Cystic Acne and Nodular Acne

Medically reviewed by Carina Fung, PharmD, BCPPS

Cystic acne treatment

Prescription medication11 is usually required for severe forms of acne, including cystic and nodular acne, since over-the-counter medication alone will not work.

Your provider or dermatologist can prescribe you medications or give you recommendations on how to:

  • Control your acne
  • Avoid scarring or other damage to your skin
  • Make scars less noticeable

Acne medications work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection or reducing inflammation, which helps prevent scarring.

With most prescription acne drugs, you may not see results for four to eight weeks, and your skin may get worse before it gets better. It can take many months or years for your acne to clear up completely.

The treatment regimen your provider recommends depends on your age, the type and severity of your acne, and what you are willing to commit to. For example, you may need to wash and apply medications to the affected skin twice a day for several weeks.

Often, topical medications and drugs you take by mouth (oral medication) are used in combination. Pregnant women will not be able to use oral prescription medications for acne.

Talk with your provider about the risks and benefits of medications and other treatments you are considering.

Topical medications for acne

Your provider will prescribe you the right type of topical medication12 based on the severity and type of acne you have. The most common topical prescription medications for acne are:

  • Retinoids and retinoid-like drugs. Retinoids refer to drugs derived from vitamin A. These come as creams, gels and lotions. Retinoid drugs include tretinoin (Avita, Retin-A, others), isotretinoin (Absorica, Claravis, others) adapalene (Differin) and tazarotene (Tazorac, Avage).

Since retinoids make your skin sensitive to UV light, you apply this medication in the evening, beginning with three times a week, then daily as your skin becomes used to it. Retinoids are not recommended for women who are pregnant or trying to conceive.

  • Antibiotics. These work by killing excess skin bacteria and reducing inflammation. For the first few months of treatment, you may use both a retinoid and an antibiotic, with the antibiotic applied in the morning and the retinoid in the evening.

The antibiotics are often combined with benzoyl peroxide to reduce the likelihood of developing antibiotic resistance. Examples include clindamycin with benzoyl peroxide (Benzaclin, Duac, Acanya) and erythromycin with benzoyl peroxide (Benzamycin). Topical antibiotics alone aren't recommended.

  • Azelaic acid. Azelaic acid is a naturally occurring acid found in whole-grain cereals and animal products. It has antibacterial properties. A 20% azelaic acid cream seems to be as effective as many conventional acne treatments when used twice a day, in the morning and evening, for at least four weeks. It's even more effective when used in combination with erythromycin.

Prescription azelaic acid (Azelex, Finacea) is an option during pregnancy and while breast-feeding. Side effects include skin discoloration and minor skin irritation.

  • Salicylic acid. Salicylic acid may help prevent clogged hair follicles and is available as both wash-off and leave-on products. Studies showing its effectiveness are limited.

  • Dapsone. Dapsone (Aczone) 5% gel twice daily may be recommended for inflammatory acne, especially in adult females with acne. Side effects include redness and dryness.

Evidence is not strong in support of using zinc, sulfur, nicotinamide, resorcinol, sulfacetamide sodium or aluminum chloride in topical treatments for acne.

Oral medications for acne

The most common oral medications for acne are as follows:

  • Antibiotics: For moderate to severe acne, you may need oral antibiotics to reduce bacteria and fight inflammation. This is usually the first choice for treating acne is a tetracycline class of antibiotics that include minocycline and doxycycline. Macrolides such as erythromycin may also be used to treat severe acne. Oral antibiotics should be used for the shortest time possible to prevent antibiotic resistance.

Oral antibiotics are best used together with topical retinoids and benzoyl peroxide. Studies have found that using topical benzoyl peroxide along with oral antibiotics may reduce the risk of developing antibiotic resistance.

Minocycline or doxycycline may cause side effects, such as an upset stomach and dizziness. These drugs may also increase your skin's sensitivity to the sun, so wearing sunblock is recommended when taking these medications.

Tetracycline antibiotics are also not recommended to be used in pregnant women, making erythromycin the antibiotic of choice in pregnancy.

  • Combined oral contraceptives: Some combined oral contraceptives are approved by the FDA for acne therapy in women who also wish to use them for contraception. They are products that combine estrogen and progestin (Ortho Tri-Cyclen Lo, Yaz, others). You may not see the benefit of this treatment for a few months, so using other acne medications with it the first few weeks may help.

The most common side effects of these drugs are weight gain, breast tenderness, and nausea. A serious potential complication is an increased risk of blood clots.

  • Anti-androgen agents: The drug spironolactone (Aldactone) may be considered for women and adolescent girls if oral antibiotics aren't helping. It works by blocking the effect of androgen hormones on sebaceous glands. Possible side effects include breast tenderness and menstrual changes.

Cystic acne medication

When to see your provider

If self-care remedies don't clear your acne, see your primary care provider. They can prescribe stronger medications. If acne persists or is severe, you may want to seek medical treatment from a provider who specializes in the skin (dermatologist).

