What Is Nodular Acne?

Nodular acne is a severe form of acne vulgaris, a common skin condition that occurs when hair follicles become clogged with oil, dead skin cells, and bacteria.¹ It is characterised by the development of large, inflamed, and painful lesions deep within the skin. These lesions are called nodules and are larger and more serious than typical acne pimples.

Overview

Acne is a very common inflammatory skin disease that affects the skin pores. It is common in adolescence, and the characteristic lesions are open (black) and closed (white) skin pores called comedones, inflammatory bumps called papules, pustules (when the bumps are filled with pus), nodules (firm or hard bumps), and cysts (fluid-filled bumps), and may lead to scarring and pigmentation on the skin. Nodular acne is a severe type of acne with nodules that appear as large hard lumps that are 1cm or greater. They build up beneath the surface of the skin and are often painful. The nodules can last weeks to months and require treatment to resolve. Usually, hormones and food, as well as bacteria, dead skin cells, and oil in pores, cause nodular acne. Cutibacterium acnes (C. acnes), a bacterium that can cause infection and inflammation, become trapped inside these nodules.¹ 

Treatment for nodular acne typically involves a combination of topical medications, oral medications, and, in some cases, procedures performed by a dermatologist. Teenagers assigned males at birth (AMAB) and young adults have acne nodules on their bodies and faces, while adult persons assigned females at birth (AFAB) frequently get nodular acne on their necks, chin, and jawline. Hormonal changes cause an increase in acne nodules right before the start of menstrual periods.²

Causes of nodular acne

The primary reason for the formation of acne is clogged skin pores.¹ Clogged pores may result from the accumulation of dirt, oil, or dead skin cells. If the body produces too much sebum (an oily substance produced in the skin) or the skin is not adequately cleaned, blocked pores may develop. They can also result from

• Excessive sweat– Nodular acne may be more likely to occur in those with hyperhidrosis, which causes excessive sweating. Sweaty skin is more prone to nodular acne.
• Genetics– There is an increased likelihood of developing nodular acne if you have a family history of it.
• Hormones– As hormone levels shift during puberty, young people are more likely to have acne breakouts. Skin oil can thicken due to elevated levels of the hormone androgen, resulting in clogged pores. Androgen is more prevalent in teenagers and young adults who were assigned male at birth. Nodular acne can also occur during pregnancy, menstruation, or going through menopause.
• Drugs–Some medications, such as corticosteroids, can make nodular acne worse.
• Skincare products– A few creams, lotions, and makeup products have the potential to block pores and cause acne nodules.
• Anxiety and stress– The body produces cortisol as a "stress hormone." The body may produce more sebum due to the increased cortisol level as a result of increased stress and anxiety 

Characteristics of nodular acne

The severity of this acne is based on the distribution, type and number of lesions and the presence or absence of scarring. Nodular acne can appear on the face, chest, or back. 

The nodules appear as hard lumps beneath the surface of the skin and may be of the same colour as the skin or appear red and inflamed. Acne nodules can reoccur for weeks or even months and can leave scarring if not treated properly.

Risk factors of nodular acne

Like other types of acne, nodular acne can be influenced by several risk factors.^1,7 The following are some typical risk factors associated with the development of nodular acne

• Hormonal changes– Nodular acne, in particular, is at increased risk due to hormonal changes. The sebaceous glands can be stimulated by hormones like androgens to generate more oil, which can result in clogged pores and the development of acne.
• Genetics– The chance of developing acne is influenced by family history. There is an increased risk of developing nodular acne if parents or other close family members have suffered from severe acne.
• Age and gender– Acne is most commonly experienced during adolescence and early adulthood. The hormonal changes that occur during puberty make teenagers more susceptible to acne. Nodular acne, however, can affect people of any age or gender.
• Stress: Chronic stress can exacerbate acne by triggering hormonal responses that lead to increased oil production and inflammation
• Diet– While the exact relationship between diet and acne is still debated, some studies suggest that a high-glycaemic diet (rich in sugary and processed foods) and dairy products may influence acne development
• Medications– Certain medications, such as corticosteroids, androgens, and lithium, can trigger or worsen acne, including nodular acne.
• Cosmetics and skincare Products– Using certain oily or comedogenic cosmetics and skin care products can contribute to acne formation, including nodules, by clogging skin pores
• Environmental Factors– Exposure to pollutants and certain occupational chemicals may also play a role in acne development.
• Picking and Squeezing Acne– Manipulating acne lesions can lead to more inflammation and potentially worsen nodular acne, increasing the risk of scarring.

