It’s one of the most eye-poppingly common woes of young adulthood: Eight in ten people between the ages of 11 and 30 get acne, according to the National Institutes of Health. But it only takes a quick survey of the average school gym class to note that not everyone is affected by the same type. When you imagine red, swollen, painful pimples, you’re thinking about cystic acne—the kind that also leaves scars. While the causes behind cystic acne are still not entirely understood, and researchers are always looking for new and improved ways to treat it, there is still a lot you can do to effectively tame it and keep it from leaving a lasting mark.
What is cystic acne?
Cystic acne is an inflammatory type of acne that causes bumps deep under the skin that are usually tender, red, and painful. “Often they come up in big crops and wax and wane over time,” says Laura Ferris, a dermatologist and an associate professor of dermatology at the University of Pittsburgh. Cystic acne most commonly appears on the face, Ferris says, but it’s also found on the back, chest, upper arms, and shoulders. It’s different from other, more superficial types of types of acne, like blackheads and whiteheads, because it’s deeper down in your skin.
“Because of the depth and the amount of inflammation, cystic acne is the one that causes scarring,” says Bruce Robinson, a New York City-based dermatologist and clinical instructor of dermatology at Lenox Hill Hospital.
What causes cystic acne?
Oil glands that keep your skin moist are attached to your pores, which is where hair grows and dead skin cells are eliminated. All types of acne pop up when your pores get plugged with oil and dead skin. With cystic acne, bacteria trapped deep in your pores cause inflammation—i.e., redness, swelling, and pain.
There are lots of different factors that increase the risk of cystic acne. “For some people it’s genetic, for others it’s hormonal, and some people are just acne-prone,” says Nada Elbuluk, an associate professor of dermatology at the University of Southern California Keck School of Medicine.
Because cystic acne is linked to testosterone, men tend to be slightly more susceptible. For women, acne can get worse around menstrual cycles.
Does diet trigger cystic acne?
A lot of studies have tried to look at diet and acne, Ferris says, but the jury is still out. One study linked acne to skim milk, while others have tied it to eating too many sugary foods. Robinson says some people do find they get more cystic acne when they eat gluten or dairy, although they’re not necessarily gluten- or dairy-intolerant. Ultimately, experts say diet has nothing to do with acne for the vast majority of people.
In the meantime, it’s always a safe bet to cut back on sugary foods and eat a well-rounded diet—without going overboard. “There’s no evidence that elimination diets work for acne,” Ferris says.
When do most people get cystic acne and how long does it last?
Cystic acne is strongly linked to hormones; an estimated 85 percent of the time it hits around hormone-heavy puberty and tends to stick around until your 20s. “But I certainly see women and men in their 40s who have cystic acne, even for the first time,” Ferris says. In fact, a growing number of women in their 30s, 40s and 50s are getting acne, according to the AAD.
In women, hormonal changes that happen during pregnancy can trigger cystic acne later in life. PCOS, a hormonal imbalance where the body makes more testosterone-like hormones behind cystic acne, is another common cause. Because fat cells can convert female hormones into weak male hormones, Robinson notes, obesity—which is also linked to PCOS—ups the odds of cystic acne. Even menopause rarely causes cystic acne due to hormonal fluctuations. “It’s a big trigger for some women. That’s usually when you’ll see another peak,” says Robinson. Hormonal-linked acne usually appears around the jawline and the mouth, he adds.
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If you get cystic acne for the first time in your 30s or 40s, your doctor will usually work with a gynecologist or endocrinologist to test for hormonal imbalances and work together to treat it. “There are even more rare syndromes that can be associated with acne, so if someone suddenly got bad acne later in life we look for another underlying cause,” Ferris says.
How to treat cystic acne
Although it’s worth testing OTC treatments like benzoyl peroxide or salicylic acid at home, if you have severe acne you’re better off seeing a dermatologist to minimize breakouts and scarring, Robinson says. The treatment your doctor will pick depends on the cause behind your breakouts, the severity, whether there’s scarring and if you’ve been on other treatments that failed in past.
While creams and washes are sometimes enough for surface acne like whiteheads, blackheads, and pustules, you’ll usually need to pop a pill to treat cystic acne, Elbuluk says. Your doctor may start you off with oral antibiotics for three to six months, although if flare-ups happen around your menstrual cycle, Robinson says he sometimes prescribes it for regular brief periods around your period.
