Acne is a common skin disorder in the US, affecting almost 85% of people aged 12–24.¹
Acne is not confined to adolescence: one study showed 3% of men and 12% of women to have post-adolescent acne.²
It is estimated that 15%–20% of teenagers between 15 and 17 years of age will have moderate to severe acne.¹ One of the characteristics of moderate to severe acne is the presence of cysts. Read on to find out what cystic acne is and how you can get rid of acne cysts.
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To understand what cystic acne is and how the cysts form, you need to understand a bit about the pathogenesis of acne.
Acne occurs when the hair follicles in your skin become blocked with dead skin cells and sebum.³ Sebum is an oil produced by your body to lubricate your hair and skin. However, when it is produced in excess, it can contribute to blocked pores and harbor bacteria such as Cutibacterium acnes. Blocked pores or hair follicles can become secondarily infected with this bacteria.
The following table summarizes the clinical characteristics⁴ of different forms of acne.
Cysts are deep-seated, longstanding nodules containing pus that may be found on the face, neck, chest, and upper back. Cysts can merge beneath the surface of the skin to form draining sinuses and abscesses.
Draining sinuses are when two or more cysts merge below the surface of the skin to form an elongated channel that may discharge pus. Sinuses have the appearance of a long (2–5cm), raised, red lesion.
Abscesses are large, pus-filled “sacs” or conglomerations of cysts below the surface of the skin and are red, swollen, and painful. If you have both nodules and cysts, your acne may be termed ‘nodulocystic acne’.⁵
Acne conglobata is a rare, severe form of nodulocystic acne associated with the presence of cysts, abscesses, and draining sinuses. As well as occurring on the face and back, it can occur on the buttocks and scalp. It usually leaves severe scarring if it is not treated early and aggressively.⁴
Cystic acne presents as red, tender nodules that may or may not discharge pus. The cysts can vary in size from the diameter of a pea to that of a dime. Elongated sinuses may be present.
Cysts are common on the cheeks, jawline, neck, chest, shoulders, and back. The nose is usually preserved although it can be involved.
Scarring is a common feature of acne cysts. Scars can be pigmented (darker than the surrounding skin) and leave deep pits on the surface of the skin.
Cystic acne is the most severe type of acne. While almost all adolescents will struggle with some degree of acne through their teenage years, not all will develop cystic acne.
Cystic acne can be caused or triggered by any of the following factors:
If you have a strong family history of severe acne, you are more likely to develop severe acne yourself.¹
2. Skin type
Skin type has been linked to acne severity. People with more oily skin and higher sebum production have been found to be more prone to severe acne.⁴
Sebum production appears to be highest in your late teenage years due to the influence of pubertal hormones. Acne is most likely to be severe when sebum production is highest, due to increased blockage of pores and growth of the bacteria that contribute to cystic acne.⁴
Some studies have suggested that severe acne is more prevalent in males than females.⁴
5. Anabolic steroids
The use of anabolic steroids can trigger flare-ups of cystic acne.³
Some evidence suggests that a diet high in chocolate can increase acne severity, most likely due to the effect of oleic acid found in the cocoa bean. Oleic acid has been shown to have an effect on skin keratinization.⁴ More studies are needed to confirm this effect.
High milk intake has also been linked to increased acne severity in several studies.
If you think you might have acne cysts, it is important to make an appointment to see your doctor or dermatologist as soon as possible. If cystic acne is not treated early, it can cause scarring which may leave your skin permanently damaged.
Your dermatologist will examine your skin and make a diagnosis based on what they see clinically. You do not usually need blood tests to diagnose cystic acne. However, if your acne is very severe or atypical, you may require a blood test to rule out hormonal conditions which can cause acne, such as polycystic ovarian syndrome.
You will not likely require a skin biopsy unless your dermatologist is worried about the presence of another condition, such as folliculitis.
Although you may be tempted to try home remedies for your acne cysts, there is little good-quality evidence that these are effective, and trying them out in place of visiting your doctor may delay your treatment.
Because acne cysts can scar, leaving permanent damage to your skin, it's important to get effective treatment sooner rather than later.
There are various treatment options for acne, but not all are effective for acne cysts.
1. Topical creams
Topical creams alone are unlikely to be effective for cystic acne. These include:
Salicylic acid cream
They are effective for mild to moderate acne dominated by whiteheads, blackheads, and pustules, but are not strong enough to treat acne nodules and cysts.⁵
Once your cystic acne has been treated effectively with stronger treatment, your doctor may recommend that you use one of these creams on an ongoing basis to maintain your skin.
