Inflammatory acne comes in several forms — the most severe being deep, painful nodules and cysts. Sometimes referred to as nodulocystic (or just cystic) acne, these lesions lie deep within the dermis, and are likely to leave scars. 

While acne cysts seem to get more attention, acne nodules are actually the more common of the two. So how can you tell if you have nodular acne, and what can you do about it? We asked Dr. Sandra Lee (aka Dr. Pimple Popper) for guidance. 

What does nodular acne look like?

This type of inflammatory acne is characterized by hard, painful bumps (aka nodules) beneath the skin. On the surface, they appear as raised red lumps that are sore.

Several features distinguish nodules from other types of inflammatory acne:

• Depth: affects the dermis, unlike papules that lie in the epidermis only
• Makeup: doesn’t contain a white center like a pustule does
• Texture: feels hard to the touch, rather than slightly spongy like a cyst
• Sensation: often quite painful, especially when pressed
• Duration: these pimples can last many weeks, even months

The primary difference between nodules and cysts — and the reason they feel different when you press on them — is that cysts contain pus, while nodules do not.

What causes nodular acne?

Nodular acne begins like all other forms of acne: when pores become clogged with dead skin cells and sebum. This can trap C. acnes bacteria — which feeds off the debris — inside the pore, triggering an immune response in your skin. 

If the infection is severe enough, it can break through the walls of the pore deep inside your skin. This releases the dead skin, sebum, inflammatory substances and bacteria into the dermis, creating even more irritation. The result is an inflamed area of tissue called a nodule.

Because this process happens within the dermis, it can lead to damage to the extracellular matrix (ECM) — the proteins and fibers, including collagen, that give skin its structure. This is why nodular acne tends to scar: inflammatory chemicals adversely affect the collagen repair process.

How do you treat nodulocystic acne?

According to Dr. Lee, if you’re experiencing deep acne nodules and/or cysts, you should meet with a dermatologist. They can help you find the right treatment to help clear up the lesions and avoid scarring. 

It’s worth noting that you should never try to pop an acne nodule. These lesions are solid and have nothing to “pop” at all — and trying to do so can result in permanent skin damage.

Though every patient is different, medical treatment for nodular acne may include:  

• Tretinoin: a more potent, prescription form of retinol
• Isotretinoin: a highly potent, oral form of vitamin A that requires doctor supervision and a pledge to avoid pregnancy, as it causes birth defects
• Hormone therapy: for females only, oral contraceptives and spironolactone can regulate acne-causing androgens
• Oral antibiotics: typically used in conjunction with topical treatments, cannot be combined with isotretinoin
• Cortisone shot: a quick fix for individual nodules, can shrink pimples within 24 hours

Can you prevent nodular acne?

While everyone’s skin is different, keeping mild to moderate forms of acne in check can help ward off more severe breakouts. Dr. Lee says that keeping pores clear — before they can become comedones — will help stop more advanced forms of acne from forming in the first place. Her recommendations include:

• Salicylic acid: this beta hydroxy acid exfoliates and penetrates into pores to discourage clogging. Try: SLMD Salicylic Acid Cleanser, AHA/BHA Swipes, Salicylic Acid Body Spray.
• Retinol: this powerful antioxidant helps prevent excessive skin cell buildup. Try SLMD Retinol Resurfacing Serum.

If your acne has progressed to the inflammatory stage, it’s time to add ingredients that inhibit the growth of C. acnes bacteria:

• Benzoyl peroxide: an antibacterial, anti-inflammatory agent that kills C. acnes. Try: SLMD Benzoyl Peroxide Acne Lotion, BP Acne Spot Treatment, and BP Body Wash.
• Sulfur: ideal for those with sensitive skin, this mineral hinders the ability of C. acnes to reproduce.

For a complete skincare regimen that incorporates these ingredients, try Acne System and Body Acne System.

Dr. Lee’s last word

I get a lot of questions about severe forms of acne, and whether you can treat it at home or if you need to see a dermatologist. The good news is that many people are able to manage acne nodules and cysts with an effective regimen that addresses inflammation. But if your breakouts don’t subside, there are a variety of prescription options we can try.

—Dr. Sandra Lee