Cystic Acne on the Body
Body Skin Contains Larger Skin Oil Glands and Can More Easily Develop Cystic Acne Lesions
The Essential Information
Cystic acne, also called nodulocystic acne, is a severe type of acne that comes with two types of large (over 5mm in diameter) lesions that frequently scar:
- Nodules (much more common) - firm, fibrous lesions with no pus inside
- Cysts (far less common) - fluid filled lesions that feel "movable" when touched
Cystic acne can appear on both face and body, but appears more often on the body because the body has larger skin pores and skin oil glands.
When we say "body" that also includes the back of the neck, a common location for cystic lesions.
Who gets it: Cystic body acne tends to afflict teenagers and young adults the most. It is more common in males, but females also can battle with it, particularly during pregnancy and during the premenstrual window (7-10 days before the onset of menstruation).
Treatment: Recommended treatment for mild-to-moderate cystic body acne normally consists of a properly applied benzoyl peroxide + glycolic acid regimen. For especially severe and widespread cases, isotretinoin (Accutane) is an option you and your doctor can discuss, but can come with lifelong side effects. For one or two occasional nodules or cysts that show up on the body, making an appointment with your doctor for a quick cortisone injection can quickly reduce inflammation and speed healing.
Cystic acne, also known as nodulocystic acne, is a severe form of acne that presents with two types of lesions: (1) nodules, and (2) cysts. Nodulocystic lesions that can be found on both the body and face. However, the body often develops more nodulocystic acne lesions than the face, most likely because the sebaceous (skin oil producing) glands are bigger on the body compared to the face.
Mild nodulocystic acne comes with just a few nodules and/or cysts. Severe nodulocystic acne comes with many nodules and cysts spread across a large area of skin.1,2
- Nodules are by far the most common type of nodulocystic acne lesions. Often mistaken for cysts, nodules are large (over 5 millimeters in diameter), red, painful, fibrous bumps that extend deep into the skin and do not contain pus.3 are stubborn lesions that usually remain on the body for weeks, months, or even longer, and tend to leave scars behind. The body is the most common location of nodules, and they tend to appear most often on the back, chest, and/or back of the neck. Nodules can also be found on the face, especially on the forehead. The most likely explanation for why nodules appear in these areas is that the sebaceous glands are larger in these areas. The larger the gland is, the more sebum (skin oil) is produced. Since sebum is a prerequisite for acne development, more sebum often means more acne and more severe acne lesions like nodules.
- Cysts are large (greater than 5 millimeters but usually between 7 - 15 millimeters), red, painful lumps that extend deep into the skin and, unlike nodules, do contain pus. Cysts are soft lesions and, when touched, the soft pus inside can be felt moving. Cysts can sometimes leak to the surface, and contain a cheesy, waxy material with an offending, rotting smell.3,4 Like nodules, the body is a common place for cysts, particularly on the back, neck, and back of the neck. Generally, cysts tend to occur in similar areas as nodules, and likely have a common cause - larger sebaceous glands in these areas. Cysts are stubborn acne lesions and last for months and sometimes even years, and may grow to 5 centimeters in diameter and cause permanent scars. Most cysts are actually lesions referred to as "pseudocysts," which are simply nodules that have filled with pus. True cysts are extremely uncommon.
Who Is Likely to Experience Nodulocystic Acne on the Body?
Certain people are more susceptible to developing nodulocystic acne than others. There are several factors that increase the likelihood that a person will develop nodulocystic acne on the body or face. These factors include:
- Hormones: Androgens, which are male hormones found in both males and females, increase the production of skin oil, called sebum, which is a substance necessary for the development of acne. Most nodulocystic acne patients have elevated androgen levels in their bodies, both in their blood and in their skin. There are several types of androgens, but those associated with acne include DHEA-S, testosterone, and DHT.
- Genetics: People are more likely to have nodulocystic acne, such as on the body, if their parents or other close relatives had it.
- Location: Nodulocystic acne is more prevalent in people who live in tropical regions of the world. The reason for this is unknown.
- Age: This form of acne is more common in teenagers and young adults, i.e., in their 20s, but nodules and cysts can develop in younger or older people as well.
