Cystic Acne

Cystic acne is the most serious type of acne because it is so difficult to treat and because it can leave deep and lasting scars on the skin. There are many myths about its causes, which are unknown. But it should not be treated with over-the-counter ointments, creams or scrubs.

Last Modified: September 5, 2023
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What Is Cystic Acne?

Cystic acne is an inflammatory skin condition of large, painful, pus-filled pimples that form deep under the skin. It occurs when pores in your skin become clogged, usually with oil and dead skin cells. Bacteria get trapped within the pores, causing pain, swelling and redness.

Typically, acne includes smaller pimples, whiteheads, papules and blackheads. Cystic acne is considered to be the most severe form of acne and is much less common.

If cysts burst, infection can spread throughout the layers of the skin and cause more breakouts. This form of acne can create long-lasting damage, both psychologically and physically. Severe cases can cause long-term scarring of the skin.

Cystic Acne Symptoms

Also known as nodulocystic acne, cystic acne is more visible than regular acne and produces nodules, pustules, cysts and inflammatory papules on the face and other areas of the body. Large blemishes typically measure several centimeters across, setting the table for acne scarring that can be long-lasting or even permanent.

People with nodulocystic acne develop acne cysts and nodules. Acne nodules are hard, painful lumps that are larger than acne papules and form deep underneath the skin’s surface. Nodules take longer to heal.

Acne cysts present as:
  • A red lump under the skin
  • Painful or tender to the touch
  • Small as a pea or as big as a dime
  • Crusty
  • Oozing pus from a whitish yellow head

Cystic acne damages and destroys healthy skin tissue. Treating this form of acne can help minimize the risk and impact of scarring.

Where Does Cystic Acne Develop?

Cystic acne breakouts can be extensive, covering large areas on the upper body. Most people experience breakouts on their face, which contains more oil glands than other parts of the body.

Other areas where cystic acne may form include:

  • Back
  • Neck
  • Chest
  • Buttocks
  • Shoulders
  • Upper Arms

The back is a common area for cystic acne to form as sweat, oil, dead skin cells and bacteria get trapped in pores. Sweaty clothing, backpacks and sleeping on your back can worsen back acne and cause recurrence.

There are types of outbreaks that can develop in the groin that are similar in appearance to cystic acne but are considered a distinct condition.

Cystic Acne Causes

Healthy skin has pores and sebaceous glands that secrete an oily substance called sebum. Normal sebum secretions protect the skin and hair follicles. Overproduction of sebum and an overgrowth of skin cells causes pores to clog, creating pimples and setting the stage for severe acne.

Having bacteria on the skin is healthy and an important component of the skin’s infection prevention system. Acne can be seen as a disruption in this protection and maintenance system.

Doctors don’t know the exact causes of cystic acne, but they cite certain potential triggers and irritants. These possible causes include hormonal changes, genetics, medications and diet.

  • Hormonal changes. During puberty, the body’s androgen hormones increase dramatically, increasing the production of sebum. Skin cells also grow faster, and the higher cell turnover leads to a greater chance of pores clogging. Menstruation, pregnancy, menopause and polycystic ovary syndrome can also trigger cystic acne.
  • Genetics. Some people may be predisposed to cystic acne because of a family history of the condition.
  • Medications. Some prescription drugs and chemicals such as lithium, corticosteroids, testosterone, isoniazid and phenytoin may start or worsen acne.
  • Diet. Researchers are studying the link between consuming certain foods and acne. Although the relationship between diet and acne is uncertain, it’s an area of ongoing investigation. Recent studies have indicated that a diet high in fruits and vegetables and low in refined carbohydrates and dairy may help protect against acne outbreaks.
  • Comedogenic cosmetics. Oily or greasy cosmetics, lotions and even cleansers can be comedogenic, or pore clogging. These blockages can cause or worsen acne.

Many myths and misconceptions persist about causes of acne that research does not support. Scientific studies suggest that eating greasy or spicy foods, chocolate or nuts likely does not cause acne. Poor hygiene also does not cause acne. In fact, excessively scrubbing the skin or using harsh chemicals or soaps to cleanse the face irritates the skin and can trigger or worsen acne.