Complications of nodular acne

Potential complications of nodular acne are associated with scarring and hyperpigmentation, resulting in psychological effects.⁴ Complications associated with nodular acne include

• Scarring
• Anxiety
• social withdrawal
• Poor facial aesthetics
• Lack of self-esteem
• Depression

Diagnosis of nodular acne

Nodular acne is primarily diagnosed clinically and requires a dermatologist. If there is an underlying reason for the acne, such as a medication or an endocrine condition producing hyperandrogenism (such as polycystic ovarian syndrome), it can be determined through a history and physical examination. The nodules are deeper and more inflamed than regular pimples or blackheads, leading to significant discomfort and potential scarring. To properly manage the illness, the dermatologist also recommends lifestyle changes and a skincare regimen.^1,2

Treatment of nodular acne

Acne cannot be cured, but it can be managed with the right medication.³ Nodular acne requires treatment from a dermatologist as, typically, over-the-counter acne treatments are ineffective for nodular acne.^4,6 They aid in the removal of excess sebum and dead skin cells on the surface of the skin but won't help much with nodules, which are located deep within the skin. Dermatologist-recommended treatment options include

• Topical retinoids– Prescription-strength retinoids like tretinoin can help unclog pores and reduce inflammation. They also promote cell turnover, which can prevent new acne lesions from forming.
• Topical antibiotics– Antibiotics like clindamycin or erythromycin may be prescribed to reduce bacteria on the skin and decrease inflammation
• Oral antibiotics– In cases of widespread or severe nodular acne, oral antibiotics like doxycycline, minocycline, or tetracycline may be prescribed to target bacteria and reduce inflammation
• Hormonal therapy–For women with hormonal acne, oral contraceptives (birth control pills) or anti-androgen medications may be used to regulate hormones and improve acne
• Isotretinoin (Accutane)– Isotretinoin is a powerful oral medication used for severe nodular acne that does not respond to other treatments. It works by reducing the production of oil and preventing the clogging of pores. However, it comes with potential side effects and requires close monitoring by a healthcare professional.
• Corticosteroid injections– Corticosteroid injections into the nodule can help rapidly reduce the inflammation and pain associated with large nodules.
• Laser and light therapies– Some dermatologists may use lasers or light-based therapies to target acne-causing bacteria or reduce inflammation
• Extraction– Dermatologists can perform a procedure to extract large, painful nodules to relieve pressure and promote healing. However, this should only be done by a professional to avoid complications.

Home care for nodular acne

While home care for nodular acne can help manage the condition, it is essential to consult with a dermatologist for a proper diagnosis and personalised treatment plan.^5,8 Gentle cleansing and proper skin care are recommended to reduce the development of acne. Recommended self-help techniques to reduce acne include

• Gentle cleansing–Wash your face twice daily with a gentle, non-comedogenic cleanser. Avoid scrubbing vigorously, as it can irritate the skin and worsen the condition.
• Keep hands off–Avoid touching, picking, or squeezing the nodules, as it can lead to further inflammation, infection, and scarring.
• Moisturise–The use of a lightweight, non-comedogenic moisturiser can keep skin hydrated without clogging pores
• Over-the-counter topicals–Consider using over-the-counter products containing benzoyl peroxide or salicylic acid. These can help reduce inflammation and keep pores clear. However, start with a lower strength and patch test first, as some people with sensitive skin may experience irritation.
• Warm compress–A warm compress can assist in decreasing swelling and encouraging drainage of the nodules. Do not squeeze the lesion; let it drain naturally. 
• Avoid irritants–Avoid harsh or oil-based cosmetics and hair products that can aggravate acne.
• Sun protection–Protect your skin from the sun's harmful rays by using a broad-spectrum sunscreen with at least SPF 30
• Diet and hydration–A well-balanced diet with plenty of fruits, vegetables, and water can contribute to overall skin health. While diet alone won't cure acne, a healthy lifestyle can support the effectiveness of medical treatments.

Conclusion

Nodular acne is a severe form of acne that is characterised by large, inflamed, and painful nodules or cysts beneath the skin's surface. It occurs when hair follicles become blocked with excess oil, dead skin cells, and bacteria, leading to the formation of painful, tender bumps. It often requires specialised medical treatment. The exact causes of nodular acne are not fully understood, but it is believed to be influenced by various factors, including genetics, hormonal changes, stress, and certain medications. 

The treatment of nodular acne typically involves a combination of topical treatments (e.g., retinoids, antibiotics), oral medications (e.g., antibiotics, hormonal therapy), and in some cases, procedures like drainage or corticosteroid injections for particularly large and painful nodules. Hormonal therapy may be used in addition to the other treatments for acne in persons assigned female at birth (AFAB). Maintaining good skin care practices and avoiding factors that may trigger acne flare-ups can help reduce the likelihood of developing nodular acne.