While you wouldn’t be able to tell from her clear complexion, Holly Cutler battled with severe cystic acne 20 years ago. She tried medical and topical treatments with no success. Amid the physical difficulties, cystic acne also affected her emotionally. “The emotional impact of having cystic acne all over my face was devastating,” she says. “You wouldn’t believe the comments people actually made to my face to blame me for the breakouts.” People even called her ugly to her face. Eventually an esthetician managed to resolve her cystic acne through multiple sessions that involved European-style facials and light-based therapy. But, as is the case for many people who have cystic acne, Holly’s skin was scarred afterward. She says this was a shocking surprise, especially since there were no scar-reversing treatments available at the time. This journey prompted her to look into ways of healing her skin’s scars—and eventually she did just that. 
The emotional impact of having cystic acne motivated Holly to become a medical esthetician herself. Now a well-known figure in the field, she founded FACE Skincare~Medical~Wellness in Bingham Farms, Michigan, where she and her staff use approaches that she says are far more advanced than those that cured her cystic acne nearly 20 years ago as they incorporate lasers, injectables, and naturopathy. Cystic acne affects many people and as with Holly, it can have a huge emotional impact. Fortunately, it can be treated. Here’s what you need to know about your cystic acne treatment options.
What is cystic acne?
“Acne occurs when a pore gets clogged. Typically, a clogged pore will have dirt, dead skin cells, and bacteria inside,” says Janet Prystowsky, MD, a Manhattan-based dermatologist. “When the clogged pore is deep in your skin, then it can develop into a cyst, i.e. a tender bump from inflammation.” A cystic acne pimple is deeper than a regular whitehead. As a result, it doesn’t have a white bump that can be popped, says Prystowsky. The cyst can feel painful and might be felt under the skin before it shows. The area around the cyst might also appear inflamed and red. Cystic acne can affect people of all ages, but it’s most likely to affect people in their teens and early twenties, says Toni Stockton, MD, a board-certified dermatologist based in Arizona. “The most common age to develop acne is between 12 and 24 years of age but we still see some patients continue to have to deal with this frustrating condition well into their forties and fifties,” she notes. The acne typically appears on one’s face, back, neck, chest, and upper arms. 
“Genetics are probably playing a role in some patients but hormones are a more common cause for cystic acne,” says Stockton. Endocrine conditions like polycystic ovary syndrome, for example, can increase your chances of developing cystic acne. “The type of sebum (oil) that we that we produce can play a role in whether we get small bumps, whiteheads and blackheads, or cystic lesions,” she adds. “In some patients, their sebum causes only a small reaction in the skin but in others, their bodies make a lot of inflammatory cells that cause a deeper inflammation.”
How can cystic acne be treated?
Unfortunately, cystic acne isn’t something that simply goes away over time—so don’t wait to get help, or the scarring will just get worse, warns Holly. Cystic acne can be painful and inconvenient, but fortunately, it’s treatable. Your best bet is to see a dermatologist as soon as possible so that they can treat your acne before it becomes more severe. According to Stockton and Prystowsky, there are a number of different treatments available for those who suffer from cystic acne. 
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Steroid Injections
A cortisone shot, or direct injection of cortisone into a cystic pimple, can be a really effective way to reduce its size and impact. There are side effects, though: The area might look sunken in after some time, as the cortisone affects the fatty tissue in the area around the injection site. Additionally, if cortisone shots are administered too often, they can adversely impact the skin’s ability to heal itself.
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Antibiotics
Antibiotics like minocycline or tetracycline can help reduce cystic acne by preventing the spread of bacteria, a main cause of acne. “We do try to limit the length of time that we use antibiotics to three to six months if possible due to the development of drug resistance,” says Stockton. “If a patient is not getting better in this period of time then we would move to another treatment option.” Note that these medications aren’t advisable for pregnant women or those who might conceive while on a course of treatment for cystic acne.
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Topical Treatments
Your dermatologist might recommend retinoid creams and benzoyl peroxide washes to treat your cystic acne. Retinoid topicals, which include a derivative of vitamin A, work to unclog pores whereas benzoyl peroxide topicals reduce acne by killing the acne-causing bacteria on your skin. Some people might be sensitive to these topicals and have adverse reactions that could include painful, red, itching or peeling skin at the application site.
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Oral Contraception
Certain forms of oral contraception can improve skin conditions by balancing the hormones, which in turn will regulate sebum production. Of course, some people experience mental and physical side effects when they’re on birth control, which means this treatment isn’t advisable for everyone.
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Cryosurgery
A more invasive therapy used by Stockton and other dermatologists to treat cystic acne is cryosurgery. Cryo means cold and cryosurgery involves applying extremely cold substances, like liquid nitrogen or cold carbon dioxide, to the cysts. Cryosurgery causes ice crystals to form within the damaged skin cells, which eventually tears those cells apart. It also reduces blood flow to the cysts, and it can reduce acne scarring. Note that you may feel a tingling, uncomfortable sensation after treatment.
