Cystic acne, also called nodulocystic acne, is a severe type of acne consisting of larger, more painful lesions called nodules and cysts.
Nodules are by far the most common nodulocystic acne lesion type. A nodule develops when a clogged pore “explodes” deep within the skin, causing the body to react with intense inflammation.
An acne cyst is much more rare and occurs when the pore only partially bursts and the skin builds a secondary, thick lining around the damaged pore.
Either type of lesion can take weeks or even months to resolve and are extremely prone to scarring. This is why it is vitally important that people with cystic acne treat their skin early and aggressively to reduce the potential for life-long scarring.
- A Closer Look into Acne Nodules and Cysts
- Causes of Nodulocystic Acne
- Treatment of Nodulocystic Acne
- Cystic Acne Scarring
- Rare Forms of Nodulocystic Acne
- Draining Sinuses
Cystic acne, also called nodulocystic acne, is a severe form of acne classified by multiple large, red, sore acne lesions called nodules and cysts on the face, neck, back, and chest.
Cystic acne is the same disease as what people normally know as regular acne, but just more severe.
All acne starts when tiny hair follicles, also called pores, become clogged. This clog results in a buildup of sebum (skin oil), dead skin cells, and bacteria inside the pore. This buildup can cause the pore to burst, which leads to the redness and soreness that we see in acne lesions. Nodulocystic acne develops when the pore bursts especially deep within the skin. This creates a severe inflammatory reaction and produces one of two types of cystic acne lesions: (1) a nodule, or (2) a cyst.
A Closer Look into Acne Nodules and Cysts
Nodules are much more common than cysts.
They appear as large, red, painful lesions over 5 millimeters in diameter. They are not filled with pus, and instead are solid fibrous masses.
Nodules develop when there is an extensive rupture of the pore especially deep within the skin, which dermatologists often refer to as a "complete explosion of a pore."
They tend to appear on the back, neck, forehead, and chest, and scientists believe this is likely because these regions have pores with larger skin oil-producing glands.
Due to the extensive damage caused by the pore rupture, nodules may remain for weeks or months before healing.
Cysts appear as large, red, painful lesions between 7–15 millimeters in diameter.
Unlike nodules, they are filled with pus that can be felt as it moves beneath the skin when touched.
Similar to nodules, cysts also tend to appear on the back, neck, forehead, and chest, probably because these regions have larger glands that produce skin oil (sebum).
Cysts develop when only a small area of the pore wall bursts, and instead of releasing its contents into the skin, the body builds a thick and strong secondary wall around the expelled contents.
However, true acne cysts with a secondary wall like this are rare. Most acne cysts are best described as “pseudocysts” because in reality they are simply nodules that fill with pus. For clarity, we will use the term cyst to describe pseudocysts.
Acne cysts can last for weeks, months, or even years and can sometimes grow to 5 centimeters in diameter. They contain waxy, foul-smelling pus, and this pus can leak from the cyst onto the skin, or be expelled spontaneously by the body. However, it is never a good idea to try to pop a cyst.
The table below displays the characteristics of nodules and cysts:
Causes of Nodulocystic Acne
No one knows what causes nodulocystic acne, but researchers have found some common threads that may in part explain its development.
- Genetic predisposition: A person is more likely to develop nodulocystic acne if his parents experienced it. As such, there may be a genetic component to some cases.
- Hormones: Androgens, which are male hormones found in both males and females, are highly associated with acne, including nodulocystic acne. Generally speaking, increased androgen levels, including dehydroepiandrosterone sulfate (DHEA-S) and testosterone, result in more acne and more severe acne because they increase the production of skin oil (sebum). Sebum is a contributing factor to acne, and people with nodulocystic acne often retain an elevated level of it in their skin.
- Gender: Especially severe nodulocystic acne is more common in males. However, females can develop this form of acne too, and are at a higher risk of developing it during pregnancy. The differences in gender may also support the idea of hormones playing a role in nodulocystic acne development.
- Location: Nodulocystic acne is more prevalent in tropical areas of the world, but the reason of this observation is unknown.
- Type of acne: People with severe acne tend to develop nodulocystic acne. In comparison, people who have less severe acne do not usually develop nodules or cysts.
