A breakdown of types, treatments and more

Close up of adult skin acne with pimples and blemishes.

Severe acne is more than just an inconvenience – it’s stubborn, requires dermatologist care, and can be extremely painful, leaving physical and emotional scars in its wake. Those who suffer from more severe types of acne (from cystic bumps to more severe immune responses) understand how harrowing the process of identifying and treating these skin conditions can be. TLDR: It’s more complicated than putting on a hydrocolloid patch and changing your pillowcase.

To better understand the types of severe acne, we enlisted board-certified dermatologist Anthony Rossi, MD — a recognized sensitive skin expert at Memorial Sloan Kettering Cancer Center — to give us an overview of the key players, their causes, and the ways most effective in dealing with them. But first, what is meant by severe acne?

“Severe types have larger, inflamed cystic nodules that can be painful and lead to pitted acne scarring, as well as hyperpigmentation and dermal atrophy of the skin,” Dr. Rossi told POPSUGAR. It’s also extremely common – in fact, it’s the most common skin condition in teens, with up to 30 out of 100 teens suffering from moderate to severe forms of acne. And while there are different types of severe acne and ways to treat them (more on that below), there are two main commandments, according to Dr. Rossi: “See a board-certified dermatologist and don’t pick, pop , or press.”

Type of severe acne: nodulocystic acne

What it is: “This is a severe form of inflammatory acne that causes nodules and cysts that can be painful and lead to scarring,” says Dr. Rossi. They are deeper, bigger and very uncomfortable. It can also have consequences beyond the physical. “This can lead to lower self-esteem and physical dissatisfaction, which can cause people to withdraw more from social engagements.”

What are the causes: If skincare originated with a villain, it might look like this: excess oil and/or dead skin cells block a pore, forming a comedone. The bacteria enter the cat and the comedone turns to the dark side – becoming a very large inflamed nodule. It sounds scary, we know, but why is it happening? It turns out that nodulocystic acne is usually the by-product of genetics, hormonal fluctuations (especially for those who menstruate), and bacteria that cause inflammation.

How to treat it: If you think your breakout is nodulocystic acne, you’ll want to skip over-the-counter products and schedule an appointment with a dermis. “This usually requires oral retinoids such as isotretinoin to be brought under control, while steroid injections can help reduce individual lesions,” says Dr. Rossi, adding that photodynamic therapy may be an option for people susceptible to isotretinoin.

Type of severe acne: acne conglobata

What it is: “It’s part of a group of skin disorders called the follicular occlusion tetrad,” says Dr. Rossi, which means acne conglobata has friends in the low spots – along with a few other unwanted skin conditions that form. in the same way. Acne conglobata (a severe type of nodulocystic acne) begins with blocked hair follicles that form clusters of comedones that turn into pus-filled cysts. These nodular cysts then create a network of sores that can appear anywhere on the body: face, chest, back, shoulders and arms, thighs and buttocks. The nodules are red and tender to the touch.

What are the causes: According to Dr. Rossi, acne conglobata can be caused by “hormones, a genetic predisposition and an inflammatory response to a bacterium known as propionibacterium acnes”. Simply put, it often appears in the same way as common acne (acne vulgaris). However, there are other possible, albeit rare, causes. “Ingestion of thyroid medications and exposure to halogenated aromatic hydrocarbons – a type of environmental pollutant – may also be implicated in acne conglobata, as well as androgen hormones and anabolic steroids,” says Dr. Rossi.

How to treat it: Because acne conglobata is notorious for causing scarring, you’ll want to get in touch with a dermatologist for a treatment plan as soon as possible. Fortunately, the treatment is quite simple. Dr. Rossi advises following a prescription for isotretinoin and systemic steroids.

Type of severe acne: fulminant acne

What it is: Rapid onset severe acne that results in open sores on the face, chest or back. Acne fulminans is “a rare systemic disorder characterized by the presentation of nodules and cysts,” says Dr. Rossi. Although it looks like acne conglobata at first glance, acne fulminans can also affect other organ systems, potentially leading to anemia, an enlarged spleen, liver abnormalities, joint pain and/or fever. “SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis) can also be a serious complication of acne fulminant,” says Dr. Rossi; SAPHO syndrome is a rare chronic inflammatory disease.

How to treat it: It is important to see a dermatologist immediately, as it can take several months and medication to get under control. “Acne fulminans requires treatment with systemic corticosteroids as well as anti-inflammatories, antibiotics, and oral isotretinoin,” says Dr. Rossi.

Type of severe acne: Gram-negative folliculitis

What it is: “Gram-negative folliculitis is a bacterial infection of the hair follicle that looks and mimics acne, but the papules and pustules are centered around the hair follicle,” says Dr. Rossi, explaining that “gram-negative” in the name makes refers to a type of bacteria. It looks like an eruption of acne-like pustules (rather than papules or comedones) and sometimes penetrates the skin at a deeper level to form cyst-like lesions.

What are the causes: As mentioned above, Gram-negative folliculitis is specifically caused by a family of bacteria that includes Pseudomonas, E. coli, klebsiella, and proteus. Often patients with this infection will have tried traditional acne treatments (such as acne-specific antibiotics) without success, in which case a bacterial test is the best route.

How to treat it: “If there is suspicion, the dermatologist can do a bacterial culture to detect the bacteria and see which antibiotics it is sensitive or resistant to,” explains Dr. Rossi. Once gram-negative folliculitis is confirmed, it “can be treated with topical antibiotics and antibacterial washes, as well as oral antibiotics for more severe or widespread cases.”

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