Cystic acne is a severe type of acne in which the pores in the skin become blocked, leading to infection and inflammation.
The skin condition mainly affects the face, but also often affects the upper trunk and upper arms.
Cystic acne is the most severe form and affects far fewer people.
In 2009, the Centers for Disease Control and Prevention (CDC) found that acne was the top reason people gave for visiting a dermatologist.
The 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 characterized by nodules and cysts may need referral to a specialist, as it might leave scars or already show signs of scarring. 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 Propionibacterium acnes (P. acnes). Some benzoyl peroxide treatments are also available to purchase online.
It also breaks up comedones. These include whiteheads and blackheads.
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 do not commonly occur.
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, including Absorica, Amnesteem, Claravis, Myorisan, and Sotret.
Isotretinoin is a very effective treatment, but it has significant side effects and is dangerous to an unborn child. It is usually taken at a dosage of 1 milligram (mg) for every kilogram of body weight once daily for 16 to 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 congenital deformities.
Isotretinoin may also lead to the loss of the pregnancy or premature birth and can cause the death of the newborn infant.
Women who can 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.
The conditions for being prescribed the drug include producing two negative pregnancy tests.
Injecting a corticosteroid medication called 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.
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:
- small, deep pits, known as “ice-pick scars”
- larger pits
- shallow depressions in the skin
- red, raised scars
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 P. acnes.
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, as 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
- poor hygiene or inadequate face washing
- masturbation or sex
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: Picking and squeezing is likely to worsen the acne.
- Avoid using heavy makeup: When applying makeup, choose water-based, non-comedogenic formulations, avoid oily formulations, and make sure to remove makeup before bed.
If you have milder acne, or want to reduce the risk of developing acne on clear skin, the following steps can help:
- Clean the skin gently in the morning, before you go to sleep, and after strenuous exercise.
- Try to avoid touching the skin where possible.
- Shave with care and soften the beard with soapy water before grooming. Be sure to find the most comfortable shaving method for you and shave only when necessary.
- Avoid being over-exposed to the sun, as it can affect skin health and appearance.
- Shampoo the hair regularly. People with oily hair may want to do so daily.
There are other factors that cause and escalate acne, such as genetics, but these tips can help stop normal acne becoming cystic.