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Nearly every teenager experiences zits. Fortunately, most kids live through only a few unhappy years dutifully applying store-bought skincare products to get rid of embarrassing blemishes and oily skin. For an unfortunate few—including some adults—the infection and swelling that causes acne can penetrate deep into the skin, generating large, swollen nodules called cystic acne. Store-bought products are powerless against cystic acne. Once blemishes grow into nodules and cysts, it’s time to visit a dermatologist.
What is cystic acne?
Cystic acne is the most severe type of acne and is characterized by large, swollen, boil-like nodules. Most cystic acne does not involve true cysts, so medical professionals more often call the condition severe nodular acne or stage 4 acne. As with milder acne, most cystic acne pimples and nodules form on the face and jawline but can also appear on the back, shoulders, neck, or chest.
Four major factors contribute to the development of what doctors call acne vulgaris (“common acne”): excess shedding of skin cells in follicles, excess oil production in the follicle’s sebaceous glands, bacterial colonization in the follicles, and inflammation caused by the immune system’s reaction to the bacterial infection.
Acne starts with a blockage of follicles on the skin’s surface. Every pore on the surface of the skin opens to a canal called a follicle, which contains a hair and oil gland (known as a sebaceous gland). Increased levels of male hormones, or androgens, stimulate skin cells in hair follicles to turn over rapidly, filling the hair follicle with excess skin cells. Androgens also stimulate greater oil (sebum) production by the follicle’s oil glands. The excess skin cells block the oil gland opening, and sebum backs up behind the blockage, producing a comedo, more familiarly known as a whitehead or blackhead. This is stage 1 or mild acne.
Bacteria—primarily Cutibacterium acnes—grows rapidly within the blocked oil, so when excess oil ruptures into the surrounding skin tissue, the immune system fires up an inflammatory response. This produces tiny, swollen, red lumps (papules or “pinheads”) or larger bumps that are swollen, red, and filled with pus (pustules or “pimples”). Nodules and cysts form when oil and bacteria in one or more pimples join and extend deep into the skin tissues, creating large, swollen, and hard boils.
Cystic acne often leaves scars or dark spots, particularly if the nodules are picked at or squeezed. For this reason, they should be treated by a dermatologist to minimize scarring.
However, the most serious complications of cystic acne are psychological and social. The psychological and social cost of cystic acne equals that of severely debilitating diseases such as diabetes and epilepsy. Anxiety, shame, depression, social withdrawal, interpersonal problems, and loss of employment opportunities can result in lifelong consequences.
Cystic acne is a rare condition. While acne of any kind affects around 85% of people between the ages of 15 and 25, cystic acne affects a very small percentage of the U.S. population. Treatment is difficult and lengthy. A combination of prescription topical and oral medications are required to clear the problem.
How is cystic acne diagnosed?
Cystic acne is diagnosed through a physical examination. While the condition can be diagnosed and treated by a general practitioner, cystic acne usually requires the services of a dermatologist.
Cystic acne symptoms are large, red, boil-like swellings called cysts or nodules that can be found on the face, jawline, neck, back, or chest. Some of them may be painful or tender to the touch.
A patient’s medical history will reveal possible causes or risk factors such as age, pregnancy, family history of acne, medication use, use of anabolic steroids, or stress.
Blood tests will not be required unless the doctor suspects high levels of androgens are a factor. In women, high androgen levels are often indicated by unwanted hair growth or menstrual problems.
Cystic acne treatment options
Cystic acne is difficult to treat. Most over-the-counter acne medications are powerless against deep and extensive skin infections. The standard treatment for cystic acne involves a combination of topical and oral medications that address several factors that contribute to the condition. Stubborn cases may require corticosteroid injections or surgery.
Medications
First-line treatment of cystic acne involves using several topical and oral medications addressing the multiple factors that cause severe acne. These drugs include antibiotics, drugs that remove excess skin, unclog pores, reduce swelling, or decrease the skin’s oil production. More stubborn cases may require corticosteroid injections into the cysts to reduce inflammation and pain, or pills to reduce androgens.
