phase before it stabilizes. If you quit during this phase thinking the treatment is ineffective, you will end up back at square one.

The doctor will give you a personalized timeline for re-evaluation right after your first consultation, so you know when to expect visible changes.

What happens after the acne is gone?

Acne is a condition prone to recurrence, especially when maintenance care is stopped or when there are changes in hormones, lifestyle, or environment. Therefore, post-treatment maintenance guidelines are just as important as the active treatment phase. The doctor will discuss this with you at the end of your treatment course.

If you are struggling with closed comedones and have tried various methods without success, the issue might not lie in the products you choose. Coming in for a consultation to let a doctor identify exactly what you are dealing with is the first meaningful step.

When you visit, please bring along or take photos of all the products you are currently using. The doctor will point out which ones to keep and which ones to discard.

BonBoz Aesthetic and Dermatology Clinic — 66–68 Võ Văn Tần, Phường Xuân Hòa, TP.HCM.

Content compiled and reviewed by the medical team at BonBoz Clinic.