How to deal with cystic acne

Is it cystic acne or a surface pimple?

Cystic acne develops deep beneath the skin, unlike whiteheads and blackheads near the surface. You can sometimes feel a deep bump more easily than you can see it. Nodules are large, hard bumps; cysts are softer bumps containing fluid. Both can be painful. People often use "cystic acne" for either, and both need medical assessment when they are persistent or recurring. Nodulocystic acne is the term for severe acne involving these deep lumps. It can affect the face, neck, chest and back, not just the chin.245

Why do deep bumps develop?

Acne starts when oil and dead skin cells block a hair follicle, the opening containing a hair and an oil gland. Bacteria and the body's inflammatory response contribute to painful bumps. Severe nodulocystic acne involves several factors, including oil gland activity, how cells build up inside follicles and genetics. Hormonal changes, some medicines and greasy skin or hair products can contribute to acne. Anabolic steroids and whey supplements are specific risk factors for nodulocystic acne. Tell your clinician about medicines and supplements you use so these can be considered alongside treatment.56

What can you do for one deep, painful pimple?

These steps help care for an individual bump while you arrange medical treatment for persistent or repeated deep breakouts.

1. 1Apply a warm, damp washcloth for 10 to 15 minutes, three times daily. Use a clean washcloth each time. The warmth helps the bump move closer to the surface so it can heal.
2. 2Leave the bump alone, even if it develops a visible head. Squeezing increases the risk of infection, discoloration and scarring.
3. 3For a surface blemish, apply a thin layer of an acne treatment containing adapalene, azelaic acid, benzoyl peroxide or salicylic acid. Follow the product's directions. Topical treatments work better when the pimple is near the surface; using more can irritate skin.
4. 4Consider a hydrocolloid acne patch to protect the area and support healing.
5. 5Protect exposed skin with broad spectrum, water resistant sunscreen with SPF 30 or higher. Choose a noncomedogenic formula, meaning one designed not to clog pores, and also use shade and protective clothing.

Inflammation can leave dark marks called postinflammatory hyperpigmentation. Sun exposure increases that risk, and some acne ingredients make skin more sensitive to sunlight. A deep bump that does not go away with home care, or several deep painful bumps, needs a dermatologist rather than repeated spot treatment.2

What should your daily routine look like?

• Wash morning and evening with a gentle cleanser, and clean your skin after exercise. Avoid scrubbing or repeatedly washing throughout the day.
• Moisturize with an oil free, water based, noncomedogenic product.
• Use your prescribed acne treatment exactly as directed, rather than replacing it with a new spot product whenever a bump appears.
• Remove makeup before bed, because foundation does not need overnight accommodation.
• Choose noncomedogenic skincare and makeup, so the shopping list has a useful filter instead of another beauty slogan.
• For body acne, wear loose, breathable clothing, especially during exercise or sweating.

Can benzoyl peroxide or adapalene clear cystic acne?

Topical treatments are usually ineffective on their own for established nodulocystic acne. They can still have a role in treating other blemishes alongside the deep bumps. Adapalene helps unclog pores, and a benzoyl peroxide wash reduces acne bacteria. Salicylic acid or benzoyl peroxide washes are options for smaller inflamed pimples. These are not reasons to delay an appointment for cysts. Apply shop bought treatments sparingly and follow their directions. Redness, dryness and excessive peeling can occur; get advice if irritation makes treatment difficult to tolerate. Benzoyl peroxide can also bleach towels and clothing.156

What treatments can a clinician offer?

Isotretinoin should be considered early for severe nodulocystic acne to help prevent scarring. Treatment lasts at least five months, and some people need another course. It requires close monitoring because of side effects, including regular blood tests. Isotretinoin must not be taken during pregnancy because it causes severe birth defects. In the US, treatment requires enrollment in the iPledge program and pregnancy prevention requirements for patients who can become pregnant. If you are pregnant or planning pregnancy, discuss acne medicines with your clinician before starting treatment.56

How long does treatment take?

Acne treatment often takes six to eight weeks to show a response, and clearer skin from inflammatory acne can take several months. Severe nodulocystic acne needs a longer treatment plan, not an overnight spot treatment. Acne can return during or after treatment, so continue the skincare and maintenance plan your clinician gives you after improvement. Early treatment matters because existing scars can be permanent. In darker skin tones, lingering dark marks and raised keloid scars are common complications of nodulocystic acne.456

When should you get medical help?

Seek medical help now for deep painful lumps, repeated cysts, worsening acne or scars forming as spots heal. You do not need to complete months of self treatment first. A primary care clinician can assess your skin, offer prescriptions and refer you to a dermatologist. Also seek care for possible infection, including hot, swollen, red skin; redness can be less obvious on brown or black skin. Mention emotional distress, anxiety or low mood during the appointment. Acne's effect on mental health is a reason to get help, not something you have to wait out.37