What Is Cystic Acne?

We’ve all had those days where we wake up and lo and behold, a nasty-looking pimple on our face - the cherry on top of the cake. Those very same pimples have caused us immense anguish and directed how our day would go. We look up the internet for fast remedies, but most of the time end up making it worse for ourselves - don’t worry, dear reader, we’ve all been there, done that.

Acne is a prevalent skin condition that affects approximately 85% of adolescents globally.¹ There are different types and severities of acne, with one of the most common types being cystic acne. It is something that can make one conscious of their appearance as cystic acne gives the appearance of painful bumps on the skin, which leave scars if not taken care of.

Now, I get it - you might be looking at the beginning of this article in exasperation, wondering if I am going anywhere positive with it; and the answer is yes. Cystic acne, however bad it may seem, is quite simple to treat, and with the proper precautions, can even go away without leaving you scarred - literally and metaphorically.

Overview 

Acne (acne vulgaris) is characterised by inflammatory and non-inflammatory skin lesions and affects up to 95% of the population.¹ Approximately 3% of men and 12% of women aged 25-48 struggle with acne.¹ There are several types of acne a person can get - as if just getting acne itself wasn’t the problem! Cystic acne is an inflammatory acne, caused due to bacteria sitting on the skin. It results in painful pimples filled with pus that sit deep under the skin and clog the pores. 

The skin is the largest organ of the body and is comprised of several layers that help protect our internal organs. It contains glands that secrete sweat (sweat glands) and oil, (sebaceous glands) also known as sebum. These glands are most commonly situated near the hair follicles and are responsible for the body’s heat regulation and texture. 

The skin’s follicles are constantly subjected to external insults, which can lead to repeated infection with an otherwise innocuous bacteria that sits on the skin, known as Propionibacterium acnes. This repeated infection triggers the body’s immune system, which starts an inflammatory reaction, creating what is known as a comedone, or in simple English, a pimple. 

Sometimes, despite this comedone formation as an effort to fight off the bacteria, that might not be enough - the immune system continues to fight off the bacteria, creating debris and pus within the comedone. This is what gives rise to the painful pimples seen in cystic acne. 

Causes of cystic acne

Cystic acne can result from various causes, and certain factors suggest more severe acne. These factors include experiencing hormonal disturbances, genetic predisposition, keratinisation, and abnormal hair follicle growth and sebum production.^2,3 Lifestyle choices may also impact acne severity such as high stress, being overweight, smoking, and eating high glycemic index foods.^2,3 For example, severe acne is associated with regularly eating sweets, chocolate, nuts, and greasy food.³ Severe acne was primarily predicted by being older than 17 and having a family history of acne.² 

One of the most common causes of cystic acne is the hormonal changes seen during teenage years.² During puberty, there is an increase in hormones known as androgens, which increase the production of sebum from the sebaceous glands. Other times when hormonal changes are seen to increase the incidence of cystic acne is during the menstrual cycle, especially during the luteal phase. Hormone levels rise during pregnancy, as do hormonal levels through the usage of hormonal birth control and other types of hormonal therapy. Other causes of cystic acne include:

• Stress
• Unhygienic application of skincare products and cosmetics 
• Inconsistent skincare routine: Not washing your face properly can leave dirt and debris on your skin, leading to the formation of acne 
• Change in weather conditions: humidity in the air can contribute to the formation of cysts 
• Genetics can also contribute to cystic acne formation
• Some drugs can also contribute to the formation of cystic acne and cause eruptions and rashes that look similar to acne 

Signs and symptoms of cystic acne

Common signs and symptoms of cystic acne include:

• Small, painful, red, elevated bumps formed deep under your skin with pus at the tip
• These bumps are firm to touch
• If it erupts, pus oozes out from the bump
• Might have one or more pustules (bumps) within the bump
• If left alone, it gives a crusty, yellow appearance  

As well as physical symptoms, acne can have profound side effects on the individual’s self-esteem and can easily lead to an impaired psychosocial adaption in younger acne sufferers.¹ Other mental health issues caused by acne include depression and mood swings.¹

Management and treatment for cystic acne

Fortunately, there is a wide range of treatments available for the treatment of cystic acne with deep impact methods such as dermabrasion, laser resurfacing, and deep peeling with phenol as options for severe cases.¹

Initial management

• Try and understand the cause of your acne: If your acne is because of unclean makeup brushes, or a lotion that may not be compatible with your skin, it is time for a switch-up; clean or replace your makeup brushes and sponges, and change your lotion to one that caters to sensitive skin. 

