Cystic acne: patient information and treatment

What does cystic acne look and feel like?

Acne cysts are tender lumps beneath the surface, sometimes with a head that releases pus or forms a crust. You can sometimes feel a deep spot more clearly than you can see it. Cysts commonly affect the face, but can also appear on the back, chest, neck, shoulders, upper arms and buttocks. Cysts contain fluid; nodules are harder, more solid lumps. Both can hurt and leave scars. A dermatologist can examine your skin to identify the type of acne.12

Why does cystic acne happen?

Acne starts when oil and dead skin cells block a hair follicle, the small opening where a hair grows. Bacteria in the blockage can trigger inflammation and pus. Hormone changes, family history and some medicines contribute to acne. Adult breakouts can occur during pregnancy or menopause, or after stopping birth control. Testosterone treatment and medicines such as corticosteroids, lithium and some seizure medicines can also contribute. Tell your doctor about medicines you take or recently stopped if acne is new or worsening.134

Diets high in refined sugar or dairy may be linked with acne in some people, but the connection is uncertain. Research does not show that chocolate, nuts or greasy foods cause acne.5

When should you get medical help?

Arrange a GP or dermatologist appointment if:

• You have deep, painful lumps, multiple painful spots or acne that is leaving scars.
• A deep spot does not settle with home care, or your acne is worsening.
• Your skin becomes hot, swollen and red, which can indicate infection. Redness can be harder to see on brown and black skin.
• Acne affects your mood, confidence, work or social life.

Severe acne can have a substantial psychological impact as well as causing scars, and effective treatments are available. Tell your clinician what acne is stopping you from doing, such as attending meetings or seeing friends. That information helps shape a treatment discussion; the number of visible spots is not the only concern worth raising.67

How should you care for your skin each day?

• Wash gently morning and evening, and after exercise or sweating. Use a mild cleanser, lukewarm water and your fingers rather than a sponge or scrubbing cloth.
• Apply an oil free moisturizer if your skin feels dry.
• Choose skincare and makeup labelled noncomedogenic. Noncomedogenic is the label term to look for, which is an unnecessarily long way to say a product is designed not to clog pores.
• Remove makeup before bed, wash oily hair regularly and keep hair away from your face.
• Wear loose, breathable clothing if you have body acne, particularly during exercise.

Do not scrub, repeatedly wash, pick or squeeze your spots. Scrubbing can irritate skin and worsen acne; squeezing can cause infection, slower healing and scars. For adults, especially those with aging skin, the strongest acne product on the shelf can be too drying. Choose gentle care instead of treating product strength as the main buying criterion.45

What can you do for one painful spot?

These steps can support an individual deep pimple while you arrange care for ongoing cystic acne.

1. 1Apply a clean, warm, damp washcloth for 10 to 15 minutes, three times daily. Use a clean cloth each time and do not pop the spot.
2. 2For a shop bought acne treatment, options include adapalene, azelaic acid, benzoyl peroxide or salicylic acid. Apply a thin layer following the product directions. Topical treatments work better when a spot is nearer the surface.
3. 3A hydrocolloid acne patch can protect the area and support healing.
4. 4Seek shade, wear protective clothing and use broad spectrum, water resistant sunscreen with SPF 30 or higher on exposed skin. Choose one labelled noncomedogenic or "won't clog pores."

Some acne ingredients increase sun sensitivity. Sun protection also helps limit dark marks after inflammation, which are more likely to darken without protection. Picking increases the risk of discoloration, particularly in darker skin.2

What treatments can a doctor offer?

Prescription treatment can include medicines applied to the skin and tablets. Topical retinoids, such as adapalene or tretinoin, help prevent spots and reduce inflammation and oiliness. Topical or oral antibiotics target bacteria involved in inflammation and pus. Hormonal treatments, including the combined contraceptive pill or spironolactone, are options for some women with hormone related acne. A clinician can sometimes inject a large painful cyst to shrink it quickly, or drain it as a procedure. These are not home treatments.134

Isotretinoin is an oral retinoid used for cystic acne with scarring. It requires close monitoring and regular blood tests because of its side effects. Do not take isotretinoin during pregnancy: it causes severe birth defects. In the US, isotretinoin involves enrollment in iPledge, with pregnancy prevention requirements for patients who can become pregnant. Discuss pregnancy and contraception with the prescriber before treatment.5

Acne products can cause redness, dryness or excessive peeling. Follow directions carefully, use them sparingly and discuss troublesome effects with your clinician. Benzoyl peroxide can bleach towels and clothing. Ask which products belong in your prescription routine rather than adding more acne treatments yourself.5

How long does treatment take?

Acne treatment can take 6 to 8 weeks to show a response, and clearing cysts can take three months or longer. Flat areas of changed skin colour after a cyst clears can take more than a year to fade. Those colour changes are different from scars that change skin texture.15

What should you bring to your appointment?

Bring a list of the treatments you have tried, so the appointment does not become a memory test with bottles. Explain what you want treatment to achieve and how acne affects your daily life. Ask when to expect improvement, what side effects to watch for and how to prevent scarring. Agreeing on those details helps you make an informed treatment choice.17