Cystic Acne Treatments

Although certain home remedies can help with regular acne, cystic acne requires attention from a medical practitioner. The condition can be difficult to treat and manage, and over-the-counter treatments are not effective.

It can take three months or more to clear up acne cysts. Early acne treatment can also help prevent scarring.

Top cystic acne treatments include:
  • Spironolactone: Reduces the production of excess oil, and is typically used in treatment-resistant or severe cases. Doctors don’t prescribe this medication to men, because one of the side effects is breast growth.
  • Oral antibiotics: Lower inflammation and help control bacteria. The antibiotic most commonly used is doxycycline.
  • Benzoyl peroxide: Kills bacteria on your skin and fights inflammation.
  • Birth control pills: Regulate hormones and reduce the hormone spikes that encourage sebum production and lead to clogged pores.
  • Retinoids: A type of Vitamin A in lotion, cream, gel or foam that can unclog pores and aid antibiotics. They also encourage the skin’s natural healing process. Isotretinoin, previously known by the brand name Accutane, is an oral retinoid pill. Current brand names include Amnesteem, Absorica and Zenatane.
  • Steroids: Typically reserved for treatment-resistant or severe cases. When injected into the cysts or taken orally, they reduce inflammation and prevent scarring.

Avoid poking, squeezing or popping cysts or nodules. Doing so can seriously damage your skin, worsen your acne and lead to more acne scarring.

Cystic Acne Complications

With early care from a dermatologist, you can successfully manage cystic acne. But complications can still sometimes occur.

Common complications include:
  • Scars
  • Hyperpigmentation or hypopigmentation
  • Large, uneven indents
  • Wider pits

The worst cystic acne complications can result from picking at the cysts, which can cause infections such as cellulitis and scarring.

To avoid complications:
  • Do not squeeze, scratch, rub or pick the pimples or cysts. This can lead to skin infections, scarring and slower healing.
  • Avoid wearing tight baseball caps, headbands and other hats.
  • Avoid greasy cosmetics and creams.
  • Avoid touching your face with your hands or fingers.
  • Do not leave makeup on overnight.

If scarring does occur, your dermatologist can also help treat acne scars to eliminate them or minimize their appearance. Most treatment for acne scars will not begin until cystic acne is managed.

Cystic Acne Prevention

While preventive measures cannot guarantee the avoidance of acne or even cystic acne, some steps may help reduce the risk or help reduce their severity. Discuss skin care regimens with your doctor.

These steps may help prevent cystic acne:
  • Apply an oil-free moisturizer if your skin feels dry.
  • Use a mild foaming facial cleanser, lukewarm water and your fingers rather than a washcloth or sponge to wash your face.
  • Wash your face gently after you wake up, before going to bed and after exercising or sweating.
  • Do not sleep with makeup on and use a nonabrasive makeup remover.
  • Use noncomedogenic, water-based makeup and facial products.
  • Try to avoid touching your face.
  • Wash your hair regularly and try to keep it from touching your face.
  • Do not pick at or pop pimples or scabs.
  • Avoid foods high in simple sugars and dairy (high glycemic index diet).
  • Avoid being overly exposed to the sun. Be sure to wash your face to remove sunblock when you are out of the sun.
  • Shave with care and apply warm, soapy water before grooming. Warm water opens the pores and allows the soap to penetrate deeper, removing more debris.

Although certain factors, such as genetics, predispose some people to cystic acne, the tips above may help prevent acne, stop acne from becoming cystic and prevent acne flare ups.

When to Talk to a Doctor

Severe untreated cystic acne can have an impact on how you feel about your appearance and your overall self-esteem. Some symptoms can also be physically painful and uncomfortable and can benefit from a dermatologist’s care.

Call your healthcare provider if:
  • You have swollen, red, painful pimples
  • You have signs of a skin infection
  • Your acne becomes progressively worse even after medication
  • You develop scars
  • You experience a sudden onset of severe acne as an older adult

If acne affects your quality of life, talk to a dermatologist, or contact your general practitioner if you require a referral. Your child’s pediatrician can also recommend a pediatric dermatologist if needed. They can also advise on general health information that may be helpful.

Please seek the advice of a medical professional before making health care decisions.