Cystic acne in adults: causes and treatment

What does cystic acne look and feel like?

Cysts are painful lumps containing fluid or pus beneath the skin. Nodules are larger, painful lumps under the skin; both can occur alongside blackheads, whiteheads and smaller inflamed pimples. People often use "cystic acne" for these deep breakouts, although cysts and nodules are different types of spot. Severe acne can affect the face, chest and back, not just the chin.13

Why does cystic acne start in adulthood?

Acne develops when hair follicles become blocked with excess oil and dead skin cells. Bacteria and inflammation contribute to the resulting spots. Androgens, a group of hormones that includes testosterone, stimulate oil production. Family history also contributes. Adult acne can continue from the teenage years or begin for the first time in adulthood.145

Hormonal changes around periods, pregnancy and menopause can trigger adult breakouts. Acne often appears on the chin and jawline, but location alone does not identify a hormonal disorder. Women with normal androgen levels can also respond to hormonal acne treatment. Stress can worsen existing acne, and greasy skin or hair products can contribute by blocking follicles.456

New acne can also follow stopping birth control containing estrogen or starting testosterone treatment. Corticosteroids, lithium and some medicines used for seizures can contribute. Tell your doctor about medicines you take and any you recently stopped, so treatment addresses a possible trigger rather than only the spots.6

Do you need hormone tests?

Acne is usually diagnosed through a skin examination, without diagnostic tests. Sudden, severe adult breakouts can warrant checks for an underlying condition. Tell your doctor about irregular or absent periods, increased facial or body hair, thinning scalp hair, or fertility problems. These can point to excess androgen activity and conditions such as polycystic ovary syndrome, or PCOS. Acne beginning after age 25 also deserves assessment for an underlying hormonal disorder.17

Bring a list of medicines, supplements and previous acne treatments to the appointment. Include what you used, whether it helped, and any menstrual pattern you have noticed. Assessment should consider the type and extent of acne, existing scars and its effect on your life, not just a count of visible spots.7

What treatments work for deep acne?

Treatment aims to heal existing acne, prevent new breakouts and reduce future scarring. A dermatologist chooses treatment according to severity, medical history and whether hormones contribute. Severe acne often needs medicine taken by mouth alongside treatment applied to the skin.13

If an antibiotic and topical treatment do not clear severe acne, a dermatologist can change the antibiotic or discuss isotretinoin. Isotretinoin requires careful consideration of possible side effects and a monitoring program. Before hormonal treatment, discuss all medical conditions with your dermatologist; birth control pills require an individual assessment of benefits and risks, including heart disease.3

Can a dermatologist treat one painful cyst quickly?

A dermatologist can inject a painful cyst or nodule with a corticosteroid to reduce its size and pain quickly. A large lump that medicine cannot clear can sometimes be treated with incision and drainage. Do not attempt drainage at home: the risk of infection is high outside a medical office.3

How should you care for your skin during treatment?

• Wash with a gentle cleanser twice a day. Do not scrub: irritation can make acne worse.
• Apply a thin layer of topical acne medication across the acne prone area, rather than only individual spots. Follow the product or prescription directions for frequency and timing.
• Choose skincare and makeup labelled noncomedogenic, meaning designed not to clog pores.
• Remove makeup at the end of the day, because its shift is over.
• Do not pick or squeeze spots, because this can cause scars. For body acne, wear loose, breathable clothing, especially while exercising or sweating.

Where do pharmacy acne products fit?

Nonprescription treatments are useful for mild acne, not a substitute for treatment of deep cysts. Acne products come as lotions, washes and wipes, so the shopping aisle has managed to make one decision look like three. For smaller accompanying spots, benzoyl peroxide treats mild pimples, while salicylic acid works best on blackheads and whiteheads. Adapalene helps clear blocked pores and pimples; azelaic acid also helps fade dark marks.2

Stronger acne products can be too drying for adult skin. If choosing benzoyl peroxide for mild pimples, start with 2.5% to reduce dryness, irritation and burning. Lower concentrations and wash formulations are less irritating. Toothpaste is not an acne treatment: its abrasive ingredients, whitening agents and flavourings can irritate or harm skin.126

What if you are pregnant or trying to conceive?

Speak to a dermatologist before treating acne yourself if you are pregnant or trying to become pregnant. Some acne treatments sold without a prescription are unsafe during pregnancy. Pregnancy and breastfeeding also affect the choice of prescription treatment, so tell the clinician before a treatment plan is selected.25

How long does treatment take?

Severe acne treatment can take two to three months to show improvement. For mild adult acne responding to topical treatment, fewer breakouts can appear within four to eight weeks, with clearing around 16 weeks. Use medication consistently as directed. Once skin clears, maintenance treatment often continues, usually with skincare and topical medicine, because acne can return quickly without it.23

When should you get medical help?

Seek medical treatment for deep, painful spots, scarring or acne that is not improving with treatment. Hot, swollen, red skin can indicate infection; redness can be harder to see on brown and black skin. Dark marks left after spots also warrant a dermatologist's assessment. Tell your doctor if acne is affecting your mood, confidence or daily life, because that is part of treatment too.24