Severe Acne: Types, Causes, Treatments and More

• Severe acne develops when widespread, inflamed acne lesions form deep within skin tissue
• This type of acne is typically managed through a multimodal approach that combines topical and systemic treatments as well as professional therapies
• It’s important to see a dermatologist without delay to begin treatment and minimize the risk of tissue damage and scarring

Inflammatory acne develops when sebum (an oily substance secreted from the sebaceous glands to protect skin) combines with dead skin cells, debris and acne-causing bacteria. This triggers a response from the immune system which causes inflammation in the form of redness, swelling and pus-filled lesions.

Severe acne types include cystic and nodular acne which forms deep within tissue and is characterized by widespread, painful inflamed lesions. These can cause extensive damage to skin including dark hyperpigmented spots, scarring and tissue damage. As such, severe acne can impact quality of life and self-esteem.   

What Is Severe Acne? 

Acne vulgaris first presents as comedones, in the form of whiteheads or blackheads. These are plugs of oil, dead skin cells and debris that form in hair follicles (pores) and are considered noninflammatory acne lesions.

If left untreated, Cutibacterium acnes bacteria can flourish causing comedones to degrade to papules or pustules as the bacteria breaks down the follicle walls and spreads, triggering a response from the immune system. This results in the formation of painful pus-filled pustules and cysts.

Severe acne is characterized by the presence of numerous pustules and cysts (sometimes very large) as well as hardened nodules that develop deep within tissue. Without intervention, bacteria spreads and causes worsening symptoms, resulting in significant tissue damage and acne scars.

Severe acne can be notoriously difficult to treat because the inflammation is both deep within the dermis and extensive. An effective treatment plan relies on combination therapy to manage this disorder in a targeted manner: therapeutic agents include topical acne medications, systemic retinoids, hormonal therapy and antibiotics.

This approach aims to kill C. acnes bacteria and calm inflammation, reduce sebum-producing activity, clear skin of pore-clogging debris and dead skin cells, and normalize hormone levels. All these effects work together to help clear skin of acne lesions and help prevent future flare-ups.

Severe acne, like any acne, tends to form most often where there are the greatest number of sebaceous glands such as on the face, jawline, chest and upper back.    

Severe acne scars

Severe acne causes widespread inflammation which is likely to cause extensive scarring. This occurs when large inflamed cysts and nodules resolve and leave behind pockets of damaged tissue and skin.    

Acne causes atrophic and hypertrophic scars to form; the former causes shallow depressions in skin, the latter are thick and raised. Dark spots resulting from postinflammatory hyperpigmentation (PIH) can also form once inflamed lesions heal. 

Both types are due to an abnormal wound healing process, whereby the body produces too little or too much collagen, a main component of skin that gives it strength and elasticity.

Acne scar treatments

Acne scars are considered difficult to treat. For people with darker skin tones, such as those who fall under the category of Fitzpatrick skin types IV–VI, face additional challenges due to the elevated level of melanin in their skin which increases the risk of hyperpigmented dark marks.

For best results, treatment typically requires combination therapy to soften, smooth, fill out and improve the look of scars. 

• Dermal fillers such as hyaluronic acid can effectively fill depressed scars to smooth the skin’s surface and promote collagen production. Fillers have temporary effects, however, so periodic injections are required
• Dermabrasion uses a rotating brush to resurface skin by removing the top layer to help minimize the look of both depressed and raised scars to even skin’s texture. Repeat appointments are necessary to achieve significant results
• Laser skin resurfacing breaks up scar tissue on the top layers of skin and stimulates collagen production to fill in depressed scars for a more even appearance

Types of Severe Acne 

Acne is classified by its severity as well as the type of lesions present. 

Cystic acne is characterized by the formation of persistent, inflamed cysts that are red and pus-filled. These form deep beneath the skin and contain bacteria as well as dead skin cells and sebum. They are visible on the skin’s surface as white-tipped lesions that resemble boils.   

Nodular acne develops when acne bacteria multiply and spread deep within skin tissue resulting in widespread inflammation and the formation of cysts and large, hard nodules. These nodules create tunneling wounds called sinus tracts which cause deep tissue damage.

These two types of lesions are characteristic of two types of severe acne: acne conglobata and acne fulminans.

Acne conglobata

Acne conglobata is a rare but severe form of acne that describes deep burrowing abscesses, cysts and nodules that connect and form painful nodules which spread within tissue. Discharge from these cysts are released to the skin’s surface and emit a foul order. As well, comedones and noninflammatory lesions may also be present. 

Acne conglobata is a chronic, progressive skin disorder that can cause extensive tissue damage and disfiguring scars.

