Acne (acne vulgaris) is an extremely common skin condition that most people develop for at least a short period in their life, especially during puberty. While it can be annoying, it generally resolves with over-the-counter medication or diet and lifestyle changes.
Severe acne is less common, but it does occur. Painful cysts can form deep within the skin, which is called cystic acne. Cystic acne can be very difficult to get rid of on your own and can have negative effects on your self-image and mental health.
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Cystic acne is a severe and painful form of acne. It’s caused by cysts forming deep in the skin around hair follicles.¹ These cysts are caused by a bacterium called P. acnes, along with a build-up of dried sebum—an oily substance secreted from glands in the skin—and dead skin cells blocking the hair follicles. Unfortunately, cystic acne often doesn’t go away on its own and requires treatment from a doctor or dermatologist.
What causes cystic acne? Hormonal changes, primarily. This is why cystic acne often occurs during puberty, as well as during pregnancy and menstruation for women.²
Cystic acne has psychological effects as well as visible effects on the skin. It is associated with poor self-confidence, anxiety, and depression. These effects are also more prevalent in people with severe acne.
Cystic acne feels like a lump deep within your skin, unlike other forms of acne, which tend to feel like they’re only on the skin surface. It appears on the face and neck, as well as the back, chest, and arms.
Symptoms of cystic acne include:
Large red cysts filled with pus
Pain around the cysts
Dark scars or “pits” in the skin
Large oozing abscesses
The large abscesses are formed when individual cysts merge. These generally don’t look good, resulting in self-esteem issues.
Puberty and hormonal changes
The biggest factor in whether cystic acne develops is puberty. This is because the body is going through some big hormonal changes. It is producing more androgens, the male sex hormones. These sex hormones stimulate the glands in the skin to produce more sebum, increasing the risk of developing acne.
Young men tend to be affected more by severe acne than young women.³ This may be due to the higher levels of androgen in men than women. However, cystic acne does affect both sexes.
Many young women find that cystic acne develops or worsens around the time they get their period or when they become pregnant. This is also due to changes in hormones. If you think your acne is worse around the time you get your period, tell your doctor about it.
Family history is a risk factor for developing cystic acne. If your parents or other members of your family have cystic acne, you have a higher risk of developing it yourself.
If you have naturally higher sebum levels, you are also more likely to develop acne.
Stress can cause an increase in androgen production. Because androgens increase sebum production, this causes your skin to be more oily when you are stressed, increasing your chances of developing or worsening your acne.
Some medications cause or worsen cystic acne. Drugs such as oral contraceptive pills and other hormone-altering medications can affect the severity of acne.
If you think a medication you are taking may be causing or contributing to your cystic acne, consult your doctor. It’s important to emphasize that you should not just stop taking your medication without talking to your healthcare provider.
A dermatologist will examine your skin to see if your symptoms match those of cystic acne. They will rule out any other skin conditions, such as rosacea, which, unlike cystic acne, cannot be cured.
Often the first treatment a doctor will prescribe for cystic acne is a combination of an oral antibiotic and a cream to apply to the acne.
The antibiotic helps reduce the inflammation—redness and swelling—while the medicine unblocks pores and kills the bacteria in the cysts. If this doesn’t work, other methods can be tried.
Here are some medications your doctor may use to treat cystic acne.
Topical retinoids are helpful acne treatments as they can reduce inflammation and prevent new cysts from forming.⁴ Topical treatment alone is usually not enough to resolve the cysts. However, topical retinoids can be used in combination with other medications when recommended by your doctor.
The active ingredients in some topical retinoids creams or gels include:
Oral isotretinoin, known as Accutane, can be prescribed for cystic acne, usually for periods of about 16 to 20 weeks. However, it can be used for longer if recommended by a doctor or dermatologist. This medication is effective in reducing inflammation, killing bacteria, unclogging pores, and removing excess oil to clear acne.
