The Best Treatment for Very Severe Nodulocystic Acne

 

Very Severe Nodulocystic Acne
Very Severe Nodulocystic Acne should be treated on an emergency footing

How to Manage Very Severe Acne

The best treatment options for very severe nodulocystic type of acne include systemic medications, surgical interventions and combined topical therapies.

Very severe acne comprises of numerous pustules, deep fluctuant nodules and cysts on the face, chest, back, and at times, on the buttocks, groin and armpits. The main concern of treating this grade 4 nodulocystic acne is prevention of scarring, which is present in more than 90% of affected individuals.

The Best Treatment for Very Severe Nodulocystic Acne

 The best medication available for very severe nodulocystic acne is oral isotretinoin. The dosage is 0.5 to 1 mg per kg body weight per day as a single dose.

As isotretinoin is teratogenic (causes birth deformities), women of child bearing age group should avoid this medication unless absolutely necessary. Pregnancy should be avoided during and two months after treatment with isotretinoin. All patients should be aware of side effects of isotretinoin and how to avoid them.

For those who would like to avoid isotretinoin, the following are the alternative choices to treat their very severe pimples:

  1. Initiate therapy with Minocycline 100 mg twice a day with topical application of either Benzoyl peroxide 5% or topical tretinoin 0.05% at night.
  2. Deep seated nodules and cysts should be drained to enhance the therapeutic effects of the antibiotics and aid the healing.
  3. Intralesional triamcinolone injection at a strength of 5mg/ml into the nodules hastens the healing process.
  4. In explosive cases of nodulocystic acne (known as pyoderma faciale), which is more common in females, a combination of oral steroids and isotretinoin works wonders in clearing the eruptive bumps at a faster rate.
  5. After 4-6 weeks, the response to treatment is reassessed. If the nodules and cysts have healed, minocycline is continued at a dose of 100 mg per day for another 4-6 weeks.
  6. If there is no recurrence and the acne bumps have healed well, minocycline may be replaced with doxycycline 100 mg daily for another one month and then tapered over a period of 2-4 months.
  7. While the oral medications are tapered, add topical clindamycin as morning applications with topical tretinoin replacing benzoyl peroxide as a maintenance therapy.
  8. If any recurrence is there, a short course of oral minocycline is repeated.
  9. If, after 4-6 weeks of minocycline, the response to treatment is not satisfactory, then the option of oral isotretinoin is explored for the patient.
Acne Conglobata
Very Severe Acne: Acne Conglobata

Females with explosive nodulocystic acne, with or without associated increased hair growth (hirsutism), should be investigated for diseases like polycystic ovarian disease.

Patients who have been treated satisfactorily should modify their life style and follow the specific tips to prevent recurrence of acne in the future.


Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

Very Severe Nodulocystic Acne: FAQ

 

Frequently Asked Questions about Very Severe Acne

Sudden, very severe eruptions of nodules and cysts on the face, chest and back have to be dealt with on an emergency basis as these are potentially deep scar forming conditions.

Very Severe Nodulocystic Acne FAQ
Very Severe Nodulocystic Acne

What is Nodulocystic Acne?

Nodulocystic acne is the very severe grade 4 acne consisting of deep seated fluctuant nodules and cysts and numerous pus filled bumps. Most of the face, front of chest and back is commonly involved in nodulocystic acne.

How is Nodulocystic Acne Formed?

The basic pathogenesis of nodulocystic acne is similar to formation of other types of acne. Increased sebum secretion and inflammation caused by the bacteria P.acnes causes stretching and weakening of the wall of the sebaceous gland and hair follicle. This leads to rupture of the contents in to the dermis. A severe foreign body reaction takes place and the whole inflammatory debris and cells are segregated into fluctuant nodules and cysts deep within the dermis. Thus is formed the nodulocystic acne.

What is the Best Treatment for the Very Severe Nodulocystic Acne?

The best treatment for the very severe type of nodulocystic acne includes drainage of the pus, intralesional steroids, and oral isotretinoin. Isotretinoin gives very good results in this type of very severe acne, but its toxicity reduces its appeal to many patients. It is absolutely contraindicated in pregnancy. The second line of treatment involves use of minocycline in place of isotretinoin.

Other principles of treatment of acne also have to be observed in the case of nodulocystic acne. Avoiding acne triggers is also an important part of the management of nodulocystic acne.

What are the Complications of Very Severe Pimples?

Acne Conglobata
Very Severe Acne: Acne Conglobata result in deep scars

The nodules and cysts in the very severe type of pimples are situated deep within the dermis and when they heal, leave depressed, deep scars. Chances of hypertrophic scars are also high and in those with keloidal tendency, these will form disfiguring keloidal scars. Immediate institution of isotretinoin and other measures help reduce the severity of scarring in nodulocystic acne.

