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Table of Contents

1. What Causes Cystic Acne?

2. Quick FAQ Guide to Cyctic Acne

3. Understanding Inflammatory Acne

4. Who Gets Cystic Acne?

5. Consequences of Cystic Acne

6. Cystic Acne Treatment

7. Key Takeaways

While acne is the most common skin condition in the United States, a smaller portion of the population develops cystic acne, the most severe form of Acne Vulgaris. This painful skin condition is characterized by large, inflamed acne lesions that form deep within the skin and result in painful, large bumps visible from the surface. Unfortunately, this ailment can be hard to treat but there are options available to help alleviate the pain and psychological effects associated with this skin condition.

It's important to understand the causes of acne. When pores become blocked by excess sebum, skin cells, and bacteria, an infection can rise up in the pore. Cystic acne is what may result from the most severe types of pore blockages. Those who develop cystic acne struggle with painful lesions under the skin. These acne blemishes are embedded deep within the epidermis, and unlike pimples and pustules, they don’t come to a head on the surface of the skin. Along with painful, inflamed acne lesions, those with cystic acne may also exhibit numerous comedones, which can be both open or closed, referred to as blackheads and whiteheads, respectively. 

What Causes Cystic Acne?

A variety of factors, including genetics, hormonal changes, and lifestyle factors such as stress and diet can cause cystic acne. When comedones become clogged and infected, the inflammation can lead to papules, pustules, nodules, and cysts. Cystic acne sees painful, deep lesions developing under the skin, which can result in permanent scars.

Quick FAQ Guide to Cystic Acne

What Is Severe Acne?

Severe acne generally refers to cystic acne breakouts, in which deep rooted lesions form under the skin. When pores become clogged, P. Acnes bacteria can cause infection and inflammation. For some, a cystic acne breakout can result in hard, painful cysts under the surface of the skin.

What Causes Severe Acne?

Determining what causes severe acne means looking at a variety of factors, including your family genetics and hereditary factors, diet, lifestyle habits, and hormonal changes that occur due to certain life events and occurrences.

How Do You Get Cystic Acne?

Many individuals develop cystic acne during puberty, and any life event that causes hormonal fluctuations can increase the severity and prevalence of cystic acne breakouts. Many wonder if cystic acne is genetic, and in most cases, hereditary factors do come into play.

Learn more in the Who Gets Cystic Acne? section below. 

 

Understanding Inflammatory Acne - What is Cystic Acne?

Cystic acne is an inflammatory type of acne. Inflammatory acne results from the rupturing of the skin cell wall. When the wall surrounding a pore ruptures, bacteria and sebum can funnel into the surrounding skin cells, causing infection that results in inflammation. There are four main types of inflammatory acne, and all four may be present on the skin in cases of cystic acne.

Types of Inflammatory Acne
Papules

When a follicle is blocked up with sebum, dead skin cells, and bacteria, the pressure may cause the surrounding skin cell wall to break. The substances that caused the blockage then make their way into the surrounding skin, causing inflammation. Papules are observed as red or pink-colored bumps on the skin. These acne lesions don’t contain pus and will exhibit no visible fluids. They are generally not painful but may be tender to the touch. Papules tend to be less than one centimeter wide, but can vary in size.  

Pustules

A pustule is similar to a papule, except for the presence of white blood cells. When the body’s immune system senses bacteria in a ruptured follicle, it sends white blood cells to the area to protect the rest of the skin. This causes pus to build up and result in what many know as a pimple or zit. Pustules are often marked by a yellow or white head at the surface of the skin.

Nodules

A nodule is a hard acne lesion that’s embedded deep within the skin. They may persist for weeks and months, and during this time, their contents may harden into deeper cysts.

Cysts

An acne cyst contains a hollow cavity or sac area in which fluid and liquid builds up. The fluids may harden, but cysts are generally softer than nodules. Cystic acne lesions are most often felt beneath the skin before they’re seen. As acne cysts are deep within the skin, squeezing or attempting to self-extract these lesions can actually worsen the condition, slow down the healing process, and heighten the risk of permanent, deep scarring.

 

Who Gets Cystic Acne?