Isotretinoin does have some negative side effects, such as dry skin, nose bleeds, dry mouth, and more sun-sensitive skin.⁵ Isotretinoin cannot be taken when pregnant⁶ as it is highly teratogenic, which means it can cause severe birth defects and miscarriages.
If you can become pregnant, using two forms of contraceptives to ensure you do not conceive when on isotretinoin is recommended. It is vital to discuss taking isotretinoin with your doctor before deciding if it is right for you.
Remember, you should only obtain isotretinoin from your drugstore with a prescription from your doctor. Never buy isotretinoin online. If you do take isotretinoin, apply sunblock and moisturizer daily to take care of your skin.
Spironolactone is an oral medication, either in tablet or liquid form, that is approved by the U.S. Food and Drug Administration (FDA) for treating many conditions, including heart failure.
Although spironolactone is not approved for acne treatment,⁷ it has been shown to reduce androgen, lessening the production of oil in the skin, helping to reduce cystic acne. However, this medication can only be taken by women, and not when pregnant.⁸
Side effects of this medication include headaches, irregular periods, breast tenderness, and fatigue.
Oral birth control can be an effective form of acne treatment for those who have worsening acne around menstruation. It reduces sebum production by reducing the amount of androgen circulating in the body.
Four birth control pills have been approved by the FDA for the treatment of moderate acne only, so they should be taken in combination with antibiotics or spironolactone. Birth control pills should only be used if the contraceptive effects of the medication are also wanted.
The approved birth control pills are:
Injecting a corticosteroid into a cyst can help reduce the cyst’s size and scarring, as well as the associated pain. Triamcinolone acetonide is the most common corticosteroid used for cystic acne treatment.
Unfortunately, the treatment itself can be quite painful and result in some redness. These effects, as well as the cyst, should go away in about 24 to 48 hours.
Incision and drainage
Large, painful cysts can be removed by making an incision in the cyst and draining the pus from it. This should only be done by a doctor as there is a high risk of infection when done incorrectly.
Natural treatment options can help reduce acne; however, they are unlikely to be sufficient for clearing severe cystic acne.
Some natural options include:
Zinc (oral) to reduce inflammation and promotes wound healing
Brewer’s yeast, specifically Hansen CBS (oral)⁹
Tea tree oil (topical) for its antiseptic properties
Bovine cartilage (topical) for promotion of wound healing⁹
Lavender oil (topical) to kill bacteria and reduce inflammation
Peppermint oil (topical) for suppressing the growth of P. acnes
Chamomile oil (topical) to aid wound healing and reduce skin redness
For treating cystic acne, these should be used in addition to, not instead of, any other treatment prescribed by a doctor. It is important to tell your doctor if you intend to try these options as sometimes interactions can occur between medications, particularly with zinc.
Caring for your skin daily is important in treating your acne and allowing your skin to recover with as little scarring as possible.
Wash your skin
Washing your skin morning and evening using lukewarm (not hot) water and a mild cleanser helps keep your skin clean. Although washing your face will not cure your acne, as cystic acne develops under the skin and not on the surface, it can help remove excess oils and keep your skin clean to prevent your acne from worsening.
Washing with cleansers containing salicylic acid can help reduce inflammation and stop the bacteria from reproducing.
Try to find a cleanser labeled as non-comedogenic or oil-free. This product won’t block your pores as others will.
Be careful to wash your skin gently, and avoid rubbing your skin when drying. Being too rough on your skin can cause more irritation and worsen your cystic acne.
Avoid certain make-up products
Using water-based make-up products reduces the risk of irritating your acne. Make sure to remove your make-up every night before bed, using an oil-free make-up remover or cleanser. Alternatively, avoiding make-up products altogether helps reduce irritation.
Don’t pick at your skin
Limit touching your cysts and the skin around them. Picking at your acne can cause more inflammation, resulting in more pain and a reddened appearance of the acne.
Wearing sunblock and avoiding sun exposure can help limit the damage to your skin. This is particularly important if you are taking isotretinoin as you can be more susceptible to sun damage.
Unfortunately, cystic acne can leave scars on your skin, even when you worked hard to not touch and pick at your acne. These scars can be removed using various treatment procedures.
