Nodular Acne: Treatments, Prevention, Natural Remedies and More

• Nodular acne is a severe form of inflammatory acne that is characterized by large, painful nodules that form deep within skin tissue
• Like all acne, it first develops when excess oils and debris become trapped within hair follicles
• Nodular acne is treated with prescription-strength topical and oral medications as well as corticosteroid injections

Acne develops when hair follicles become trapped with excess sebum (oil), dead skin cells and other debris. When bacteria proliferates, symptoms can worsen and spread to the deeper layers of skin, creating hard, painful nodules. Nodular acne is one of the most severe forms of acne and can cause significant scarring, tissue damage and impact quality of life (QoL).  

What Is Nodular Acne?

Nodular acne is one type of inflammatory acne, and is characterized by large, hard knots that form within the deeper layers of skin. These cause wide-range redness and inflammation. Unlike other forms of inflammatory lesions, there is no pus present.

This type of acne is difficult to treat due to its severity and persistence, and the damage it causes to tissue and skin.  As such, it requires aggressive treatment to manage symptoms and mitigate damage.

Like other acne lesions, nodules typically develop where sebaceous glands are the largest such the face, jawline, neck, chest or back. 

What causes nodular acne?

When debris and oils combine, they form hard plugs called comedones (whiteheads and blackheads). 

Over time this blockage encourages Cutibacterium acnes bacteria to multiply, and If left untreated, will worsen progressively. Inflammatory acne lesions will form in the following order of severity: papules, pustules, cysts and nodules.

Nodules result when pus-filled pimples called pustules form, erupt and spread inflammation to form larger cysts; eventually, the contents will consolidate, harden and form painful nodules. 

Acne can develop at any time but is most prevalent during hormonal fluctuations which is common during puberty, menstruation, pregnancy and menopause. These fluctuations cause sebaceous glands to secrete excess sebum.    

Genetics have also been implicated, as well as stress, diet and a faulty skin care routine. All these causes are related to excess sebum accumulating within pores – the main driver of acne formation.

Nodular acne vs. cystic acne

Both cystic and nodular acne are two severe forms of inflammatory acne that impact the deeper layers of skin, and can produce large lesions and extensive scarring.

Cysts are the precursors to nodules. Like nodules, they are large, red and painful; and contain bacteria, sebum, dead skin cells and debris. They differ from nodules in that they resemble boils on the surface of skin, are soft to the touch, red and swollen and pus-filled. 

Nodules are deep-seated, firm to the touch and do not release pus. They can be identified by raised inflamed bumps on the surface of skin.

Does Nodular Acne Cause Scarring? 

If not properly treated, nodular acne can cause several types of scars to develop due to tissue inflammation as well as the healing process on the surface of skin. 

• Atrophic scars are depressed areas that develop due to a lack of connective tissue forming during the wound-healing process
• Hypertrophic scars are raised areas of tissue that form due to an overproduction of collagen during the healing process
• Keloid scars are large raised areas of scar tissue that develop due to an over response of the healing process, causing the scar to be larger than the original wound; keloids can continue to grow for years if not properly treated

In addition to scar formation, wound healing commonly results in postinflammatory hyperpigmentation (PIH), dark pigmented marks that remain once the lesion has healed.  

Nodular scar in-office treatments

Several effective treatments are available to treat acne scars that fill in depressed tissue and reduce the appearance of raised scars. Your dermatologist will recommend the best course of action for you and may opt for several types of therapy to achieve the best results.

• Chemical peels remove damaged layers of skin to smooth hypertrophic scars and lighten damaged pigmented skin cells. Results will depend on the extent of the scarring as well as the strength of the peel; typically 3–6 session are required over a length of several months
• Cortisone injections are a mainstay treatment for hypertrophic scars and can  effectively reduce scar tissue by breaking up the bonds that hold collagen fibers together; several injections are required over 3–6 months produce noticeable results
• Cryotherapy uses liquid nitrogen to freeze raised hypertrophic and keloid scars from the core outward which ensures the entire scar is frozen; studies have shown that one single treatment can reduce keloids by 67%
• Nonablative lasers treat depressed scars by stimulating collagen production to resurface skin; 3–6 sessions are typically required over several months to achieve best results
• Silicone gel sheeting (SGS) or gels are considered the gold standard for raised scars and work through several mechanisms of action, including breaking down excess collagen; after treatment, one study showed a grading of normal in 60% of participants
• Soft tissue fillers are gel-like substances that are injected into atrophic scars to add volume and level skin; several sessions are required depending on severity. Results last from several months to 5 years depending on the filler
• Surgical excision can effectively remove both hypertrophic and keloid scars; however, keloid scar excision should be used alongside other treatments such as corticosteroid injections as recurrence rates are as high as 45%–100%.  