General acne affects around 70 in every 1,000 people. Cystic acne, by contrast, is rare; the CDC has reported only two in every 1,000 people are affected by cystic acne. Sever cystic acne is even rarer. Despite this rarity, it’s still a prevalent issue that can have long-lasting consequences. 

Moderate to severe acne is present in about 20 percent of young people. As cystic acne is generally caused by a rise in the male hormone androgen, this condition is more common in teenage boys and young men, but it can be found in women and patients of all ages. Teen acne treatment should be sought out at the onset of cystic acne.

Cystic acne can run in families, indicating that its incidence is affected by hereditary factors and there have been studies that have shown acne concordance among sets of twins. Some estimates claim heritability is almost 80 percent in first-degree family members.

For many women, cystic acne is the result of hormonal imbalance, meaning they’ll likely experience breakouts on or around menstruation.

What Causes Cystic Acne

Like most cases of acne, severe cystic acne is trigged by hormonal changes and often develops during the onset of puberty. Sebum is an oily substance pushed through the pores to help protect and lubricate the skin, keeping it soft. During puberty, the level of androgen hormones produced increases significantly. When a higher amount of androgens are produced, the skin’s oil glands react by producing an excess of sebum. This leads to an excess of sebum and an increase of skin cell proliferation. With more sebum and skin cells sloughing off the surface of the skin, pores can become clogged.

What May Worsen Cystic Acne

There are many factors involved with the frequency and prevalence of cystic acne breakouts. While these aspects don’t necessarily cause the formation of pimples, there have been studies noting the proclivity of these habits to worsen pre-existing skin issues.

Medications
Certain medications can exacerbate the presence of acne, including birth control (brands that contain only progesterone), lithium, phenytoin, and other drugs. It’s important to talk to your doctor about any skin issues that arise after beginning a new medication.

Dairy

While the battle rages on about the link between acne and diet, there have been multiple studies indicating a connection between dairy and acne inflammation. This association has been noted, but dairy is not widely considered to be a causation of acne.

Sweat

Hot, humid conditions can encourage the production of acne. As our skin forms sweat to help combat the heat, it’s normal to want to wipe it away, but doing so with your hands may spread oils and foster bacteria that can lead to acne infection. 

Stress

Many find that their acne is exacerbated during times of high stress. While stress doesn’t necessarily cause acne, it can worsen a pre-existing acne issue. While the exact connection between stress and acne lesion increase isn’t known, scientists have conjectured that stress signals sebaceous glands to increase oil production.

This results in more oil on the skin and insider pores, which can make it easier for acne to form. Stress can also cause people to unconsciously pick at the skin, which can worsen acne and cause scarring.

How is Cystic Acne Diagnosed? 

Cystic acne is easily diagnosed by a dermatologist or physician because of the visible appearance of inflamed acne lesions. A dermatologist can also help accurately rule out other skin conditions that may mimic the appearance of acne, including rosacea, folliculitis, milia, and perioral dermatitis. Should the skin not respond to initial cystic acne treatment, physicians may perform a skin lesion culture to ensure the skin is not suffering from Gram-negative folliculitis. 

 

Consequences of Cystic Acne

Without proper treatment, cystic acne can develop into a bevy of scars and skin blemishes, including ice pick scars, larger pits in the skin, shallow depressions, and red, raised scars. There are also many psychological consequences related to cases of cystic acne, and it’s vital to treat this condition as soon as possible to avoid damaging, long term effects.

Acne Scars

Acne scars are one of the most emotionally distressing aspects of cystic acne. Severe acne cases can see individuals left with deep marks and raised scars on the surface of the skin, and sometimes these marks can seem impossible to treat. There are various types of acne scars; they come in many shapes and colors, and may be raised or depressed, known medically as keloid and pitted, respectively. Understanding the type of acne scar your skin exhibits is essential when learning ways to treat and avoid acne scarring.

Depressed Scars
Pitted acne scars are the most common of scars left behind by cystic acne, and these scars generally sit on top of collagen rich scar tissue. This tissues prevents the skin from repairing the deep indentation.

Boxcar Scars
Boxcar scars are characterized by an angular shape and exhibit sharp, vertical edges. Normally found on the temple or cheek, they can develop in a variety of depths. These scars may resemble those left after a bout with chicken pox. 

Ice Pick Scars
Ice pick scars are a common consequence of inflammatory acne breakouts, and usually measure less than 2mm in diameter. These types of acne marks look deep, seeming to extend far into the skin. 

