Everything you need to know about cystic acne

Cystic acne is a severe form of acne characterised by deep, painful, pus-filled spots under the skin⁽¹⁾. It often leaves significant scars and can have a significant impact on quality of life and self-esteem. 

So how can you recognise this type of acne? What causes it? What treatments are effective? 

Here is everything you need to know to understand and treat cystic acne. 

What is cystic acne? 

Cystic acne, also known as nodulocystic acne, is one of the most severe forms of acne. It occurs more frequently in boys after puberty⁽¹⁾. 
Cystic acne is characterised by deep and very painful lesions called "cysts". These cysts are filled with pus (inflammatory fluid) and form beneath the surface of the skin. 

In reality, cystic acne can include several types of deep and extensive inflammatory lesions. These are mainly nodules and cysts:

• Nodules^{(1 and 2)} are solid, hard, deep, red and painful lesions without purulent discharge. Nodular acne is when nodules are predominantly present.
• Cysts are lesions filled with pus, located even deeper under the skin. They are very painful, larger and can leave permanent scars⁽¹⁾.

Typically, nodules often appear before cysts, and if the inflammation persists or worsens, these nodules can develop into cysts. This is why dermatologists often group these severe forms of acne (nodular acne and cystic acne) under the term "nodulocystic acne"⁽²⁾, highlighting their clinical similarities and shared severity. 

Causes of cystic acne 

Several factors combined can lead to the development of cystic acne⁽¹⁾:

• Excessive sebum production, often due to hormonal changes.
• An imbalance in the skin's microbiota, particularly with the increased presence of Cutibacterium acnes, which aggravates inflammation under the skin. 
• A genetic predisposition: in other words, if your parents had severe acne, you are more at risk of developing severe acne (nodular acne or cystic acne) as well. 
• Environmental factors (significant stress, an unbalanced diet or cosmetics that are unsuitable for your skin can aggravate acne). 

Possible complications

Without proper treatment, cystic acne can cause: 

• deep and permanent scars;
• persistent pigment spots;
• psychological disorders such as anxiety, stress or depression. 

In very rare cases, it can develop into acne fulminans, a very severe form requiring urgent medical attention. 

Symptoms and identifying cystic acne

Like most types of acne, cystic acne appears on the face, but it also very often spreads to other areas of the body: back, chest, shoulders, buttocks, etc.
In general, several types of lesions coexist in cystic acne:

• retentional lesions (presence of open comedones and closed comedones).
• inflammatory lesions with papules, pustules (red spots less than 5 mm in size), nodules (red, hard bumps without pus), cysts (deep spots filled with fluid) or abscesses. 

All of this leads to a high risk of scarring.

Cystic acne lesions are highly visible and unsightly, and can lead to isolation and withdrawal⁽¹⁾. At secondary school, sixth form or university, other pupils may think that it is a contagious disease or a lack of personal hygiene, when this is not the case at all. 

The different types of treatment for cystic acne

Effectively treating cystic acne often requires a combination of oral medications, topical treatments, and specific dermatological procedures. The main treatment options are as follows:

Oral treatments and antibiotics

Isotretinoin is highly effective: this medicine is considered the most effective treatment for severe acne (nodular acne and cystic acne), as it significantly reduces the size and activity of the sebaceous glands. It reduces inflammation and eliminates the bacteria linked to acne. However, this treatment requires strict medical supervision due to significant potential side effects (risk of birth defects in the event of pregnancy, severe dryness, possible impact on mood). Take the time to discuss this with your dermatologist to accurately assess the benefits and risks^{(1 and 3)}. In everyday life, for example, certain measures are necessary: sun protection, gentle cleansing, moisturising the skin and lips, using eye lubricants in cases of dry eyes, etc. 

In cases of cystic acne, oral antibiotics may also be prescribed to control inflammation and reduce bacterial growth. 

For women suffering from cystic acne linked to hormonal imbalances, a dermatologist may prescribe oral contraception or specific anti-androgen treatments to stabilise the hormonal activity responsible for the acne.

Over-the-counter creams

Over-the-counter creams (containing benzoyl peroxide or retinoids) can improve superficial spots by helping to unblock pores and reduce local inflammation. However, their effectiveness is very limited on very deep lesions such as nodules or cysts that have already formed, as is the case with cystic acne (or nodular acne). 

They are mainly used as a supplement to oral medication to prevent further flare-ups.

Procedural therapy: drainage, peels, laser treatment

To treat cystic acne, certain procedures can be particularly beneficial in effectively treating the most resistant lesions⁽¹⁾: 

• Corticosteroid injections directly into painful nodules or cysts help to quickly reduce inflammation and promote healing in cystic acne.
• Drainage and extraction of cysts, performed by a dermatologist, also provides rapid relief from deep, painful cystic acne lesions.
• Chemical peels or laser treatments help smooth the skin and reduce scarring, but only once cystic acne has been brought under control. 
• Photodynamic therapy⁽⁴⁾, which combines light and specific agents, is also an interesting option for deep treatment.

Natural remedies

Certain natural treatments, such as zinc supplements, can complement conventional treatments prescribed for cystic acne. Always consult with your dermatologist before using them. 

Prevention: how to avoid cystic acne

Here are some tips to limit the onset or worsening of cystic acne:

• Cleanse your skin with a soap-free cleanser suitable for sensitive or acne-prone skin.
• Avoid harsh exfoliants and irritating cosmetics at all costs.
• Moisturise your skin with a non-comedogenic cream to prevent dryness.
• Eat a balanced diet rich in anti-inflammatory foods such as fruit, green vegetables and oily fish.
• Incorporate relaxing activities into your daily routine, such as yoga, meditation or regular exercise, as stress can trigger severe acne flare-ups and therefore cystic acne^{(5 and 6)}.
• Protect your skin from sun exposure to avoid increasing the risk of scarring. 

Be sure to consult with a dermatologist as soon as you notice the first symptoms of nodular or cystic acne, as early consultation will enable an accurate diagnosis and appropriate treatment, and will limit the risk of scarring.
Especially as cystic acne, which is a severe form of inflammatory acne, can sometimes be mistaken for fungal acne. These two forms of acne are similar⁽⁷⁾ but have completely different causes: fungal acne is caused by a proliferation of fungi, and its treatment requires specific care that differs from that used for cystic acne. An accurate diagnosis is therefore essential in order to choose the right treatment. 
Finally, regular check-ups with your dermatologist are also important to ensure good hormonal balance.