For many women, acne can persist for decades, with flares common a week before menstruation. This type of acne tends to clear up without treatment in women who use contraceptives.

In older adults, a sudden onset of severe acne may signal an underlying disease requiring medical attention.

The Food and Drug Administration (FDA) warns that some popular nonprescription acne products like lotions and cleansers can cause a serious reaction. These types of reactions are quite rare, however—don't confuse them with the redness, irritation, or itchiness that may appear where you've applied medications or products.

Seek emergency medical help if after using a skin product you experience:

  • Faintness
  • Difficulty breathing
  • Swelling of the eyes, face, lips or tongue
  • Tightness of the throat

May be prescribed

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Therapies for acne

These therapies may be suggested in select cases, either alone or in combination with medications:

  • Lasers and photodynamic therapy: A variety of light-based therapies have been tried with some success. But further study is needed to determine the ideal method, light source, and dose.

  • Chemical peel: This procedure uses repeated applications of a chemical solution, such as salicylic acid, glycolic acid or retinoic acid. Any improvement in acne is not long lasting, so repeat treatments are usually needed.

  • Extraction of whiteheads and blackheads: Your provider may use special tools to gently remove whiteheads and blackheads (comedones) that haven't cleared up with topical medications. This technique may cause scarring.

  • Steroid injection: Nodular and cystic lesions can be treated by injecting a steroid drug, triamcinolone acetonide, directly into them. This therapy has resulted in rapid improvement and decreased pain. Side effects may include thinning skin in the treated area.

Treating acne in children

Most studies of acne drugs have involved people 12 years of age or older. Increasingly, younger children are getting acne as well. In one study13 of 365 girls ages 9 to 10, 78% of them had acne lesions.

If your child has acne, consider consulting a pediatric dermatologist. Ask about drugs to avoid in children, appropriate doses, drug interactions, side effects, and how treatment may affect a child's growth and development.

Lifestyle and home remedies for acne

You can try to avoid or control mild acne with nonprescription products, good basic skin care and other self-care techniques:

  • Wash problem areas with a gentle cleanser: Twice a day, use your hands to wash your face with mild soap and warm water. If you tend to develop acne around your hairline, shampoo your hair every day. And be gentle if you're shaving affected skin.

    Avoid certain products, such as facial scrubs, astringents and masks. They tend to irritate the skin, which can worsen acne. Excessive washing and scrubbing also can irritate the skin.

  • Try over-the-counter acne products to dry excess oil and promote peeling: Look for products containing benzoyl peroxide as the active ingredient. You might also try products containing salicylic acid, glycolic acid or alpha hydroxy acids, which may help with mild and moderate acne. It may take a few weeks before you see any improvement.

Nonprescription acne medications may cause initial side effects, such as redness, dryness and scaling that often improve after the first month of using them.

  • Avoid irritants: Avoid oily or greasy cosmetics, sunscreens, hair styling products or acne concealers. Products that may trigger comedones are called “comedogenic.” Use products labeled water-based or non-comedogenic, which means they are less likely to cause acne.
  • Protect your skin from the sun: For some people, the sun worsens acne. And some acne medications make you more susceptible to the sun's rays. Check with your provider to see if your medication is one of these. If it is, stay out of the sun as much as possible. Regularly use an oil-free, non-comedogenic moisturizer with SPF.
  • Avoid friction or pressure on your skin: Protect your acne-prone skin from contact with items such as phones, helmets, tight collars or straps, and backpacks.
  • Avoid touching or picking at the problem areas: Doing so can trigger more acne or lead to infection or scarring.
  • Shower after strenuous activities: Oil and sweat on your skin can lead to breakouts.

How to get rid of acne scars

Acne breakouts can be frustrating, and they can also leave scars on the face and other areas of the body. Cystic and nodular acne are particularly likely to lead to scarring.

Some people find that acne scars are an unwanted reminder of a painful and bothersome condition. However, acne scars do not have to be permanent, as some medical treatments can help get rid of them.

Here are a few recent, up-to-date methods of getting rid of acne scars:

  • Microdermabrasion: Microdermabrasion is an easy and safe14 technique. With this procedure15, your dermatologist or skin care specialist will use a small handheld device to gently remove the outer layer of your skin (epidermis). This process will reveal the smooth, toned skin underneath.

  • Laser resurfacing: This procedure16 uses a wand-like laser instrument to remove the upper layers of skin from acne scarring. It is sometimes referred to as "laser peeling" since it removes old skin cells in order to reveal newer, more youthful cells.

Disclaimer: The information on this site is generalized and is not medical advice. It is intended to supplement, not substitute for, the expertise and judgment of your healthcare professional. Always seek the advice of your healthcare professional with any questions you may have regarding a medical condition. Never disregard seeking advice or delay in seeking treatment because of something you have read on our site. RxSaver makes no warranty as to the accuracy, reliability or completeness of this information.

If you are in crisis or you think you may have a medical emergency, call your doctor or 911 immediately.