Physical removal and surgery
Dermabrasion and laser light therapy, while commonly used for mild cases of acne, are not considered successful treatments for cystic acne. Because of the risk of acne scars, many dermatologists reserve surgical treatment only for painful nodules or cysts. In those cases, the nodules will either be removed (excision) or drained (incision and drainage).
Cystic acne medications
Medications for cystic acne target one or more of the factors that contribute to the development of pimples and nodules: excessive skin cell turnover and blockage of the pores by dead skin, excessive oil production, bacterial infection, inflammation, or hormones. Keratolytic agents, retinoids, antibiotics, anti-inflammatory drugs, and hormone agents each treat one or more of these contributing factors.
Topical keratolytic agents
Keratolytic agents help to remove excess skin blocking pores. Several keratolytic agents can help with mild or moderate acne, but doctors stick with benzoyl peroxide for cystic acne. Over-the-counter keratolytic cleansers, such as salicylic acid or azelaic acid, which primarily work by removing dead skin cells, will not help treat cystic acne. Benzoyl peroxide peels off excess skin, quickly unclogging pores. Benzoyl peroxide is also a potent anti-inflammatory drug and antibacterial agent. Many doctors will prescribe benzoyl peroxide combination medications such as Epiduo (benzoyl peroxide and adapalene) or Benzamycin (benzoyl peroxide and erythromycin).
Retinoids
Retinoids are substances similar to vitamin A. They are powerful keratolytics and anti-inflammatory agents. They primarily help cystic acne by promoting the rapid shedding of excess skin, removing dead skin cells, helping to unclog pores. For cystic acne, dermatologists will typically prescribe a topical retinoid such as adapalene or tretinoin. Stubborn cases may require oral isotretinoin, a retinoid that shrinks the oil glands and decreases oil production.
Topical antibiotics
Topical antibiotics (clindamycin or erythromycin) are the foundation of cystic acne treatment. They are prescribed along with a topical keratolytic agent and a topical retinoid. Topical antibiotics are applied directly to acne lesions. The drug is then absorbed into pimples and nodules where it attacks the bacteria colonies thriving in the excess oil. Dapsone is another commonly-used topical antibiotic for cystic acne because of its powerful anti-inflammatory effects.
Oral antibiotics
The bacterial infection partly responsible for cystic acne penetrates deep within the skin. Topical antibiotics may not be sufficient, so a dermatologist may include an oral antibiotic such as erythromycin, minocycline, doxycycline, tetracycline, or trimethoprim-sulfamethoxazole as part of the treatment regimen.
Corticosteroids
To reduce inflammation, a dermatologist may prescribe topical corticosteroids such as hydrocortisone. Corticosteroids suppress the immune system and block the formation of substances that cause the redness and swelling of acne nodules. Alternatively, a dermatologist may inject a corticosteroid such as triamcinolone directly into a nodule or between nodules to provide a longer-term reduction in swelling. An oral corticosteroid such as prednisone may be prescribed to reduce androgens that may be causing cystic acne.
Hormone agents
To reduce androgens causing cystic acne, a woman might receive a prescription for combination birth control pills or spironolactone, or both. The progesterone in some birth control pills reduces androgens by suppressing androgen production in the ovaries. Spironolactone is normally prescribed as a diuretic (water pill) for patients with high blood pressure or heart failure, but it also blocks androgen receptors on the body’s cells, reducing the effects of male hormones.
What is the best medication for cystic acne?
Cystic acne requires a regimen of medications that address all the mechanisms that cause acne. Several different drug combinations may need to be tried to clear the condition. For this reason, there is no “best” medication for cystic acne.
