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The True Identity of Acne — 1.1 Folliculitis vs Acne

How to Stop It Now — 3.1 The Importance of Drainage · 3.2 Understanding Intralesional Acne Injections properly

Managing Leftover Marks — 4.1 PIH·PIE·Atrophic·Hypertrophic

Not all acne is created equal. If it's at the tiny, non-inflammatory comedo stage, you can prevent scars almost entirely just by avoiding squeezing it too hard. However, once it progresses to firm, deep nodules or painful cysts, the collagen within your dermis* breaks down, leading to permanent scars. Squeezing in itself doesn't cause scarring; rather, it’s determined by how deep the inflammation has penetrated.

Not all acne is created equal. If it's at the tiny, non-inflammatory comedo stage, you can prevent scars almost entirely just by avoiding squeezing it too hard. However, once it progresses to firm, deep nodules or painful cysts, the collagen within your dermis* breaks down, leading to permanent scars. Squeezing in itself doesn't cause scarring; rather, it’s determined by how deep the inflammation has penetrated.

Comedones and papules are stages that only leave temporary marks

Comedones like whiteheads and blackheads are non-inflammatory stages where sebum is simply trapped inside the pores. Since there is almost no damage to the dermis, they can subside without scarring if you leave them alone or manage them with retinoids*. However, picking at them with your fingernails can scratch the epidermis and shallow dermis, leaving brown marks (PIH) or red marks (PIE).

The same goes for swollen, red papules. If left untouched, they only leave a temporary mark that fades away over time. Up to this stage, the risk of turning into a scar is very low.

* Dermis: The layer below the epidermis where collagen and elastic fibers are interwoven like a net. This is exactly where the fate of acne scars is decided. If only the epidermis is damaged, it ends as a temporary mark; if the dermal collagen collapses, it solidifies into a scar.

For pustules, how you pop them is the turning point

Pustules with a visible yellow head in the center are filled with pus. If the head has formed on the surface, evacuating the pressure using sterile tools will speed up recovery. The question is "how" you extract it.

If you squeeze it with your fingers or fingernails, the pus can be pushed into the surrounding dermis, widening the area of inflammation. This leads to long-lasting marks or shallow scars. Even with the same pustule, extracting it through a hygienic incision drainage significantly lowers the risk of scarring. We will cover drainage methods in greater detail in the next article of this series.

Starting from nodules, the dermis gets damaged

Nodules are deep, hard inflammatory lumps that remain flat on the surface but are swollen underneath. Because they are located deep in the dermis, the surface doesn't move easily even when pressed with a finger. From this stage on, the inflammation directly damages the collagen mesh.

Once damaged, collagen does not easily replenish on its own. Therefore, if you leave nodules untreated, the indentations deepen with every passing day. Instead of forcing them open, the key to minimizing scars is to "quickly soothe the inflammation." What helps at this stage is a corticosteroid injection, delivered directly into the lesion in very small amounts.

Cysts almost always leave scars

A cyst is a state where pus and inflammatory substances fill a "sac" deep within the dermis. It feels soft to the touch and comes with significant pain. The internal pressure pushes down on the dermis and subcutaneous tissue, causing collagen loss even without touching it.

The most effective approach for the cystic stage is a combination of two methods: incision drainage to relieve internal pressure and clear out inflammatory debris, and a Triamcinolone* injection to rapidly calm the inflammation. Using both together will reduce the volume within a few days. If it is a deep, recurring case, oral medications like isotretinoin should be considered together.

* Triamcinolone: A topical corticosteroid. Injecting a small amount (diluted to 2.5–5 mg/mL) directly into nodules or cysts calms inflammation within 24 to 48 hours. Unlike systemic steroids, it is injected "only into the lesion," meaning side effects are localized.

Repeated breakouts in the exact same spot will solidify into lasting marks

When pustules and nodules repeatedly occur in the same spot, the dermis is continuously damaged with no time to heal. This causes PIH and PIE to settle in as permanent marks, easily progressing to atrophic scars. This is why it is so crucial to break the cycle before the inflammation runs deep.

Here is a summary of the risk of scarring by acne stage:

Take a moment to see where your breakouts fall on this chart. If you have comedones or papules, simply not squeezing them is more than enough. However, once they reach the pustule stage or beyond, the real game-changers for preventing scars are "how they are extracted" and "how quickly you calm the inflammation."

Frequently Asked Questions

Q. Does putting an acne patch over a nodule help?

For superficial pustules, patches help by absorbing discharge and shielding the area from irritation. However, for nodules and cysts that are flat on the surface, the source of pressure is deep within the skin, so a patch alone won't do much. If the volume doesn't decrease after a few days of use, visiting a dermatologist is the fastest solution.

Q. If a large breakout doesn't go away in a few days, will it leave a scar?

If a nodule or cyst stays in the same spot for more than a week, the likelihood of collagen loss increases. Whenever possible, calming it with an lesions injection or drainage within the first few days is the most effective way to prevent scarring.

Q. Can comedones be squeezed safely without leaving scars?

Yes, hygienic extraction that exposes only the comedo is safe. However, squeezing and twisting with your fingernails can scratch the epidermis and irritate the surrounding dermis, leaving long-lasting brown or red marks. At the comedo stage, it's much cleaner to avoid squeezing altogether and let retinoids soothe it.

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