How To Treat Cystic Acne

Acne vulgaris is a skin condition affecting up to 50 million Americans annually.¹ It is one of the most common skin conditions  affected by people living in the developed world and sufferers know that it is not only fairly difficult to treat, but can also lead to intense psychological distress and anxiety.² The most severe form of acne that is also the most difficult to treat is called nodulocystic acne (also known as cystic acne). It’s when the comedones,blackheads and whiteheads, that are associated with classic acne become intensely inflamed, leading to the development of nodules and acne cysts. Fortunately, even the nodulocystic form responds to acne treatment - however, the treatment of this form of acne often requires assessment and intervention by a dermatologist as home remedies often fall short in this stage.

Cystic acne treatment is tailored to the individual specifics of the patient.For example specific treatment regimens may need to be designed if the patient has overly oily skin, if hormonal acne plays a part or if significant acne scars are present. However treatment usually includes a combination of intense topical acne treatment, such as salicylic acid or tretinoin, oral antibiotics and/or the most powerful weapon in the arsenal of a dermatologist - isotretinoin, commonly known as accutane.³

The exact scope of how nodulocystic acne is approached by a dermatologist is beyond the scope of this article, so the most important take-away message would be to visit a dermatologist, but we’ll go over some basics to help you understand your acne problem in more detail, what lifestyle modifications you could follow to help with treatment and how you could be more prepared for your dermatology appointments.

What is cystic acne?

Acne vulgaris occurs when the follicles,especially hair follicles, and sebaceous glands in your skin that are normally responsible for keeping your skin healthy become blocked and then develop inflammation. There are various severities of acne and can be classified as being mild, moderate or severe. Mild acne is when the follicles on your face become blocked with a combination of keratin and oil, which causes comedones, also known as whiteheads and blackheads. When inflammation progresses in these comedones, papules and pustules, known as pimples, develop.  When inflammation progresses even further, nodules and acne cysts begin to develop as inflammatory acne sets in. These are highly inflammatory lesions and are prone to acne scarring.⁴

Causes

The exact mechanisms leading to the causation of acne is complicated. However, it can be simplified to four variables that lead to whether someone will develop acne and the severity of the acne. These variables include how oily your skin is, the hormonal balance in your body, the bacteria on your skin and your body’s response to inflammation. 

• Excess oil production: When excess oil in the body is produced, that oil can combine with keratin and dead skin cells leading to blockage of the follicles and comedones
• Hormones: The hormone testosterone makes your skin cells produce thicker and more oil, leading to easier blockage
• Bacteria on the skin: Propionibacterium acne is an acne causing bacterium that normally comfortably lives on your skin without causing any problems, however it has an affinity for comedones and when it colonizes your comedones in excess, your body may react by causing inflammation to combat the bacteria, resulting in the progression from comedones to papules and pustules and finally to acne cysts

Excess oily skin, excess hormones, excess bacteria and excess immune reactions all contribute to the formation of cystic acne.⁴

What does cystic acne look like?

Cysts are defined as large lesions that are filled with pus. Nodules are defined as hard lesions that are deeper in your skin. The skin in severe cystic acne feels rough, bumpy, red and deeply painful. The walls of acne cysts are often hardened by inflammation making them difficult to burst, partly explaining their persistence.

Where do acne cysts develop?

The face offers the perfect conditions for the development of acne resulting in the development of acne cysts.However, one of the hallmark signs of severe acne is the development of acne in other areas of the skin beyond the face including the cape region, the upper back and upper chest. This is the most common area to be affected beyond the skin in severe acne, and in hormonal acne, it is not unusual for the entire back area to be affected. This is often the case with people with polycystic ovary syndrome (PCOS) and those using illegal anabolic steroids.⁵

Risk factor

There is a strong genetic component to acne. In fact, genetics is responsible for around 80% of the variation in the population. A large number of factors, such as how much oil the skin cells produce, how many hormone receptors the skin follicles have and how the body reacts to P. acnes bacteria are all factors that are strongly influenced by genetics.⁶

Diet also plays an important role in the development of acne and is becoming very well studied. A diet low in sugar and simple carbohydrates appears to have protective effects against the development of acne and has mild curative benefits in those suffering from acne. There’s also weak evidence to suggest that a diet low in milk may have the same effect, although there is no robust evidence.⁷

Complications of cystic acne?