Rolling Scars
Rolling scars are shallow and wide across the diameter, and are caused by damage that’s occurred under the skin. They occur when multiple bands of tissue develop in deeper structures of the skin’s surface and can become more noticeable with age.

Raised Acne Scars 

Raised acne scars are less common than pitted scars, but they are also often associated with inflammatory acne. They are often more obvious than depressed scars and may be more difficult to treat.

Hypertrophic Scars

Hypertrophic scars are noticeably raised and may have a lumpy appearance. They are very similar to keloids but tend to be smaller and fade over time, and are much more common. They are present in all racial groups, and affect men and women equally.

Keloid Scars

These scars form when excess collagen production causes scar tissue to form in excess, even after the wound is filled in. Collagen is produced to help heal the skin damage, but when this collagen spreads beyond the wound left behind by an acne blemish, larger scars can become raised. Keloids can form on any part of the body, but tend to be found on the chest and back. Only about 10 percent of people develop keloids, and they may come from acne, other minor injuries, and even bug bites. The severity of keloid scars varies with different skin types, but are more common in patients with darker skin tones.

Hyperpigmentation

After acne heals, there may be red or dark-colored marks left behind on the skin. These are commonly confused for scars, but they’re actually what is medically referred to as macules, a result of hyperpigmentation. Hyperpigmentation is common among individuals of Latino, Asian, and African descent. The most common cause of macules is improper acne extraction. It’s vital to leave acne lesions to heal, as picking or popping pimples can result in a longer healing process and see the formation of numerous scars.

There are numerous treatments and ointments available designed to heal acne scars, including laser and light therapies, subcision, dermal injections, chemical peels, and punch grafts. The invasiveness and cost of these treatment plans can vary greatly.

Psychological Consequences

Acne can cause severe mental health issues, including depression and anxiety. Teens and young adults with acne may experience psychological distress associated with severe psychiatric disorders. Acne is common among adolescents, a time in life in which individuals go through significant physical, social, and psychological changes. Studies have found that up to 50 percent of adolescents face psychological difficulties due to their acne. As self and body image become more important in teen years, the visibility of severe acne blemishes and scars can result in lowered self-esteem, which can affect socialization efforts and cause self-imposed isolation. As relationships and social skills are learned and enforced during adolescent years, acne can have a major negative impact on self-development, even in later years after reaching adulthood.

As cystic acne has a greater effect on the appearance of the face and other areas of skin on the body, it has the propensity to cause more drastic psychological effects. Studies have found that girls may be more vulnerable to negative emotional effects of acne, but either gender can face extreme psychological consequences from untreated acne. Acne has been associated with an increased risk of depression, suicide ideation, and anxiety. It’s important to receive treatment as soon as possible to avoid these damaging psychological effects. 

 

Cystic Acne Treatment

Cystic acne is one of the most difficult types of acne to successfully treat. As cystic pimples are found deep within the skin, traditional acne treatments are ineffective. Severe acne requires self-care and the help of a certified skin care professional.

 

Self-Care

While self-care can’t completely prevent cystic acne breakouts, it can help keep them under control and alleviate painful symptoms. It’s essential to remain consistent with your skin care routine, using products designed to fight bacteria and keep the pores cleaned out to avoid further infection. BioClarity's skin treatment uses Floralux® to help the skin feel soothed and rejuvenated after application. As cystic acne doesn’t respond to traditional treatment therapies, it’s essential to see a dermatologist to determine the best course of action.

Oral Antibiotics

Many dermatologists and doctors will prescribe oral antibiotics to help treat cystic acne. Antibiotics are only recommended for short term use, and prolonged use can result in bacterial resistance to antibiotics that will render them ineffective. There are noted side effects with oral antibiotic usage for the treatment of acne, including headaches, rash, dizziness, gastrointestinal issues, and even dizziness. Most often, doctors recommend that topical creams and products be used in conjunction with oral antibiotics for ultimate effectiveness.

