Cystic acne is the most severe type of acne. Untreated, the condition can last for years and leave behind permanent physical and emotional scars. Fortunately, most people with acne have mild to moderate acne that can usually be controlled with an effective topical acne treatment. However, roughly 20% of people with acne who experience severe cystic acne often require additional therapies to achieve clear skin.
What are acne cysts versus nodules?
An acne cyst is a small “sac” under the skin in which there is an excessive build-up of sebum (oil), bacteria, and dead skin cells. Inflamed tissue with enlarged capillaries usually surrounds this "sac," causing them to protrude from the skin. Cystic acne lesions are most often felt beneath the skin before they’re seen.
A nodule is hardened cysts. In nodules, the fluid is replaced with scar tissue. Post-acne nodules can persist for weeks and months.
What causes cystic acne?
There are several acne causes, including genetic predisposition, hormonal changes or imbalances, and external factors such as certain medications, stress, diet, and improper skin care products. All acne starts when the opening of the skin's oil glands is clogged and accumulates sebum, which feeds acne-causing bacteria. In these enlarged, clogged oil glands, the build-up of bacteria triggers inflammation and, in turn, leads to pimples.
Cystic acne develops when the inflamed sebaceous gland ruptures and bacteria and sebum spread to the surrounding tissue. This causes a bigger infection that results in immensely painful inflammation. Unfortunately, this damage can lead to long-term or even permanent acne scars in many cases. Severe and cystic acne can cover the face, chest, and back. It can also spread along the jawline and neck and even armpits and buttocks.
How prevalent is cystic acne?
Acne is the most common skin disorder, affecting over 50 million people in the United States alone. Moderate to severe acne is present in about 20% percent of young people. Cystic acne can also run in families - some estimates claim heritability is almost 80% in first-degree family members.
What are the psychological effects of cystic acne?
Cystic acne can cause profound negative psychological and emotional effects that should not be taken lightly. Studies have found that up to 50% of adolescents face psychological difficulties due to their acne. Many people with cystic acne report lowered self-esteem, increased anxiety, and even depression, with additional negative impacts on social life, education, and employment.
What are the best topical treatments for cystic acne, according to dermatologists?
As with any acne type, it is best to start a medicated topical skincare treatment right away. A good skincare routine should include a medicated cleanser, treatment cream, and moisturizer with active ingredients such as salicylic acid and/or benzoyl peroxide to help unclog the skin's pores remove excess oil, and kill the acne-causing bacteria. While many over-the-counter acne products are available, an acne patient must use treatment products in the right formulas and concentrations for their acne severity, skin type, and sensitivities to ensure maximum efficacy while minimizing irritation.
Dermatologist-approved tip: Acne treatment creams should be applied to the entire face (not used as just individual pimples acne spot treatment) to maximize the treatment of existing breakouts and prevent future cystic breakouts.
To find the right acne treatment products for your unique skin, take the free MDacne skin analysis.
What oral medications are used to treat cystic acne breakouts?
Most acne patients will see benefits from the right topical treatments. But in some cases of severe cystic acne that do not respond adequately to topical treatments, dermatologists may recommend the addition of an oral treatment such as one of the following:
- Antibiotics: Antibiotics work by killing the bacteria and calming the inflammation that contributes to acne. Although useful for the short term, oral antibiotics do not have a long-term effect and will usually not “cure” cystic acne. Oral antibiotics also have some nasty side effects. Changing the gut's normal flora, oral antibiotics (minocycline and doxycycline) are frequently associated with increased abdominal pain, diarrhea, and nausea. They can cause bacterial resistance, making your acne worse in the long run.
- Isotretinoin (Accutane): Accutane (a derivative of vitamin a) is the single most potent drug used today to treat acne. It is highly effective in even the most severe cystic acne treatment. About 70% of patients see permanent clearing after one course of isotretinoin, and the rest will be acne-free for many years. Due to possible side effects, you will need to consider whether you want to take this medicine carefully. If you decide to take isotretinoin, you must enroll in an ongoing monitoring program.
- Birth Control Pill (females Only): Birth control pills containing both progesterone and estrogen can result in a decreased level of androgens in the blood. The fewer androgens produced, the less sebum secreted. With sebum production under control, the likelihood and severity of breakout are decreased. Birth control pills containing progesterone should be avoided, as these can often make acne worse. One should also remember that birth control pills (oral contraceptives ) can also have side effects; blood clots, weight gain, nausea, spotting, and mood changes. To learn more about the best birth controls to treat acne, click here.
- Spironolactone (females Only): Spironolactone (Aldactone) is an oral drug created to treat hypertension. This drug is an androgen (male hormones) blocker; as it disrupts androgens' production, sebum production is decreased, which can result in fewer acne breakouts. As it is a diuretic, it can cause an increase in the level of potassium in the blood.
Dermatologist office treatments for cystic acne
As acne cysts are deep within the skin, squeezing or attempting to self-extract these lesions can worsen the condition, slow down the healing process, and heighten the risk of permanent, deep scarring and hyperpigmentation. One way your dermatologist can get rid of a painful cyst or nodule is to inject it with a corticosteroid.
The benefits of cortisone injections
Intralesional steroid injections for cystic acne can help reduce cyst size and pain and promote healing much more quickly. After injection, the acne cysts will shrink within eight hours and improve for several days. Larger cysts can also be incised (sliced open) and drained if necessary. This procedure should be done only when the cyst is large, very painful, and should be performed only in sterile medical office conditions by a licensed physician.
Possible side effects of cortisone injections
While cortisone injections help with existing cysts, they reduce existing bacteria and therefore do not help prevent future cysts. They can also sometimes cause side effects, the most common of which is "pitting" in the skin. However, these typically heal on their own.
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To find the right acne treatments for your unique skin, take the free skin assessment by clicking here.