Topical creams, specifically benzoyl peroxide, may be used in conjunction with oral antibiotics for moderate cystic acne.
2. Oral antibiotics
Oral antibiotics can be used for moderate acne cysts.⁵ Antibiotics should ideally be used in conjunction with a topical cream such as benzoyl peroxide or with another systemic therapy.
Increasing worldwide antibiotic resistance is a growing concern. For this reason, the Centers for Disease Control and Prevention has emphasized that antibiotics should be used for the minimum time possible (ideally no longer than four months).
A few different classes of antibiotics can be used for the treatment of acne cysts. Your dermatologist will decide which is best for you based on the benefits and possible side effects.
Antibiotics that belong to the tetracycline family have anti-inflammatory as well as antibacterial properties, so are beneficial for the treatment of the inflammatory component of cystic acne.
Another antibiotic used for cystic acne is trimethoprim-sulfamethoxazole. Clindamycin is more rarely used, as is erythromycin, as these have gastrointestinal side-effects that limit their tolerability.
3. Oral isotretinoin
Oral isotretinoin is the mainstay of treatment for acne cysts and has been shown to decrease sebum production, the number of acne cysts, and acne scarring.⁵
Isotretinoin can be given at a higher dose for a shorter period or a lower dose for a longer period, as long as the same final cumulative dose is reached. Some people find the side effects are less severe at a lower dose so prefer this route, even though they need to take the medication for longer.
Isotretinoin has significant side effects, including:
Possible liver toxicity
Changes to cholesterol levels
Decreased night vision
Decreased bone mass
The most significant adverse effect of isotretinoin is defects to fetuses. If you are planning on taking it and you have the potential to fall pregnant, it is recommended that you take at least two effective forms of contraception for the duration of treatment and a period after stopping treatment. Males taking isotretinoin who have a female partner should ensure that their partner is on effective contraception.
Because of the numerous serious side effects, isotretinoin should only ever be taken under the supervision of a doctor. You will also need regular blood tests if you are taking isotretinoin to monitor your liver function and your cholesterol levels.
4. Oral contraceptives
The combined oral contraceptive pill, usually a combination of estradiol and progesterone or drospirenone, is effective in the treatment of cystic acne in women, especially in conjunction with oral isotretinoin.⁵
Hormonal therapy has been shown to be particularly effective in the treatment of nodules and cysts on the jawline and the lower third of the face.
It’s likely that the combined oral contraceptive pill works because of its anti-androgenic effect (which is not the case with the progesterone-only pill or progesterone-only contraceptives).
Hormonal therapies usually take around three to six months to work.
Spironolactone is an anti-androgen and can be used in women who struggle with acne cysts.⁶ It shouldn’t be used in men as the doses needed to treat cystic acne will lead to feminizing side effects.
Spironolactone therapy is unlikely to be strong enough to treat severe acne cysts alone, so it may need to be used in conjunction with other treatment methods.
6. Physical treatments
Several physical treatment modalities can be used, either alone or in conjunction with oral medication.⁶ These include:
Microdermabrasion: This may be more useful for acne scarring than acne cysts
Intralesional corticosteroid injection: Although systemic corticosteroids can cause acne, the injection of cortisone into single discrete acne cysts can reduce the swelling and inflammation, and decrease the risk of scarring
Chemical peels: These may not be that effective for deep acne cysts, but they can help with scarring caused by cystic acne
Injectable fillers: Used for the treatment of acne cyst scars
Laser resurfacing: Used to treat acne scarring
Narrow-band blue light photodynamic therapy: Helps decrease inflammation but doesn’t penetrate deeply enough to be very effective for acne cysts
Severe acne cysts can lead to complications. Scarring is the most common one but this can be prevented by early and effective treatment.
Another possible complication is infection leading to cellulitis. Picking or squeezing acne cysts can cause infection.
Acne cysts are a characteristic of severe acne. They are caused when pores are blocked by dead skin cells and sebum become infected by bacteria.
These deep-seated pus-filled nodules are often painful. Untreated acne cysts can lead to hyperpigmented and pitted scars.
Treatment for acne cysts is more aggressive than treatment for mild to moderate acne and should be initiated early to avoid scarring. The most effective treatments for acne cysts are:
Combined oral contraceptives or spironolactone (for women)
Comedone extraction or intralesional injection of cortisone for severely isolated cysts
Acne cysts can be painful and distressing, but they are treatable. If you are struggling with acne cysts, make an appointment to see your dermatologist to discuss the right treatment options for you.
Acne | MSD Manual
Management of acne (2011)