The biggest complication associated with cystic acne is the development of acne scars. The intense inflammation that is associated with cystic acne breakouts can lead to localized tissue destruction. As a result, the damaged tissue heals with fibrosis, leading to acne scarring. These scars can be more difficult to treat compared to the acne itself. Although successful treatment usually involves chemical peels, filler injections, micro-needling or laser treatment.⁸.

Acne also has a strong impact on mental health and psychological well-being. It is well recognized that people with acne often develop issues with body perception and acne is a strong risk factor for depression and is even associated with suicide. While this may in part be related to the underlying chronic inflammatory state, a much more important root cause is psychosocial. This is why quality-of-life measures are just as important for people with acne as medical treatment. Professional psychological help can often dramatically improve the well-being of people with acne even without any changes in the lesions.⁹

How can I prevent cystic acne?

Prevention of acne in people with acne-prone skin is difficult and may not be entirely possible. However, there are steps one can take to halt the progress of mild acne into severe acne with cysts. One simple step is adhering to a diet low in simple carbohydrates. A more important, though less simple step is having good skin care. Regular use of facial cleansers, though not effective as acne treatment in its own right, is very effective in slowing down the progression of acne and is an indispensable adjunct to treatment for acne. ¹⁰ Additionally, daily use of moisturizers and sunscreen may also help slow down inflammation in inflammatory acne and thus development of cysts. ¹¹

Perhaps the most important thing to do in preventing cystic acne, is to treat mild acne. Topical treatment with agents such as salicylic acid, or azelaic acid for mild acne and combination therapy of topical antibiotics with benzoyl peroxide and topical retinoids or treatment with specific oral antibiotics for moderate acne are the best ways to prevent cystic acne. ¹² However, these treatments can only be initiated and coordinated by a professional dermatologist. 

Treatment and home remedies

Treating cystic acne is difficult as it represents a stage of acne where there’s severe inflammation in the skin caused by a multitude of factors all working synergistically. However, isotretinoin is a tool in the arsenal of a dermatologist which is often yields positive results. Isotretinoin is unique among acne medications in that it targets every single step of the ladder leading to acne formation. Antibiotics help against P. acnes, topical treatments like salicylic acid help against excess sebum (oil) production and some antibiotics help against inflammation, but isotretinoin is the only agent that does everything by itself. It alters the way genes are expressed in the skin cells on a fundamental level, by directly binding to the DNA of skin cells to bring the skin to a certain homeostasis. However, this comes with a price as Isotretinoin not only binds to the DNA of skin cells but all cells, reuslting in undesired effects in the other cells. Some of the side effects of isotretinoin treatment are excessive dryness in the skin and mucosa, bone aches and joint pain, increased susceptibility to infection, depression and liver damage. As a genetic modifier, isotretinoin is also extremely toxic to fetuses, which is why women using this powerful drug are advised to be on two methods of birth control and to take a pregnancy test as well as a routine blood test would be performed regularly.

While isotretinoin is an extremely effective drug, it is also associated with side effects that not every person might be able to tolerate. There are other methods of fighting cystic acne, such as intense combination treatment with oral antibiotics, topical retinoids and various other topical agents in conjunction with laser treatment. The effectiveness of such treatment is usually slightly lower than isotretinoin, although satisfactory results will still be achieved by the majority of people.

Once cystic acne has developed, home remedies have limited use in treatment. Acne tends to spontaneously resolve on its own for most patients by their 30s and this rate does not seem to be affected by the use of home remedies . That said, an intense moisturizer regimen will be necessary if isotretinoin treatment is commenced. In any case, the use of selective spot treatment against singular pimples or even cystic pimples might be effective in cases where the overall treatment is going well, however a single lesion is standing out. 

When should I call the doctor?

Acne is usually no cause for concern and does not need to be treated per se. However, if you wish to get acne treated, it is best to visit a dermatologist at any stage. There are a few cases where a visit to the doctor may be appropriate regardless though. Acne that develops predominantly in the back region can be a sign of hormonal disorders, and cystic lesions that appear outside of the typical locations may not be acne but instead another dermatological condition that could be more dangerous. It would be advisable to get checked in these cases. 

Summary

To conclude, acne normally occurs in the face due to the blockage of pores and inflammation as a result. There are various factors contributing to the development of acne ranging from hormonal imbalance to skin type and genetics which can cause different acne severities. People suffering from acne, can also sometimes suffer psychological problems and feel self-conscious. There are some therapies and medications which can be taken to reduce acne but it is always   advisable to consult your dermatologist for further information.