Cystic Acne: What You Need to Know About the Devil

Dealing with cystic acne isn’t easy. It’s big, red, painful, and last forever. And if that wasn’t enough, you have to deal with constant judgement—how many times has someone asked you if you’ve washed your face.   

While you might see some improvements with topicals (i.e. retinoids, benzoyl peroxide, sulfur, and azelaic acid), the key to treating cystic acne is to seek professional help. Dermatologists will assess your skin and prescribe you something—like antibiotics, hormone blockers, and/or isotretinoin (aka Accutane)—to fight cystic acne at its root.

Keep reading to find out more about causes and treatments for cystic acne.

What Is Cystic Acne?

Acne develops in four steps:

  • Step 1: Your sebaceous glands kick sebum production into high gear
  • Step 2: Sebum and dead skin cells stick together to form a blockage
  • Step 3: The blockage creates a perfect breeding ground for bacteria (particularly Propionibacterium acnes)
  • Step 4: Inflammation occurs

If you have it, you already know that cystic acne is the most severe type of acne.

It’s formed when inflammation occurs deep within your skin. Furthermore, these types of breakout consist of large, red, painful, headless nodules that can take months to resolve.

Left untreated, cystic acne can cause permanent scarring—think icepick and boxcar scars.

Cause #1: Your Hormones Are Out of Whack

Cystic acne is often triggered by hormones.

While there are a bunch of hormones that can impact acne, in this post, we’re going to focus on androgens.

Quick recap: Androgens, as you might recall from your high school biology class, are “male” sex hormones. But that doesn’t mean that they’re exclusive to men. In fact, they’re secreted by the ovaries (as well as the adrenal glands) and are essential for estrogen synthesis.

Although androgens are part of normal bodily function, you can have too much of a good thing. Moreover, when you’re body starts overproducing androgens, you’ll start seeing some unwanted changes.  

The thing is, androgens (particularly DHEA-S) stimulate sebum production. And increased sebum production often leads to one thing. Yep, that’s right—acne.

In women, it’s not uncommon to see acne rear its head during menstruation or even during pregnancy—you know, when hormones are in full swing. At this juncture, cystic acne is usually situated on and around the jawline.

Aside from menstruation, another thing that can cause cystic acne in women is polycystic ovary syndrome. PCOS is an endocrine disorder characterized by irregular menstrual cycles and an overproduction of androgens.

According to a study, acne is the most common skin-related disorder in women diagnosed with PCOS.

Last thing—and this doesn’t pertain specifically to women.

Getting juiced-up (with anabolic steroids) might get you jacked. But it won’t do you any dermatological favors. Actually, one study found that 43% of users develop acne as a direct result of steroid use.

Cause #2: It’s Genetic

It’s important to stick to a routine. But if you have cystic acne, you might have noticed that babying your skin (with expensive lotions and potions) doesn’t really do anything. And it doesn’t do anything because acne is, in large part, controlled by genetics.

Let’s take a quick look at some studies:

  • One study compared the immediate relatives of two groups—204 acne patients and 144 controls. The findings of this study suggest that having an immediate relative with acne makes you 4 times as likely to develop acne yourself.
  • A cross-sectional study conducted in Iran concluded that a mother’s acne history was the biggest indicator of acne and acne severity in teens.
  • A large study based on 1557 pairs of twins (both identical and fraternal) found that 81% of acne was attributed to genetics, while the remaining 19% was attributed to environmental factors (like stress, medication, diet, etc.).
  • Recently, Nature Communications published a breakthrough study on severe acne. They found that the genes responsible for hair follicle formation are, to a large degree, responsible for severe acne. Identifying the risk factors can greatly impact how we treat acne.

Bottom line: A strong family history of acne is a great indicator for the development of acne in family members.