Best Prescription Treatments for Nodular Acne

Nodular acne is best treated at the first signs of inflammation to treat and prevent the spread of  the infection; and control and reduce symptoms. This goes a long way in preventing skin and tissue damage.   

As nodular acne is considered a serious form of acne, over-the-counter (OTC) solutions are not the best solution. Effective treatment consists of prescription topicals and oral medications, and typically requires a combination of both for efficacy.

Antibiotics

Systemic antibiotics treat nodular acne by killing bacteria and easing inflammation. The following have been demonstrated to be the most effective: tetracycline, doxycycline, minocycline and erythromycin. In general, these have an excellent safety profile. 

Oral antibiotics are often prescribed alongside other treatments such as benzoyl peroxide to provide both a topical and systemic approach to treating nodules.

Benzoyl peroxide 

Prescription-strength benzoyl peroxide is more potent than an OTC product, and is a standard add-on therapy to antibiotics or retinoids to control nodular acne. As well, it is ideal as long-term maintenance therapy once a round of antibiotics is completed.

Benzoyl peroxide is an antimicrobial that works to eliminate acne-causing bacteria, helps slough off dead skin cells and clears oils from the surface of skin.

Retinoids

Retinoids play an important role in treating severe forms of acne. Isotretinoin is the only therapy that impacts all of the major contributing factors implicated in acne development: it reduces the size of sebaceous glands to dramatically slow sebum excretion, normalizes keratinization to exfoliate and slough off dead skin cells, and reduces inflammation. 

Early treatment with high doses of isotretinoin has been shown to produce improvements in moderate acne but results were significantly greater for severe acne. 

Dosage is based on weight, can be administered in low or high doses; with the course of treatment lasting from 4–6 months, on average. 

Hormonal therapy

For nodular acne resulting from hormonal imbalances, women who require contraception may be prescribed birth control pills to regulate this imbalance which in turn modulates sebum excretion. 

Another effective solution for women is spironolactone, a medication that blocks androgen hormones from stimulating sebaceous glands. In one study researchers found 75.5%, 84.0%, and 80.2% of patients had a reduction or complete clearance of acne on the face, chest and back, respectively.

For birth control, improvement in skin could take several weeks to months; spironolactone can take 3–6 months.

Your doctor may also prescribe a topical medication such as benzoyl peroxide to target acne using a combined approach for greater results.

Natural Remedies for Nodular Acne

Natural remedies can be used alongside prescribed treatments to relieve uncomfortable symptoms.

• Apple cider vinegar has antibacterial properties to kill bacteria and soothe itchy skin. To use, combine one part apple cider vinegar to four parts water and gently apply to your skin using a cotton ball; allow to rest for 10 minutes, then rinse off
• Tea tree oil is an essential oil that has a number of skin-soothing benefits to alleviate redness and swelling and calm irritation and pain. Dilute 2 drops of tea tree oil with 12 drops of carrier oil and gently apply to your skin using a cotton ball
• Wrap an ice pack or several ice cubes in a thin clean cloth and apply to skin for 5–10 minute intervals; this will relieve pain, swelling and discomfort

How to Prevent Nodular Acne

The best way to prevent nodular acne from forming is to treat mild acne symptoms early; this will guard against infection and worsening symptoms. Following are some tips to consider:

• Wash your face once or twice a day (depending on your skin type) using a mild pH cleanser; follow with a good quality moisturizer 
• Exfoliate several times a week with glycolic or salicylic acid to maintain clear pores
• Choose noncomedogenic products for all your skin and hair needs
• If you are prone to acne breakouts, include skin care products that contain benzoyl peroxide as a preventive measure 
• Avoid touching your face as this can transfer bacteria and oils to your skin

When to See a Dermatologist

If you’re seeing signs of acne developing or if your symptoms are worsening despite OTC treatments then this is the time to see your dermatologist.

Acne can present in multiple forms and be a sign of mild, noninflammatory acne or the beginning of a more severe form. By having a dermatologist examine your skin, they will be able to formulate a personalized plan for you and begin immediate treatment.

Not only will this prevent worsening symptoms but this will greatly reduce the risk of scar formation and hyperpigmentation once lesions heal.

Takeaway

Nodular acne is a severe form of acne that is characterized by large nodules that form deep within skin tissue and are made up of hardened sebum, debris, dead skin cells and bacteria.

This form of acne can be difficult to treat as it can be wide-spread and resistant to treatment, causing extensive damage to skin and tissue.

As such, it is important to seek professional treatment quickly to begin a course of treatment and control the infection. There are a number of effective options available to your dermatologist including oral antibiotics, retinoids, hormone stabilizers and topical benzoyl peroxide

These medications treat nodular acne by either killing bacteria, reducing sebum production or clearing pores of debris to ease symptoms and clear the infection. A common strategy is to use combination therapy to achieve greater results; as well, you may be prescribed an oral agent and then a topical as maintenance therapy.