The truth is, that while there is no wonder cure for this often emotionally distressing problem, severe acne can be managed effectively with the help of doctors, and medical treatment can result in the prevention of some of the worst effects of cystic acne.
Fast facts on cystic acne
Here are some key points about cystic acne. More details and supporting information is in the body of this article.
- While acne is very common, cystic acne is relatively uncommon and more severe.
- The main factors behind cystic acne are the hormonal changes in puberty, but it can occur in older individuals, too.
- Cystic acne is not caused by chocolate, nuts, or greasy foods, nor by poor hygiene or masturbation.
- Cystic acne can be painful, as well as emotionally distressing because of its effects on facial appearance.
What is cystic acne?
Acne is a familiar sight among teenagers.
The pores of the skin have sebaceous glands that secrete an oily substance known as sebum.
Normal sebum secretions help protect the hair follicles and skin, but overproduction of sebum and overgrowth of skin cells can cause the pores to become plugged. This can create the perfect conditions for the overgrowth of a type of bacteria called Propionibacterium acnes, which is normally found on the skin.
These plugs are also known as comedones and can have white or black heads. If the comedones are uninfected, the condition is called non-inflammatory acne. If the comedones become infected and inflamed, papules, pustules, nodules, or cysts may develop.
- Papules occur when the P. acnes bacteria lead to irritation of the hair follicles.
- Pustules occur when the P. acnes bacteria lead to inflammation of the hair follicles, causing swollen red bumps.
- Cysts occur when the inflammation leads to rupture of the hair follicles, which can also be caused by squeezing the spots, or by harsh scrubbing. Rupture releases compounds that trigger wider inflammation, and deeper, hard, painful cysts.
Acne most often affects adolescents and young adults, with an estimated 80 percent of people between 11 and 30 years of age experiencing acne at some point.
Cystic acne is the most severe form, and affects far fewer people.
In 2009, the CDC found that acne was the top reason people gave for visiting a dermatologist, and was among the top five diagnoses made by doctors that year.
What causes cystic acne?
As discussed above, acne is characterized by a blockage of the skin pores because of the overproduction of sebum, or skin cells, combined with inflammation triggered by bacteria. Cysts are the most inflamed, ruptured type of acne.
The biggest factor causing acne is the hormonal changes in adolescent teenage years. During puberty, levels of circulating androgen hormones increase dramatically, which causes an increase in sebum production; skin cells also begin to grow quicker.
Acne is not confined to teenagers, however, and other factors are involved, including:
- hormonal changes related to the menstrual cycle, pregnancy, birth control, the use of hormone therapy, and stress.
- greasy cosmetics, cleansers, lotions, and clothing.
- high levels of humidity and sweating.
- genetics - some people are naturally more susceptible.
- some drugs and chemicals, for example, corticosteroids, lithium, phenytoin, and isoniazid, which may worsen or cause eruptions that are similar to acne.
There are numerous myths about the causes of acne, which blame factors that have been dismissed by scientific research.
Acne, including cystic acne, is not caused by:
- chocolate, nuts, or greasy foods
- most other dietary choices (although research has found an association between intake of milk products and acne, as well as a high glycemic index diet and acne)
- poor hygiene or inadequate face washing
- masturbation or sex
Treatment and prevention of cystic acne
Cysts can cause damage in the skin that leads to scarring.
Treatment of severe, cystic acne requires the help of a specialist doctor and some self-care measures. Drug treatment can be effective at preventing cysts and scarring.
Mild or moderate acne can be managed with the help of a doctor. However, severe acne that is characterized by nodules and cysts, which might leave scars or already show signs of scarring, may need referral to a specialist. This is partly because the main drugs used to treat cystic acne are tightly controlled.
Benzoyl peroxide is a treatment available to people with acne of any severity. It is also a treatment option for people with severe acne who are awaiting specialist treatment.
Benzoyl peroxide is available directly from pharmacies over the counter in a number of formulations that may be applied to the skin. It has been a mainstay in the treatment of acne for over 50 years, and works by killing bacteria, particularly P. acnes, and breaking up comedones.
