Introduction

Acne is a chronic inflammatory condition affecting the skin, most common in adolescence. There are approximately 650 million individuals affected by acne worldwide.¹ Persistent breakouts can have lasting psychological effects, especially in instances where dark scarring occurs. Acne is often defined by the manifestation of a combination of the following four factors:²

• Increased sebum (oil) production
• Irregular cellular shedding of the skin
• Bacteria infiltration of follicles
• Inflammation in the localised area

These factors work through a complex and multifactorial mode of action that can be influenced by a number of external factors. 

There are five common forms of acne:³

Cystic acne

• Extremely painful 
• Requires dermatological intervention

Bacterial acne

• Otherwise known as common acne 
• Characterised by pimples and pus-filled bumps (pustules)

Fungal acne

• Uniform pimples or pustules 
• Can be itchy
• May cause a burning sensation
• Commonly misdiagnosed as common acne 

Hormonal acne

• Caused by hormonal fluctuations
• Often pimples, pustules, and occasionally deeper cysts or nodules

Adult acne

• Acne diagnosed after the age of 25 years

Acne is further classified by wound level and the severity of blemishes (Table 1). These lesions are usually located on the face, back, chest, and neck because these areas have many follicles. Blackheads are classified as non-inflammatory disease states and all injury types beyond such are of inflammatory origin.⁴ 

Table 1. Acne clinical classification

It is important to understand different types of acne because this will influence the treatment method, regarding achieving effectiveness and reducing effects. Nodular acne, one of the most severe types, often requires the influence of a dermatologist in prescribing medication to reduce scarring and remove bacteria from the skin. 

What is nodular acne?

Nodular acne is characterised by deep-set lesions that can involve the entirety of the face, neck, chest and back. These lesions can become so severe that they form cavities within the skin's surface that are susceptible to infection, and further inflammation.⁵ 

Characteristics of nodular acne

Nodular acne can be identified by the following characteristics:⁶ 

• Red, inflamed bumps on the skin
• They do not have a head (do not contain pus)
• Extremely painful and large in size

They are most commonly located on the:⁶

• Face (especially the cheeks and jawline)
• Neck 
• Chest 
• Upper back 
• Upper arms 

Causes and risk factors

The cause of nodular acne is largely unknown, however, there are a number of factors that influence the likelihood of developing it. These include:⁷

Hormonal influence

• Testosterone increases sebum production 
• Hormone changes during the period cycle or pregnancy can increase susceptibility to acne 
• PCOS (polycystic ovary syndrome) can cause large fluctuations in hormone levels, which increase acne susceptibility 

Genetics

• If your parents had, or still have acne, then the likelihood of you developing symptoms is high 
• If both parents had acne then the severity is likely to increase 

Environment and lifestyle

• Some cosmetic products can cause irritation (is it important that these are washed off the skin before bed)
• Some medications cause increased sebum production (most commonly steroids and lithium)
• Smoking increases the likelihood of adult acne 
• A diet high in complex sugars (carbohydrates) increases disease manifestation and is mainly linked with diabetes 

Common myths

There are a number of common misconceptions surrounding acne causes and treatments:⁷

Squeezing spots will solve the problem 

• This may worsen symptoms as it introduces dirt through the skin's barrier 
• This could cause excessive scarring 

You have acne because you don’t wash enough

• Acne occurs below the skin and, therefore, what is on your skin has little to no effect
• Often, excessive washing can be more damaging as it causes irritation and dryness 

Toothpaste can be used to dry out spots

• While toothpaste has some antibacterial properties, other active ingredients can cause skin aggravation 
• A doctor-recommended skin treatment is much safer for use

Diagnosis

Diagnosis is carried out by a GP, who will prescribe a relevant course of treatment, or refer you to a dermatologist in severe cases. A simple inspection of the skin to establish spot type can help a GP diagnose the acne type.⁷

Treatment options

Acne treatments are predominantly used to control an active disease state, reducing the length of time suffering from active lesions and minimising lasting scarring. Often, results are not seen until 3-6 weeks after commencement of treatment. Throughout this time, management of healing, alongside prevention of disease progression, is imperative.²

Over-the-counter treatments

Over-the-counter treatments are most commonly used in individuals with a mild condition that manifests as a few small, non-inflammatory spots. A simple gel, cream, or face wash that contains benzoyl peroxide can successfully clear up the skin.⁷

Prescription medications

These medications may be administered as a tablet, lotion, cream, or gel and are largely based on a patient’s age, site and severity of the acne, and patient preference. Topical retinoids (e.g. tretinoin) in combination with benzoyl peroxide are the usual first-line treatments. However, for more inflamed acne, topical antibiotics (e.g. clindamycin, erythromycin and minocycline) are often given in addition to other therapies. These reduce swelling but have little to no effect on scarring. Therefore, azelaic acid is used to reduce hyperpigmentation beyond treatment of the primary lesions. For severe acne, topical steroids may be given.⁸ 

If acne becomes unresponsive to topical treatments, oral antibiotics (e.g. doxycycline, minocycline) are often given as a second-line therapy. These are commonly more effective in cases of nodular acne, but can only be used for up to 6 months. Hormonal therapy may be available to women who are post-puberty or post-pregnancy; here oral contraceptives are the most used therapy.⁸

Dermatological procedures 

Dermatological procedures, such as manual extraction, chemical peels, microneedling, laser resurfacing and drainage, are all used in acne treatment. All of these procedures must be carried out by a dermatologist who can assess your skin and decide on a regime that is suitable for you. Often these procedures are used at a later stage to manage scarring rather than active lesions.⁸

Prevention and management

Daily skincare routines can be designed for your skin type to help maintain a healthy look. This may include twice daily face washing with a sensitive cleanser, application of gels containing retinol (to reduce fine lines), and use of creams that contain SPF (to protect against ultraviolet (UV) sensitivity).⁹ A diet change may be applicable for some individuals because particular food groups may cause breakouts and lowering sugar/saturated fat intake maintains gut health.¹⁰ Managing stress and sleep can also help to maintain a healthy skin profile by controlling hormonal influence. 

Psychological and social impact

Suffering from prolonged periods of acne flare-ups can have a profound effect on confidence and self-esteem. It is essential to understand that it does not make you dirty and, often, it is a condition that is entirely out of your control. Visits to the dermatologist will help to get on top of your condition, however, patience and perseverance are essential. It may take several months to achieve completely clear skin, however, if skin routines and treatment regimes are adhered to, then it is attainable.¹¹ 

Summary

Nodular acne can be incredibly debilitating, however, it can be rectified with professional advice. Seeking help from a GP or dermatologist will allow for correct diagnosis and the development of a treatment programme tailored to you and your skin. Nodular acne can be highly damaging to one's confidence; it is important to remember that almost 95% of all 11 to 30-year-olds worldwide are affected by acne to some extent.⁷ So, you are not alone!