Last Updated on August 6th, 2020
By Dr. Jaggi Rao, MD, FRCPC, Double board-certified dermatologist
Cystic acne is a specific form of acne that involves large, painful bumps that can appear on the face, chest, back, or anywhere else acne commonly appears. Unlike blackheads, whiteheads, or pimples, the infection in this kind of acne does not rise to the surface of the skin. Instead, healthy skin grows over it, leaving your immune system to fight a doomed battle against your clogged pores beneath the surface.
Relatively rare and severe, treatments are more limited than for more typical acne, but treatment is still available. 💡 This article will explain exactly what cystic acne is and why it happens, describe the various treatments available, and answer some of the most frequently asked questions about this skin condition.
Article Table of Contents
Most acne is the result of a minor skin infection caused by inflammation and bacteria called Propionibacterium acnes (P. acnes). In typical blackheads, whiteheads, and pimples, this infection remains close to the surface, meaning treatments can easily reach it and expose the acne to the open air (p. acnes is anaerobic, meaning it cannot survive in the air, which is why it burrows into the natural oils produced by your skin).
When skin grows quickly over one of these minor infections and forms a thicker layer of skin, the bacteria can burrow deeper and the infection can grow. Even though it seems backwards, this increased infection is often caused by your immune system trying to fight off the minor infection.
When your immune system detects an infection, it releases inflammatory properties to help fight it. ⚔️ Infection-fighting immune system agents, like antibodies and macrophages are carried to the site of the infection via the bloodstream. These agents fight the invading cells, creating pus as a byproduct and causing increased swelling. In most cases, this process goes on until the bacteria are destroyed.
The immune system tries to do this with cystic acne, but with significantly less effective results. When the skin becomes inflamed, the infection has restricted access to air, which usually helps kill bacteria, but for p. acnes, this lack of air is actually an advantage. Inflammation also tends to increase sebum production (natural skin oils) which p. acnes can use as a food source. The macrophages and antibodies that usually help defeat infections aren’t overly helpful either: when they attack the bacteria, it triggers the creation of chemicals from the bacteria that generate more infection. All of this adds up to an infectious battle that your immune system just can’t win alone.
It seems like acne always happens to people in their teens or 20s, which is just about the worst time to be dealing with highly visible blemishes. This is partially due to increased stress and sex hormones at that time of life, but you may also be experiencing more acne because your skin is still young and growing, producing new skin cells quickly. 👨👩 This combination of increased hormones (which usually leads to increased sebum production and clogged pores) and fast skin regeneration can be the perfect storm for cystic acne. Clogged pores can lead to regular acne, but when the skin quickly forms a nice, thick layer of skin over top of the clogged pore, that’s when the self-destructive immune response described above can kick in and cause cysts.
Even though newborn babies are also generating new skin cells at a very quick rate, cysts that develop in babies are usually because of an immune deficiency of some kind. The immune system contributes to all cysts, and babies are still developing their immune system when they’re born. 👶👶🏼👶🏽 If a baby’s immune system is running a little behind or has any number of minor newborn immune issues, normal baby acne can turn into cystic acne.
Polycystic Ovarian Syndrom (PCOS) is a tricky disorder to nail down because, like many reproductive/female-oriented disorders, there has been relatively little research done on the topic. The symptoms range from ovarian cysts (though it is not a requirement for diagnosis) to high blood pressure to increased acne.
PCOS is related to insulin-resistance, which can lead to increased blood sugar levels. The different organs in the body find ways to “burn” this blood sugar—the ovaries specifically produce more androgens (typically classified as “male” hormones, although people of all sexes produce some level of androgens).
Androgens typically increase sebum production, which can lead to anything from blackheads to cysts.
Some PCOS-specific solutions include cutting down on processed sugars in your diet (these can exacerbate the insulin-resistance problem and generate more acne-causing androgens), oral contraceptives to balance hormones, or anti-androgen medication.
Each person has a relatively unique set of symptoms so if you think you could have PCOS, it’s important to see a gynecologist, preferably one with significant experience diagnosing and treating PCOS. Because it is not yet well understood, you may encounter doctors who do not take your experience seriously. 👩⚕️👨⚕️ Your visit may be more validating and productive if you research reviews of different doctors in your area or get recommendations from people online in PCOS forums before scheduling an appointment.
Some trans men use testosterone (T) therapy as part of their transition, which obviously increases testosterone, an androgen. In some cases, this can lead to increased sebum production, more clogged pores, and more acne. Based on the few studies done on the influence of T on acne in trans men, cystic acne is not a common reaction, but it has been reported. Cysts resulting from T therapy respond to the same treatments available for all cystic acne.