Antibiotics work by killing the bacteria and calming the inflammation that contribute to acne, Elbuluk says. Problem is, they also come with loads of not-so-nice side effects: Antibiotics can cause abdominal pain, diarrhea, and nausea, and some make your skin more prone to sunburn, Ferris says. Relying on them for long periods of time can affect the balance of good bacteria in your gut and skin. And they can contribute to antibiotic resistance, where they become less effective against more serious bacterial infections. That’s a problem, Ferris says, since some of the drugs doctors prescribe for acne are also used to treat Lyme disease and MRSA.
Here’s the other issue: As soon as you go off of antibiotics, acne tends to roar right back. “Acne isn’t a short-term problem,” Ferris says. That’s why doctors will usually try an antibiotic cream or other surface treatment like Retin A, a vitamin A cream that increases the rate your body sheds dead skin cells to prevent clogging, Elbuluk says. “I’ll often mix and match, depending on the patient’s sensitivity and the types of acne they have.”
If you’re a woman and your acne is likely hormone-related, your dermatologist may refer you to an OB/GYN for a birth control prescription to help regulate your hormones, a few of which are FDA-approved to treat acne. Your OB or dermatologist might also suggest spironolactone, another type of hormonal treatment for women only that reduces testosterone levels to reduce oil production and cut back on acne, Ferris says.
Doctors agree, however, that by far the best cystic acne treatment is isotretinoin (i.e. Accutane), an oral form of vitamin A that targets all the sources of cystic acne by killing acne-causing bacteria, unclogging pores and cutting back on excess oil and inflammation. It’s the only medicine that permanently stops cystic acne instead of just treating it while you’re using it, Robinson says. “It permanently shrinks oil glands so your skin will never be as oily as it used to be. It also changes the way your skin cells mature, so your pores don’t get blocked. It can even help improve scarring, he says. You’ll need to go on just one round that lasts four to six months, which clears up acne for 85 percent of people, Elbuluk says.
While isotretinoin is safe—the most common side effect is dryness of skin and peeling of lips—it can cause serious birth defects, so your doctor will only prescribe it if you’re on birth control and using a second form of protection to avoid getting pregnant. The good news is, if you are hoping for a mini-me any time in the future, it’s perfectly safe to get pregnant as soon as one month after coming off Accutane, Ferris says.
If all else fails—or if you’re just really against using antibiotics or Accutane—your dermatologist may try photodynamic therapy, the most effective laser treatment for severe acne, Elbuluk says. After applying a special prescription medication to your skin and letting it sit for up to three hours, he or she will shine a special light that activates and kills acne-causing bacteria.
While there is no way to prevent cystic acne, getting treated ASAP is important to prevent scarring. “That’s one of the reasons why if someone does have fairly severe acne, most of us will push to move on to Accutane or topical creams like Retin A,” Ferris says.
Caring for acne-prone skin
Day in and out, doctors recommend using a gentle cleanser (like Cetaphyl or Purpose) and lukewarm water morning and night. If you have oilier skin, your doc might suggest a more drying soap (like Ivory or Dial), Robinson says. Use a moisturizer with sunscreen every morning, and skip harsh scrubs, astringents and toners, which cause more dryness, redness, and inflammation.
The future of cystic acne treatments
You’ve probably heard a lot about your microbiome, the mix of bacteria in your body that impacts your metabolism, immune system, and gut health. Turns out, variations in your personal mix of bacteria may even impact the likelihood of getting cystic acne.
Research last year found that people who suffer from acne have more of one of two versions of a type of bacteria, propionibacterium acnes (P. acnes), on their skin that’s more likely to cause breakouts. Although the research is preliminary, it could eventually lead to treatments like bacteriophages and probiotics that only target that particular strain of bacteria that causes acne or boost good-for-your-skin strains.
“This study showed that the P acnes in patients with acne is different than the P acnes in patients without acne,” Ferris says. “Therapy that could target the pathogenic strain of P acnes could be a new approach to treating acne.”
Robinson adds, “As medicine advances, we seek to better target causative agents like P. acnes and not perturb the normal flora of the skin and gut.”
Getting rid of cystic acne scars
If you do end up with cystic acne scars, lots of treatments can help reduce or eliminate them, including chemical peels, laser resurfacing, and micro needling, Elbuluk says. Most people need around four laser treatments or four to six peels to clear up cystic acne scars, depending on how severe they are. Robinson says these treatments cause way less injury to the skin than older options like microdermabrasion and can work wonders to heal cystic acne scars within weeks of treatment up to decades later.
For more severe cystic acne scars that are deeply tethered down, another more invasive procedure known as subcision involves using a needle to physically loosen them and allow the skin to better pop out, Robinson says. A doctor may even surgically remove scar tissue and sew the skin back together, he adds. Just keep in mind all of these treatments can come with a pretty price tag, since they’re usually not covered by insurance, Ferris says.
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