Cystic acne vulgaris: What it is and how to treat it

What is the difference between cystic acne and acne vulgaris?

Acne vulgaris is the broader condition. It includes blackheads, whiteheads, smaller inflamed pimples and deeper lumps. Cystic acne describes the deeper, inflammatory form. Several kinds of blemish can appear together, so having blackheads alongside painful lumps does not make them separate diseases.34

What does cystic acne look and feel like?

Nodules are large, firm bumps buried beneath the skin. Cysts are softer lumps containing fluid, usually pus. Both can be painful. Acne commonly affects the face and upper trunk, and different blemishes can be present at different stages. A visible white tip is not required for a deep acne lump.5

On darker skin, redness can be less obvious, while dark marks left after inflammation can be more noticeable and persist after the blemish has gone. These marks are called postinflammatory hyperpigmentation. Acne can also leave scars, including raised keloid scars, which are more common in skin of colour, particularly along the jawline, chest and upper back.3

Why does deep acne develop?

Acne involves excess skin oil, blocked hair follicles, bacteria called Cutibacterium acnes and inflammation. These bacteria normally live on human skin. When an inflamed follicle ruptures into deeper skin, its contents trigger further inflammation. Harsh scrubbing or manipulating a blemish can contribute to that rupture.5

Hormonal changes during puberty, pregnancy or the menstrual cycle can trigger acne. Products and clothing that trap material against the skin, high humidity and sweating can also contribute. Family history matters, particularly a history of severe acne. Acne is not explained by inadequate face washing. Some studies suggest links with dairy or diets that raise blood sugar quickly, but those associations are not settled causes.5

When should you see a doctor?

Seek help early for deep, painful breakouts because treatment can reduce the risk of permanent scars. A dermatologist can identify the blemish types and choose treatment that addresses blocked pores, bacteria, inflammation and excess oil. Do not wait for acne to become widespread before asking for help. Severe acne can also affect emotional wellbeing, including increased rates of anxiety and depression.6

A primary care clinician or dermatologist usually diagnoses acne by examining the skin. Expect questions about your medicines, family history and whether breakouts follow your menstrual cycle. Sudden, severe acne in adulthood can prompt investigation for an underlying condition. Treatment choice depends on your age, acne type and severity, rather than simply how oily your skin feels.1

What treatments help cystic acne?

Medicines applied to the skin can be part of treatment. Benzoyl peroxide targets bacteria; lower concentrations and wash formulas are less irritating. Salicylic acid helps remove dead skin cells that block follicles. Azelaic acid reduces swelling and microorganisms. Topical antibiotics such as clindamycin are more effective when combined with benzoyl peroxide.1

Topical retinoids, medicines related to vitamin A, help prevent blocked pores. They are used across the area affected by acne rather than only on individual spots. They often need several months to show positive results. Follow the directions for the prescribed medicine rather than borrowing another product's schedule.1

Moderate acne can need oral antibiotics or hormonal treatment, while severe acne can require oral isotretinoin. The decision takes account of how extensive the acne is, how long it has been present and how previous treatments worked. These are treatment options to discuss with a clinician, not interchangeable upgrades to a cleanser.3

What if the breakouts seem hormonal?

Persistent, deep breakouts on the chin, jawline or lower cheeks can occur with hormonal acne. Higher androgen hormone levels can increase oil production and slow skin turnover, making blocked pores more likely. Appearance alone cannot diagnose an ovarian hormonal condition; a clinician can decide whether hormone testing or other investigations are needed.7

Certain birth control pills can improve acne, but not all types have that effect. Spironolactone can help hormonal acne when other treatments have not worked. Do not become pregnant while taking spironolactone because it can harm a developing fetus. If you are pregnant or planning pregnancy, discuss treatment selection before starting or combining acne medicines.7

How should you care for your skin?

Choose your cleanser by skin type as well as acne type. Creamy formulas tend to be more hydrating; foaming and gel cleansers can dry the skin. Benzoyl peroxide washes come in strengths from 2.5% to 10%, while salicylic acid washes commonly contain 2%. Added ingredients can irritate, and harsh exfoliation can make acne worse. A cleanser is one part of acne care, even if the bottle looks ready to take all the credit.2

Wash in the morning and at night using this sequence:

1. 1Wet your skin and apply cleanser with your fingers.
2. 2Massage gently without scrubbing.
3. 3Rinse with warm water.
4. 4Pat dry with a soft, clean towel.

Moisturize morning and night, remove makeup before bed and cleanse after exercise. Choose products labelled oil free or noncomedogenic, meaning formulated not to clog pores, which is a fairly simple request wearing a very long word. Use an oil free, noncomedogenic sunscreen: many acne treatments increase vulnerability to sunburn. Follow your clinician's treatment instructions alongside this basic care.46

Can you squeeze or pop a cyst?

Do not squeeze, pick or pop deep blemishes. Doing so can damage follicles, push bacteria further into the skin and cause more blemishes, infection, pain and scars. A clinician can sometimes inject cortisone into a blemish. Procedures to remove acne lesions belong in professional care, not at home.4

How long does improvement take?

Allow 6 to 8 weeks of consistent acne treatment to see improvement. A reduction in swelling can make a blemish look better sooner, but preventing new breakouts takes longer. Deep papules and nodules can persist for months, unlike many individual surface blemishes that last less than two weeks.36

Inflammatory acne often needs several months of care and treatment, and it can return during or after treatment. Continue a skincare regimen after improvement to help limit future breakouts. If your skin has not improved after a few months, seek a treatment review; deep, painful acne warrants help earlier.4

What is the difference between acne and acne vulgaris?

Acne vulgaris is the medical name for common acne. Acne and acne vulgaris mean the same thing here.1

Is cystic acne a type of acne vulgaris?

Yes. Cysts and nodules fall within inflammatory acne vulgaris. Blackheads and whiteheads are the noninflammatory forms, also called comedones. The distinction helps determine treatment: an approach for surface plugs alone does not address every factor involved in deep, painful acne.56