However, while some cisgender people can benefit from a relatively short, intensive treatment regimen, trans men will likely need treatment that is ongoing. In many cases, T therapy is consistent throughout a trans man’s life, so the acne-causing testosterone levels will be consistently heightened, meaning it is typically best treated by a consistent treatment regimen.
It’s important to address racial differences in skin conditions, but words like “Hispanic” or “Latinx” could refer to any number of skin tones. When it comes to cystic acne, the skin tones most susceptible to this particular condition are known as Fitzpatrick skin phenotypes IV and V. These are the skin tones between light brown and deep brown. 👦🏼👧🏽 Phenotype IV only burns slightly and can tan easily, while type V rarely burns and tans darkly without trouble. Although there are studies that confirm higher incidences in these skin tones, there is limited research on why it seems to affect brown skin tones more.
It is especially important for those with brown skin tones to seek treatment for cysts as soon as they develop, because Latinx and Hispanic skin tends to scar prominently. Untreated, it can lead to significant scarring and hyperpigmentation.
Finding a skin care routine that helps reduce your acne while still treating your skin gently won’t cure cysts, but it can go a long way in treating them. If you can prevent those minor p. acnes infections, you can also prevent the possibility of further infection leading to cysts. Many acne treatments contain benzoyl peroxide to help exfoliate skin, reduce excess sebum, and fight bacteria, or salicylic acid to soothe inflammation and exfoliate skin. These two ingredients can be combined to create an incredibly effective acne treatment and prevention product, but many skincare lines use concentrations that are so high, they often dry skin out and make acne even worse.
One brand that we like to recommend is Exposed Skincare because they combine benzoyl peroxide and salicylic acid in a proportion tough enough to beat acne but gentle enough to keep your skin healthy. 🍃 This is due in large part to the natural ingredients they use to create their product, like green tea extract, tea tree oil, and aloe vera. All put together, these natural and active ingredients can make a significant difference in most acne. Even though cystic acne is different from other kinds of acne and usually requires a form of oral medication, a regular skin care routine like Exposed can make a big difference.
Cysts can appear on the face, but it can also appear on the chest, back, shoulders, and arms. This is called truncal acne, and it typically needs a stronger treatment than facial acne. If you buy a product that turns out to be too harsh on your face, try it out on your truncal acne, or try Exposed Skincare’s body acne kit.
Although a good skincare routine can help somewhat, the most effective treatment for cystic acne is typically oral medication. There are several medications that have proven useful, such as contraceptives and anti-androgens, antibiotics, and retinoids.
Oral Contraceptives and Anti-Androgens: These treatments are most useful for teenagers and 20-somethings whose hormones are still primarily responsible for much of their acne, or people with PCOS. Birth control medicine and anti-androgens can both suppress the production of androgens such as testosterone. These hormones can cause increased sebum production and can lead to clogged pores and acne.
As a note, these treatments are typically not recommended for men since they can result in more feminine features, such as reduced body hair or enlarged breast tissue.
Antibiotics: One of the main features of cystic acne is that it is the result of increased infection and inflammation. Both of these problems can be reduced with the help of oral antibiotics. 💊 Doxycycline and lymecicline are commonly prescribed to help, as is clindamycin, although it is typically reserved for even more severe cases.
Retinoids: The most common retinoid prescribed to treat cystic acne is isotretinoin, as it typically improves skin dramatically. However, it does come with several concerns and risks. It can build up in the blood and cause toxicity, which is why its use must always be carefully monitored by a doctor.
Isotretinoin is also a teratogen, meaning it can cause significant birth defects, even after discontinuing treatment. 🤰🏻🤰🏼🤰🏿 Because of this, users who can become pregnant should follow a careful birth control regimen while taking isotretinoin.
Although no causal relationship has been proven, anecdotal evidence suggests that another complication of isotretinoin is severe psychiatric reactions, such as mood swings, psychosis, or suicidal ideation/attempts.
Even though it can be tempting, you should never pop or lance a cyst at home, for several reasons. First, cystic acne is defined by its increased infection, so when you pop a cyst, you release all of the pus and infection. Although this exposes the p. acnes bacteria to the air, which it cannot survive in, this could cause the bacteria to seek refuge in your sebum somewhere else on your skin, causing the cysts to spread. It could also cause the bacteria to retreat further into your skin, making the infection even deeper. Finally, it can lead to significant scarring when the cyst does finally heal.
Some dermatologists offer surgical removal of cysts, which sounds scary, but is a relatively safe treatment option. The dermatologist will numb the area, remove all of the cells that are creating the pocket where the infection is growing, and stitch the opening from the inside and outside. This prevents scars that look like indentations in the skin. Instead, you will likely have a small, smooth scar, unlike the raised, pocked, or darkened scars that can develop from popping cysts at home.
