Follicular disorder

Nodulocystic acne

What is nodulocystic acne?

Nodulocystic acne is a severe form ofacne affecting the face and upper trunk, characterised bynodules andcysts that typically resolve withscarring.

Nodulocystic acne of the face and upper trunk

Nodulocystic acne: face 

 

Nodulocystic acne 

Who gets nodulocystic acne?

Nodulocystic acne is usually a disorder of adolescence and early adult life seen most commonly in males. However there is a rarejuvenile form with onset before 6 years of age, also with a male predominance.

No studies have shown an increasedincidence in specific racial groups.

Nodulocystic acne is associated with otherfollicular occlusion disorders particularlyhidradenitis suppurativa.

The acne conglobata variant of nodulocystic acne is the 'A' in a number of syndromes including:SAPHO, PASH, PASS, andPAPA.

What causes nodulocystic acne?

Thepathogenesis of acne is believed to bemultifactorial involving increasedsebaceousgland activity, abnormalkeratinisation offollicles, the action ofmicroorganisms, and subsequentinflammation.

Specific risk factors for nodulocystic acne include:

• Genetic factors
• Drugs including anabolic steroids,etanercept,imatinib
• Dietary supplements such as whey
• Haemodialysis.

What are the clinical features of nodulocystic acne?

• Solitary or multipleinflammatory nodules andpseudocysts
• Firm,fluctuant, and/or tender
• Involvement of the face, neck, and trunk

Nodulocystic acne: cheek 

Nodulocystic acne: chest 

Nodulocystic acne: face 

More images of acne ...

• Facial acne
• Back acne

What is acne conglobata?

Acne conglobata is a rare severe form of nodulocystic acne. It presents with groups of multiplecomedones and inflammatorypapules,pustules, and nodules involving the trunk, limbs, and buttocks. Interconnectingabscesses and drainingsinuses become secondarily infected causing pain andmalodour. Healing is slow, leaving unsightlyhypertrophic andatrophic scars. Acne conglobata is often verypersistent, lasting into the 30s or 40s.

How does nodulocystic acne present in different skin types?

Postinflammatory hyperpigmentation and keloid scarring are common complications of nodulocystic acne in skin of colour.

What are the complications of nodulocystic acne?

• Psychological effects of acne
• Keloid, hypertrophic and atrophic scars
• Pyogenic granuloma

What is the differential diagnosis of nodulocystic acne?

• Acne fulminans
• Pyoderma faciale
• Steatocystoma multiplex

How is nodulocystic acne diagnosed?

Nodulocystic acne is a clinical diagnosis. Hormone studies may be considered in the presence of suggestive clinical features.

What is the treatment for nodulocystic acne?

Topical treatment is usually ineffective for nodulocystic acne.

The recommended treatment is oralisotretinoin which should be commenced early to preventscarring. Treatment is required for at least five months, and further courses are sometimes necessary.Intralesional steroids followingcyst drainage, can be used for individual persistent or large inflammatory nodules or cysts.

Patients with acne conglobata often need additional treatments, such as:

• Oralantibiotics for secondarybacterialinfection
• Systemic corticosteroids to reduce inflammation
• Adalimumab, used off-label, for resistant severe disease .

What is the outlook for nodulocystic acne?

Nodulocystic acne typicallypersist into adult life. Unless treated early and effectively, nodulocystic acne results in scarring particularly on the torso.

Bibliography

• Melnik B, Jansen T, Grabbe S. Abuse of anabolic-androgenic steroids and bodybuilding acne: an underestimated health problem. J Dtsch Dermatol Ges. 2007;5(2):110–17. doi:10.1111/j.1610-0387.2007.06176.x. PubMed 
• Sand FL, Thomsen SF. Adalimumab for the treatment of refractory acne conglobata. JAMA Dermatol. 2013;149(11):1306–7. doi:10.1001/jamadermatol.2013.6678. Journal 
• Zamil DH, Perez-Sanchez A, Katta R. Acne related to dietary supplements. Dermatol Online J. 2020;26(8):13030/qt9rp7t2p2.Journal 

On DermNet

• Acne
• Acne and other follicular disorders
• Acne fulminans
• Acne scarring
• Acne treatment
• Acne vulgaris 
• Cutaneous cysts and pseudocysts
• Follicular occlusion syndrome
• Inflammatory lesions in acne
• PAPA syndrome
• Psychological effects of acne
• SAPHO
• What causes acne?

Other websites

• Acne Conglobata — Medscape Reference

Books about skin diseases

• Books about the skin
• Dermatology Made Easy - second edition