A symmetric distribution in the face of a teenage boy. This image clearly shows that even nodulocystic acne starts with comedones—both open and closed comedones can be seen in his face—which then transform into papulopustular lesions that enlarge and coalesce, eventually leading to nodulocystic acne. It is not surprising that these lesions are very painful, and it is understandable that nodulocystic acne also severely impacts the social life of these adolescents.