How to Manage Severe Acne

Prescription medications and in-office procedures may be your best bet if you're dealing with severe acne.Getty Images

Severe acne isn’t just a pimple here or there. It’s a deep, often painful type of acne that’s uncomfortable and distressing.

The best thing you can do for severe acne is to see a dermatologist who can guide you toward treatment, which usually involves prescription medication. Severe acne can also leave scars, so treatment aims to decrease the likelihood of scarring.

Understanding severe acne, as well as its causes, triggers, and treatment options can help you regain control of your complexion.

What Is Severe Acne?

Severe acne is a type of acne in which numerous breakouts occur on the face, chest, back, jawline, or buttocks.^[1]

These breakouts feature two types of lesions: cysts (which contain pus) and nodules (which do not contain pus). These lesions tend to be deep, tender, and painful, says S. Tyler Hollmig, MD, the director of laser and cosmetic dermatology at Austin Dell Medical School at the University of Texas.

In addition, severe acne has the potential to leave long-term scarring, Dr. Hollmig says. This type of acne can also affect your quality of life, self-esteem, and self-confidence.^[2]

Causes and Triggers of Severe Acne

Severe acne occurs when the pores and hair follicles in your skin get clogged with sebum (an oily substance that creates a protective skin barrier), bacteria, or dead skin cells. This clog creates a pimple, which triggers inflammation, pain, and redness.^[3]

Acne can be mild (a few bumps) or severe. Genetics play a significant role in severe acne. Research shows that genes influence two key drivers of acne: inflammation and the activity of your skin’s sebaceous (oil) glands.^[4]

Other factors that can cause or worsen acne include:

• Stress^[3]
• Hormonal changes (as during puberty, menstrual periods, pregnancy, or using hormonal contraceptives)^[5]
• Certain medications, such as corticosteroids and hormonal contraceptives^[5]
• Oily skin-care products and cosmetics^[3]
• Tight-fitting clothing^[3]
• Picking at acne^[3]

Treatment Options for Severe Acne

It can seem like an endless journey to get from severe breakouts to clear skin, but with the right treatment, you can heal your acne and prevent new acne from forming.

Over-the-Counter Medications

There are many over-the-counter (OTC) topical medications for treating acne. Medications typically one or more of the following active ingredients:

• Salicylic Acid Salicylic acid helps clear debris from pores and reduces swelling.^[6]
• Benzoyl Peroxide Benzoyl peroxide kills the C. acnes bacteria that contributes to acne.^[7]
• Retinol or Retinoids These chemical compounds are derivatives of vitamin A. They slough off dead skin cells to prevent them from clogging pores and reduce risk of acne scarring.^[8]

OTC topical medications that contain these ingredients may help with cystic acne.^[9]

Unfortunately, they aren’t effective for nodular acne.^[10]

Prescription Medications

Prescription medications may be your best bet for treating nodular and cystic acne. Your dermatologist can offer recommendations based on your acne type and health background. Options include:

• Oral Retinoids Isotretinoin, an oral retinoid medication, is a gold-standard for treating severe acne, says Helen He, MD, the codirector of the Mount Sinai–Clinique Healthy Skin Dermatology Center in New York City. “It’s probably the most effective agent we have for clearing acne, especially for severe cystic patients,” she says. People who can become pregnant must use birth control when on this medication because of the risk of serious birth defects from isotretinoin.^[10]
• Oral Antibiotics An oral antibiotic such as tetracycline may help reduce inflammation and treat severe acne.^[11]

But there’s one hitch: “We only want to use them if needed due to the risk of antibiotic resistance,” says Brian Zelickson, MD, a dermatologist at Schweiger Dermatology Group in Edina, Minnesota. These medications may be warranted if others have been ineffective or are not the right choices based on your current health, he notes.

• Oral Contraceptives Some oral contraceptives are approved by the U.S. Food and Drug Administration (FDA) for the treatment of hormone-driven cystic or nodular acne.^[12]
• Spironolactone While spironolactone is typically used to treat hypertension (high blood pressure), it can also address hormonal causes of cystic or nodular acne, says Dr. Zelickson. Compared with placebo treatment, spironolactone was found to be more effective in healing acne in women (including those with severe acne) over six months, according to research.^[13]
• Prescription Topical Treatments Your dermatologist may suggest a cream, gel, or foam containing benzoyl peroxide, salicylic acid, and prescription-strength retinoids.^[10]

Another option is clascoterone, an FDA-approved topical cream that addresses hormonal causes of acne by reducing sebum production.^[14]

Topical antibiotics such as dapsone, clindamycin, clindamycin with benzoyl peroxide, erythromycin, and erythromycin with benzoyl peroxide kill the bacteria that cause acne and reduce inflammation.^[15]

Procedures

In-office procedures can help shrink extra-large nodules or cysts and help fade scarring.