This type of acne is seen more often in men than women and less often in darker skin tones. Typically, it presents in those who have a history of acne but C.acnes bacteria also plays a key role as it is believed to trigger an immune response that initiates a chronic inflammatory state. 

Acne fulminans

Acne fulminans is similar to acne conglobata but is not associated with comedones or noninflamed lesions. It too is linked to a hypersensitivity to the presence of C. acnes bacteria on skin. 

This rare form of acne has a sudden onset, is destructive and explosive in nature. It manifests as dramatically worsening and ulcerating skin lesions. Multiple inflamed nodules develop on the trunk to include the chest, abdomen, pelvis and back. These are covered with crusts and are painful to the touch.

Acne fulminans primarily affects adolescent males and may or may not be linked to systemic symptoms such as fever, weight loss, loss of appetite and joint pain. Causal factors include genetics, an autoimmune disorder, drug intake and androgen hormone imbalance.

Causes of Severe Acne

Acne develops due to the accumulation of debris, dead skin cells and oils. This accumulation also causes acne-causing bacteria to become trapped where it can freely multiply; this triggers a protective immune response from the body and inflammation occurs. 

There are several causes that prompt fluctuations in sebum production as well as hyperkeratinization– when follicular cells do not shed normally, leading to clogged pores. These all contribute to acne formation and  influence acne severity.   

Genetics

Science has established that there is a genetic component to acne. This not only influences acne formation but severity as well: the degree of acne severity in adolescence is linked to history of severe acne in first-degree relatives, especially the mother.

In one large study of twins, researchers found family history was associated with an increased risk of acne development. Further, 81% of this disease was attributable to additive genetic effects – multiple genes that work together and exert influence.

Hormones

Androgen hormones can greatly influence acne. They are believed to do so in two separate ways: by stimulating secretion of sebum from sebaceous glands and because the glands of patients with acne are more sensitive to the effects of these androgens.

Fluctuations in hormones are very common throughout significant life stages such as puberty,  pregnancy and menopause. Oily skin increases the risk of acne lesions and can lead to severe acne if not controlled.

Some medications

Acne can occasionally be caused or aggravated by some systemic medications such as corticosteroids, lithium, vitamin B12, antibiotics and antiepileptics drugs. As well, some progestin-only contraceptives can cause or worsen acne.

Severe Acne Treatments

Prompt and consistent treatment can mitigate damage, heal cysts and nodules, and manage future breakouts. To prevent reoccurring flare-ups, topical retinoids are required for maintenance therapy to prevent reoccurring outbreaks.

Severe acne requires a combination of both typical and oral prescription-strength medications to control and manage symptoms; each targets the multiple factors that combine to result in acne formation, and selecting which agent depends on severity, patient preference and tolerability.

As such, oral antibiotics, hormonal therapies and isotretinoin (a retinoid) are the mainstay systemic therapies for acne.

Over the counter topicals

Over-the-counter (OTC) topical treatments are not adequate as severe acne solutions. Prescription-strength options are your best recourse as they are far more effective and will provide faster healing to subdue inflammation and minimize acne scarring. 

Oral medications

In addition to topical combination therapy, all forms of severe acne require systemic treatment as they can target deep seated inflammation; kill acne-causing bacteria; tamp down inflammation and redness; and clear pores and deeply rooted lesions.  

In addition, add-on combination therapies may be considered depending on degree of severity, response to treatment, tolerance to medications and drug history.

Antibiotics

Oral antibiotics, especially tetracyclines, are considered first-line therapy for severe cystic and nodular acne, which are both considered difficult to treat. There are a number of prescribed treatments that fall under the tetracycline category such as doxycycline and minocycline.

Macrolides are another group of antibiotics, and include azithromycin and erythromycin. While there is no data to support choosing one antibiotic over the other, the tetracycline class is purported to be superior as it has antibacterial and anti-inflammatory activities. 

Antibiotics are very effective at relieving painful inflamed lesions as they kill bacteria which reduces inflammation, however they must be used in conjunction with other prescribed oral or topical agents to reduce and control symptoms. 

Oral contraceptives

Birth control pills can be effective for women experiencing hormonal acne who also want a form of contraceptive.

These pills contain estrogen and progestin, which reduce the activity of androgens, the hormones that regulate sebum production. This reduces and stabilizes sebum output to help prevent acne lesions from forming. Androgens are the most important of all hormones regulating sebum production.

Contraceptive pills have been demonstrated to lead to significant reductions in both lesion count and type. When combined with spironolactone, greater effects can be had as this medication is also an antiandrogen. 

Retinoids 

Isotretinoin is a well-known retinoid that is the generic form of discontinued brand name Accutane. Retinoids are the gold standard in severe acne treatment. 