 

What are the Side Effects of Isotretinoin?

The main side effect of isotretinoin is the teratogenic effect on the fetus. Because of the risk of deformities, women should take care that they do not become pregnant during and two months after the course of isotretinoin. Most other side effects of isotretinoin in acne are related to the extreme dryness caused by the medication.

What are the Other Different Types of Very Severe Acne?

In addition to the nodulocystic acne, acne conglobata, pyoderma faciale and acne fulminans are the most severe types of pimples that are seen in patients.

What is Acne Conglobata?

Acne conglobata runs a chronic course with involved areas of the face and trunk filled with communicating cysts, abscesses and draining sinuses. The healing is with hypertrophic and atrophic scars. Recurrent episodes of joint inflammation may also be present in some patients. Treatment is similar to nodulocystic acne.

What is Pyoderma Faciale?

Pyoderma faciale commonly affects females and presents with an explosive eruption of large, tender, red cysts, mainly in the central part of the face. Spontaneous purulent discharge is present from the cysts. Comedones are conspicuous by their absence in this type of acne. Treatment is with drainage, oral isotretinoin and systemic steroids. In fact this is one of the rarer forms of acne where a short course of systemic steroids can bring fast relief to the patient.

What is Acne Fulminans?

Acne fulminans is a rare, ulcerative type of acne that mainly affects young adolescent males. There is an abrupt eruption of inflamed, necrotic acne leaving superficial and deep ulcers on the skin surface. Associated systemic symptoms of fever, weight loss, muscle and joint pains give the patient a toxic and weak appearance. Treatment is similar to pyoderma faciale.

Nodulocystic acne and other types of very severe types of acne are dermatological emergencies which need to be treated aggressively in early stages to avoid permanent deep scars.

Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

How to Treat Severe Acne

The Best Treatment for Severe Acne: Treat Early to Prevent Acne Scars

The best treatment for severe acne is a combination of oral retinoids or antibiotics and topical anti-acne medications.

Severe acne, with high number of inflammatory pustules and nodules, should be treated promptly to prevent deep ice pick and hypertrophic acne scars.

Severe Acne
Severe Acne: Early Treatment Prevent Scar

In severe acne, there are pus filled lesions, formed fresh or from already existing papules, and a few nodules. Numerous red, painful, pus filled bumps and humps are seen on the face, chest and back.

 How is Severe Acne Treated?

 As with other types of acne, there are specific and general measures to deal with the severe type of acne. In general, the specific treatment of inflammatory acne consists of oral retinoids, oral antibiotics, topical antibiotics, benzoyl peroxide and topical retinoids.

What is the Best Treatment for Severe Acne?

 Oral isotretinoin is the single best treatment for acne. But it is a medication to be used with care and only under the supervision of a dermatologist. It is absolutely contraindicated in pregnancy .

Following is the treatment protocol for severe acne followed by most dermatologists:

  1. Treatment is started with oral isotretinoin at a dose of 1-2 mg per kg body weight per day in males and non pregnant females who are on double contraception during and two months after the medication.
  2. From family history, depth and severity of the inflamed acne bumps, if there is less chance for scar formation, and in those where oral retinoids are not advisable the treatment is initiated with oral antibiotics (minocycline, tetracycline or doxycycline), with a gradual tapering of dosage over a period of 6-8 weeks. In pregnancy, only if severe pustular or nodular bumps are there is systemic treatment advised. The drug of choice for inflammatory acne in pregnancy is erythromycin. All medications are best avoided in the first trimester of pregnancy.
  3. Topical therapy of severe acne is same as in the moderate type of acne. Morning topical clindamycin/erythromycin and evening benzoyl peroxide 5% gel is the preferred combination used in severe acne.
  4. Once the pustules regress, topical benzoyl peroxide is replaced with topical isotretinoin.
  5. Benzoyl peroxide and Topical Tretinoin cause irritation in some patients because of their peeling effect on the epidermis. The following steps will help reduce the irritation in sensitive individuals:
    • Tretinoin and benzoyl peroxide should be applied at night only.
    • A non-comedogenic water based sun screen is used during daytime to avoid sun-sensitization.
    • If redness and scaling occur and skin becomes dried up, wash off the benzoyl peroxide or tretinoin cream/gel after 2 hours in the first week of application. Once the skin starts tolerating the medication, overnight application can be restarted.
    • In these patients, lower strengths of benzoyl peroxide and tretinoin is used in the first two weeks, later shifting to higher strengths, if necessary.
    • At times, after 2-3 weeks of treatment, topical retinoids can cause a flare up. This indicates an inflammatory blowup of the acne bumps and is a good sign. There is no need to discontinue the application.
    • A post inflammatory reddish brown pigmentation is seen after treatment with benzoyl peroxide. This will gradually disappear on continued treatment. A sun protection cream should be used during daytime till the pigmentation subsides.