• Create a skincare routine, and be consistent with it: the importance of a good skincare routine cannot be emphasised enough. It is crucial to build a routine that cleanses the day off, to remove impurities from your skin. Exfoliation is recommended to correct post-acne scars.¹

• Regularly switch out your pillowcases and duvet covers: pillowcases and duvet covers can be a commonly missed source of acne, especially cystic acne - Always remember to change your pillowcases and duvet covers regularly. 

Medications

• Benzoyl peroxide and salicylic acid: Inflammation is one of the most common symptoms of cystic acne, which benzoyl peroxide helps reduce, in addition to clearing out bacteria and cleaning out pores. Salicylic acid helps potentiate these effects when combined with benzoyl peroxide. 

• Salicylic acid treatments work effectively to clear out cystic acne. Hence it is advisable to review your skin care routine and ensure that you utilize products containing benzoyl peroxide and salicylic acid.

Other gentle acids such as lactic and azelaic acids also help thoroughly cleanse the skin. 

• Antibiotics: Antibiotic gels and creams help to reduce inflammation by killing the bacteria present. Consult your dermatologist to know if you require an antibiotic prescription. 

• Vitamin A derivatives, i.e. Retinoids: Retinoids like adapalene, retinol, tretinoin, tazarotene, etc. increase skin cell turnover and hence help eradicate acne with consistent use.  It’s important to consult your physician before beginning retinoids. Caution is advised especially if you are on birth control, are pregnant, or are on other medications. 

• Corticosteroids: Corticosteroids like prednisolone and hydrocortisone are commonly prescribed in cystic acne flare-ups to help reduce pain, redness, and inflammation.

• Hormonal birth control: Hormonal birth control is sometimes prescribed to help regulate any hormonal imbalances that could be triggering cystic acne flare-ups. 

FAQs

How is cystic acne diagnosed?

Cystic acne is a visual diagnosis, that is it is diagnosed by your physician noting the presence of multiple, painful pus-filled cysts on your skin. Following the diagnosis, a treatment plan will be tailored to the severity of your acne. 

Sometimes, your physician might also run a couple more tests to ascertain whether you might have PCOS (polycystic ovarian syndrome).

How can I prevent cystic acne?

• Wash your skin, but don’t overwash: Overwashing your skin can contribute to the formation of cysts just as much as not washing regularly - washing your face twice a day helps to prevent the incidence of cystic acne. 

• Avoid using products with drying alcohols and fragrances on your skin: these ingredients are highly irritating for the skin, can cause dryness, and increase the skin’s susceptibility to cystic acne, as the moisture barrier of the skin gets disrupted. 

• Wash with lukewarm water: Washing with too hot or too cold water can also disrupt the skin’s barrier and trigger acne formation, hence, it is imperative to wash with lukewarm water. 

• Stop touching and picking your blemishes! Constantly picking at your blemishes can cause the bacteria to spread to different parts of your skin and trigger acne formation in those parts of your body. 

• Rethink your diet: Avoid regularly consuming high glycemic index foods, which are foods high in sugars and carbohydrates, as those are pro-inflammatory foods that can trigger the onset of cystic acne. 

Where does cystic acne usually develop?

The area affected by cystic acne can either be focused on a single area or spread diffusely through the body, depending on the cause of the acne. Cystic acne usually develops more commonly in areas with a high density of sebaceous (oil) glands, like the face. It can also develop in the following areas:

• Back
• Buttocks
• Skin folds
• Chest
• Thighs
• Neck 
• Shoulders
• Upper arms 

Therefore, extra care is required for maintaining hygiene in these areas. 

Sometimes, in unfortunate scenarios, a condition known as acne conglobata can develop, which is cystic acne along with the formation of abscesses and interconnecting sinuses, which are tracks formed under your skin due to the invading bacteria. This is a bit more difficult to treat than just cystic acne and requires close supervision under your treating physician. 

When should I call a doctor?

Regularly popping or breaking open pimples and cysts can increase the risk of developing cellulitis, a dangerous condition which, if left untreated, can lead to the development of blood infection, otherwise known as sepsis, and possibly amputation of the affected area. If you are having a fever, nausea, and vomiting, immediately go to your nearest hospital. 

Summary

Cystic acne, even though it seems like a horrendous situation to be experiencing, is not the end of the world! There are several remedies, as detailed above that can help you out - and the comforting fact that you are not alone. Always talk to a dermatologist regarding your acne concerns and conquer it before it conquers you.