This medication has a number of qualities to help heal severe acne. It has been proven to significantly decrease the size and secretion rates of sebaceous glands by 90%, with continued suppressed activity one year later once treatment concludes.

As an anti-inflammatory, it  can alleviate redness, swelling and pain; it can also promote skin cell turnover to clear skin.

While isotretinoin can’t kill acne-causing bacteria, it can lower P. acnes levels on skin. It does so by promoting an unfavorable environment for bacteria to thrive by eliminating excess oils and dead skin cell buildup.

Treatment course, dose and results will vary but 16 weeks of therapy has been demonstrated to  achieve clearance in 85% of patience. Unfortunately, relapses are quite common. 

Isotretinoin is reserved for severe and difficult-to-treat acne due to the risk of serious side effects including birth defects, depression and psychosis; as such patients are closely monitored. 

Professional procedures

The following professional procedures are used as part of combination therapy to treat severe acne.

In addition to prescribed medications, your dermatologist may also administer intralesional steroid injections directly into the cysts or nodules to deliver active ingredients exactly where needed. This produces a favorable response; cysts shrink, pain is reduced and lesions heal faster.

Intralesional injections are also beneficial as they can alleviate discomfort and inflammation while a patient is waiting or preparing to begin systemic therapy. 

Incision and drainage is a procedure that uses a needle or surgical blade to open up and release the contents of large cysts or nodules which can reduce pain and swelling, and in some circumstances, lead to complete healing. 

At-Home Tips for Managing Severe Acne

Acne is a chronic skin disease, meaning it can go into remission only to return with varying intensity; you can be symptom-free for months or years but it is very likely that symptoms will reoccur.

Severe acne is also very difficult to control and typically requires months or years of consistent combined therapy to manage this condition. 

Simple at-home treatments and habits can add a level of support and self-care to help manage uncomfortable symptoms. 

Apply warm and cold compress

To treat cysts, apply a warm compress for 5–10 minutes. The moisture combined with the warmth will help draw the contents of the cysts to the surface. Repeat several times a day until the cyst drains on its own; do not squeeze or manipulate them as this will worsen symptoms.

Apply ice wrapped in a thin cloth for 5–10 minute intervals to constrict blood vessels; this will help tamp down swelling as well as ease pain.

Protect your skin from UV exposure

The best thing you can do for your skin is to protect it from damaging UVA and UVB rays by applying a broad-spectrum sunscreen. 

The sun can have a profound effect on skin and cause premature aging in the form of wrinkles, lines, sagging skin, hyperpigmented spots; damage underlying tissue; and increase the risk of skin cancer. The same negative effects can be had with tanning beds.

The sun can also dry skin which can trigger sebaceous glands to overproduce oils. This can worsen acne. 

Do not pop or pick at your acne

Allow your skin to heal naturally, and resist touching, picking, popping or squeezing lesions. Not only can this cause postinflammatory hyperpigmentation (PIH) but it can contribute to scarring.  Touching your face can also introduce and spread bacteria to intensify inflammation.

Skin care routine

Follow an effective skin care routine that includes a gentle nonabrasive cleanser, purifying toner and ceramide moisturizer. 

Ensure the skin care products you use are noncomedogenic, alcohol- and fragrance-free to avoid irritating your skin. You can have a discussion with your dermatologist as to what active ingredients would be best to relieve uncomfortable symptoms and to help support your treatment regimen. 

Follow your dermatologists instructions and use all prescribed topical medications as prescribed so that your acne can be controlled and the healing process can begin.

When To See a Dermatologist

If OTC solutions are not improving your acne, see a dermatologist. They will determine what is best for your situation. 

If you are already under a dermatologist’s care and your acne is worsening, it is important to  speak with your dermatologist; they will either add on another medication or adjust your current regimen. 

Takeaway

Noninflammatory acne begins with the accumulation of oil, dead skin cells and debris which form comedones. When bacteria proliferates, inflammatory acne develops and causes inflamed lesions to form.

Severe acne is characterized by large, red pus-filled cysts and hardened nodules that form deep within tissue and are visible and on the skin’s surface. Severe acne requires immediate attention as it can cause extensive tissue damage and scarring. This has an impact on quality of life.  

Severe acne may be caused by genetics, hormonal factors such as the menstrual cycle or pregnancy, or even certain medications which affect the hormones or immune function. 

Acne is a chronic skin disease and severe acne is especially challenging to treat. As such, effective treatment  and management requires prescription-strength combination therapy such as topical medications, oral retinoids, contraceptives and antibiotics. 

It is vital to seek treatment for severe acne as it can worsen with time; it can also damage and scar skin.