What are the General Measures in the Treatment of Severe Acne?

 General measures include advices on skin care, washing, diet and life style management. These and the tips on preventing new acne eruptions are the same for all types of acne.

 What are the Complications of Untreated Severe Acne?

Untreated severe acne causes deep ice pick scars and hypertrophic scars in most patients. Post inflammatory pigmentation is common, especially in the dark skinned individuals.

The best treatment for severe acne is a combination of oral retinoids or antibiotics and topical anti-acne medications. The treatment is individualized according to the extent, type of acne and sex and age of the patient.



Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Severe Acne: Frequently Asked Questions

 

Because of the predominance of inflammatory acne lesions, severe grade type 4 acne calls for prompt aggressive systemic and topical therapy.

 What Comprises Severe Acne?

Severe Grade 3 Inflammed Acne
Severe Grade 3 Inflammed Acne
Severe Grade 3 Acne
Severe Acne consists of Inflamed papules and pustules

 Inflammatory pustules and deep acne bumps (nodules) are predominant in severe acne or acne grade 4. More than 100 comedones, or more than 50 papules or pustules and more than 5 nodules with a total count of more than 125 acne bumps comprise severe acne.

Severe Inflammed Acne
Grade 3 Severe Pustular Acne

How is Severe Acne Formed?

The initial pathogenesis behind severe acne is similar to other types of acne, viz, hormone stimulation of the sebaceous glands, thickening of the follicular wall and blockage of the hair pores.

In severe acne, the resident bacteria of the hair follicle, P.acnes, multiplies in the medium of the sebum causing breakdown of its components. This causes a chemical irritation, attracting inflammatory white blood cells known as neutrophils.

Neutrophils release some chemical mediators and enzymes which cause the typical characteristics of an inflammatory reaction within the sebaceous glands and the associated hair follicles: calor, rubor, dolor, tumor and functio-lesa, meaning: heat, redness, pain, swelling and loss of function of the affected area.

The inflammation and the resultant destruction of the follicular walls, sebaceous glands and the debris from the inflammatory reaction results in formation of pus filled bumps known as pustules.

The wall and sheath of the gland and hair follicle expand in the dermis with the pus to form deep seated nodules.

What are the Triggers of Severe Acne?

The acne triggers inducing, aggravating and maintaining severe acne is similar to all other types of acne. Picking at the acne bumps and application of topical steroids worsen the severe acne. Picking at the acne bumps and application of topical steroids worsen the severe acne.

What is the Best Treatment for Severe Acne?

The best treatment for severe acne is systemic retinoids. Because this is a strong medication with local and systemic side effects and chances of fetal abnormalities, it is not usually advised to females of child-bearing age group and during pregnancy. Females and their partners should use a double contraception of barrier plus pills while on retinoids.

How Long Should Severe Acne be Treated?

The duration of treatment varies from individual to individual and the response to anti-acne treatment. The average duration of treatment with oral isotretinoin is 18-20 weeks up to a maximum of 24 weeks. An interval of 3 months is given in between before a fresh course is started.

Those on oral antibiotics and topical applications may have to continue treatment for longer duration, till the active acne bumps stop appearing. Then, the dosage is reduced gradually, and stopped over a period of 1-2 months. The topical antibiotics are also stopped like wise. Topical benzoyl peroxide is continued till no fresh acne bumps appear for a period of 2-3 months.

Maintenance therapy of healed severe acne is with topical tretinoin, usually with the 0.025% concentration. This is important in preventing recurrences. Any recurrence is dealt with the same way as new acne bumps and the best treatment for severe acne re-instituted at the earliest to prevent formation of acne scars.


Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

Treatment of Moderate Acne

Grade 3 or Papulopustular Acne
Moderate Acne: Grade 3 or Papulopustular Acne

Moderate acne is a transition state between the non-inflammatory and inflammatory pimples. Skin colored bumps (papules) and comedones predominate in moderate acne, also called grade 2 acne. A moderate amount of pustules (pus filled bumps) is also seen in some patients.

Is it Necessary to Treat Moderate Acne?

The aim of treating acne is to reduce and clear the unsightly bumps thus preventing scarring. Being non-inflammatory acne, expert advice should be sought and treatment started in moderate acne without delay. Remember early, appropriate treatment drastically reduces the chances of acne scar formation.

How is Moderate Acne Treated?