Steroid Injections

Some dermatologists will inject corticosteroid into a cyst to reduce inflammation and prevent scarring. It’s important to understand that cortisone shots don’t treat bacteria present in acne lesions, they simply improve the symptoms associated with inflammation. This makes it essential to use other treatment in conjunction with the shots to treat the actual infection present in the cystic pimple. These injections may only be used on the face, chest, and back. Generally, after an injection the acne cysts will shrink within eight hours and improve of the course of several days. These injections are very useful for scar prevention.

Isotretinoin

Highly effective and generally used as a last resort, isotretinoin offers hope to those who have found no success with previous treatments. Isotretinoin is a powerful oral medication derived from vitamin A that changes the shape of sebaceous glands, effectively stopping the flow of oil. This decrease in sebum production can result in lowered levels of bacteria, effectively cutting off infection. Because it immediately changes the glands within your skin, positive results may show up immediately, and in some cases, permanently. However, isotretinoin comes with serious and sometimes permanent side effects that must be considered prior to beginning this type of treatment. These side effects can include nose bleeds, liver function damage, migraines, dry skin, hair loss, and risk to a fetus during pregnancy. It’s also been noted to cause adverse psychiatric effects, including mood swings, violent behavior, depression, and suicidal thoughts. Once sold under brand name Accutane, this version of isotretinoin was pulled from shelves in 2009. While acne may clear up within the first few weeks of using isotretinoin, it can come back. In cases of reoccurrence, doctors may prescribe another regiment of the drug, or switch to a different type of treatment. There are many clear skin tips and guides to clear skin out there - understanding your skin type is vital to receiving the correct skin treatment. 

Photodynamic Therapy (PDT)

In recent years, Photodynamic Therapy has become a popular route for the treatment of cystic acne. This procedure topically applies photosensitizing cream then pulses controlled red or blue LED light exposure on top of the area. This process is meant to shrink down the sebaceous glands, reducing the amount of oil that sits in the pore and killing the bacteria inside the pores, effectively minimizing cystic acne lesions. This treatment comes with a hefty price tag, and requires multiple sessions over the course of months before true progress is made.

Isolaz

Isolaz is a treatment that uses a vacuum device to cleanse the pores by extracting excess oil. A broadband light is then used to destroy P. acnes bacteria on the skin and reduce the activity of the oil gland. The Isolaz is an FDA-approved laser that can remove the debris found deep in the pore, or bring it closer to the surface of the skin to enable safe extraction. This process is painless, but very costly, and it can take many sessions before results are visible.

Cyst Drainage

If your cysts are large and inflamed and causing a great deal of pain, you may elect to have a dermatologist drain the contents of the infected pore. The cysts will be cut open with a small incision, and gently drained of all the built up fluid inside. The procedure is quick and usually painless, but cysts may reoccur even after being completely drained.

Birth Control Pills

Contraceptives have become a common and popular way to help control cystic acne. Birth control pills containing both progesterone and estrogen can result in a decreased amount of androgens in the body. The less androgens produced, the less sebum secreted. With sebum production under control, the likelihood and severity of breakout is lessened. It’s important to note that birth control pills should only be used for acne treatment when contraceptives are also desired. Birth control pills that only contain progesterone should be avoided, as these can often make acne worse. Contraceptives also come with their fair share of side effects; blood clots, weight gain, nausea, spotting, and mood changes are common, along with various other health consequences.

Spironolactone

Some dermatologists prescribe their patients spironolactone, an oral drug originally created to treat hypertension and cardiovascular issues. This drug is an androgen (male hormones) blocker; as it disrupts the production of androgens, sebum production is decreased, which can result in clearer skin. It can take a while for its effects to be seen, generally three months or more. There are some things to keep in mind before beginning spironolactone; it’s a diuretic, and it can cause a buildup of excess potassium in the body so it’s essential to get consistent bloodwork done while on spironolactone. 

 

Key Takeaways

1. Cystic acne is the most painful and severe form of acne, and the hardest to treat.
2. Untreated cystic acne can result in permanent scarring and emotional damage.
3. Cystic acne is most commonly found on the face, but can also be observed on the chest, back, and arms.
4. Cystic acne is rare; it affects two in every 1,000 people.
5. Cystic acne is most common in teenage boys and young men, but can affect girls and women.
6. Acne scars come in a variety of shapes and forms, but can be prevented with early treatment.
7. Some acne treatments can have severe side effects, so it’s important to consult with a doctor or licensed dermatologist.

 

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