Water-based and alcohol-based formulations of benzoyl peroxide are available, and the most appropriate form depends on skin type. Alcohol-based preparations have a drying effect, making these more suitable for people with oily skin.
Benzoyl peroxide products, which include cleansing liquids and bars, lotions, creams, and gels, are used once or twice a day. The most common side-effect is skin irritation; allergies occur rarely.8
Practical measures to avoid making acne worse are useful for anyone with acne, including people with cystic acne:
- Do not wash too often - twice a day is enough, use a mild soap or cleanser and lukewarm water.
- Do not scrub harshly when washing - avoid abrasive soaps, cleansing granules, astringents, or exfoliating agents.
- Leave pimples alone since picking and squeezing is likely to worsen the acne.
- Avoid using heavy makeup, choose water-based, non-comedogenic formulations, avoid oily formulations, and make sure to remove makeup before bed.
Drug treatment with isotretinoin
Isotretinoin is a prescription drug for the treatment of cystic acne, sold under a number of brand names in the United States (U.S.), including Absorica, Amnesteem, Claravis, Myorisan, and Sotret.
Isotretinoin is a very effective treatment, but it has significant side effects, and is dangerous to the unborn child. It is usually taken at a dosage of 1 milligram for every kilogram of body weight once daily for 16-20 weeks.
For cases of moderate acne, isotretinoin is not recommended until standard treatment with oral antibiotics has been tried and found to be ineffective. Isotretinoin is, however, recommended as a first-line treatment for severe acne.
Potential adverse effects associated with the use of isotretinoin include:
- eye and genital dryness
- chapped lips
- joint pains
- liver damage
- elevated lipid levels
Isotretinoin is a teratogenic drug; this means that taking it during pregnancy (at any dose, even for a short time) can lead to birth defects.
Isotretinoin may also lead to the loss of the pregnancy or premature birth, and can cause death of the newborn.
Women who have the capacity to become pregnant are, therefore, required to use two methods of contraception for 1 month before, during, and at least a month after treatment with isotretinoin.
Testing for pregnancy is also required before starting isotretinoin and then every month until 1 month after stopping the drug.
Because of the danger of taking isotretinoin during pregnancy, the availability of the drug is restricted and can only be given by registered prescribers and dispensed at registered pharmacies as part of the iPLEDGE program, which also requires the registration of the patient. The conditions for being prescribed the drug include producing two negative pregnancy tests.
An injection of corticosteroid (triamcinolone) directly into a cyst can help reduce inflammation and prevent scarring. This treatment is carried out by a dermatologist.
There may be short-lived localized side effects after the injection.
Dermatologists may also offer incision and drainage of certain large cysts, but it is strongly recommended that people do not attempt this themselves as it will likely worsen the skin problem and could cause serious scarring and deeper infection.
Birth control pills
Long-term treatment of acne in women can involve the birth-control pill, which suppresses sebum production. Where appropriate, an oral medication containing estrogen and progesterone may be used for 6 months or more.
A drug called spironolactone may also be prescribed with the pill. This is a synthetic steroid that inhibits androgens.
Signs and symptoms of cystic acne
Acne produces symptoms familiar to all of us. Cystic acne is even more visible because it is the most severe form and produces cysts and nodules alongside inflammatory papules and pustules. Acne can also cause visible scarring.
All forms of acne can affect self-esteem and mood, but the risk of psychological distress is higher for cystic acne as it typically has a greater impact on the appearance of the face and disproportionately affects young adults who may be more socially sensitive.
Most people with acne do not usually experience physical symptoms, but the skin's appearance can cause emotional distress. In cystic acne, however, the distress may be greater, and the cysts may be painful.
The importance of treatment is underlined by the risk of scarring from long-term cystic acne. This can produce long-term and permanent damage in the form of:
- 'ice pick' scars (small, deep pits)
- larger pits
- shallow depressions
- hypertrophic scarring (red, raised scars)