How to treat cystic acne

What counts as cystic acne?

Cystic acne involves deep lumps beneath the skin, often called nodulocystic acne. Cysts contain pus, while nodules are deeper masses that are often painful. You can have these alongside blackheads, whiteheads and smaller pimples. Acne develops when oil and dead skin cells block follicles, the openings where hairs grow, and bacteria contribute to inflammation. Severe acne can also have a substantial psychological impact. Effective treatments are available, including for severe cystic acne.1234

When should you see a doctor?

Book an appointment if your spots are deep, painful, numerous or leaving scars. You do not need to wait several months to seek help for cysts. Also seek medical advice if acne is worsening, home treatment is not helping, or acne is affecting your mental health. Hot, swollen skin with redness can indicate an infection; redness can be harder to see on brown and black skin. A GP can prescribe treatment or refer you to a dermatologist.1

Which treatments can help?

Tell your clinician about medicines you take and whether breakouts follow your menstrual cycle. Hormonal changes and some medicines can contribute to acne. Birth control pills help some women but worsen acne in others, so they are not an automatic choice. An individual cyst procedure and a plan for recurring breakouts serve different purposes: discuss both if one lump is particularly troublesome.23

What should you do at home?

1. 1Wash gently morning and evening with a mild cleanser, and cleanse after exercise. Avoid repeated washing and scrubbing, which can irritate skin and worsen acne.
2. 2Use your prescribed skin treatment exactly as directed. For nonprescription products, follow the label and apply sparingly rather than adding extra applications.
3. 3Choose skincare and makeup labelled noncomedogenic, meaning formulated to avoid clogging pores. Choose a moisturizer with that label if you need one.
4. 4Remove makeup at the end of the day. Keep oily hair away from your face, and use loose, breathable clothing if breakouts affect your body.
5. 5Leave lumps alone. Do not pick, squeeze, scratch or try to drain them with tools.

Cleanser and cosmetics have supporting roles here, even if the bathroom shelf looks ready to open its own clinic.3

Can benzoyl peroxide or other shop bought treatments help?

Nonprescription medicines are options for milder acne, not a substitute for assessment of cystic acne. Benzoyl peroxide can cause dryness; lower concentrations and wash formulations are less irritating. Salicylic acid helps remove dead skin cells that block follicles. Retinoids help prevent blocked pores but can cause peeling or changes in skin colour. Using a retinoid every other day or alongside moisturizer can reduce these effects, where your treatment directions allow. Ask your pharmacist or prescriber about troublesome irritation rather than increasing the strength. Benzoyl peroxide can also bleach towels and clothing.23

How can you ease a painful lump?

A warm compress can help a pimple heal. Use a clean washcloth soaked in warm water around 35 degrees Celsius, three to four times daily. Ice wrapped in a light towel can reduce inflammation and pain. These are general comfort measures for pimples, not a replacement for cystic acne treatment. A deep lump without a visible head can last a few weeks or longer. Squeezing can damage skin without emptying the lump, and introduces a risk of infection and scarring.3

How long does treatment take?

Acne treatment can take 6 to 8 weeks to show a response, and breakouts can flare again. Continue the agreed treatment plan rather than judging it after a few days. Contact your prescriber if acne is getting worse or scars are developing. The time needed for one deep lump to settle is different from the time needed to control recurring acne.2

What should you know about isotretinoin?

Isotretinoin is a prescription capsule for severe acne when other prescription medicines have failed. Take capsules whole with food, following your own prescription. Treatment length and dose depend on your symptoms, and regular appointments and blood tests are required. Dry or itchy skin, sore eyes and muscle or joint pain are possible. Tell your prescriber about existing medical conditions, past mental health problems and all medicines or supplements, especially vitamin A and antibiotics such as doxycycline.5

Do not take isotretinoin during pregnancy, while trying to become pregnant or while breastfeeding. If pregnancy is possible, contraception must start at least one month before treatment and continue for at least one month afterwards. Follow the pregnancy prevention requirements given by your prescriber. While taking isotretinoin, avoid salicylic acid, benzoyl peroxide, chemical peels, microdermabrasion, waxing and laser hair removal. Use SPF 30 or higher sunscreen outdoors and reapply regularly. Avoid sunbeds, excessive sun exposure and intense exercise. It is best not to drink alcohol during treatment.5

Speak to your prescriber about side effects that persist or bother you; continue treatment unless advised to stop. Get urgent medical help for suspected serious side effects, including breathing difficulty, severe abdominal pain, seizures, hallucinations or thoughts of harming yourself. In the UK, contact NHS 111 for suspected serious isotretinoin side effects.5

Do LED masks and lasers treat cystic acne?

Visible blue and red light devices treat pimples, but not cysts or nodules. Infrared light and photopneumatic therapy also cannot treat cysts. Photodynamic therapy, which uses a solution to make skin sensitive to light before professional light treatment, shows promise for severe acne; some patients with cysts have remained clear for years. A dermatologist can assess whether it belongs in your plan.6

Laser and light treatments rarely clear acne alone, usually require several sessions and can need maintenance treatments. A powered device does not make treatment instant, despite the appealing administrative simplicity of an on button. Best results can appear weeks after the last session. Redness, swelling and stinging are possible, with rarer risks including burns, colour changes and scarring. Follow all treatment instructions; after photodynamic therapy, sunlight must be avoided for 48 hours.6

How do you reduce the risk of scars?

Treating acne early and continuing treatment can reduce the risk of scars. Deep, painful acne is more likely to scar, and having a parent or sibling with acne scars increases your risk. Picking and squeezing increase inflammation, infection risk and discoloration. Scars can fade but rarely disappear completely without treatment. A flat patch of colour after a breakout usually represents post inflammatory hyperpigmentation, a colour change rather than a scar. A depression or raised area is a change in skin texture. If these develop, ask a dermatologist about scar treatment as well as controlling new breakouts.7