Cause #3: Your Lifestyle Is Triggering It

The two greatest lifestyle factors that can influence cystic acne are:

  1. Stress. From a personal standpoint, I can attest to this one—the only time I get cystic acne is when I’m super stressed. And it’s not just me. One study conducted on 6th year med students found that students with higher stress levels exhibited higher acne severity. The researchers behind this study suspect that stress decreases your skin’s ability to heal itself and stress increases hormones (like CRH) that stimulate sebum, keratinocytes (skin cells), and inflammation.
  2. Diet. Although there aren’t too many solid studies on how diet affects acne, it’s generally accepted that dairy and high glycemic index foods (like. sugar, chips, white bread) often trigger acne. It’s no secret that carbo-loading spikes insulin. Well, this spike fuels androgens. Androgens fuel sebum. And ultimately you’re caught in acne’s vicious cycle.

Make an Appointment with Your Dermatologist ASAP

Here’s the thing:

Cystic acne is stubborn—it can linger on your skin for weeks, months, and even years.  

The longer you let it linger, the greater your chances of permanent scarring.

Now you might think that you can take care of cystic acne on your own. But this simply isn’t the case. Having cystic acne isn’t like having mild acne—it’s not a surface level problem. And accordingly, you can’t slap-on a spot treatment and expect your pimple to go away overnight.

More often than not, you need medical-grade solutions.

And the only person who can provide you with those solutions is your dermatologist.

Common treatments/medications are discussed in the following sections.

Side note: Whatever you do, don’t buy medications from shady online businesses. You need a doctor to monitor your current health, the side effects of the medication, and the progress of your treatment. Taking that guidance away, can absolutely wreck your health!

Derm Treatment #1: Cortisone Injections

If you’re gearing up for an event—like a wedding—and you want to get rid of cystic acne fast, cortisone injections (scientifically known as intralesional corticosteroid injections) might be right for you.

Cortisone injections reduce inflammation. So after your dermatologist injects it straight into your pimple, you’ll see a rapid reduction in the size of your pimple. Within 48 hours, it should be more-or-less flat.

The good thing is that, as long you don’t wait to go the the dermatologist to get your fix, it can reduce scarring.

On the other hand, cortisone injections have a couple negatives. First, it can induce scarring if too much cortisone is used. Second, it can cause hypopigmentation around the injection site. From my understanding, these side effects are uncommon, but they do happen.

Bottom line: Cortisone injections are a good option when you want a quick fix for a painful pimple. That being said, these injections do not represent a long-term treatment plan. If you have a case of severe cystic acne, you should talk to your dermatologist about some other options.

Derm Treatment #2: Antibiotics

Although it’s become slightly less popular over the years, most dermatologists still use antibiotics as a first-line treatment for moderate-to-severe acne.

Antibiotics have anti-bacterial and anti-inflammatory properties. So they’re thought to reduce P. Acnes (aka acne-causing bacteria) and, consequently, flatten bumpy skin.

Unlike cortisone injections, however, you shouldn’t expect to see immediate results. On average, antibiotics take 3-6 months to work. And even then, results aren’t guaranteed. The thing is, some strains of P. acnes are resistant to antibiotics.

Since resistance is an issue, most dermatologists recommend a two-pronged treatment. Studies have shown that using benzoyl peroxide alongside oral antibiotics can suppress resistance..

The most common antibiotics prescribed for acne are tetracyclines (minocycline & doxycycline). But, depending on your background, your dermatologist might prescribe you with something else.

Every antibiotic has a different side effect. These can include headaches, stomach pain, rashes, vaginal candidiasis, pancreatitis, and even drug-induced lupus (Minocycline only).

Bottom line: Antibiotics are used to get acne under control. 3 months is usually enough to see a significant improvement. From there, your dermatologist should provide you with an exit strategy so that you’re not taking antibiotics forever.

Derm Treatment #2: Spironolactone

You might be surprised to find out that spironolactone isn’t marketed as an acne drug. It’s actually marketed as a “potassium-sparing” diuretic that treats high blood pressure.

When it was prescribed to women with PCOS, doctors noticed that it helped with acne, alopecia, and hirsutism. And from there, it was discovered that spironolactone has the ability to block androgen receptors.

