Everything You Need to Know About Cystic Acne

<p>yuuurin / Getty Images</p>

yuuurin / Getty Images

Medically reviewed by Brendan Camp, MD

If you struggle with acne, you are not alone. Acne is the most common skin condition in the United States, affecting more than 50 million people every year.

Of all types of acne, cystic acne is the most severe form of acne. It affects fewer people but it can be incredibly painful.

Causes of Cystic Acne

Cystic acne develops when sebum, an oily substance that lubricates your skin, gets trapped deep underneath your skin. This can result from a combination of bacteria, oil, and dead skin cells that clog your pores. All of these factors contribute to an increase in inflammation underneath the skin.

Anyone can develop cystic acne. However, it tends to occur more frequently in people with oily skin, teens, women, and older adults with hormonal imbalances. Here are some contributing factors of cystic acne:

  • Hormones: Just before your period starts, estrogen and progesterone levels drop, which can trigger your sebaceous glands to secrete more sebum. An increase in androgen levels during puberty can also increase oil production in your skin. Too much sebum can result in clogged pores and breakouts.

  • Genetic factors: There is research that supports that genetics may have an impact on your chances of developing acne. For example, there are 29 genetic variants more common in people with acne. Additionally, a family history of acne is also shown to be a predictive factor of acne breakouts in teenagers.

  • Diet: Foods with a high sugar or starch load can cause inflammation and activate oil glands, leading to breakouts.

  • Stress: Stress doesn’t directly cause acne. However, studies show that if you already have acne, stress can certainly make it worse. When you're stressed, your body releases cortisol and androgens, which can increase sebum production. Studies have also found that this may be due to a slower healing process when you’re under stress, which can make pimples stay on your face longer.

Treatment for Cystic Acne

There are many ways to treat cystic acne. If you are not sure where to start, it is best to consult your healthcare provider or dermatologist for proper diagnosis and treatment of your cystic acne. They may suggest the following treatments:

Medications

Medications like isotretinoin (Accutane), Spironolactone, and oral antibiotics may be prescribed.

  • Isotretinoin (Accutane): Isotretinoin is an oral retinoid (vitamin A derivative) typically used for people with resistant, severe, or nodular acne. “It is the closest medication to a cure and not only can clear pimples but also give long-lasting remissions,” Joshua Zeichner, MD, an associate professor of dermatology at Mount Sinai Hospital in New York, told Health. Accutane works by shrinking the oil glands, preventing clogged pores, and reducing acne-causing bacteria, oil production, and inflammation. About 85% of people who take it see improvements within 4-6 months.

  • Spironolactone (Aldactone): Although traditionally used as a diuretic to help treat edema and hypertension (high blood pressure), this can also help manage the hormonal imbalances that stimulate oil glands. It reduces oil production by interfering with hormonal signals on sebaceous glands. Studies find that 50-100 milligrams (mg) per day work best, and it’s particularly effective for women with hormonal acne (acne on their jawline or lower face).

  • Oral antibiotics: Oral antibiotics decrease acne-causing bacteria and reduce inflammation in the skin. However, these should only be used short term to prevent developing a bacterial resistance to them. Long-term use can also affect the balance of bacteria on your skin and your gut.

Hormonal Therapy

Hormonal therapy like combined oral contraceptives (COCs) may be helpful for cystic acne that’s caused by hormonal fluctuations due to your menstrual cycle. Birth control pills contain estrogen, which can help regulate hormone levels and possibly reduce acne. They may also be prescribed along with spironolactone.

Topical Treatments

Several topical treatments can help treat cystic acne, including over-the-counter (OTC) and prescription topicals.

  • OTC Topicals: Benzoyl peroxide is perhaps the most effective topical ingredient to treat mild to moderate acne. It works by lowering levels of acne-causing bacteria and causing the skin to dry and peel. Salicylic acid penetrates pores to flush them and clean them of excess oil and dead skin cells.

  • Prescription topicals: Topical prescription options include medications that contain benzoyl peroxide, salicylic acid, dapsone, or topical retinoids. Retinoids are also derived from vitamin A (like tretinoin) but aren’t as strong. They promote skin cell turnover, making way for new cell growth underneath. Popular brands of retinoids include Retin-A, Differin, and Tazorac.

Corticosteroid Injections

To reduce the inflammation, swelling, and pain of cystic acne, a dermatologist can inject a diluted corticosteroid directly into a cyst. It can be very effective at shrinking cystic acne. However, this option should be reserved for cysts that aren’t responding to typical acne therapies.

“In extreme emergency cases, such as weddings and events, a cyst can be injected with a little steroid to decrease the size of the cyst,” Purvisha Patel, MD, board-certified dermatologist and Founder of Visha Skincare, told Health. “Over a long period of time, this is not an acceptable treatment, as the injections cause skin thinning and atrophic scarring.”

Related: How to Get Rid of a Pimple

How To Prevent Cystic Acne

You can prevent cystic acne with lifestyle, diet, and skincare changes. For example:

  • Minimize stress: Try to find ways to alleviate unnecessary stress with strategies like exercise andmeditation. Stress is linked to worsening acne breakouts.

  • Practice good skincare: Wash your face at least once a day in the evening with a cleanser with benzoyl peroxide or salicylic acid. Use a treatment skin care product with retinol or salicylic acid, or get a prescription retinoid from your healthcare provider. Use non-comedogenic makeup products (don’t clog pores), and never go to bed with your makeup on.

  • Avoid picking at your skin: When you pick, you are increasing the risk of inflammation and infection, which increases the healing time and chances of getting discoloration and scarring.

  • Try milk alternatives: Research shows that consuming dairy products can worsen acne. “Cows are given hormones to produce milk and these hormones in dairy can increase hormonal oil production and cause cystic acne,” Dr. Patel said. Try milk products like almond milk, coconut milk, or oat milk.

  • Minimize your sugar intake: High glycemic foods have been linked to acne. “A low-sugar diet is important as it will decrease inflammation in the gut, and this helps with the inflammatory component of acne,” Dr. Patel said.

  • Try in-office treatments: Skin treatments like laser resurfacing, radiofrequency, chemical peels, and dermal fillers are all options to treat textural acne scars. Some lasers, like AviClear, can be used to treat acne as well.

A Quick Review

Cystic acne is caused by hormones, genetics, diet and stress. While you can try various at-home skincare treatments combined with diet and lifestyle changes, medical treatment may be necessary to treat acne and prevent scarring.

If cystic acne is negatively impacting your mental health or body image, visit your healthcare provider  for proper diagnosis and treatment.

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