Cystic Acne: Causes, Treatment, and Prevention

Everybody gets a pimple from time to time. And some of us struggle with more frequent breakouts throughout our lives.

But cystic acne is a different and more serious skin condition. While mild cases of acne may cause blackheads, whiteheads, or pimples, cystic acne is a severe form of acne that appears in large cysts located deep in the skin. This condition can often cause both physical and emotional pain.

What is Cystic Acne?

Cystic acne is a severe form of acne that is relatively uncommon. It differs from the more common forms of acne in size and depth — cystic acne usually produces very large pimples that form deep underneath the skin. Other forms of acne usually include just surface level blemishes and pimples.

In fact, cystic acne could easily be mistaken for boils. Cystic pimples are often tender to the touch and can be white or red in color. They also often contain pus.

Although cystic acne is most often found on a person’s face, it can also appear on many other body parts. Cystic acne may form on the neck, behind the ears, on the trunk, or on the limbs.

Additionally, cystic acne doesn’t clear up easily and is very prone to scarring. Scars are especially likely to form if you try to extract, pop, or pick at cystic pimples.

Infographic on acne severity

So, unlike many milder forms of acne, cystic acne will usually need to be diagnosed and treated by a dermatologist in order to help the skin get and stay clear.

How Does Acne Form? 

Acne comes in many forms, but the basic process that causes acne to develop is usually the same. All over your skin, you have tiny hair follicles or pores. Within these pores, there are also sebaceous glands, which produce sebum. Sebum is a normal and healthy oil that is produced in order to maintain your skin’s moisture levels.

But sometimes, your sebaceous glands produce too much oil. This could be due to hormonal changes, such as those that occur during puberty, or other factors such as stress. Some people just have a naturally oily skin type. If your skin is oily for any reason, this may contribute to acne breakouts.

There are also certain bacteria found in pores called Propionibacterium acnes that will multiply in the presence of excess sebum. This is because Propionibacterium acnes actually feeds on sebum. It is this bacteria that can cause infection and inflammation in the pore.

Sometimes dead skin cells are not shed efficiently. If dead skin cells start to accumulate, they often mix with the sebum and end up clogging the pore. If clogged pores become almost or completely blocked at the opening, they are called closed comedones. If clogged pores remain open they are referred to as open comedones. Open comedones are usually called blackheads because they appear black in color. Closed comedones are called whiteheads because they typically appear as small white bumps.

Now, in both open and closed comedones, the build-up of sebum and dead skin cells can cause the cells around the pore to become inflamed. Once these surrounding cells are inflamed, they may also become infected with the Propionibacterium acnes bacteria growing inside the pore.

Now, at this point, the acne has not erupted into a pimple yet. It is still a blackhead or whitehead at this stage. It is only when the continued build-up of sebum and dead skin cells exerts so much pressure on the cells around the pore that a rupture occurs. The rupture of the pore allows the sebum and acne-causing bacteria to enter the surrounding tissues. This bacteria then causes an infection, visible to use the red raised area of skin known as a pimple.

Infographic on the stages of acne

This is how the typical pimple is formed. But in cases of cystic acne, the problem of sebum and bacteria infecting the skin around the pore goes further. Instead of the infection remaining mainly at the surface, the infection goes farther and deeper into the skin. These large and deep areas of infected skin are the cysts, or nodules, that are characteristic of cystic acne.

Because these infections are so much deeper and widespread in the skin, they are harder to treat. Most topical treatments are usually not able to penetrate enough to address this deep-seated infection. And it is this widespread inflammation that is also more likely to leave scars behind even once a cyst is finally gone.

What Causes Cystic Acne to Develop?

The exact reasons why someone gets cystic acne is not known. What is known is that androgen hormones are a contributing cause of the development of cystic acne. An increase in androgen hormones causes excess sebum production and thus oily skin.

Any increase in androgen hormones and oil production can cause reactions in your skin, including acne and cystic acne. This means that teenagers going through puberty, adult men, and women who have polycystic ovary syndrome or who are going through pregnancy or menopause are more likely to experience the hormone shifts that trigger cystic acne. However, it possible that a person of any age or health status could develop cystic acne.

It may also be that cystic acne runs in families. If one of your parents had or has cystic acne, you may be more likely to have it as well.

Stress can also cause an increase in hormones that may trigger or worsen acne. Those who lead a stressful or unhealthy lifestyle may find this affects their skin and correlates to breakouts.

Some other things may possibly exacerbate oily skin conditions and acne, such as environmental conditions. For example, if the climate you live in very hot and humid, you may produce more sweat and this may be another factor in your breakouts.

It is also important for those who are more prone to cystic acne to avoid heavy or greasy skin products and to stay away from cosmetics that may cause unnecessary irritation in their already vulnerable skin.

Treatment Options for Cystic Acne

Cystic acne can be a very hard condition to live with. Not only are the breakouts painful, but they often cause mental distress due to the way they make your skin look. And without proper treatment, cystic acne can leave behind permanent scars.