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Isotretinoin
Isotretinoin, also known as Accutane or Roaccutane, is a strong and effective treatment for acne. It contains a strong form of vitamin A. While Stockton prescribes it to her patients, she notes that it’s only used as a last resort for cystic acne that resists other forms of treatment. This is because isotretinoin unfortunately has many side-effects, including dry mouth, chapped lips, and nosebleeds. As with antibiotics, isotretinoin is not advisable for pregnant women or those who may become pregnant, as it can be lethal to a fetus.
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Changes in Diet and Lifestyle
One possible way to reduce cystic acne is to start with the food you consume. Stockton says that dairy and whey protein products can trigger or worsen cystic acne. Prystowsky recommends patients avoid whey, dairy, and sugary foods to see how their skin responds. Many people are interested in naturopathic, holistic approaches to treating cystic acne. Doug Cutler, ND, of Cutler Integrative Medicine notes that diet and food sensitivities can be linked to cystic acne. As a naturopathic physician, he treats patients by first running a full food sensitivity panel and a comprehensive stool analysis. “Food sensitivities originate in the gut and create chronic inflammation, which can impact every part of the body,” he explains. “80 percent of our immune system is found in the gut, so we want to make sure there is no chronic inflammation, which can imbalance the hormones and lead to cystic acne.” From there, he might place the patient on an elimination diet for a few months. This involves removing certain foods from your diet to see whether you have an intolerance for them. The elimination diet can help heal the gut and reduce inflammation.
Cutler also suggests supplements like probiotics and addressing emotional and lifestyle factors. “Internalizing stressors and negative emotions can lead to inflammation and skin issues,” he points out. “It is important to recognize our emotional habits and make lifestyle changes, as well as do mind–body medicine therapies throughout our life.” Cutler’s assertion that stress has been linked to skin conditions and aggravating hormonal imbalances is also supported by ample research and more mainstream MDs. Of course, many people are drawn to alternative cystic acne treatments because of the side effects associated with mainstream treatments. That said, it’s important to remember that alternative treatments may have side effects, too. Stockton notes that many of the alternative treatments that are suggested for cystic acne haven’t been studied thoroughly. Because of this, certain alternative treatments can be risky unless done under the supervision of a health practitioner. For example, alternative treatments like including supplements and herbs in one’s diet require straightforward conversations with healthcare providers, and it’s imperative to tell your doctor which supplements you’re taking since they can interact with other medications. 
“We have to be careful with these types of products because these are not regulated, so some of the products can obtain other materials in them and some of these contain very high levels of supplementation that can even be toxic in the younger population,” Stockton says. “There are a few products that have some support. The best help with navigating alternative treatments is to make a consultation with a medical provider who is knowledgeable with the current use of these products.” In addition to supplementation and dietary changes, many people are after natural home remedies for cystic acne, but Stockton and Prystowsky both advise that there aren’t any effective home remedies. Seeing your dermatologist should be your first port-of-call, and from there, they can advise you on how to properly care for your skin.
Should you pop the pimples caused by cystic acne?
Definitely not, according to Stockton. “The more you manipulate it, the more likely you are to cause permanent scarring,” she says. “I would suggest leaving the surgical treatment of acne to skincare professionals to avoid unnecessary scarring of the skin.” As tempting as it may be, the depth of cystic acne means the follicle will just burst within the skin, causing further inflammation. 
Speaking of scarring, one of the most difficult aspects of cystic acne is dealing with the scars it leaves behind. “The best way to reduce your chances of permanent scarring is to seek care early, before you develop the scars and to avoid picking and squeezing cystic lesions,” says Stockton. “Understand this can be a long process, but most of the time, we can successfully control the condition.”
The Psychological Impact of Cystic Acne
Unfortunately, we live in a society where clear skin is seen as essential to beauty. For many people with cystic acne, this can be heartbreaking as they can be made to feel unattractive and undervalued. As in Holly’s case, people might also be bullied or teased because of their skin condition. Cystic acne can have an effect on your mental wellbeing, too. One study shows that adolescents with acne—especially teenage girls—are likely to experience negative psychological impacts including anxiety due to their skin conditions. Another study links acne to poorer mental health and lower self-worth. Of course, this stress isn’t good for your soul or your skin, and unfortunately stress is related to more agitated and blemished skin, as well as a range of physical and mental health issues.
There is hope for Cystic Acne Sufferers
Therapy can be a useful way to work through these feelings. Kelley Kitley, LCSW, says that she often has clients who struggle with self-image and body-image issues due to acne. She recommends therapy to anyone who struggles with self-esteem and confidence issues due to acne or any other cause. 
“The treatment I often use is cognitive behavioral therapy, which is restructuring automatic negative thoughts and focusing on the positive,” she says. “If they are getting treatment for the acne, we work on recognizing that the acne is temporary.” While it’s important to sort out the physical effects of cystic acne as soon as possible, the same can be said for the emotional effects of acne. It’s best to see a therapist sooner rather than later. Holly feels that she’s lucky because her cystic acne motivated her to find her true calling. “I will never forget my experience with cystic acne, and would never want to go through it again, but it did provide me with a life changing experience,” she says. “If we use our challenges instead of letting our challenges use us, we can change the world one person at a time. That is my purpose and destiny now, every day.”
