Nodular acne develops deep under your skin, causing painful, red bumps. Topical treatments and oral medications can help to clear up nodular acne.

All acne begins with a trapped pore. Oil (sebum) mixes with dead skin cells, clogging your pores. This combination often causes blackheads and whiteheads to form.

Nodular acne also involves bacteria called p. acne. Although it’s normal to have this type of bacteria on your skin, it can turn into an infection when it gets trapped in your pores alongside sebum and dead skin cells. The resulting infection can go deep underneath your skin, causing the affected pores to become red and swollen.

Because it causes issues deep within the skin, nodular acne is considered a more severe form of acne. Unlike other types of acne, such as blackheads, acne nodules can’t be cleared up with over-the-counter (OTC) products alone.

An acne nodule looks like a small bump under your skin. It may be skin toned, but it can also turn red as the surrounding area gets more inflamed. It doesn’t have a “head” like a less severe pimple might. Nodular acne is also painful to the touch.

Nodular acne and cystic acne are two of the most severe forms of acne. They’re sometimes confused with one another because they both form deep underneath the surface of the skin:

  • On the surface, cystic acne can look like large, red boils. Cysts, like nodules, reside deep underneath the skin’s surface. But because they’re filled with pus, cysts are softer than nodules. The pimples that define cystic acne burst open, often leading to infection. Acne cysts develop when the contents of blackheads and or whiteheads “spill” into surrounding areas of the skin. In an effort to fix the situation, the body perceives an attack, and the local immune system responds by producing pus.
  • By contrast, acne nodules remain intact, deep under the skin. Nodular acne may also be skin toned. Nodules may persist for weeks or even months, with the result of their contents hardening into deep (and stubborn) cysts.

OTC acne products usually don’t work for nodular acne. Widely available OTC ingredients, such as salicylic acid and benzoyl peroxide, help shed excess sebum and dead skin cells at the surface only. This can help clear up a clogged pore at the skin’s surface, but it will do little good for nodules, which are deep underneath the skin.

Talk to your healthcare provider about all of your treatment options. They might recommend one or more of the following.

Topical acne medications

Prescription, rather than OTC, topicals are applied directly to the acne nodule. These are the preferred first steps for nodular acne, especially if you’re trying to treat more-isolated cases where you only have one or two nodules at a time.

Your healthcare provider may prescribe:

  • antibiotics to help kill the bacteria trapped in your pores
  • prescription-strength benzoyl peroxide, which is much more concentrated than drugstore varieties
  • prescription-strength salicylic acid to dry out dead skin and oil trapped in the nodule
  • retinoids, which are powerful vitamin A derivatives that unclog trapped hair follicles

Oral antibiotics

Widespread cases of nodular acne could indicate a problem with too much p. acne bacteria on your skin. You might notice that acne nodules keep coming back after treatment, or the nodules might be widespread all over your body.

In such cases, your healthcare provider may recommend an oral antibiotic to help clear up excess bacteria. This is done so that the bacteria doesn’t get trapped under your pores and lead to nodular acne. Antibiotics can also reduce the painful inflammation associated with this type of acne.

Other medications

The problem with oral antibiotics is that you should only take them for a short period of time — usually 7 to 10 days at a time so that your body doesn’t become resistant to bacteria — but can be continued for several months if necessary.

With this in mind, your healthcare provider may recommend other types of medications that may be taken on a long-term basis. For women, birth control pills can help control the hormonal fluctuations that sometimes cause acne.

Another option is isotretinoin (commonly known by the brand name, Accutane, although that brand is no longer on the market). This is also made from vitamin A, but it’s much more powerful than retinoids. This is a daily medication that can be used to treat all types of acne—including nodules. However, it can take months for the medication to take full effect.

If you’re pregnant or plan to become pregnant, your healthcare provider may recommend prescription-strength benzoyl peroxide — isotretinoin (Accutane) and some types of antibiotics cannot be taken during this time.

Office procedures

Certain office procedures may also be beneficial when combined with prescription medication.

These procedures can help reduce bacteria and inflammation as well as help prevent scars:

Nodular acne can scar for two reasons. First, a failure to treat the nodule can lead to further inflammation, which can damage surrounding skin cells. Once you do finally seek treatment, the inflamed skin can turn into a dark spot.

According to the American Academy of Dermatology, dark spots may take several months (even years) to clear up. They may even turn into permanent scars.

More significant scarring can develop if you pick or try to pop nodular acne. You’ll also likely be left with a scab and an enlarged pore.

The best way to prevent scars from nodular acne is to treat it promptly while also resisting the urge to pop it. If you end up with acne scars post-treatment, consider getting a prescription with hydroquinone to reduce inflammation and darkened skin. Hydroquinone is only available as a prescription through your doctor. Previously it had been available OTC, but the status was changed in 2021 following a ruling by the FDA

As with other forms of acne, preventing nodular acne starts with good skin care. At minimum, make sure you’re doing this.

Skin care 101

  • Wash your face twice a day. If you exercise in the middle of the day, another quick wash with a gentle cleanser can help prevent bacteria from clogging your pores.
  • Remove all makeup at night. This will reduce the amount of oil and bacteria that builds up on your skin.
  • Apply a lightweight moisturizer after cleansing your face.
  • Use a clay mask twice a week to extract oil, dead skin cells, and bacteria from your pores.
  • Be sure to wear an SPF 30 sunscreen every day. If you take Accutane or use retinols, it is especially important to do this to prevent sunburn.
  • Avoid touching your face so that you don’t transfer bacteria onto your skin.
  • Always wash your hands before applying cosmetics.
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Nodular acne can be difficult to get rid of, but it’s certainly not impossible. Good skin care habits coupled with resisting the urge to pop acne nodules is a start. Your dermatologist can offer further advice for acne nodules and their treatment.

As a bonus, your dermatologist is also a great resource for addressing acne scars. If OTC products don’t do the trick, they might recommend in-house procedures, such as professional dermabrasion treatments or laser therapy.

It’s especially important to see your dermatologist if you have recurring cases of nodular acne. You might need more preventive treatment measures to help keep the nodules from coming back.