Cystic Acne Agony

Cystic acne is one of the most difficult types of acne to treat. Though it is most likely caused by the same bacteria (p. acnes) as regular acne, cystic acne lesions are far more painful and have more risk of scarring compared to mild or moderate acne.

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Cystic acne is one of the most difficult types of acne to treat. Though it is most likely caused by the same bacteria (p. acnes) as regular acne, cystic acne lesions are far more painful and have more risk of scarring compared to mild or moderate acne.

Why is cystic acne so hard to treat? Cystic acne lesions actually rupture beneath the surface of the skin, pushing the blockage and swollen contents beyond the reach of traditional, topically-applied anti-acne products. Many dermatologists regard cystic as the most severe type of acne, and, many admit that traditional acne treatments are largely ineffective. Due to the slow healing time of cystic acne lesions, the potential for scarring and the extent of damage is something to take seriously. It’s especially important to be informed about potential triggers and treatment options—otherwise, you’re likely to make matters worse and even more painful.

What Causes Cystic Acne?

Like almost every type of acne, the cystic variety is triggered by hormones. With cystic acne, for reasons unknown, the skin’s oil glands become hypersensitive to excess male hormones (women have male hormones that trigger acne), and react by overproducing sebum (an oily substance produced by the body to lubricate and waterproof skin). [1]

The amount of sebum produced is so excessive that the oil gland itself becomes engorged, swollen, and hardened with the excess. Unable to push almost any of the extra oil to the surface, the gland bursts underneath the skin, creating the large swollen mass (called a nodule or cyst) below the skin’s surface. Once that occurs, you are officially dealing with this terribly painful and unsightly type of acne.

Although not a lot is known about what causes some people to get cystic acne, there is likely a genetic component involved. Given the strong hormonal component, it is most likely to occur during these times or if certain disorders are present:

  • The onset of puberty (when hormones go bonkers)
  • Pregnancy
  • Menstrual cycle
  • Perimenopause and menopause
  • Polycystic ovary syndrome (a condition caused by a hormonal imbalance in a woman’s ovaries)[2]

What Does Cystic Acne Look Like?

  • Cystic acne nodules appear as raised, red bumps that extend deep beneath the skin.
  • Generally they do not have a “whitehead” showing, but this is not always the case.
  • They are almost always painful to the touch, or even when not touched.
  • Cystic acne lesions are usually felt beneath the skin before they are seen.

The unique appearance of a cystic acne lesion is due to the acute damage to the oil gland causing intense inflammation and irritation which leads to redness, soreness, and swelling. Because of the depth of these lesions, squeezing or picking can be completely ineffective and can actually extend the lesion’s healing time (from days to weeks), not to mention increasing the risk of permanent scarring.

How Can I Treat Cystic Acne?

There is no way to completely avoid cystic acne (you’re either prone to it or you’re not), but there are ways you can minimize its occurrence while doing what’s best for your skin – and it doesn’t need to involve using drying, irritating products.

As with all types of acne, the first place to start is with over-the-counter products and common sense skincare tips:

  • Keep your skincare routine as simple as possible and follow it religiously.
  • Use a gentle, but effective water soluble cleanser twice a day (drying, harsh cleansers only make matters worse).
  • Avoid bar cleansers (the ingredients that keep bar soap in bar form can clog pores).
  • Exfoliate once or twice a day with a salicylic acid (BHA) based exfoliant to reduce redness and swelling, help reduce bacteria in the pore, and exfoliate on the surface and inside the pore to improve oil flow. Paula’s Choice offers a variety of effective BHA exfoliants.
  • Apply benzoyl peroxide to kill the bacteria in the pore (be sure the benzoyl peroxide product you choose contains no irritants such as menthol or alcohol which will increase redness and inflammation). Paula’s Choice CLEAR offers two benzoyl peroxide-based lotions.
  • Never use thick moisturizers (especially creams) in the areas where any type of acne occurs (these can clog pores). Stick with lightweight options with gel or lotion textures.