Treatment of Nodulocystic Acne
Less severe cases of nodulocystic acne, with only a few cystic lesions, are often treated with topical benzoyl peroxide, retinoids, and/or oral antibiotics.
Isotretinoin (Accutane) - for more severe cases
For people with severe nodulocystic acne, doctors may prescribe the oral medication, isotretinoin (Accutane®), normally for 15–20 weeks. However, isotretinoin causes severe side effects, including birth defects, and can produce permanent side effects to the entire body, so its use should be carefully considered alongside a trusted physician, and never as a first-line treatment.1–12
Hormonal treatments - females only
Doctors will sometimes prescribe hormonal treatment, such as oral contraceptives or anti-androgen medications, to females with nodulocystic acne.
Cortisone shots - treating one lesion at a time
A shot of cortisone directly into a nodule or cyst can significantly help heal it and prevent scarring. Cortisone shots are effective and helpful, but should not be used on many nodules or cysts at one time.
Cystic Acne Scarring
Nodulocystic acne often causes scarring. Normal acne can also scar, but generally causes less severe scars than those from cysts or nodules.
The scarring associated with nodulocystic acne is the reason it is important to treat nodulocystic acne promptly.
There are three main types of acne scars that nodules or cysts can leave behind.
- Indented (most common): Indented scars, called atrophic scars, appear as indents in the skin with smooth or sharp edges. They are the most common type of scars.
- Raised: Raised scars, called hypertrophic scars, appear as elevations above the skin. When they first form, they are the same size as the original cyst or nodule, but over time these elevated scars may decrease in size. People with darker skin are more prone to develop hypertrophic scars.
- Raised (Keloid): Keloid scars are a specific kind of hypertrophic scar that are bigger than the original cyst or nodule, and do not decrease with time. People with darker skin are also more prone to develop keloid scars.
Because cystic acne scars often are large, they can cause significant emotional distress. This emotional suffering can cause people to miss school or work and can even sometimes cause patients to refrain from seeing a doctor. However, the longer cystic acne goes untreated, the worse the scarring can be. Therefore, it is important that patients suffering from cystic acne seek out treatment immediately to prevent severe scarring.13
Rare Forms of Nodulocystic Acne
In addition to general nodulocystic acne, there are three rare forms of the nodulocystic variety that are unique.
- Pyoderma faciale, also known as rosacea fulminans, is a distinct form of nodulocystic acne that is only found on the faces of females. It results in large, painful, pus-filled, red cysts mainly on the central region of the cheeks. Redness around these lesions can be intense. Generally, pyoderma faciale develops in teen to adult females without a prior history of acne. It is normally treated with a steroid called oral prednisolone at a dosage of 1mg/kg every day for one to two weeks--with gradual reduction of the dose during the following two to three weeks--combined with isotretinoin at a dosage of 0.2–0.5mg/kg daily later in the course. Treatment with isotretinoin continues until all lesions are cleared, which can take up to four months.
- Acne conglobata is a distinct form of nodulocystic acne that is frequently found on the face, chest, back, and limbs of boys and young males, especially those who live in warmer climates. This acne type is highly inflammatory and presents a mixture of comedones, papules, pustules, nodules, and/or cysts. Acne conglobata, if left untreated, may last for years and result in widespread atrophic or keloidal scarring.
- Acne fulminans is a distinct form of nodulocystic acne that is commonly present on the chest, back, neck, and face. It includes nodules, cysts, and hemorrhagic ulcerations (bleeding ulcers) and is accompanied by other symptoms, including fever, fatigue, pain in the joints and bones, and weight loss. The lesions and symptoms of this type of acne most commonly affect adolescent Caucasian males.11
This table compares the three rare types of nodulocystic acne:
Occasionally, a disorder called draining sinuses develops in patients suffering from nodulocystic acne. It is especially common in people who suffer from one of the three rare forms of nodulocystic acne described above. Draining sinuses occur when two or more cysts merge into one huge, inflamed acne lesion. This lesion can discharge its pus at any time, but generally does not heal quickly or easily. Often these lesions appear around the nose, upper lip, and/or neck.14
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