While most people experience mild to moderate acne at some point in their lives, some of us suffer from a more severe form of acne called cystic acne.
Cystic acne is a type of acne that occurs when the pores in our skin become blocked with dead skin cells, excess oil, and bacteria. The resulting pimple gets trapped and ruptures under the skin breaking the , and a pus-filled cyst is formed by your body to contain the perceived attack. Cysts are typically large and inflamed, they often don’t ever come to a head, and they can take weeks to heal. Sometimes, cystic acne is not visible as much as it is felt under the skin and it can be very painful when pressure is applied. Cystic acne usually appears on the face, neck, chest, and back, and can be extremely difficult to treat without professional help.
In this article, we’re going to look at what cystic acne is, what causes cystic acne, and how to treat cystic acne with both prescription treatments and over-the-counter remedies.
What is the Difference Between Cystic Acne and Nodular Acne?
The main difference between cystic and nodular acne is the type of lesion—cysts vs. nodules.
Both cysts and nodules are made when the clogged follicle ruptures under the skin and becomes inflamed from your body’s immune response to the spilled bacteria. If the inflammation then fills with pus it becomes a cyst. Cystic acne is characterized by large, painful cysts filled with pus, while nodular acne consists of hard, painful bumps—or nodules—beneath the skin’s surface. Both cystic and nodular acne tend to be deep within the skin with cystic acne often extending deeper. Similar to cystic acne, nodular acne can be difficult to treat and can lead to scarring.
What Causes Cystic Acne?
Excessive oil production is one of the most common causes of cystic acne. When our skin produces too much oil, it can mix with dead skin cells and bacteria, clogging our pores and leading to deep acne breakouts. There is often more than one cause which can combine to cause cystic acne, including:
Is cystic acne hormonal? It can be. Hormonal fluctuations, especially during puberty, pregnancy, and menstruation, can cause our skin to produce more oil, which can our clog pores and lead to cystic acne. Hormonal acne can also be caused by polycystic ovary syndrome (PCOS), a hormonal disorder that affects up to 10 percent of women of reproductive age, which can cause your skin’s oil glands to produce more sebum, leading to clogged pores and acne.
Hormonal acne is increasingly common in adult women and often presents as cystic acne on the lower half of the face, the cheeks, jawline, chin, and neck.
Acne can run in the family, so if your genetic relatives have had acne, you may be more likely to develop cystic acne.
Stress can trigger the release of hormones such as cortisol that can increase oil production and inflammation in the skin, potentially leading to cystic acne.
Skincare and Makeup Products
Some products that we put on our faces contain ingredients that can cause or worsen our acne. While plant oils in skincare have increased in popularity with the “natural” and “clean” skincare movements, certain oils can be adverse for acne-prone skin. Any facial oils or oils in other products should be added carefully or avoided for those of us who break out easily. Other ingredients such as bismuth oxychloride, an ingredient to provide shimmer in some makeup, can block our pores and cause acne. Pay attention to the ingredients in your skincare and makeup, and add new items slowly so you can determine if they are causing breakouts.
There is some evidence that suggests that insulin resistance may contribute to the development of acne. Foods with a high glycemic index can cause a rapid increase in blood sugar levels which, in turn, triggers the release of insulin and other hormones, which may contribute to the development of acne. Additionally, refined carbohydrates might create an inflammatory response in the body which can make acne worse.
Some people also have a sensitivity to dairy products that can cause or worsen acne. While not everyone who consumes dairy products will develop cystic acne, it is possible to experience hormonal and inflammatory effects of dairy which can have an effect on your skin.
How to Treat Cystic Acne
The best way to treat cystic acne is by going to your doctor. It is important to get medical treatment if you are able to because cystic acne is so deep that treatments on the surface of your skin often will not penetrate deep enough to help, and the risk of scarring is higher than with other types of acne.
Using Isotretinoin (Accutane)
Isotretinoin, also known as Accutane, is a powerful medication that reduces oil production in the skin and can prevent acne from forming. It belongs to a class of medications known as retinoids, which are derivatives of vitamin A. Accutane works by reducing the size and activity of the oil-producing glands in the skin. It also has anti-inflammatory properties, which can help reduce the redness and swelling associated with acne.
In general, Accutane should be taken for a period of 15-20 weeks, though treatment times can vary, and the recommended dosage is based on your weight. While Accutane is highly effective, it is associated with several potential side effects, so it is typically used under close medical supervision to treat severe acne that has not responded to other treatments.
Taking Hormonal Medication
When cystic acne in adult women is determined to be hormonal, using medication to correct the imbalance can be extremely effective in reducing acne. Birth control pills containing both estrogen and progestin can help regulate the hormonal fluctuations that contribute to acne.
Another option is spironolactone, a diuretic that is often used off-label to treat hormonal acne in women by reducing the effects of androgens on the skin, which can lead to a decrease in oil production and acne.
While isotretinoin and hormonal medications target oil production to reduce acne, antibiotic treatments target the bacteria involved in cystic acne.
Oral antibiotics, such as tetracycline or doxycycline, may be prescribed for cystic acne to reduce inflammation and kill bacteria. Antibiotics are often not prescribed long term due to the risk of antibiotic resistance and the disruption they can cause in the balance of bacteria in our gut.
Applying Prescription Topical Treatments
Cystic acne is difficult to treat with topical products since the lesions are so deep, but often prescription topicals are combined with oral medication to help keep pores clear.
Prescription strength retinoids such as tretinoin (Retin-A), adapalene at 0.3 percent (Differin), and tazarotene (Tazorac) can increase skin cell turnover to help unclog pores and reduce inflammation. Topical antibiotics, prescription strength azelaic acid, and combination treatments can also help to clear our pores.