The bad news it that for some people with cystic acne, traditional therapy using over-the-counter acne products may be of little help. If over-the-counter options aren’t successful after at least four weeks of daily treatment, your next step is to see a dermatologist. Here are the treatment options your dermatologist can offer, ranked in ascending order of their potential for side effects:

    • Photodynamic Therapy (PDT): Recent research points to the promising results that cystic acne sufferers have found through a series of PDT treatments, which is a procedure that involves topical application of a photosensitizing cream and repeated, controlled blue or red LED light exposure. Though treatment takes several visits to a dermatologist over the span of a few months (and carries a high price tag), there’s enough evidence to suggest that these treatments shrink the oil glands, reduce the amount of oil in the pores and kills the bacteria, all of which can minimize cystic acne breakouts.[3, 4]
    • Oral Antibiotics: There are several types of oral antibiotics available for those with acne. All of them are worth discussing with your dermatologist and are options for short-term use under a doctor’s care. Side effects include, but are not limited to, dizziness, headache, nausea, rash, and gastrointestinal issues such as diarrhea and abdominal pain. The rise of sulfa-based antibiotics (such as Bactrim) to manage acne is due to the development of bacterial resistance to more commonly prescribed antibiotics (such as tetracycline). For best results, oral antibiotics should be used with topical products formulated to treat acne.[5, 6]


  • Hormone Therapy: For some women constant over production of androgens (hormones that produce male traits) is the chief culprit for causing cystic acne. There is a good deal of research showing that drugs (including some oral contraceptives) which block the production of androgens can be incredibly helpful. [7,8]The downside is that these prescription drugs are not without side effects (which must be discussed with your physician). To reduce side effects, anti-androgen medications (an example would be spironolactone) are generally prescribed in low dosages.[9]
  • Isotretinoin: Isotretinoin (formerly prescribed as Accutane) is an oral medication that directly affects the oil gland, literally changing its shape and stopping the flow of oil. Results can be immediate and lasting. Unfortunately, isotretinoin is associated with serious side-effects that must be taken into consideration. Risk to a fetus if you become pregnant, overly dry skin, hair loss, nose bleeds, liver function problems, and headaches are some of the more notable you should be aware of. Despite the risks, isotretinoin remains the only potentially permanent cure for cystic acne.[10]

Summing up, cystic acne is the most difficult type of acne to treat due to the depth of the breakouts and damage to the oil gland itself. Although over-the-counter acne products can be helpful for some with cystic acne, almost everyone dealing with this type of acne will need to seek help from a dermatologist. A consisent routine of anti-acne skincare along with topical and, possibly, oral prescription medications can get cystic acne under control and reduce its potential to leave permanent scars.

References Cited

  1. Lai JJ, Chang P, Lai KP, Chen L, Chang C.The Role of Androgen and Androgen Receptor in the Skin-Related Disorders. Arch Dermatol Res. 2012; 304(7): 499–510.
  2. Housman E, Reynolds RV.Polycystic ovary syndrome: a review for dermatologists: Part I. Diagnosis and manifestations.J Am Acad Dermatol. 2014;71(5):847.e1-847.e10; quiz 857-8.
  3. Ammad S, Gonzales M, Edwards C, Finlay AY, Mills C.An assessment of the efficacy of blue light phototherapy in the treatment of acne vulgaris.J Cosmet Dermatol. 2008;7(3):180-8.
  4. Lee SY, You CE, Park MY.Blue and red light combination LED phototherapy for acne vulgaris in patients with skin phototype IV.Lasers Surg Med. 2007;39(2):180-8.
  5. Turowski CB, James WD.The efficacy and safety of amoxicillin, trimethoprim-sulfamethoxazole, and spironolactone for treatment-resistant acne vulgaris.Adv Dermatol. 2007;23:155-63.
  6. Del Rosso JQ, Kim G.Optimizing use of oral antibiotics in acne vulgaris.Dermatol Clin. 2009;27(1):33-42.
  7. Palombo-Kinne E, Schellschmidt I, Schumacher U, Gräser T.Efficacy of a combined oral contraceptive containing 0.030 mg ethinylestradiol/2 mg dienogest for the treatment of papulopustular acne in comparison with placebo and 0.035 mg ethinylestradiol/2 mg cyproterone acetate.Contraception. 2009;79(4):282-9.
  8. Maloney JM, Dietze P Jr, Watson D, Niknian M, Lee-Rugh S, Sampson-Landers C, Korner P. A randomized controlled trial of a low-dose combined oral contraceptive containing 3 mg drospirenone plus 20 microg ethinylestradiol in the treatment of acne vulgaris: lesion counts, investigator ratings and subject self-assessment.J Drugs Dermatol. 2009;8(9):837-44.
  9. Sato K, Matsumoto D, Iizuka F, Aiba-Kojima E, Watanabe-Ono A, et. al. Anti-androgenic therapy using oral spironolactone for acne vulgaris in Asians.Aesthetic Plast Surg. 2006;30(6):689-94.
  10. Layton, A. The use of isotretinoin in acne. Dermatoendocrinol. 2009; 1(3): 162–169.
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