Reviewed for medical accuracy by Dr. Jaggi Rao, MD, FRCPC Double board-certified dermatologist
Severe acne is usually something you cannot treat on your own. Medical supervision and strong medication are usually needed to resolve cysts, nodules, and keloidal acne. What doctors don’t tell you about treating severe acne, however, is that the side effects of treating severe acne usually include a new case of mild to moderate acne as the skin grows so fast it flakes and peels and new sebaceous glands make lots of skin oil. Medication may get rid of the worst symptoms of severe acne, but you will have to keep it from coming back1.
Article Table of Contents
Severe acne is never something you can treat on your own.
The medications used to treat severe acne almost always have a side effect—mild to moderate acne with blackheads, whiteheads, and peeling skin.
Dermatologists can usually do “spot treatments” that help with the worst cysts and nodules.
Dermabrasion, face peels, and laser resurfacing usually do not help repair severe acne.
Water-based concealer, not oil-based concealer, helps cover up severe acne.
What Makes Severe Acne Severe?
Most people who have acne have a mild to moderate form of acne2 called acne vulgaris, also known as common acne. This form of acne can cause whiteheads, blackheads, and pimples. If you squeeze a pimple with dirty fingers, you can drive acne bacteria down into the skin so that you have nasty cyst or nodule, but most people who have mild to moderate common acne only do this once.
The people who get the most severe forms of cystic, nodular, or keloidal (scar-covered) acne often did not have to deal with acne when they were children or teenagers. These much more severe forms of acne usually crop in young adulthood, especially in person who have darker skin, and usually in men. Even fair-haired men and women, however, can also develop severe acne.
In severe acne, it is not enough to keep pores open. In fact, the skin may completely grow over a pore, encasing acne bacteria inside. The immune system constantly attacks the bacteria, but they continue to grow and even spread beneath the skin and sometimes to other parts of the body. Severe acne is painful, it is disfiguring, it can’t be treated by cleansing the skin, and it can even move into joints and bones.
What Are the Types of Severe Acne?
The best-known form of severe acne is cystic acne. It is mostly likely to strike people who have “perfect” skin. In cystic acne, healthy skin grows over an infected pore, trapping bacteria inside. The bacteria release chemicals that make surrounding tissues vulnerable to attack3 by the immune system, which destroys more and more of the lower layers of the skin. The cyst is visible and painful, but it cannot drain without being lanced (something you should never try at home) or treated with a topical retinoid such as Accutane, Retin-A, Adapalene, or Differin.
Another common form of severe acne is acne keloidalis nuchae. It differs from common acne in that it occurs in hair shafts, not in pores in facial skin, and that no acne bacteria are involved. In this form of acne, an ingrown hair gets stuck in its shaft4 and the immune system attempts to destroy it with inflammation. The skin seals the hair inside a pink scar that may take years to heal, or never heal at all. This problem is most common in males in the late teens and early twenties who have dark brown or black skin, who use old razors to shave, or who shave their heads with electric razors. This condition is also most commonly treated with Accutane, Retin-A, Adapalene, or Differin, all of which are dispensed under medical supervision.
Another form of acne, acne fulminans, strikes men who abuse testosterone5 or other steroids. This form of acne can strike both joints and the skin at the same time, causing disfiguring cysts and destroying joints. It cannot be treated with Accutane, Retin-A, Adapalene, or Differin, and only improves if testosterone and other steroid injections are discontinued.
What Can You Do About Severe Acne?
Everyone who has severe acne needs medical care to get better. But there are things doctors don’t tell you about living well with severe acne while it is healing. Here are some of the most important tips for living with severe acne:
Never, ever try to scrub6 your acne away. You won’t be able to reach deep-seated nodules or cysts, and the irritation of your skin will just cause it to secrete more oil, creating whiteheads, blackheads, and surface pimples.
If you have a small number of cysts, and you need to look your best for a wedding, graduation, or reunion, your doctor may be able to treat some of them with a corticosteroid injection7. Expect to have to pay cash, because this will not be covered by medical insurance. There is always a possibility that cortisone injections will cause lightening and indentation of the skin. Each injection will cost US $25 to $125.
If you fair, brown, or dark brown skin, tanning won’t make your cysts look better, because they will also tan. Tanning usually makes severe acne look even worse.
Dermabrasion, chemical peels, and laser resurfacing will not make your skin look better before acne has healed. And if you have dark brown or black skin, dermabrasion, chemical peel, or laser resurfacing treatment that is strong enough to treat a scar will also leave permanent brown or black discoloration of your skin where the cyst or nodule was.
Accutane, Retin-A, Adapalene, and Differin open up the skin, letting cysts and nodules drain8 naturally. You will probably need an antibiotic lotion to keep the rest of your skin from becoming infected with the material draining from the cysts and nodules.
Do not use oil-based concealer9, foundation, and layers of powder conceal cysts. As soon as the powder wears off, the cysts will be even more noticeable, especially on brown or black skin. Conceal cysts with water-based concealer a shade darker than your natural skin tone. Add a single layer of foundation and then loose, not pressed, powder.
Always let your dermatologist know if you are using any kind of steroids, including the cortisone creams in the drugstore. Never, ever inject a cyst on your own, especially not with an over the counter product that may be contaminated with bacteria.
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