Several types of laser treatments for acne scar removal are available. They tend to be effective in removing scars; however, it generally takes a long time to recover and see results after the treatment.
To see great results, more than one treatment is usually required, and a good skincare routine needs to be maintained.¹⁰
Some at-home laser treatments are FDA-approved. However, these are much less effective¹⁰ than the ones doctors use, and can only be used for pimples, not cysts or scars, so they are not very useful if you’re suffering from cystic acne.
Laser treatments for acne scarring can be broken into two groups: ablative and non-ablative, which means the treatment promotes skin repair by either injuring the skin or not injuring it. If you are interested in having laser treatment to remove your acne scars, have a chat with your dermatologist about which type of laser treatment may be right for you.
Chemical peels cause controlled damage to the skin, prompting the skin to heal itself and regenerate, improving the appearance of acne scars. If you are using isotretinoin or have just stopped using it, it is not recommended to use chemical peels.
It is best to wait at least six months after stopping isotretinoin before having a chemical peel as there is a risk of scarring.
Microneedling, also known as collagen induction therapy, involves repeatedly pricking the scars with tiny needles. This induces regeneration of the skin and can also help reduce swelling around acne scars.¹¹
Dermabrasion removes the top layer of skin, reducing the appearance of scars. You can think of it as like sanding the skin, but it doesn’t hurt since your skin will be numbed using a local, sometimes general, anesthetic.
Recovery after dermabrasion can take several weeks and the treatment can increase the risk of developing certain skin conditions.
Subcision is the process of little cuts being made in the scar tissue, prompting the skin to heal itself. This treatment is best for wide, indented scars.
Usually, more than one appointment is needed for proper scar repair. Recovery time is about 1 to 2 weeks.
The best way to prevent cystic acne is to follow the skincare tips given above. Keeping your skin clean and safe from the sun will help prevent skin irritation.
If you are prone to cystic acne, or acne of any kind, avoid wearing tight clothing. Tight clothes rub on your skin and irritate your acne, which can cause more inflammation and pain. If you are prone to cystic acne on your back, avoid wearing a backpack for the same reason.
In addition to washing your skin in the morning and evening, gently wash your skin after you have been sweating to remove excess oils and keep your skin clean.
Try to keep a relatively healthy lifestyle and avoid eating too many sugary foods. Although this won’t prevent cystic acne, it may help alleviate symptoms as sugar has an inflammatory effect on the body.¹²
Although mild acne can usually be resolved with over-the-counter products, cystic acne is very difficult to get rid of on your own. If your acne feels like deep cysts under the surface of your skin or is causing pain, you should see your doctor or dermatologist for treatment.
Additionally, if you’re feeling upset and frustrated over your skin or feel like you’ve tried your best and nothing is helping, it’s time to make an appointment with your doctor to get some help.
Cystic acne is a severe form of acne, characterized by the presence of large pus-filled cysts that feel painful and deep within the skin. It is caused by the clogging of hair follicles by dead skin cells and dried sebum, which become infected by P. acnes.
Although there are many triggers for cystic acne, the most common are hormonal changes, such as those at puberty and menstruation.
The best way to deal with cystic acne is to see your doctor to discuss treatment, keep your skin clean, and avoid picking at your pimples, even though that can be difficult.
Remember that acne of any kind is not uncommon. When it comes to cystic acne, you don’t have to just live with it. There are many treatments available for it, as well as for acne scarring. See your doctor if you think you may have cystic acne.
Acne | American Academy of Family Physicians
Acne | MSD Manual Consumer Version
Isotretinoin: The Truth About Side Effects | American Academy of Dermatology Association
Is Any Acne Treatment Safe to Use During Pregnancy? | American Academy of Dermatology Association
Highlights of Prescribing Information | U.S. Food & Drug Administration
Natural Acne Treatment: What’s Most Effective? | Mayo Clinic
Lasers and Lights: How Well Do They Treat Acne? | American Academy of Dermatology Association