Severe Acne: a Problem with Mysterious Causes

When bad acne inflames and scars your skin and also affects your self-esteem, you need professional treatment. Four main types of severe acne can cause chronic breakouts. And though there are a number of good treatments for severe acne, the causes remain somewhat mysterious.

What Is Severe Acne?

The occasional pimple — no matter how big and red it is, or how terrible the timing may be — isn't considered severe acne. Even a monthly acne breakout with a few bumps here and there that disappear isn't typically serious enough to need the extensive treatment that severe acne requires.

Severe acne is generally defined by having cysts and nodules. "However, that definition can be expanded to people who have a significant psychological impact from acne, people who have a large surface area of skin involved, even people studded with blackheads and whiteheads," says Joshua Zeichner, MD, a dermatologist and director of cosmetic and clinical research at Mount Sinai Medical Center in New York City. And even those with mild acne may heal with significant scarring, which may then be considered severe acne as well, Dr. Zeichner adds.

The Four Main Types of Severe Acne

There are other types of severe acne, but these are the most common:

Nodulocystic acne. The distinguishing feature of nodulocystic acne is inflamed cysts, which are bumps filled with pus, fluid, or some other material, according to the New Zealand Dermatological Society. These painful cysts can be large — a few centimeters in size — and are most often found on the:

  • Shoulders
    • Back
  • Chest
    • NeckFace

One cyst may occur independently, or you may have large groups of cysts clustered together. Nodulocystic acne is difficult to treat, but treatment options include:

  • Acne surgery — drainage and excision of the cysts
  • The medication isotretinoin (Sotret, Claravis, Absorica, Amnesteem, Myorisan, and Zenatane)
  • Antibiotics
  • Corticosteroid injections into the cyst

Acne conglobata. Acne conglobata is a rare and unusually severe form of nodulocystic acne. It occurs when large, painful cysts form and connect beneath the skin, creating visible and even disfiguring scars, Zeichner explains. It most often strikes young men.

The first sign of acne conglobata may be pimples that get worse instead of better, eventually forming inflamed, infected nodules. These nodules are filled with pus and may have a foul odor.

The most common symptoms of acne conglobata are:

  • Deeply inflamed abscesses in the skin
  • Blackheads that are typically found on the buttocks, torso, upper arm area, neck, and face
  • Scars that may be thick or thin
  • Significant damage to the skin

Acne fulminans. This type of acne is characterized by sudden and severe inflammation that affects the entire body, according to the New Zealand Dermatological Society. It's related to a rise in male hormones, and is most common in males during adolescence. Its symptoms include:

  • Fever
  • Joint pain and inflammation, most often in the knees and hips
  • Severe acne with bleeding ulcers, usually on the upper body
  • Weight loss and a decrease in appetite
  • Swelling of the spleen and liver

Acne fulminans is a more severe type of acne conglobata. Treatment focuses on managing the inflammation, so non-steroidal anti-inflammatory drugs (NSAIDs) are often prescribed, according to the New Zealand Dermatological Society. Corticosteroid drugs may also be needed to help control inflammation. This recurrent type of severe acne should be monitored and treated over the long term by a dermatologist, and may need treatment with the systemic medication isotretinoin.

Gram negative folliculitis. Gram negative folliculitis is a type of infection that looks like bad acne. It occurs when follicles in the skin become inflamed from a bacterial infection. It can sometimes develop in people who are trying to treat another form of severe acne with topical or oral antibiotics over a long period of time, according to the New Zealand Dermatological Society.

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