- Sex: Nodulocystic acne, particularly when it is on the body, is more common in males, but females can develop it too. Females are at a higher risk of developing it during pregnancy, menopause, and during the premenstrual window.5
Treatment of Nodulocystic Acne on the Body
Treatment of nodulocystic acne on the body is the same as treatment on the face. Generally, people with only a few nodules or cysts can be treated with one or more of these therapies:
- Benzoyl peroxide - when combined in a regimen with glycolic acid, the combination can often clear the skin completely
- Topical retinoids - normally provide only moderate clearing
- Oral antibiotics - must always be combined with other treatments
More severe nodulocystic acne sometimes requires treatment with isotretinoin (Accutane), which is an oral medication normally prescribed for 15-20 weeks. Isotretinoin works by permanently reducing sebum levels. However, it comes with a plethora of side effects, some of which can be severe and lifelong, so it should never be entered into lightly.1 There is some question of whether isotretinoin may cause the skin to age more quickly in the long term as well.
Nodulocystic Acne Scarring on the Body
Untreated nodulocystic acne lesions often leave behind scarring. There are three types of scars that can develop from nodulocystic acne lesions on the body.
- Atrophic scars are indented "pits" beneath the skin surface, with either smooth or sharp edges. They are the most common scars that develop from nodulocystic acne lesions.
- Hypertrophic scars are elevated above the skin. When they first form, they are the same size as the acne lesion was on the skin, but over time hypertrophic scars can decrease in size. People with darker skin are more prone to develop this type of scarring.
- Keloid scars are similar to hypertrophic scars except that they are larger than the acne lesion was, and this size does not decrease over time. People with darker skin are also more prone to develop keloid scars.
There is a direct relationship between the severity of scarring and the severity of acne. In other words, more severe scarring develops from larger and more abundant nodules and cysts. Also, the longer a person delays therapy for severe acne, the worse the scarring tends to be. This is why it is important to quickly and aggressively treat nodulocystic acne.6
Rare Forms of Nodulocystic Acne That Affect the Body
There are two uncommon forms of especially severe nodulocystic acne that can be found on the body:
- Acne conglobata is an extensive, severe form of acne that usually involves the back, chest, upper arms, and to a lesser extent, the face. It presents a mixture of less severe acne, including whiteheads, blackheads, papules, and pustules, as well as nodulocystic acne. Acne conglobata may last for years and leave large scars. It is more prevalent in boys and young males, and in warmer climates. One complication associated with acne conglobata is a massive type of acne lesion called a draining sinus. Draining sinuses occur when two or more cysts merge into one sizable (2 - 5 centimeters) acne lesion. They can leak pus at any time and occur most often on the face around the nose and upper lip, but are not uncommon on the neck and chest. Draining sinuses can occur in general nodulocystic acne, but they are commonly associated with acne conglobata.1,7,8
- Acne fulminans is a systemic disease that includes fever, fatigue, joint and bone pain, weight loss, and also severe acne. Most frequently the acne lesions associated with this form of acne are found on the chest, back, neck, and face. Researchers suspect that hypersensitivity to a normal type of skin bacteria called C. acnes is in part responsible for acne fulminans.4
- Habif, T. P. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 231 - 233 (2016). https://www.elsevier.com/books/clinical-dermatology/habif/978-0-323-26183-8
- Nodulocystic acne. https://www.dermnetnz.org/topics/nodulocystic-acne/
- Acne. https://en.wikipedia.org/wiki/Acne
- Plewig, G. & Kligman, A. Acne and Rosacea. (Springer International Publishing, 2000). https://www.springer.com/gp/book/9783642640964
- Arndt, K. Manual of Dermatologic Therapeutics (7th Edition). 5 - 8 (LWW (PE), 2007). https://shop.lww.com/Manual-of-Dermatologic-Therapeutics/p/9781451176346
- Layton, A., Henderson, C. & Cunliffe, W. A clinical evaluation of acne scarring and its incidence. Clin. Exp. Dermatol. 19, 303 - 308 (1994). https://www.ncbi.nlm.nih.gov/pubmed/7955470
- Jansen, T., Lindner, A. & Plewig, G. Draining sinus in acne and rosacea. A clinical, histopathologic and experimental study. Hautarzt 46, 417 - 420 (1995). https://www.ncbi.nlm.nih.gov/pubmed/7642386
- Acne Conglobata. https://emedicine.medscape.com/article/1072716-overview
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