Comedone extraction in clinic: standard procedure

1. Patient selection

• Numerous open comedones or superficial closed comedones
• Stable, noninflamed lesions
• Patient seeking short-term cosmetic improvement alongside medical acne therapy
• Comedonal acne inadequately clearing with appropriate topical treatment

• Tender papules, pustules, nodules, cysts, or acne fulminans
• Active bacterial, viral, or fungal infection in the treatment area
• Excoriated skin, dermatitis, sunburn, or impaired skin barrier
• Known tendency to hypertrophic scars or keloids, especially if incision may be required
• Poorly controlled bleeding risk or anticoagulant use when a lancet is contemplated
• Recent aggressive peeling, laser treatment, waxing, or other procedure that has left the skin irritated

2. Equipment

• Good overhead lighting and magnification
• Examination gloves
• Clean gauze, cotton-tipped applicators, tissues
• Gentle cleanser or sterile saline
• Antiseptic suitable for facial skin, used according to local policy
• Sterile single-use comedone extractor, preferably a small loop
• Optional sterile disposable lancet/needle only for selected superficial closed comedones and only by a trained clinician
• Noncomedogenic soothing moisturizer or bland barrier product
• Sharps container and clinical waste disposal

3. Pre-procedure steps

1. Confirm diagnosis and lesion type. Ensure lesions are comedones, not milia, folliculitis, molluscum, or inflamed acne lesions.
2. Explain realistic outcomes. Extraction is an adjunct, not a cure. Recurrence is expected without maintenance treatment.
3. Discuss risks and obtain consent. Pain, transient redness, pinpoint bleeding, bruising, infection, post-inflammatory hyperpigmentation, incomplete extraction, and rarely scar formation.
4. Review relevant history. Active skin infection, bleeding tendency, anticoagulants, isotretinoin use, prior adverse pigmentary/scarring response, and current acne regimen.
5. Take photographs if this is part of the clinic’s acne documentation protocol.
6. Cleanse the skin gently and dry it fully. Do not extract through makeup, sunscreen, or heavy topical products.
7. Prepare the skin and instruments using clinic infection-control policy.

4. Extraction technique

A. Open comedones

1. Stretch the surrounding skin gently with the nondominant hand.
2. Center the sterile extractor loop around the follicular opening.
3. Apply light, even, perpendicular pressure around the lesion, not forceful digging or lateral scraping.
4. Allow the keratin-sebum plug to express onto gauze.
5. Stop once material has expressed or if resistance is substantial.
6. Wipe the area gently with clean gauze.

B. Closed comedones

1. Select only superficial, clearly defined lesions.
2. Do not attempt forceful pressure through intact skin.
3. If the clinic protocol and clinician competency permit, a very superficial sterile opening may be made to release the follicular ostium.
4. Use minimal pressure with the loop extractor to express contents.
5. Stop immediately if there is significant resistance, bleeding, marked pain, or dermal trauma.

C. Do not extract

• Deep closed comedones
• Inflamed papules, pustules, nodules, or cysts
• Lesions near active herpes simplex infection
• Lesions that cannot be expressed with minimal pressure
• Any lesion with uncertain diagnosis

5. Immediate post-procedure care

1. Remove residue with sterile saline or a gentle cleanser.
2. Apply brief cool compresses if there is redness or discomfort.
3. Apply a thin layer of bland, noncomedogenic moisturizer or barrier product.
4. Avoid irritating agents on freshly traumatized areas that day, such as scrubs, alcohol-based toners, retinoids, benzoyl peroxide, salicylic acid, and strong acids, unless your clinic protocol specifies otherwise.
5. Apply broad-spectrum sunscreen during daytime, particularly in patients at risk for post-inflammatory hyperpigmentation.
6. Document treated areas, lesion count or approximate number, instrument used, any incision, complications, tolerance, and aftercare advice.

6. Patient aftercare instructions

• Mild redness and tenderness for 24 to 48 hours can occur.
• Do not touch, pick, squeeze, scrub, wax, or exfoliate the treated areas.
• Use a gentle cleanser and noncomedogenic moisturizer.
• Resume topical acne medication as advised, commonly the next day if the skin is not irritated.
• Use sunscreen daily.
• Contact the clinic for increasing pain, swelling, spreading redness, warmth, pus, crusting, blistering, or persistent dark marks/scarring.

7. Maintenance and follow-up

• Continue comedone-preventing treatment, commonly a topical retinoid if tolerated and clinically suitable.
• Benzoyl peroxide and other therapies may be added based on the inflammatory component of acne.
• Review in approximately 4 to 8 weeks to assess treatment response and adverse effects.
• Avoid scheduling frequent aggressive extraction sessions. The goal is to reduce lesion burden while medical therapy suppresses new comedone formation.