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How to Treat Severe Acne Vulgaris

We're getting close to wrapping up my series on the different acne types and how to treat them. If you don't know which kind of acne you have, take my quiz to find out. If your acne is mild, you can see my treatment suggestions here, and if it is moderate, you can check out treatments options here.

Severe acne vulgaris can be really painful, both emotionally and physically, but do not despair if this is your diagnosis! There are effective treatment options for you, too. But I'm gonna be straight with you: If this what you have, you must see a dermatologist, because there just isn't much that over-the-counter treatments can do for this kind of acne.

Just a quick refresher: Severe acne vulgaris consists of cysts and nodules. Nodules are solid, dome-shaped lesions. They're inflamed and painful, they extend into deeper layers of the skin, and they may cause tissue destruction that results in scarring. A cyst is a sac-like lesion containing liquid or semiliquid material consisting of white blood cells, dead cells, and bacteria. It is larger than a pustule, may be severely inflamed, extends into deeper layers of the skin, may be very painful, and can result in scarring. Cysts and nodules often occur together in a severe form of acne called nodulocystic. If that describes your acne, see your treatment options when you


  • Retinoids: This is the most common, and most proven effective treatment for severe nodulocystic acne. Retinoids come in two forms: oral and topical. Topical retinoids are better suited for mild to moderate acne, but for severe acne, an oral retinoid like Accutane can be a lifesaver as it actually reduces sebum production (often permanently). To read more about what retinoids are and what they can do for your skin, check out this post. To find out more about how Accutane works and decide whether or not it's for you, check out this post.
  • Hormone therapy: Since it is known that male hormones can play a role in the overproduction of sebum, females may benefit from certain combinations of estrogen medications such as birth control. In fact, as this study shows, hormonal birth control pills can significantly reduce the appearance of acne lesions in up to three-quarters of cases studied. To see more about the pill and acne, check out this post.
  • In-office options: Not as scary as it sounds, I promise! If you need immediate relief from a particularly painful or unsightly cyst, you can visit your doctor for a cortisone shot. It is injected directly into the inflamed lesion, and eliminates the painful swelling and redness in a jiffy. It's not a miracle cure, though, as it does not treat the underlying causes of acne. It is also painful, and too much cortisone can have unpleasant side effects like nausea and headaches. A doctor can also treat large and painful lesions with cryotherapy, which is essentially freezing them off using liquid nitrogen. This can be quite painful, but the cyst will disappear immediately. Side effects can be a bit rough, including peeling, blistering, and swelling, so this is best to only use in extreme cases of unbearable cysts.
  • Surgery: Not as scary as it sounds, but still only for use in extreme cases on cysts that have not responded to any other treatment. Your doctor will use a sharp instrument to drain the lesion of pus, oil, and bacteria, which relieves the pain and pressure while speeding up the healing time.
  • Some things to keep in mind if you are suffering from severe acne: First of all, there is hope! Do not despair if your skin doesn't respond to the same cleanser or antibiotics that worked wonders on your friend's skin. Everyone's skin chemistry is different. And I cannot stress this enough: You must see a doctor if you have cystic acne. I know it can be pricey, but think about all the money you will save on makeup if you address the source of the problem, not to mention the priceless mental relief of having clear skin. Let me know if anyone has tried any of the above treatments, as I would be interested to hear your stories.