Treatment of moderate acne involves general measures and specific measures. General measures are similar to all other types of acne and involve advice on avoiding the acne triggers, skin care and observing healthy dietary and life styles.

Specific measures in the treatment of moderate acne involve use of topical antiacne medications.

  1. Topical retinoids are the first line of therapy for moderate acne where comedones predominate. Treatment is started with tretinoin or isotretinoin applied sparingly at night. Adapalene or tazarotene are alternative retinoids that may be used.
  2. For papule and pustule predominant moderate acne, a topical antibacterial solution is also added. Clindamycin and erythromycin are the usual topicals used in acne. Azelaic acid is a useful alternative, especially in the healing stages, when mild pigmentary changes are prominent.
  3. If the number of pustules are more, and there is sign of deeper inflammation, an oral antibiotic like doxycycline or azithromycin.
  4. In those with pustule predominant moderate acne, benzoyl peroxide is the second line of treatment, along with either topical retinoids or antibiotics.
  5. Retinoids and benzoyl peroxide are applied at night only, as these can sensitize your skin to sunlight, especially the retinoids.

Some may experience a flare up in the first 2-3 weeks of starting the topical treatment. This is a good sign and there is no need to stop medication, though concentration and frequency may be reduced till the inflammatory blowout is controlled.

 How Long Should Moderate Acne be Treated?

Duration of treatment of acne varies from individual to individual and the type, severity and extent of the zits. In general, treatment should be continued till 6-8 weeks after the acne bumps subside completely and there is no fresh outbreak. A maintenance application with topical retinoids should continue weekly twice or thrice for a few months to years, depending upon previous history of recurrences and the life style of the acne sufferer. Regular treatment will have to be re-instituted, should there be any recurrence.

Treatment of moderate acne involves avoidance of acne triggers , a combination treatment with topical anti-acne medications and following tips on how to prevent acne recurrences.


Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

Moderate Acne: Frequently Asked Questions

 

Moderate eruption of acne, being the minimally inflammatory type of pimples, could cause scarring in some affected individuals. This calls for early consultation with a dermatologist to get rid of the acne at the earliest stage itself.

 What is Moderate Acne?

 Acne is divided into different types. Moderate acne comprises of skin colored bumps (papules) predominant acne eruption.

Moderate Acne
Moderate Acne: Minimally Inflammatory Papular Acne

Some comedones and pustules (pus filled bumps) are also present. When the number of comedones are higher than 20, even without the presence of papules or pustules, it may be considered as moderate grade 2 acne. In a nutshell, 20-100 comedones and/or 15-50 inflamed papules or pustules with a total count of 30-125 acne bumps comprise moderate acne.

 How Does Moderate Acne Develop?

The events of acne formation start with the increased production of androgen hormones. These stimulate the sebaceous glands to produce more sebum and also produce changes in the lining of the hair and sebaceous ducts. Keratinous plugs are formed in the opening of the hair follicle, the open and closed comedones. When the normal resident bacteria of the hair follicle, known as Propionibacterium acne, start multiplying within the oily sebum and produce irritant side products, this triggers an inflammatory response within the hair follicle and sebaceous glands.

Mild, Moderate and Severe Acne
Mild, Moderate and Severe Acne

When the inflammation is minimal and contained within, the sebum and the products of the inflammation accumulate within the hair duct, raising the surface of the skin, forming skin colored or slightly reddish bumps.

What is Grade 2 Moderate Acne?
Grade 2 Moderate Acne

When the inflammation is significant, these results in formation of pus, which is actually the debris formed from the inflammatory cells, dead and damaged cells and living and dead bacteria. Thus are formed pustules, the other type of lesions seen in moderate acne, albeit in a limited number.

 

What are the Triggers for Moderate Acne?

The acne triggers inducing, exacerbating and maintaining moderate acne is similar to all other types of acne.

What are the Complications of Moderate Acne?

As with other inflammatory acne, there are chances of scar formation in untreated moderate acne patients. Though it is not possible to predict who will get scarring, a family history of scarring and predominance of papules and pustules should alert the acne sufferer to seek early treatment.

While healing, post inflammatory pigmentation (dark spots) may occur in some patients, especially those with dark skin.

Anxiety and depression may affect the individual from fear of disfigurement from the pimples.

What is the Best Treatment for Moderate Acne?

The best treatment of moderate acne is a combination of topical retinoids (isotretinoin, tretinoin, adapalene) and antibacterials, along with oral antibiotics when inflamed bumps are present.

Being the transition state between non-inflammatory and inflammatory types of acne, it is imperative for moderate acne be treated early so as to avoid the complications of scarring and progression to severe type of acne.

 

Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD