Cystic Acne Treatment: What’s Up With Those Large, Painful Pimples That Won’t Go Away?

You’ve probably experienced a few different types of acne since your teenage years, from annoying blackheads to juicy papules. But if you’ve ever developed one of those large, deep, painful red pimples that doesn’t go away, and sometimes never comes to a head, you know it’s a different beast altogether. 

If you’ve been slathering your topical on an inflamed pimple for weeks to no avail, you might have what dermatologists call a cyst, nodule, or, more generally, “nodulo-cystic acne.” These bumps run deeper under the skin than your classic cystic pimple, and thus come with a higher risk for scarring. (That’s why cystic acne treatment is a little more complicated than other acne treatments.) Here’s what you need to know to identify, treat, and ideally even prevent those big, annoying bumps.

So, what is nodulocystic acne, anyway?

“Cysts and nodules are large, deep and painful bumps, filled initially with blood, then with pus,” Dendy Engelman, M.D., a board-certified dermatologic surgeon at Medical Dermatology and Cosmetic Surgery in New York City, tells SELF. Delightful, right? You might not even be able to pop it should you want to. “These bumps can linger under the surface for weeks or even months and can eventually harden,” Dr. Engelman says.  

To break it down further, this form of acne is composed of two parts. Technically, “nodular” refers to bumps over one centimeter in diameter, and “cystic” refers to a lesion that’s under the skin and lined by a hair follicle, Hooman Khorasani, M.D., chief of dermatologic and cosmetic surgery at Mount Sinai Health System, tells SELF.

“These are different than typical acne, which are white or black comedones,” Dr. Khorasani says. “They are larger, deeper bumps under the skin.”

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Cysts and nodules can occur on their own or together, but they are caused by different circumstances. “A nodule is when a pore ruptures under the skin, resulting in a large, raised bump,” Dr. Engelman says. On the other hand, “a cyst happens when a pore is clogged with oil, dead skin cells, or bacteria. The pore ruptures under the skin, causing the inflammation to spill out into the surrounding tissue,” she explains. “The difference here is that the body forms a cyst around it to stop the inflammation from spreading.” Plus, that makes them super painful.

And, because cysts and nodules form so deep in the skin, they are more likely to result in a scar than other types of acne, Dr. Khorasani says.

Who is most likely to get cystic or nodular acne?

Some people are more prone to nodulocystic acne. “Acne-related cysts and nodules are usually due to chronic inflammation of the hair follicle and sweat gland,” Sruthi Renati, M.D., a dermatologist at Michigan Medicine, tells SELF. “Multiple factors can influence this form of acne, including increased oil production by the sweat glands, proliferation of acne-causing bacteria on the skin, or hormones.”

Unfortunately, a lot of the predisposition for cysts and nodules is simply genetic, Dr. Engelman says. Your skin’s tendency toward oil production, for instance, is not something you can control. There’s also the influence of stress: “These bumps are often caused when there is a hormonal imbalance or during periods of stress, when your body responds by producing more cortisol,” Dr. Engelman says. “Both hormones overstimulate the sebaceous oil glands, making your body produce more oil that gets stuck in your pores, thus trapping bacteria.”

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If you’ve had several large inflamed bumps recently, talk to your doctor about whether hormones might be playing a role in your acne. They might recommend trying a form of hormonal birth control to manage those fluctuations and prevent this type of acne. And although you can’t necessarily control every stressful situation in your life or your body’s reaction to them, you can develop some stress-management and self-care strategies to make things a little less disruptive.

Here’s the deal with cystic and nodular acne treatment.

“If a drugstore treatment hasn’t cleared up acne after two weeks, then you need to see a dermatologist for a prescription treatment,” Dr. Engelman explains. And, of course, if you have any pimple that doesn’t heal after a few weeks or months, it’s important to get it checked out because that could be a sign of skin cancer, Dr. Renati says.

Sadly, you are very unlikely to see improvement of nodulo-cystic acne with over-the-counter treatments. “Usually topical medicines [like benzoyl peroxide and salicylic acid] aren’t effective in treating these lesions because they are so deep and topical medicines can’t penetrate that far,” Dr. Khorasani says, noting that cystic acne treatment is typically more of a tailored, multi-step approach from a derm.

While you’re waiting for your dermatologist appointment, avoid the temptation to pop or pick a cyst or nodule; you’re probably not going to be able to actually pop something that deep, but you are likely to develop scars from these pimples. So, especially with these types of pimples, resist the urge to mess with them.

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Once you do get to see your derm, a few things may happen: First, they can inject the pimple with a corticosteroid, which will reduce the inflammation and shrink the swelling within six to 48 hours, Dr. Engelman says. That could be the extent of your treatment. But if you tend to get a lot of pimples like this, your dermatologist may want to start you on a more long-term treatment plan that could include a prescription topical treatment, like a retinoid. That will help treat any other active acne you have and will help prevent future breakouts.

Depending on your exact situation, your dermatologist might also suggest blue light therapy, which “works by killing bacteria within the pores,” Dr. Engelman says. “This treatment can be more effective than topical treatments, because it works to eliminate acne at the source, the bacteria, as opposed to treating the symptoms, inflammation and redness.”

Oral antibiotics are also an option because they can kill the P. acnes bacteria that contributes to acne. “Some antibiotics, like those in the tetracycline family, are also anti-inflammatory, which helps improve acne,” Dr. Engelman says. And other oral medications, like hormonal birth control pills and spironolactone, can address the hormonal component of your acne, Dr. Renati says.

Painful, deep cystic and nodular acne pimples tend to be difficult to treat on your own. But with the right combination of treatment options—and the guidance of a dermatologist—you can find a way to manage these little beasts.


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