• Cortisone Injection As steroid medication is a powerful anti-inflammatory, your dermatologist may recommend cortisone shots to shrink large, painful, or long-lasting acne nodules or cysts, says Zelickson. Your provider will inject a steroid medication directly into the nodule or cyst.^[10]
• Incision and Drainage For large, painful acne cysts or nodules that won’t go away with medication, your dermatologist may perform a procedure called incision and drainage.^[16]

The procedure involves opening and draining the cyst or nodule with a sterile needle or surgical blade. An incision and drainage should only be performed by a dermatologist; trying to do it yourself can increase your risk of infection, scars, worsening acne, and inflammation.^[17]

• Photodynamic Therapy While there are a few laser and light treatments that can be used to treat acne, only photodynamic therapy (PDT) has shown promise in treating severe acne, including acne cysts. During PDT, a provider applies a solution to your skin to make the skin more sensitive to light. The solution sits on your skin between 15 minutes and three hours before a dermatologist treats your skin with a laser or light device.^[18]
• Chemical Peel During this in-office procedure, a chemical solution is applied to your skin to remove the top layers, so the skin grows back smoother.^[19]

A chemical peel won’t necessarily treat severe acne, but it may help fade acne scars.^[20]

3 Tips to Prevent Severe Acne

Severe acne has many causes. Some causes, like genes, are beyond your control. But there are some things you can do to maintain healthy skin.

1. Practice healthy skin-care habits. Clean your skin with a gentle cleanser in the morning and before bed. Use noncomedogenic makeup and skin care (these are products that won’t clog pores) to reduce the chance you'll develop acne.^[21]
2. Eat a healthy diet. Research indicates that diet may aggravate acne, says Zelickson. Data suggests that diets rich in milk, sugary drinks, and high-fat or high-sugar foods are associated with acne.^[22]

These foods may increase inflammation, which promotes the development of acne, the researchers say.

1. Follow your treatment plan. Keep using medications and skin-care products as recommended by your dermatologist, Hollmig says. Consistent treatment will help heal severe acne and prevent it from forming. 

The Takeaway

Severe acne happens when the pores and hair follicles in your skin get clogged with oil, bacteria, or dead skin cells. This causes breakouts that feature two types of lesions: acne nodules and cysts. A dermatologist may recommend oral or topical prescription treatments to forestall and heal outbreaks of severe acne. Early treatment is key to prevent scarring.

Sources:

1. What Can Clear Severe Acne. American Academy of Dermatology.
2. Acne Can Affect More Than Your Skin. American Academy of Dermatology Association.
3. Acne. Cleveland Clinic. January 4, 2023.
4. Heng AHS et al. Gene Variants Associated With Acne Vulgaris Presentation and Severity: A Systematic Review and Meta-Analysis. BMC Medical Genomics. April 13, 2021.
5. What Is Acne? Penn Medicine. July 1, 2023.
6. Salicylic Acid Topical. MedlinePlus. October 15, 2023.
7. Matin T et al. Benzoyl Peroxide. StatPearls. March 1, 2024.
8. Retinoid or Retinol? American Academy of Dermatology Association. May 25, 2021.
9. Cystic Acne. Cleveland Clinic. August 25, 2021.
10. Nodular Acne. Cleveland Clinic. May 2, 2022.
11. Baldwin H. Oral Antibiotic Treatment Options for Acne Vulgaris. Journal of Clinical and Aesthetic Dermatology. September 1, 2020.
12. Stubborn Acne? Hormonal Therapy May Help. American Academy of Dermatology Association.
13. Santer M et al. Effectiveness of Spironolactone for Women With Acne Vulgaris (SAFA) in England and Wales: Pragmatic, Multicentre, Phase 3, Double Blind, Randomised Controlled Trial. BMJ. 2023.
14. Ludmann P. Acne: Diagnosis and Treatment. American Academy of Dermatology Association. June 19, 2024.
15. Acne. Mayo Clinic. July 20, 2024.
16. What Can Clear Severe Acne? American Academy of Dermatology Association.
17. Pimple Popping: Why Only a Dermatologist Should Do It. American Academy of Dermatology Association. October 17, 2023.
18. Lasers and Lights: How Well Do They Treat Acne? American Academy of Dermatology Association.
19. Chemical Peels. Cleveland Clinic. March 22, 2021.
20. Chemical Peel. Mayo Clinic. March 13, 2024.
21. Ludmann P. Acne: Tips for Managing. American Academy of Dermatology Association. November 16, 2022.
22. Penso L et al. Association Between Adult Acne and Dietary Behaviors: Findings From the NutriNet-Santé Prospective Cohort Study. JAMA Dermatology. August 2020.

Important Notice: This article was originally published at www.everydayhealth.com by Jessica Migala where all credits are due. Medically reviewed by Jacquelyn Dosal, MD

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