Join The Conversation
tossie tossie 9 years
mama lotion on skincare rx!
lily8206 lily8206 9 years
Wren: My insurance plan covers the cortisone shot, but not all of it. Just thought I'd reiterate what Bella was saying for those who are currently suffering... There is hope. I know how awful it can make you feel, but keep your faith that one day it will all be gone. And most importantly, you are still beautiful despite what you think when you look in the mirror.
tiffykat tiffykat 9 years
I feel the need to make a real comment about acne vulgaris. I am now 28 yrs old, at the age of 23 I never really had pimples at all- and then one day, bam, a huge bee-sting like cyst on my cheek appeared. It was very painful and very big (smaller than a dime of course). I had 2 dermatologists: 1 that I knew would cut my cysts open, drain them & also give me cortisone (the fastest way to healing) and 1 that would just do cortisone shots. Depending on how bad they were I would go to one or the other Doctor. The 'slicing' method wasn't too painful, but definitely leaves scars. I kept getting them in the same spots on both of my cheeks. I found proactiv really helped as far as face washes go and cortisone pills were about the only effective treatment otherwise. I haven't gotten them in about 2 years - but I think about them all the time and PRAY that they never come back! They're embarassing, painful, and it's not cheap to keep going back to the derm...he suggested plastic surgery to go in and remove the sacs, but I didn't want more scars than I already had. So the minute you see a "zit" that isn't very "zit like", more of a cyst - get on treatments immediately and go see your derm! My scars are slowly healing, yours will do the same. I now wash with Brevoxyl and it's AMAZING! Proactiv is too expensive and doesn't get as deep down as most prescription methods.
Anabellatc Anabellatc 9 years
Oh...also, before Accutane I had a couple of the Cortisone shots (I believe they were covered by my insurance). A little painful and not sure if I ever benefited from them; don't remember having considerable/memorable results. But hey, you can always give it a try!
Anabellatc Anabellatc 9 years
I also took Accutane for about 5-6months and it completely changed my life. It's been about 3 years since I stopped and I have never been nearly as bad as I was before Accutane, as a matter of fact, I haven't been bad at all. I get the occasional break out but very small and it usually goes away without leaving traces/scar. Definitely consider it if NO other solution has worked for you. Like others have said, the blood tests, chapped lips and dry eyes were uncomfortable, but bearable and definitely worth it! Good luck :)
audrina audrina 9 years
When I was 25 I was put on Accutane by my dermatologist. It was the best thing ever for me. Physically and Emotionally. I was on it for 6 months course. However it was kind of a pain because you are constantly monitored with blood tests and you have to be on the pill to avoid pregnancy. I had dry eyes and fingernails, but It was super worth it. I was in remission for about 2 - 3 years and then I broke out a little bit after that. I was put on some other medication (not as strong) and it went away. I am now 43 years old. I still get occasional breakouts and oily skin still, but not as bad as I had it at 25. And oh, the reports about suicide. I had absolutely no thoughts of it at all. The reports state that it may affect teenagers going through puberty, but rarily is the case for adults. It is definitely worth taking if you have really bad acne that cannot be cleared up.
tglynn tglynn 9 years
I was on Accutane for 2 1/2 years, and the correlation with suicide is a serious issue. Anyone who gets emotional often should definitely NOT take Accutane. ever. That thing was a roller coaster for me and I'm extremely optimistic. It's only for the worst of the worst. I had It all over my body, and they were so painful I couldn't even lie down in my bed to go to sleep or wear form-fitting clothing. Now my skin is amazingly clear, I only get 1 or two pimples a month (quite obvious when) My dermatologist recommended that I continue to take Yasmin to help control it. I'd say anyone with severe acne definitely needs to see a dermatologist. They can personalize treatment, and it's just amazing what they can do for you :D
nobodymuch nobodymuch 9 years
Accutane is amazing, definitely a pain in the butt w/ blood tests and all, and you really have to use effective birth control. For me it wasn't permanent, but my skin was PERFECT for about 5 years, and after that, it's been, normal instead of terrible. The only side effects I had were really painfully chapped lips and my hair texture changed. Also, as far as birth control pills go, there are other kinds that may help with acne without decreasing libido -- diane 35 actually contains a progestin that's also an androgen antagonist, which causes the libido hit. Most other pills, esp ones with newer progestins will help with acne, even if not as much, and shouldn't affect libido as much. If you're in the US, I might start with yasmin or my favorite, nuva ring, but there are a million decent choices, check with your doctor.
mlmoreno47 mlmoreno47 9 years
I saw a news special about a corelation between accutane and suicide but I don't remember much. Scary!
gigly_grl gigly_grl 9 years
I finally got my doctor to send me to a dermatologist when I was 17 or 18. Best decision ever! She was fabulous, tried the moderate acne solutions first and when I was 19 put me on the pill (Diane35) which changed my life!!! Gone was not only the painful and strange periods but my skin was 99% clear... going back to school that fall I wore tanktops for the first time since I was like 10. I was a new person! Now I'm 26 and am currently trying other solutions since I don't want to be dependent on hormones if I don't have to (libido took a hit :P). Unfortunately my skin is horrible yet again and next on the list to consider is Accutane... anyone here done it? Does it really "cure" acne permanently?
wren1 wren1 9 years
Do you think insurance covers the cortisone shot? I could see it being denied as a cosmetic procedure.
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