So nowadays, it’s not uncommon for dermatologists to prescribe spironolactone to women with late-onset acne, especially if that acne is hormonal (aka situated on or around the jawline).

Research has shown that spironolactone, sometimes in combination with other therapies, can improve acne significantly:

  • In 2014, researchers conducted a retrospective study on 41 female patients with mild-to-severe acne. When treated with a combination of both spironolactone and topical retinoids, 85.4% saw good, excellent, or clear improvements in their acne. A large chunk of those who saw improvements (34.1%) were completely clear of acne
  • A more recent study analyzed the medical records of 110 patients using spironolactone. Overall improvements were reported in 85% of patients. 55% were completely clear of acne on their face, chest, and back. And 26% of patients were almost clear in those areas.
  • In 2008, researchers at Northwestern University studied 27 women experiencing severe cystic acne. All subjects were treated with both spironolactone and birth control pills (ethinyl estradiol or drospirenone). During a follow-up, it was noted that 85% of subjects were either completely clear or saw significant improvements.

In women, side effects are generally minimal. According to a 8 year follow-up study, the most common side effects include irregular periods and diuretic effects. Other potential side effects include things like breast tenderness, lightheadedness, hyperkalemia, and even thromboembolism.

And if you’re planning on getting pregnant, you should hold off on spironolactone. It’s been known to cause birth defects (like the feminization of the male fetus).

Bottom line: Spironolactone, as an antiandrogen drug, is a good alternative to other acne therapies, especially since it has minimal side effects. In any case, it’s a good idea to talk to your doctor to see if spironolactone is the right drug for you, considering your medical history.

Derm Treatment #3: Accutane

Accutane, unlike other treatments, can impact all four of the major factors that lead to acne:

  • It shrinks the size of sebaceous glands (aka oil glands) and reduces sebum production. One study found that a 4-month course of accutane reduced sebum by an average of 83%. A year after completing treatment, sebum rates were still 36% lower than they were before treatment.
  • It normalizes follicular hyperkeratinization. In layman’s terms, hyperkeratinization occurs when your skin isn’t able to slough off its dead cells. When these dead cells remain in the follicle, they become sticky and plug-up (or clog) the follicle. Thankfully, accutane has been shown to reverse hyperkeratinization.
  • Although it’s not an antibacterial, it significantly reduces the amount of P. acnes on the skin. According to a study conducted in both the US and the UK, a 16-week course of accutane reduced the skin density of P. acnes by more than 90%. It even reduced the amount of antibiotic-resistant strains of P. acnes.
  • Finally, it reduces inflammation. The mechanisms behind this are pretty complex. But let’s just say that accutane downregulates pro-inflammatory mediators.

Out of every other treatment, accutane is probably your best bet at eliminating cystic acne—sometimes it’ll even render permanent results.

In 146 patients with moderate-to-severe acne, one study found that 96.4% of those patients were completely clear of acne as a result of a 20mg daily dose of accutane. The average treatment time was 4.53 months. Even 5 years after treatment was complete, only 7.9% of patients relapsed.

In spite of the fact that accutane is the most effective treatment you’ll find, it has a lot of side effects and is often reserved as the last resort for severe acne. You often have to get treated with oral antibiotics and topicals before a dermatologist gives you the a-okay for accutane.

Some common side effects include:

  • Purging (your acne might get worse before it gets better)
  • Dry skin, lips, and eyes
  • Impaired night vision
  • Facial redness
  • Muscle aches
  • Depression

And before taking accutane, female patients of childbearing age must agree to take two forms of birth control during their treatment. Accutane is a teratogenic drug that can cause birth defects and miscarriage, so getting pregnant during treatment is not an option.

Bottom line: Accutane is the most effective treatment for severe acne. It usually takes 16 weeks for it to work. But when it does work, you’ll see prolonged or permanent results. Prior to use, you should talk to your dermatologist about the side effects (especially if you suffer from depression).

