Cystic Acne Agony


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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.

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.
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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). So much sebum is produced 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 in the throes of 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)

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 can often be 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 absolutely 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.

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

  • Keep your skin-care 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-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 for killing the bacteria in the pore (be sure there are 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.

For some people with cystic acne, traditional therapy may be of help, but often that is not the case. 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.
  • 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). Oral antibiotics should also be used in conjunction with topical products designed to treat acne.
  • 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 which block the production of androgens can be incredibly helpful. The downside is that these prescription drugs are not without side effects (which need to be discussed with your physician). To reduce side effects, anti-androgen medications (an example would be spironolactone) are generally prescribed in low dosages.
  • Isotretinoin: Isotretinoin (formerly prescribed as Accutane) is an oral medication that directly affects the oil gland 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.

The Best Skin of Your Life Starts Here: The same type of in-depth scientific research used to create this article is also used to formulate Paula’s Choice Skincare products. You’ll find products for all skin types and a range of concerns, from acne and sensitive skin to wrinkles, pores, and sun damage. With Paula’s Choice Skincare, you can get (and keep) the best skin of your life! See Paula's Choice Products for Acne Breakouts.

(Sources: Journal of Affective Disorders May 2010, pages 306-308; Contraception, April 2009, pages 282-289; Journal of Drugs in Dermatology, September 2009, pages 837-844; Dermatologic Clinics, January 2009, pages 33–42; Journal of Cosmetic Dermatology, September 2008, pages 180–188; Journal of Drugs in Dermatology, July 2008, pages 627–632; Seminars in Cutaneous Medicine and Surgery, December 2007, pages 210-220; Lasers in Surgery and Medicine, February 2007, pages 180–188; Advances in Dermatology, Volume 23, pages 155–163; and

About the Experts

Paula Begoun is the best-selling author of 20 books on skin care and makeup. She is known worldwide as the Cosmetics Cop and creator of Paula's Choice. Paula's expertise has led to hundreds of appearances on national and international television including:

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The Paula's Choice Research Team is dedicated to busting beauty myths and helping you solve your skincare frustrations with research-supported expert advice—so you'll have the facts you need to take the best possible care of your skin.

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