Nodular Acne

Medically Reviewed By William C. Lloyd III, MD, FACS

What is nodular acne?

Nodular acne is a form of the skin condition acne vulgaris or simply, acne. (Vulgaris is Latin for common.) There are two broad types of acne vulgaris—inflammatory and non-inflammatory. Nodular acne falls under the inflammatory category of acne vulgaris. It gets its name from the hard lumps, or nodules, that form under the skin.

Like other forms of acne, nodular acne starts in the skin’s pores. A pore is an opening with a hair follicle and a sebaceous gland at the bottom. The gland secretes an oil called sebum that moisturizes the skin. The oil carries dead skin and debris up and out of the pore as it flows from the bottom of the follicle to the pore opening. In acne, the oil and debris get trapped in the pore, forming a plug that blocks the opening. The clogged pore can also trap bacteria.

In nodular acne, a bacterium, Cutibacterium acnes, colonizes the clogged pore. This triggers an inflammatory response that can result in two types of pimples:

  • Nodules, which are large, hard, painful lumps that form deep under the skin. They form around a hair follicle and can involve more than one follicle. Acne nodules feel hard because they are solid.
  • Cysts, which are large, painful, pus-filled nodules. Because they contain pus, they don’t feel hard. This also makes them less stable than a solid nodule. Cysts can burst, causing scarring.

Often, nodular acne causes cysts or nodules on the face or neck. It can also affect the chest, upper back, and shoulders.

In general, acne is extremely common. About 80% of people between the ages of 11 and 30 years will experience an acne breakout at some point. This is the most common age group acne affects, but you can get acne at any point during your lifetime. Acne can range from mild to severe. Having a parent who had severe acne, including nodular acne, increases the risk of developing it.

Four factors contribute to the development of nodular acne—excess oil production, clogged pores, bacteria, and inflammation. However, it isn’t entirely clear why some people have problems with nodular acne and others don’t. Hormones may play a role. Acne tends to happen during phases when hormone levels are changing. This includes adolescence and female menstruation and pregnancy.

Nodular acne treatment requires the care of a dermatologist. These doctors specialize in conditions that affect the skin. Prescription treatments include oral antibiotics, retinoids, and hormonal therapies. In some cases, doctors recommend injecting medications into the cyst or nodule or draining them.

Nodular acne can cause scarring. There are several treatments to help improve the look and texture of skin with nodular acne scars. Treating nodular acne and scarring can help improve your mental and emotional health.

What are the symptoms of nodular acne?

Acne can affect just about any body part. It tends to occur most frequently on skin with a high concentration of oil glands. The most common sites for nodular acne are the face, neck, chest, upper back, and shoulders.

There are two types of pimples that occur in nodular acne:

  • Nodules, which are solid lumps deep under the skin that are painful and can be quite large
  • Cysts, which are pus-filled nodules deep under the skin that are painful, but not as hard as nodules

Inflamed skin over the nodule or cyst is very common. The redness and swelling is the result of a strong immune-mediated inflammatory response to the clogged pore and bacteria within it. The appearance of nodular acne can resemble other skin conditions. It’s important to see a dermatologist for an accurate diagnosis. A dermatologist has the expertise to effectively treat nodular acne. Seeing this skin specialist early can help you get control over your skin sooner.

What causes nodular acne?

Acne is the result of skin pores becoming clogged with oil, dead skin, and bacteria. Nodular acne occurs when deep pimples form around a hair follicle. Nodules can involve more than one follicle when they grow very large. Cysts form when pus fills the nodule.

Researchers do not fully understand exactly why some people develop nodular acne and others do not. It’s likely a combination of factors, including genetics, the immune system, and hormones levels. Rising levels of androgens during adolescence stimulate oil production and skin cell turnover. Some people may produce too much oil or may be overly sensitive to normal skin bacteria.

What are the risk factors for nodular acne?

Several factors increase the risk of developing acne, including nodular acne. There are also various factors that can trigger or worsen a breakout. Not everyone with risk factors will have problems with acne or severe acne.

