Picture this: you wake up on the day of an important event—your birthday, a first date, or an interview—excited to go about your day. Shortly after waking up, you discover a swollen, painful lump on your face, instantly plummeting your mood. 

This is the harsh reality for those suffering from nodular acne, a severe and often stubborn form of acne that originates deep within skin tissue. Many of us are familiar with the occasional pimple or blackhead; however, nodular acne is on an entirely different level, affecting deeper skin tissue and often leaving not only physical but also emotional scars.¹ 

It’s important to understand the causes and etiology of nodular acne, not only to find a cure but also to bring light to the complex interplay of factors that cause these deep and painful lesions, in hopes of helping those who feel trapped in their skin and preventing others from experiencing it.

What is nodular acne?

Nodular acne is a form of inflammatory acne that develops deep under the skin, causing hard lumps or knots known as nodules.^1,2 These nodules start below the surface of the skin and often appear as red bumps, typically without a whitehead or blackhead at the centre.¹ 

Unlike typical acne pimples, these nodules can last for weeks to months, remaining painful throughout.^1,3 They pose a risk of infection and inflammation if a bacterium called Cutibacterium acnes (C. acnes) gets trapped under the skin in the nodules.^1,2 Although this bacterium is a normal part of your skin microbiome, when it gets trapped beneath the skin with sebum and dead skin cells, the anaerobic environment enables the bacteria to multiply and produce substances that irritate the skin and cause a strong inflammatory response.⁴ 

As nodular acne starts deep within the skin, it is considered a severe form of acne and often can’t be treated with over-the-counter (OTC) products alone.¹ Acne as a whole is the most common skin condition in the UK, affecting approximately 95% of people between the ages of 11 to 30, to some extent.⁵ Of these individuals, 13% are believed to have suffered from a severe form of acne at one point, including nodular acne.⁶

Causes of nodular acne

Anyone can experience nodular acne at some point in their lives, and it can appear at any age and in all genders; however, it is most commonly observed in young people assigned male at birth.¹ 

Various factors can increase the risk of developing nodular acne. Nodular acne develops similarly to other types of pimples: it occurs when the pores of the skin become blocked, trapping dead skin cells, hair, and sebum.^1,2 The root cause is blocked pores, which can result from an overproduction of sebum, improper cleansing of the skin, and other factors, some of which can be controlled.¹

Main causes of blocked pores¹

• Excessive Sweating: Sweaty skin creates an environment conducive to acne formation. Sweat can stimulate the sebaceous glands to produce more sebum, increasing the likelihood of clogged pores. Hence, individuals with hyperhidrosis, a condition that causes excessive sweating, are more likely to develop nodular acne
• Genetics: Those with a family history of nodular acne are more likely to develop it, likely due to specific genes influencing sebum production, the inflammatory response, and skin cell turnover rates, which can contribute to acne development
• Hormones: Individuals are more likely to have an acne breakout during adolescent development due to changes in hormone levels. An increase in androgens can cause the oil in the skin to thicken, resulting in clogged pores. This also explains why males are more likely to suffer from nodular acne, as they have higher levels of these hormones
• Prolonged Stress or Anxiety: High cortisol levels can stimulate an increase in sebum production, increasing the likelihood of clogged pores
• Medications: Certain drugs, such as corticosteroids, can worsen nodular acne. Corticosteroids stimulate the sebaceous glands to produce more sebum, suppress the immune system, creating an imbalance in the skin microbiome, and increase the proliferation of acne-causing bacteria like C. acnes. They can also disrupt the skin barrier, which further alters the skin microbiome
• Certain Skincare Products: Products with comedogenic ingredients are likely to block pores, contributing to the development of nodular acne

Symptoms of nodular acne

It’s important to identify whether the acne you are experiencing is nodular acne, as this requires treatment from a dermatologist and cannot be treated through changes in skin care or OTC products alone.^1,2,3 The symptoms of nodular acne include:^1,2

• Nodules (firm lumps) that can be felt beneath the skin. Although they typically occur on the face, they can also appear on the back or chest
• Sensitivity or pain with the nodules, especially when touched
• Raised lumps; these usually appear red but can also be the same colour as your skin

Treatment of nodular acne

Nodular acne needs to be diagnosed by a dermatologist to proceed with treatment.¹ Typically, to treat nodular acne, a dermatologist would recommend:^1,2

• Prescription Topical Treatments: Medications like benzoyl peroxide, salicylic acid, and prescription-strength retinoids aim to kill bacteria on the skin and reduce oil blocking the pores. These can be in the form of a cream, gel, or face wash
• Oral Medications: For severe acne, dermatologists often recommend isotretinoin. For females, this is often taken alongside birth control due to the risk of serious birth defects while on these medications. Alternatively, antibiotics like tetracycline may be prescribed to reduce the presence of acne-causing bacteria
• Cortisone Injections: Cortisone injections may be recommended to shrink painful or large acne nodules. This works by reducing inflammation and speeding up the healing process

Other forms of management for nodular acne

While it is necessary to be diagnosed by a dermatologist for the proper treatment of nodular acne, there are some avenues to help improve acne alongside the medication:^2,3

• Diet: Having a well-balanced diet and reducing certain types of food, such as dairy and simple sugars, can support the treatment of nodular acne, as they are associated with stimulating increased oil production, which can clog pores
• Suitable Skincare Regimen: Ensuring proper cleansing of the face and consistent use of recommended products can help prevent blocked pores
• Pimple Patches: Popping nodular acne can lead to scars and enlarged pores, so using pimple patches can help prevent the urge to pop and may also help soothe the nodules. Always consult with a dermatologist when deciding to use pimple patches. Additionally, avoiding touching your face will reduce adding additional bacteria to the skin, always ensure your hands are clean before washing your face or applying any products
• Stress Management: As stress is a contributing factor to the development of acne, participating in de-stressing activities, such as exercise or meditation, can help reduce oil production and improve overall health

Summary

Nodular acne is a severe form of acne that significantly impacts those affected, both physically and emotionally. Understanding its etiology and causes is crucial for effective treatment and prevention. This skin condition originates deep within skin tissue, resulting from pores blocked with sebum, dead skin cells and hair, forming nodules. These blocked pores create an environment favourable for the growth of the bacterium C.acnes, which can cause severe inflammation and infection, causing the pain associated with nodules.  With appropriate dermatological care and lifestyle adjustments, managing nodular acne is possible, offering hope and relief to those who suffer from this challenging condition. For those whose nodular acne is influenced by lifestyle factors rather than genetics, e.g improper face cleansing, bad diet, prevention is possible.