Medically reviewed by Mary Lucas, RN
Written by Our Editorial Team
Last updated 2/24/2021
When you develop a pimple, you can generally count on it healing within a few days, even if you don’t do anything specific to treat it. Acne nodules are different. Nodules are hard, painful lesions that form deep under the skin and they can last for weeks or months at a time.
Not only can nodular acne be painful, but it can affect your confidence and self-esteem. Without timely treatment, nodular acne can also lead to permanent scarring.
Below, we’ve explained what nodular acne is and what causes it. We’ve also explained the top treatment options for nodular acne.
Let’s start with a review of what nodular acne is and how it develops.
Acne vulgaris, typically referred to as acne, is the most common skin condition in the United States, affecting roughly 50 million people each year. Nodular acne, sometimes referred to as nodulocystic acne when cysts are present, is a severe form of acne that affects the deeper layers of skin.
Unlike the typical pimple that tends to heal relatively quickly, acne nodules can be persistent. They feel like hard knots under the skin, often with large, inflamed breakouts on the surface.
Though acne nodules sometimes develop a head, they typically stay deep beneath the skin’s surface, potentially for weeks or months at a time. Acne nodules may also be accompanied by cysts, large white or pus-filled bumps that are often painful or tender to the touch. Acne nodules and cysts typically don’t respond to over-the-counter treatment.
All forms of acne begin with a clogged pore. Dead skin cells mix with sebum to create a plug that develops into a comedone.
Blackheads (open comedones) and whiteheads (closed comedones) are common in mild cases of acne but things become more serious once bacteria becomes involved. When Propionibacterium acnes, a type of bacteria naturally found on the skin, gets thrown into the mix it creates an infection that travels deep under the skin, causing redness and swelling.
What makes nodular acne different from mild forms of acne is that it is associated with the presence of excess androgen hormones. Increasing levels of androgen hormones can trigger an increase in sebum production.
Researchers and dermatologists have yet to determine why some people develop nodular acne and others don’t. Like other acne, however, there does appear to be a genetic component.
Over-the-counter acne medications don’t usually work for nodular or cystic acne. Common acne spot treatments like benzoyl peroxide and salicylic acid help clear dead cells at the skin’s surface, but nodular acne happens deep beneath the skin.
Here are some of the best dermatologist-recommended treatments for nodular acne:
Though over-the-counter acne creams don’t usually work for nodular acne, prescription-strength topical medications do. Topical retinoids like tretinoin are one of the most common treatments for severe acne.
Available in several concentrations, tretinoin creams and gels can be applied directly to the affected area. This medication helps increase the rate of skin cell turnover which helps your body shed dead cells and produce new skin more quickly.
In a 2015 study, people with facial acne who were prescribed tretinoin 0.025% and clindamycin 1% gel achieved a statistically significant reduction in the number of inflammatory acne lesions over a period of 12 weeks of treatment.
The thing to be mindful of with this medication is that your acne may get worse before it gets better. It may take several weeks to see the full benefits of this treatment. Generally speaking, however, tretinoin is considered safe and has been approved by the FDA for decades.
Isotretinoin is one of the treatments for severe acne. Once sold under the brand name Accutane®, isotretinoin is a powerful retinoid — a vitamin A derivative. It is a medication that can be used to treat all types of acne, though it is generally recommended for severe forms of acne that have not responded to other medications, and may take several months for the medication to take full effect.
Inflammatory forms of acne like nodular acne are caused both by a combination of various factors, including clogged pores and bacteria. Oral antibiotics may help control the P. acnes bacteria that contributes to the formation of nodules. Antibiotics won’t affect sebum production or the cycle of skin cell turnover, but they may help reduce the severity of your breakouts.
Because antibiotics won’t prevent acne from developing, they are generally prescribed alongside topical acne medications and other treatments. These medications are also generally intended for short-term use as long-term antibiotic therapy can disrupt the balance of healthy bacteria in your gut.
Severe nodular acne can be quite painful. In some cases, corticosteroid injections into the nodule can help reduce redness, swelling, and pain related to inflammatory acne nodules and speed up the healing process. This treatment involves injecting a diluted corticosteroid directly into the lesion with a tiny needle.
The anti-inflammatory action of the steroid shrinks the walls of the cyst, delivering short-term relief from pain and inflammation. These injections may also reduce the risk of scarring. This procedure is not without risks and therefore must be performed by a trained professional.
Women who experience hormonal acne, including worsening breakouts around their period, may benefit from oral contraceptives. Excessive levels of androgen hormones are linked with increased sebum production and subsequently the risk for clogged pores. Birth control pills may help control acne caused by changing hormone levels.
Acne is a common skin condition but it affects some more severely than others. If you’re suffering from nodular acne, talk to your dermatologist to discuss treatment options.
Over-the-counter acne treatments may not be strong enough to treat deep acne lesions like nodules and cysts, so consider trying a prescription acne cream made with powerful ingredients like tretinoin and topical antibiotics. Your skin is unique, so you deserve a customized treatment formulated specifically for your skin and your acne.
Struggling with acne breakouts and tired of wasting your time and money on treatments that don’t work? Check out our guide to science-backed acne treatments to learn everything you need to know about acne medications like tretinoin, retinoids, oral contraceptives, and more.
Insider tips, early access and more.