For every useful page of information about cystic acne brought up by an internet search, dozens more pages give thinly veiled sales pitches for commercial skin products, or claim miraculous cures among lists of home remedies, shamelessly appealing to people who have become exasperated by their skin problem.
The truth is that while there is no wonder cure for this often emotionally distressing problem, severe acne can be managed effectively with the help of doctors, and medical treatment can result in the prevention of some of the worst effects of cystic acne.
What is cystic acne?
Cystic acne is a skin condition in which the pores in the skin become blocked, leading to infection and inflammation in some cases. The skin conditions mainly affects the face, but also often affects the upper trunk and upper arms.
The medical term for the pores of the skin is pilosebaceous units, which includes the hair follicles and their accompanying sebaceous glands that secrete the oily substance known as sebum.
Normal sebum secretions help protect the hair follicles and skin, but overproduction of sebum (and overgrowth of skin cells) can cause the pores to become plugged with sebum and epidermal cells shed from the skin. This can create optimal conditions for the overgrowth of an anaerobic bacterium normally found on the skin, Propionibacterium acnes.
These plugs are also known as comedones, and can be white- or black-headed. The comedones can be uninfected - non-inflammatory acne - or they can become infected and inflamed, leading to papules, pustules, nodules, or cysts. Cystic acne is the worst of these lesions (often called "pimples," "spots" or "zits"):
- Papules occur when the P. acnes bacteria lead to irritation of the hair follicles
- Pustules occur when the P. acnes bacteria lead to inflammation of the hair follicles, causing swollen red bumps
- Cysts occur when the inflammation leads to rupture of the hair follicles (which can also be caused by squeezing the spots, or by harsh scrubbing), releasing matter that triggers wider inflammation, and deeper, hard, painful cysts.
Acne most often affects adolescents and young adults, with an estimated 80% of people between 11 and 30 years of age are affected at some point.3
Cystic acne is the most severe form, and affects far fewer people - the US Centers for Disease Control and Prevention (CDC) estimate that approximately 2 in every 1,000 people are affected by cystic acne, compared with nearly 70 in 1,000 for acne in general.
In 2009, the CDC found that acne was the top reason patients gave for visiting a dermatologist, and a top five skin diagnosis.
What causes cystic acne?
As discussed above, acne is characterized by a blockage of the skin pores because of the overproduction of sebum, or skin cells, combined with inflammation triggered by the bacterium P. acnes. Cysts are the most inflamed, ruptured form of these comedones.
The biggest factor causing acne is the hormonal change in adolescent teenage years. During puberty, levels of circulating androgen hormones increase dramatically leading to increased sebum production and greater proliferation of skin cells.
Acne is not confined to teenagers, however, and other factors are involved, including an inherited tendency for acne, alongside:
- Hormonal changes - related to puberty, the menstrual cycle, pregnancy, birth control, the use of hormone therapy, and stress
- Occlusive, greasy cosmetics, cleansers, lotions, and clothing
- High levels of humidity and sweating
- Some drugs and chemicals (for example, corticosteroids, lithium, phenytoin, isoniazid), which may worsen or cause eruptions that are similar to acne.
There are numerous myths about the causes of acne, with blame wrongly assigned to factors that have been roundly dismissed by scientific research.
Acne, including cystic acne, is not caused by:
- Chocolate, nuts, or greasy foods
- Most other dietary choices - research has found an association between intake of milk products and acne, as well as a high glycemic index diet and acne
- Poor hygiene or inadequate face washing
- Masturbation or sex.
Signs and symptoms of cystic acne
Acne produces symptoms familiar to all of us - 70-80% of people are affected at some time,3,4 and we have all seen faces affected by acne.
Cystic acne is even more visible because it is the severe form that produces cysts and nodules in addition to numerous inflammatory papules and pustules.3 Acne can also cause visible scarring.
All forms of acne can affect self-esteem and mood, but the risk of psychological distress is higher for cystic acne as it typically has a greater impact on the appearance of the face and disproportionately affects young adults who may be more socially sensitive.
Most forms of acne do not produce physical symptoms felt by the person themselves, but the skin's appearance can cause emotional distress. In cystic acne, however, the distress may be higher, and the cysts may be painful.
The importance of treatment is underlined by the risk of scarring from long-term cystic acne. This can produce long-term and permanent damage in the form of:1
- 'Ice pick' scars (small, deep pits)
- Larger pits
- Shallow depressions
- Hypertrophic scarring (red, raised scars).
Tests and diagnosis of cystic acne
Acne is diagnosed simply by examination - it is clear for a doctor to see, although there may be a need for closer examination to differentiate acne from other conditions such as rosacea.