| Best medications for cystic acne | ||||
|---|---|---|---|---|
| Drug Name | Drug Class | Administration Route | Standard Dosage | Common Side Effects |
| PanOxyl (benzoyl peroxide) | Keratolytic agent | Topical | Apply 4% cream to the skin and massage for one to 2 minutes and then rinse off thoroughly | Dryness, itching, redness |
| Benzamycin (benzoyl peroxide, erythromycin) | Keratolytic agent and antibiotic | Topical | Apply a thin film to the affected area twice per day after washing | Dryness, itching, burning |
| Retin-A (tretinoin) | Retinoid | Topical | Apply to the affected area once per day before bedtime | Redness, swelling, blistering |
| Differin (adapalene) | Retinoid | Topical | Apply a thin film of 0.3% gel to the entire face and other affected areas once daily in the evening after washing the face | Dry skin, itching, redness |
| Claravis (isotretinoin) | Retinoid | Oral | Dose depends on weight; taken twice daily with food | Birth defects, dry skin, joint and back pain |
| Cleocin-T (clindamycin phosphate) | Antibiotic | Topical | Apply a thin film to the affected area twice daily | Dryness, redness, burning |
| Doryx (doxycycline) | Antibiotic | Oral | One 100 mg tablets twice daily on the first day followed by a maintenance dose of one 50 mg tablet every 12 hours | Loss of appetite, nausea, diarrhea |
| Minocin (minocycline) | Antibiotic | Oral | One 100 mg capsule every 12 hours taken with or without food | Loss of appetite, nausea, fever |
| Aldactone (spironolactone) | Diuretic | Oral | One 25 mg tablet to two 100 mg tablets daily in a single or divided doses | Increased urination, breast development, mild nausea |
Many of the standard dosages above are from the U.S. Food and Drug Administration (FDA) and the National Institutes of Health (NIH). Dosage is determined by your doctor based on your medical condition, response to treatment, age, and weight. Other possible side effects exist. This is not a complete list.
What are the common side effects of cystic acne medication?
All cystic acne medications can cause side effects, but these effects will vary depending on the drug. Many acne medications actually make acne worse for a few days, but this does not mean they aren’t working. The following is not a complete list of side effects, so please ask a healthcare professional for more information about possible side effects and drug interactions.
Benzoyl peroxide dries out the skin, so its most common side effects are skin irritation, burning, stinging, itching, redness, drying, peeling, and blistering. Side effects are worse if the drug is not washed off the skin after one or two minutes. Though rare, an allergic reaction to benzoyl peroxide will cause severe burning, redness, blistering, peeling, and scabbing of the skin. Immediately rinse the drug from the face if you experience severe reactions.
Topical retinoids are relatively safe drugs. Side effects are limited to site reactions such as irritation, redness, swelling, and blistering. Oral isotretinoin works by shrinking oil glands and dramatically reducing oil production. This affects the entire body, so the most common side effects are dry skin, dry mouth, mouth sores, dry eyes, dry nasal passages, and nosebleeds. Headache, bone pain, nausea, and sweating are also common side effects. The most serious side effect is birth defects, so the drug will not be given to women who are pregnant or not taking necessary precautions to prevent pregnancy.
Topical antibiotics rarely cause serious side effects. The most common are site reactions such as dryness, redness, itching, and peeling. Allergic reactions are possible and can be severe. Oral antibiotics commonly cause digestive tract problems such as nausea, vomiting, diarrhea, abdominal pain, and loss of appetite. The most serious side effects are potentially life-threatening allergic reactions.
Injected or topical corticosteroids produce few side effects other than site reactions such as redness, irritation, itching, and thinning of the skin. Oral corticosteroids often cause side effects such as mood and behavior changes, increased appetite, weight gain, acne, thinning skin, and a rise in blood pressure.
Spironolactone is a diuretic, so the most common side effects are increased urination and dehydration. It also suppresses the body’s sensitivity to androgens, so breast growth and tenderness are also common side effects. Drowsiness, lightheadedness, headache, nausea, vomiting, and diarrhea are also common side effects.
What is the best home remedy for cystic acne?
Cystic acne is the most severe form of acne. Infection and swelling penetrate deep into the skin tissues, so home treatments and over-the-counter topical treatments that work for milder forms of acne do not have much of an effect on the condition. Natural remedies such as tea tree oil and beeswax are mildly effective against pimples, but they have little or no effect on cystic acne. Instead, cystic acne can only be treated with medications. Home treatments can help reduce swelling and pain, but not much more.