Risk factors and triggers include:

  • Age: Acne is most common during adolescence, but you can develop it at any age.
  • Certain medications: Examples include corticosteroids, lithium and phenytoin (an anticonvulsant).
  • Diet: Some research has implicated high-carbohydrate or high-glycemic diets as contributors to acne breakouts.
  • Heredity: Having a parent who had nodular acne makes it more likely that you will also have problems with it.
  • Skin environment: Greasy or oily cleansers, cosmetics, creams or other skin products can clog your pores. Tight clothing, high humidity, excessive sweating, and friction or pressure on the skin can contribute as well.
  • Stress: If you already have acne, stress may act as a trigger for breakouts or worsen existing breakouts.

Research also suggests there may be a link between smoking and acne breakouts.

Reducing your risk of nodular acne

You can’t completely prevent or avoid acne, including nodular acne. However, you may be able to control your acne triggers and breakouts by:

  • Avoiding abrasive or alcohol-based cleansers and greasy or oily skin products
  • Not touching your face or squeezing pimples, which can cause more irritation and worsen the problem. Picking at acne also increases the risk of scarring.
  • Shampooing your hair regularly, which means once a day for oily hair
  • Washing your face twice a day with a gentle cleanser and lukewarm water. You should also wash your face after heavy sweating. Keep in mind, scrubbing your skin or excessively washing it can make the problem worse.

If you have a parent who had nodular acne, see a dermatologist at the first sign of a problem. Your doctor may have other strategies to help you minimize triggers and breakouts.

How is nodular acne treated?

Nodular acne is an inflammatory acne that requires treatment from a dermatologist. Home remedies and over-the-counter treatments aren’t likely to help this form of moderate-to-severe acne. Instead, prescription medicines are necessary to effectively treat it.

Potential treatment options include:

  • Oral antibiotics, such as doxycycline, erythromycin, minocycline or tetracycline, in combination with topical therapy, such as tretinoin (Retin-A) or tazarotene (Tazorac). It can take up to 12 weeks to see the full benefit of oral antibiotics. Once acne is under control, doctors will taper the dose down to the lowest effective dose. The goal will be to eventually maintain control with topical medicines and avoid long-term use of oral antibiotics.
  • Oral contraceptives. This hormonal therapy is an option for women with nodular acne. Oral contraceptives are effective in treating both inflammatory and non-inflammatory acne. An alternative is spironolactone, which has anti-androgen properties.
  • Oral isotretinoin (Amnesteem, Claravis, others). This vitamin A derivative can have problematic side effects, such as depression and severe birth defects. Doctors generally reserve it for people who don’t get results with other treatments. People who take this medication must participate in a patient program. This includes a requirement for women of childbearing age to use two methods of contraception for one month before treatment, during treatment, and for one month after treatment is complete. The course of treatment lasts between 16 and 20 weeks.
  • Steroid injection with triamcinolone acetonide solution into the nodule. The steroid injection approach for nodules works quickly and can help reduce scarring.

In some cases, doctors may recommend draining cysts. However, this technique can cause scarring.

What are the potential complications of nodular acne?

Nodular acne can cause both physical and emotional complications. The physical complications include scarring and discoloration of the skin. Scarring from nodular acne can look like deep pits. It is also possible to form keloid scars, which are thick, sometimes discolored scars.

Fortunately, there are treatments available to help improve the look of acne scars. Depending on the severity of the scarring and discoloration, options may include:

  • Chemical peels
  • Dermabrasion
  • Laser resurfacing
  • Skin grafting, which removes a “punch” of skin containing the scar and replaces it with donor skin from another site

The emotional scars from acne can include anxiety, depression, low self-esteem, and social isolation. Effectively treating acne and any resulting physical scars can go a long way to healing these emotional side effects. This makes it very important to find a dermatologist with plenty of experience treating nodular acne.

Was this helpful?
  1. Acne. American Academy of Family Physicians.
  2. Acne. Johns Hopkins University.
  3. Acne. Mayo Foundation for Medical Education and Research.
  4. Acne. National Institute of Arthritis and Musculoskeletal and Skin Diseases.
  5. Acne: Signs and Symptoms. American Academy of Dermatology.
  6. Acne: Tips for Managing. American Academy of Dermatology.
  7. Acne Vulgaris. Merck Manual Professional Version.
  8. Acne: Who Gets and Causes. American Academy of Dermatology.
  9. How to Treat Different Types of Acne. American Academy of Dermatology.

Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2020 Oct 15
View All Acne Articles
THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on the site. If you think you may have a medical emergency, immediately call your doctor or dial 911.