Dermatologists can inject a corticosteroid into a cyst to reduce inflammation and speed up the healing process. This is more of a stopgap measure, and it is generally not used as a long term solution for severe cystic acne.
At Home Cystic Acne Treatment
In addition to taking prescription medications, you can add over-the-counter acne treatments if your medication doesn’t prohibit it and your skin can handle it.
If you have cystic acne and are unable to see a doctor for medical treatment, you can try a cystic acne treatment at home using topical over-the-counter acne products to help reduce inflammation and help with any non-cystic pimples. Keep in mind that it is important to add acne treatments slowly and carefully to avoid damaging your skin barrier with too many harsh products.
Here are five common at home cystic acne treatment options:
Benzoyl peroxide works by killing the bacteria that causes acne, reducing inflammation, and helping to unclog pores. When benzoyl peroxide is applied to the skin, it penetrates into the hair follicles and pores, where it releases oxygen. This oxygen creates an environment that is toxic to the bacteria that cause acne.
You can find benzoyl peroxide in face washes and leave-on treatments in strengths ranging from 2.5-10 percent. If you have never used benzoyl peroxide before, try starting with a face wash in a lower strength to see how your skin reacts before trying a higher strength or a leave-on treatment. Also, be careful of your pillowcases and towels as benzoyl peroxide can bleach fabrics.
Salicylic acid is a type of beta hydroxy acid (BHA) that works by penetrating into our pores and dissolving the sebum, dead skin cells, and other debris that can clog our hair follicles and lead to acne. It can help improve acne by reducing redness, inflammation, and excess oil on the skin’s surface.
Salicylic acid is available over-the-counter in face washes and leave-on treatments. Salicylic acid can be drying and too much may make your skin peel irritated and peeling so start slowly by using products with salicylic acid only a few days a week at first before increasing, if needed.
Retinoids are a type of vitamin A derivative that are commonly used in skincare products to treat acne. They work by increasing cell turnover in the skin, which helps to prevent the buildup of dead skin cells and other debris that can clog pores. Retinoids also have anti-inflammatory properties, and can help to regulate oil production in the skin.
You can find retinoids in the form of adapalene at 0.1 percent strength and retinol over-the-counter as leave-on treatments. Because retinoids work by increasing cell turnover, you may see a “purge” of more pimples being brought to the surface of your skin at first. Make sure to start slowly with your retinoid and expect to wait a few months before seeing an improvement.
Sulfur has been historically used to help with skin conditions by going to natural hot springs that contain sulfur.
For acne, sulfur has mild exfoliating properties which allow it to remove dead skin cells to stop them and other debris from blocking your pores, while also absorbing excess oil. Sulfur is antimicrobial, so it can help kill the bacteria that leads to acne. Sulfur is available over-the-counter in face washes, masks, and spot treatment. Although it can still irritate sensitive skin, sulfur is seen to be a gentler acne treatment than other options.
Since cystic acne lesions can stay around for so long, we are all eager to find a cystic acne spot treatment to help hasten their departure. However, because the cysts are so deep, cystic acne can be challenging to treat with spot treatments.
Traditional hydrocolloid pimple patches are ineffective since cysts live so far beneath the surface, but pimple patches with microneedles that deliver medication, such as salicylic acid, into the skin can sometimes be effective on cysts, especially if they are used early, when you first notice that deep and foreboding pain under the skin.
Benzoyl peroxide spot treatments can also work to fight bacteria on the skin and to reduce the inflammation of a cyst. While over-the-counter hydrocortisone cream can cause skin thinning and even pimples if used long term, it can be used as a spot treatment on cysts to help bring down inflammation and redness. If a cyst is forming and you have nothing else on hand, try icing it to bring down the inflammation. Icing is also useful to reduce the pain of deep cysts.
Cystic Acne Scarring
The last step of dealing with cystic acne is addressing the scars it often leaves behind. The inflammation caused by cystic acne can damage the surrounding skin tissue, including the collagen and elastin fibers that give the skin its elasticity and firmness, resulting in the formation of scars.
Cystic acne scars can be either depressed (atrophic) or raised (hypertrophic). Atrophic scars are the most common type of cystic acne scars, leaving visible indentations in the skin which are caused by the loss of tissue in the affected area. Atrophic scars can appear as shallow depressions—or deep pits—in the skin. They can also be classified as ice-pick scars, boxcar scars, or rolling scars, depending on their shape and depth. Hypertrophic or keloid scars, on the other hand, occur when the body produces too much collagen during the healing process, resulting in raised and thickened scars.
Unlike the red or brown marks of post-inflammatory hyperpigmentation which can eventually fade with time and topical treatments, scars change the texture of the skin and do not usually go away without being treated by a dermatologist. Some of the techniques used to improve cystic acne scars include chemical peels, microneedling, laser therapy, dermal fillers, subcision, and dermabrasion.
Although it may be tempting to purchase at-home products that claim to reduce indented acne scars, it would be a better use of your money to save it and eventually consult a dermatologist for professional scar correction.
Cystic acne is painful to deal with, both physically and emotionally. When treating cystic acne you should consult a dermatologist or medical professional as soon as you are able in order to determine the best course of treatment for your individual case, as the effectiveness of each treatment can vary depending on the type and severity of your acne.
Be patient. With the exception of corticosteroid injections, nothing works overnight, and cystic acne can often be a long term condition to manage. Although it sometimes seems like cysts wait to pop up just before a big event, don’t let cystic acne stop you from doing anything you want to do. Try to practice acne neutrality and continue to live your life while finding the right treatment and skincare routine for you.