Nodulocystic acne vulgaris

Cystic acne presents a severe from of acne vulgaris and requires professional advice from a physician. They are rarely cancerous but addition of inflammation and bacteria through their rupture into the skin can render them painful and pus-discharging. Occasionally bacteria enter the cyst and cause an infection which resembles a boil. Nodulocystic acne may be manifestation of a systemic disease such as androgen excess and hormonal imbalance and warrants further medical investigation.

Cystic acne should be consulted with a dermatologist. Small non-acneous cysts don’t usually require systemic treatment, but can be readily removed by a minor surgical procedure or managed using topical acne treatments. Larger ones are usually removed because they are unsightly or because they have been inflamed. Cysts are treated by making an excision in the skin. Cystic acne is usually treated with isotretinoin and oral antibiotic, however, topical treatments may also beneficial and sufficient. Some studies suggest use of carbon dioxide laser treatments combined with topical treatments for cystic acne to avoid systemic treatments and their adverse effects. Photodynamic therapy, PHT, has also been subject of multitude of studies which suggest PHT efficacy in treatment of mild to severe forms of acne. Moreover, cysts are more prone to development of acne sequels. Occasional recurrence of cysts needs further treatment.

Acne conglobata is an uncommon and unpleasant form of nodulocystic acne in which there are interconnecting abscesses and sinuses, which result in unsightly acne scarring. There are groups of large “macrocomedones” and cysts that are filled with pus. Addition of oral antibiotic to theĀ treatment protocol of choice is the most appropriate.

Treatment plan:

Nonpharmacologic treatments include: Gentle face washing, avoidance of manipulation of acne lesions. Oil-free products do not necessarily provide benefit and may stimulate further sebaceous secretions. Hypersecretion of sebaceous glands and sebum dysfunction in acne subjects render the skin depleted in essential fatty acids, which in turn further change acne microenvironment. Cleansers containing essential fatty acids may correct this deleterious event. Salicylic acid preparations have been found helpful. Evidence-based skin care has gained a substantial role in treatment of mild to moderate acne as well as maintenance treatment of severe form of acne vulgaris.

Pharmacologic treatment: This part may include discrete steps.

Begin with benzoyl peroxide gel in the morning. Add topical tretinoin or Adapalene in the evening. Add topical antibiotic such as erythromycin/clindamycin if not responsive to previous steps. Add systemic antibiotics such as tetracyclin, doxycycline, clindamycin, erythromyin. If cystic acne is diagnosed, aforementioned steps could be circumvented and systemic agents such as oral isotretinoin can be directly initiated. This agent is associated with serious, dose dependent side effects. Combination therapy with benzoyl peroxide, doxycylcine and adapalen has been proposed to be superior to oral isotretinoin.