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

Quick summary: Closed comedones form when pores are clogged by dead skin cells and sebum, sitting deep beneath the skin without causing inflammatory redness or swelling. Attempting to squeeze closed comedones at home can easily worsen the condition, leading to dark spots and hard-to-treat pitted scars. For effective resolution, a direct consultation with a dermatologist is necessary to identify the exact cause and establish a personalized treatment regimen combined with proper home care.

Under-the-skin acne (closed comedones) consists of small bumps that form when pores are clogged by dead skin cells and sebum, hidden beneath the skin's surface — with no swelling, no redness, and no head to pop, which is why topical over-the-counter products usually don't work. From a distance, the skin looks fine, but touching it reveals a bumpy, rough texture across the area. That is closed comedones. And the reason they frustrate so many people is that they keep applying one product after another, yet the skin remains unchanged.

What actually 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, disrupting the skin's smooth texture.

This is a crucial difference from inflammatory acne. Inflammatory acne involves an active inflammatory response and bacterial activity, 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. Furthermore, 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 skin cells to accumulate and clog pores.
• Skincare or cosmetic products that are unsuitable for your skin, especially comedogenic products that easily cause blockages.
• Under-cleansing or over-cleansing. Both cause issues. Washing your face too frequently with harsh products strips the skin barrier, causing it to react by producing more oil.
• Hormonal factors, which affect the amount of sebum the skin produces.
• Lifestyle and environmental factors — staying up late, prolonged stress, wearing tight masks for long periods, and dusty environments.

An important note: you should not self-diagnose the cause based on online information. Determining which category you fall into is the doctor's job after an examination, as the success of the treatment plan depends entirely on this step.

What you should not do: self-squeezing 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, what you are actually doing is applying heavy pressure to the clogged tissue. The common results:

• 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, 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 a medical consultation early instead of continuing to intervene at home.

The correct treatment approach

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

1. 1Examination and classification. The dermatologist directly examines and assesses your skin to determine the type of acne, its severity, and any accompanying skin conditions.

1. 1Identifying the cause. The doctor asks about your skincare habits, current cosmetics and medications, menstrual cycle, lifestyle, and previous treatments. This step determines the accuracy of the regimen.

1. 1Designing a personalized regimen. The doctor creates a treatment plan tailored to your specific condition, explaining what to use, why to use it, the expected timeline for re-evaluation, and the corresponding costs.

1. 1In-clinic treatment when indicated. If necessary, procedures are performed in strict accordance with the regimen and aseptic principles — not a full-face extraction in a single session.

1. 1Home care. You will receive specific instructions on the routine, product order, and equally important: what to stop using because it is worsening your skin.

1. 1Follow-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 current products, you should contact the doctor immediately instead of waiting for your scheduled follow-up.

1. 1Treating remaining dark spots and scars. Only when the acne is controlled will the dark spots and scars be evaluated — because treating hyperpigmentation and scarring while the skin is still inflamed is usually ineffective.

How long until the skin improves?

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

The response rate depends on the type of acne, severity, cause, and how strictly you adhere to the regimen. One thing to know beforehand: with certain treatment plans, the skin may go through a purging phase before stabilizing. If you quit during this stage thinking the treatment is ineffective, you will end up back at square one.

The doctor will give you a personalized re-evaluation milestone 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 instructions 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 chose. Coming in for a consultation to let the doctor identify exactly what you are dealing with is the first meaningful step.

When you come for your visit, you should 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.

Frequently Asked Questions

How do closed comedones differ from inflammatory acne? Closed comedones lie deep beneath the skin's surface, with no swelling, redness, pain, or head, as no inflammatory response has occurred yet. In contrast, inflammatory acne involves an active inflammatory response and bacterial activity, causing swelling and pain, which requires a completely different treatment approach.

Why shouldn't I squeeze closed comedones at home? Closed comedones are deep-seated and have no head. Attempting to squeeze them applies heavy pressure to the clogged tissue, which can easily push the acne core deeper, trigger an inflammatory response causing redness and swelling, and spread the damage, leading to long-lasting dark spots or hard-to-treat pitted scars.

Do I need to bring my current cosmetics to the consultation? Yes. When visiting BonBoz Clinic, you should bring along or take photos of all the skincare and cosmetic products you are currently using. The doctor will directly evaluate them to point out which suitable products can be kept and which clogging products should be discarded.

Why is my skin purging more at the beginning of treatment? With certain treatment regimens for closed comedones, the skin may go through a purging phase before stabilizing and becoming smooth again. This is a normal reaction; you need to patiently adhere to the regimen and avoid quitting halfway to prevent returning to square one.

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.