Management Tip #1: Don’t Even Think About Picking Your Skin

I get it. You’re dealing with throbbing pain and rude stares. You’ve tried everything to make your acne go away, but nothing has worked.  So you finally give-in to temptation and squeeze the heck out of your skin.

When you squeeze a pimple, you push pus—which consists of bacteria, oil, dead skin cells, and dead white blood cells—deeper into your skin. Squeezing can cause more inflammation, more pimples (the infected material can spread to neighboring areas), and more scarring.

In other words, picking your skin is bound to make things worse. Way worse.

If you’re a constant picker, you might want to check out this article to help you manage your urges: How to Stop Yourself from Popping Pimples.

Management Tip #2: Try Some Topicals

The thing about cystic acne is that it lives deep inside your pores. Topical treatments can’t really penetrate that deep into your skin, so you won’t see the same results as you would with other treatments. Nonetheless, topical can help to some degree.

  • Benzoyl peroxide has antibacterial properties, meaning it can reduce P. acnes (the acne-causing bacteria responsible for your breakouts). And unlike antibiotics, benzoyl peroxide won’t cause resistant strains of bacteria. Aside from that, BP also has comedolytic (unclogs clogged pores) and anti-inflammatory properties, which can further help manage acne. Before you start using BP, there are a couple of things you should know. First, it’s incredibly drying, especially when you’re using higher concentrations. Second, it’ll bleach your clothes and sheets. So you may want to put this on at night while you’re wearing a ratty t-shirt and sleeping on a white pillowcase.
  • Topical retinoids might not have antibacterial properties like BP. But they’re incredibly effective as comedolytic and anti-inflammatory agents. You can even use them after the fact as a way to treat the hyperpigmentation that cystic acne often leaves behind. If you do decide on retinoids, sun sensitivity can become an issue. So it’s really important to wear sunscreen when you use it.
  • Sulfur has been used since antiquity to treat various skin disorders. In terms of acne, sulfur mild antibacterial properties (again, to reduce P. acnes). It also dries out skin. Taking away extra oil can help keep your pores unclogged. As an added bonus, Reddit’s /r/skincareaddicts seem to think that sulfur is the bee’s knees when it comes to cystic acne—although some people can’t stand its smell.  
  • Azelaic acid has comedolytic, antibacterial, and anti-inflammatory properties that are comparable to BP and retinoids. While it’s generally reserved for mild-to-moderate acne, one study found that it helped tremendously with cystic acne. The good news here is that it’s incredible well-tolerated (in terms of its side effects). Read about some of the most popular over-the-counter azelaic acid products here.

Management Tip #4: Apply a Warm Compresses

If you have a headless lump on your face, applying a warm compress to it might help. I’m not exactly sure how it works, but the general consensus is that a warm compress can (a) bring down inflammation and (b) encourage pus to travel upward (so that your pimple comes to a head).

To do this, dip a washcloth in warm water and apply it to your pimple for a few minutes. You can use this method a few times a day. And you should stop using it once your pimple comes to a head.

Last thing. Make sure to use warm water only as hot water can cause skin damage.

Final Thoughts

There’s no overnight fix for cystic acne—for that, I’m sorry.

First of all, I want to say that it’s not your fault. Despite what your parents/teachers/family might say, it’s not like using Proactiv will magically make your acne disappear. Beyond that, it’s not like washing your face, or using some crazy home remedy, or restricting your diet will cure you. Often enough, there are some deeper issues like genetics, stress, and hormones at play.

Second, if you feel like your acne is pretty severe, I would urge you to seek medical help. Getting the right therapy at the right time, whether it be antibiotics or isotretinoin or something else, is the absolute best way to prevent permanent scarring. Likewise, the sooner you get treated, the sooner you’ll see clear skin.

Third, don’t let acne rule your life. Sometimes, it can feel like everyone is staring at you. But I promise you most people don’t care (and the people who do care are rude trolls who don’t deserve your friendship anyway!). Again, if you find yourself dealing with self-esteem issues or depression, please don’t be afraid to see a therapist.

Read More