If you notice cyst-like bumps on your skin, you could have cystic acne, but it could also be another skin condition, like acne conglobata or acne keloidalis nuchae.
In acne conglobata, the infection lying beneath the cysts and nodules burrows even deeper into the skin and forms abscesses which then connect beneath the skin, creating a network of infection. This is a very serious condition that can lead to scarring and skin disfigurement.
The main way to tell the difference between regular cystic acne and acne conglobata is to look for nodules. Acne conglobata features cysts, but it also presents with nodules, which are similar to cysts but they are hard to the touch.
Some cystic acne includes nodules as well, so if you find hard bumps, it is best to consult with your doctor to make sure you’re treating your acne appropriately.
Another serious skin condition that could be confused for cystic acne is acne keloidalis nuchae (AKN). AKN does not produce cysts, but it does produce papules, plaques, and keloid-like bumps that can often look like cysts. These are a result of an infection of the hair follicle specifically.
The best way to tell the difference between AKN and cystic acne is to look carefully at the bumps on your skin. If you see large bump with relatively clear edges that feels somewhat soft to the touch, it is likely a cyst. If you see raised bumps without defined edges that are relatively solid to the touch, it may be a papule. The best way to know for sure what kind of acne you’re dealing with is to see a dermatologist.
Are there any ways to hide or cover up acne cysts?
Cystic acne can be more difficult to hide than typical acne because it is typically more raised and can sometimes have a purple or yellowish tint. However, there are still ways to make cysts less noticeable. One approach that can be helpful is to apply a full face of makeup. This requires several products and makes it obvious that you are wearing makeup, but it can very effectively hide cysts by using a full coverage foundation that evens skin tone, a brightening solution that reduces redness peeking through the foundation, a spot concealer for larger or more obvious spots, ultrafine foundation powder to further even out skin, and setting spray to make sure it lasts all day.
If this routine is too complex, too expensive, or if you don’t want it to be obvious that you’re wearing makeup, there are also concealers you can apply just to the spot you want to cover. If your cysts are red or slightly purple, you’ll want to buy a concealer with a green tint, or one that says “color correcting.” If your cysts are yellowish, look for the concealer closest to your skin tone, maybe even a hair darker. Apply a very small dot of concealer to the cyst and gently rub in with a brush, q-tip, or cotton ball (don’t use fingers, oil and bacteria on fingertips can worsen acne). 💧 As with all makeup, any product you buy should say “oil-free,” “non-comedogenic,” or “non-pore-clogging.”
How can I fade scars caused by cystic acne?
Scarring can be covered with makeup, but like with other scars, there are also ways to fade them. If you’re looking to fade acne scars yourself, two good options are a topical vitamin C serum that can promote collagen production to lessen the effects of indented scars or a chemical peel that exfoliates skin to encourage fresh skin cell production to even out skin.
A dermatologist can provide more intense, but also more effective, acne scar treatment through surgery, laser therapy, skin fillers, or other injections. 💉🩺 There are procedures for both indentation scars and raised scars, but it’s important to note that these procedures are not covered by insurance and can get pricey. But if your scars are painful, it can be a very helpful option.
Is cystic acne contagious?
Cystic acne cannot be transferred to other people, but you can transfer it to yourself. Cysts are caused by a bacterial infection, and bacteria like to spread, but the reason cysts form is because the infection is trapped under your skin. Even if one of your cysts is open at the surface of the skin because of popping or natural cystic leakage, p. acnes is anaerobic, so it cannot travel through the air and affect other people the way the bacteria from a cold can.
If the cyst is open, it’s possible for the acne-causing bacteria to travel from your skin to someone else’s if they touch it directly, but even then, cystic acne specifically is not contagious. If someone who does not typically have cysts touches an open cyst and the bacteria survive the transfer to their skin (it’s likely that they will be killed by air exposure), they will not suddenly start getting cysts. The bacteria that causes cystic acne is just like regular acne, it’s just how it manifests in your skin that’s different.
So generally speaking, no, it is not contagious…to other people. It can, however, be contagious to different parts of your own body. If you have an open cyst and you touch it, then touch another part of your skin relatively quickly (before the bacteria can die), the p. acnes could invade that new spot and lead to acne, which your body could turn into cystic acne, since it is already predisposed to do so.
Are there any natural remedies?
We usually love to recommend natural treatments, since they can be a fun, less expensive way to improve your acne, but because cysts are a more serious infection, there is no home remedy that will effectively treat it. ⚕️ Many DIY treatments that help typical acne could actually worsen cysts so it’s important to follow a well-researched, dermatologist-recommended treatment plan.
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