When it comes to addressing cystic acne, the first step is making an appointment with a board-certified dermatologist. Even if you are not sure that your condition is cystic acne, you should check with a dermatologist if you are experiencing widespread, painful pimples that do not improve with over the counter treatments. If your breakouts are severe, waiting too long to get the appropriate treatment is more likely to leave you with scarring.

Doctor examining pimple on woman's cheek

The dermatologist will be able to assess your specific skin and health history to determine the best treatment options. There are topical creams, cleansers, and oral medication that may be prescribed. Which one your doctor will choose depends partially on the suspected cause of the acne. Common topical acne treatments may be tried first, but cystic acne usually requires oral medications to address the deeper causes of the condition.

1) Antibiotics

Antibiotics are a common oral medication that doctors may use to kill off the bacteria that is causing acne. This may work to end the infection that is causing the inflammation and allow the cysts to heal, but there are several downsides to taking antibiotics for acne.

Many times, antibiotics will cause unpleasant side-effects. These may include stomach pain, nausea, and diarrhea. And over time, taking antibiotics will kill off some of your good bacteria along with the bad, leading to an imbalance in your body.

Antibiotics will also only be helpful for acne if taken for extended periods of time. But this can ultimately be dangerous, causing that particular antibiotic to become less effective after some time. If later, you develop another more dangerous infection, the antibiotic may no longer work for you.

Additionally, antibiotics alone will not cure acne. In fact, once you stop taking the antibiotic, your acne will usually return with the same severity as before. It’s also true that antibiotics may not help with acne for some patients. For this reason, doctors will often prescribe antibiotics in combination with another medication, such as a topical ointment.

2) Hormonal Therapy and Contraceptives

For women with cystic acne, there are a few other options to try if your doctor suspects your acne is related to your hormones.

A common option available for women with severe hormone-related acne is oral birth control pills. Certain birth control pills are effective at treating acne caused by excess sebum production due to high levels of androgens. Pills that contain both estrogen and progestin will help reduce androgen levels and thus lower oil production in the skin.

Another option for women with cystic acne is spironolactone. This drug was originally used prescribed to treat cardiovascular disease but is also effective at lowering the androgens that cause oil production. This makes it another option that dermatologists can use to treat acne, either on its own or combined with birth control pills.

Spironolactone does have a few side effects. It’s a diuretic, which will cause you to urinate more frequently. You also have to get your blood checked regularly, to make sure your body isn’t holding on to too much potassium, another possible side effect.

3) Isotretinoin

If the above forms of treatment aren’t an option or aren’t working, there is a powerful prescription medicine that your dermatologist can prescribe, called isotretinoin. This an oral medication that is a form of vitamin A. It works by addressing all the factors that cause cystic acne. It not only kills the bacteria that causes acne, but reduces oil production and inflammation, and helps to unclog pores.

Isotretinoin can be extremely effective. Not only can it clear your current breakouts, but it can prevent cystic acne from reoccurring. This means that after taking it for several months, your skin may stay clear even after you are done taking it. For some patients, the changes in their skin are permanent. On top of that, it may help to heal any scarring that may have developed.

But, the reason that doctors don’t start with isotretinoin, to begin with, is that it can cause some serious side effects. This drug must be prescribed by a physician, and the patient has to agree to be monitored by that doctor for the duration of treatment. This includes follow up visits with your prescribing doctor every 30 days and signing a form acknowledging the known risks of the medication.

While the common side effects that a patient may experience while taking isotretinoin are dry skin and lips, there are serious birth defects that can occur if a woman gets pregnant while on the drug. For this reason, women who are of child-bearing age are required to prevent pregnancy and take pregnancy tests before and during isotretinoin treatment.

So as you can see, isotretinoin is a serious medication for only the most severe cases of acne that have not responded to other forms of treatment. While it can provide significant results, it is not for everyone. There are some medical conditions that may make it more risky for a patient to start isotretinoin. You will need to be honest and disclose your medical history to your dermatologist so that they can determine if isotretinoin is an appropriate treatment for you.

How to Prevent Cystic Acne Breakouts

If you have cystic acne, you may not be able to avoid breakouts completely without working closely with a dermatologist and taking the appropriate medications. But you can minimize breakouts, avoid spreading acne-causing bacteria and reduce scarring.

The most important thing to do if you have cystic acne is to keep your hands off your face! Do not pick or try to pop any pimples or cysts. Trying to extract the cyst will not work, since it located under the skin. Trying to pop a cyst will only cause more inflammation and possibly spread the acne-causing bacteria around.

Leaving your cysts alone is essential to preventing scars, but they may still appear even with your best efforts. To further reduce the chance of scaring, follow a gentle skin care routine and stay away from any harsh products or scrubs. Also, be sure to wear an oil-free sunscreen daily.  Some acne medications make your skin more susceptible to sun damage, and sunlight can trigger melanin production which will worsen the appearance of scars.

And of course, keep working with your dermatologist. They are the experts at treating even the toughest forms of cystic acne safely and effectively.