Use an aspirin mask
Many dermatologists recommend using an aspirin mask on acne nodules and cysts. Crushed aspirin is mixed with water to form a paste which is then topically applied to the nodule. Any aspirin that absorbs into the derm both reduces inflammation and soothes pain.
Ice
Pain and tenderness can also be managed by applying ice to the nodule for 10 to 20 minutes. Ice can also help reduce swelling.
Change your diet
Traditional medical advice holds that diet is essential to treating acne. The truth is, diet may have little or no relation to acne. Many dietary truths about acne, such as avoiding chocolate or oily foods, have proven to be myths. This doesn’t mean that dietary changes aren’t a good idea. You may notice that some foods, such as dairy products, might provoke acne breakouts. It’s probably a good idea to get those foods out of your diet. The best advice? Eat a healthy diet that is high in nutrition, low in fats, and low in foods with a high glycemic index.
Reduce stress
While stress does not cause acne, stress does make acne more severe. However, stress lowers androgens, the hormone responsible for acne, in the body, so the effects may be limited. Meditation, good sleep hygiene, mindfulness, yoga; all these techniques can dial down the daily stress index. If they don’t help with acne, they at least will make you feel worlds better.
Rethink what you put on your face
Makeup does not, as some people believe, cause acne or make it worse. Still, it may be a good idea to rethink the makeup, lotions, or sunscreen you use if you’re acne-prone. Look for products that are non-comedogenic and oil-free. It may not help, but it can’t hurt.
Get support
The simple truth is that cystic acne is hard to live with. It may not be debilitating, life-threatening, or hazardous, but it takes a big toll on psychological health and social well-being. You deserve to be happy no matter what skin you live in, so don’t take on cystic acne all by yourself. Friends, family, support groups, counseling, therapy—all can teach you skills to cope with cystic acne while it’s being treated.
Frequently asked questions about cystic acne
How can I get rid of cystic acne?
Cystic acne is a severe form of acne that will require medical treatment. A doctor or a dermatologist will prescribe a combination of topical and oral drugs that address many of the factors responsible for acne.
What do doctors prescribe for cystic acne?
The first-line therapy for cystic acne involves a combination of drugs that target specific mechanisms of acne development. The standard combination drug therapy will include benzoyl peroxide face wash or cream to unclog pores, reduce swelling, and control bacterial growth, a topical retinoid to help unclog pores, topical and oral antibiotics to kill bacteria, and possibly an oral retinoid to shrink the size of oil glands. Other medications might include corticosteroids to reduce swelling or oral contraceptives to reduce androgens.
What is the best cystic acne treatment?
There is no “best” acne treatment. A dermatologist will use a combination of prescription medications that address specific factors that contribute to acne outbreaks. Several different drugs may need to be tried before an effective combination is found.
Does isotretinoin help with cystic acne?
Isotretinoin, previously marketed as Accutane and now as other branded medications, including Claravis, is highly effective against cystic acne. It works by shrinking oil glands and reducing oil production.
How do you treat deep cystic acne?
Deep cystic acne is treated with a combination of drugs that address specific causative factors of acne outbreaks: excess male hormones (androgens), excess skin growth, excess skin oil production, bacterial growth, and inflammation.
What is the fastest way to get rid of a cystic pimple?
There is no fast way to get rid of an acne nodule or cyst. Spot treatment with store-bought skincare products won’t work. Squeezing or cutting away the nodule has a high probability of leaving a scar, so you should not play with acne nodules or cysts. The only way to treat deep acne nodules is through a combination of prescription medications, but it may take a few days to see results.
How long does cystic acne last?
Acne cysts or nodules will go away in a few weeks with or without treatment, but acne could be a lifelong condition.
Related resources for cystic acne
- Acne: Diagnosis and Treatment. American Academy of Dermatology
- Acne: What Is It? Harvard Health
- Acne: What You Need to Know. Harvard Health
- Diagnosis and treatment of acne. American Family Physician
- How Dermatologists Treat Acne. American Academy of Dermatology (AAD)
- What can clear severe acne? American Academy of Dermatology (AAD)