The doctor may ask questions (take a history) to confirm, for example, that the problem is not due to the use of drugs such as corticosteroids. The doctor is also likely to assess the psychosocial impact of severe acne - how it affects a person's activity and mood.
Cystic acne is typically diagnosed when five or more cysts are visible in addition to over 100 comedones.
Treatment and prevention of cystic acne
Treatment of severe, cystic acne requires the help of a specialist doctor and some self-care measures.3 Drug treatment is effective at preventing cysts and scarring.
Whereas mild or moderate acne can be managed with the help of a primary care physician, severe acne that is characterized by nodules and cysts, and that risks scarring (or already shows signs of scarring) may need referral to a specialist, partly because the main drug treatment is tightly controlled.
Benzoyl peroxide is a treatment available to anyone with acne of any severity, and is a treatment option for people with severe acne who are awaiting specialist treatment.
Benzoyl peroxide is available directly from pharmacies over the counter (without prescription) in a number of formulations that may be applied to the skin. It has been a mainstay in the treatment of acne for over 50 years, and works by killing bacteria, particularly P. acnes, and breaking up comedones (it has mild "comedolytic" properties).
Water-based and alcohol-based formulations of benzoyl peroxide are available, and the most appropriate form depends on skin type. Alcohol-based preparations have a drying effect, making these more suitable for people with oily skin.8
Benzoyl peroxide products, which include cleansing liquids and bars, lotions, creams and gels, are used once or twice a day.9 The most common side-effect is skin irritation, and allergies occur rarely.8
Self-care advice
Practical measures to avoid making acne worse are useful for anyone with acne, including people with the most severe form of the condition:
- Do not wash too often - twice a day is enough, using a mild soap or cleanser and lukewarm water
- Do not scrub harshly when washing - avoid abrasive soaps, cleansing granules, astringents, or exfoliating agents
- Leave pimples alone since picking and squeezing is likely to worsen the acne
- Avoid using heavy makeup, choose water-based, non-comedogenic formulations, avoid oily formulations and make sure to remove make-up before bed.
Drug treatment with isotretinoin
Isotretinoin is a prescription drug for the treatment of cystic acne, sold under a number of brand names in the US: Absorica, Accutane (no longer sold), Amnesteem, Claravis, Myorisan, and Sotret.10
Isotretinoin is a very effective treatment, but one that has side-effects, and it is dangerous to the unborn child. It is usually taken at a dosage of 1mg for every kilogram of body weight once daily for between 16 and 20 weeks.1,6
A higher daily dose of 2 mg/kg is also used, as is a lower dose (0.5 mg/kg) if adverse effects are intolerable, when the concentration is reduced to 0.5 mg/kg.
For cases of moderate acne, isotretinoin is not recommended until standard treatment with oral antibiotics has been tried and deemed ineffective. Isotretinoin is, however, recommended as a first-line treatment for severe acne.1
Potential adverse effects associated with the use of isotretinoin include:
- Eye and genital dryness
- Chapped lips
- Joint pains
- Depression
- Elevated lipid levels.
Isotretinoin is a teratogenic drug. This means that taking the therapy during pregnancy, at any dose, even for a short time, can lead to congenital malformations (birth defects in the offspring).1
Isotretinoin may also lead to the loss of the pregnancy, or premature birth, and can cause death of the newborn.
Women who have the capacity to become pregnant are, therefore, strongly advised to use two methods of contraception for a month before, during, and at least a month after treatment with isotretinoin.
Testing for pregnancy is also urged before starting isotretinoin and then every month until one month after stopping the drug.
Because of the danger during pregnancy, the availability of isotretinoin is restricted - it may be prescribed only by registered prescribers and dispensed at registered pharmacies as part of the iPLEDGE program, which also requires the registration of the patient. The conditions for being prescribed the drug include producing two negative pregnancy tests.
Steroid injections
An injection of corticosteroid directly into a cyst helps reduce inflammation to prevent scarring.1,6 Such treatment is carried out by a dermatologist.
The injection is dilute: 0.1 milliliters of triamcinolone suspension reduced to 2.5 milligrams per millilitre. There may be transient (short-lived) localized side effects after the injection.1 Dermatologists may also offer incision and drainage of certain large cysts, but it is strongly recommended that patients do not attempt this themselves as it will likely worsen the skin problem and could cause serious scarring and deeper infection.
Birth control pills
Long-term treatment of acne in women can involve the birth-control pill, which suppresses sebum production. Where appropriate, an oral contraceptive containing estrogen and progesterone may be used for six months or more.1,6
A drug called spironolactone may also be prescribed with the pill. This is a synthetic steroid that inhibits androgens.
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