Cystic Acne: Why It Happens and How to Treat It

A very common dermatological issue observed worldwide includes acne vulgaris. Typically, this manifests as a general occurrence in adolescents and young adults at their important developmental stages of life. Blackheads, whiteheads and other mild blemishes are very common on the skin while cystic acne is the most severe category of acne and is defined as deep, painful and fluid-filled nodules or cysts that can last weeks to months.

These lesions typically produce structural scarring and have a significant impact on one's self-esteem and mental health. Since the pathology of cystic acne develops deep within the dermis, this type of acne generally does not respond well to standard topical treatments. In order to treat such a severe condition, there must be a clear evidenced-based explanation as to why these deep dermal lesions occur and the approaches that target cystic acne in a comprehensive manner. 

Pathogenesis Of Cystic Acne

Typically, no one specific event will trigger cystic acne but rather a confluence of biological systemic and external factors that modify our skin. Oil production (sebum) is likely the primary reason driving the incidence of cystic acne. It creates conditions within the hair follicles conducive to the proliferation of acne causing bacteria which are directly responsible for the localized inflammatory response to rapid bacterial growth within a clogged pore with entrapped dirt, sweat and excess sebum.

Simultaneously, normally shed skin cells stop being exfoliated on the surface in people genetically susceptible to cystic breakouts. Instead, a build-up of pore-cloggers made with dead cells, traps oil and bacteria below the skin's surface. The acne-causing bacteria feed on the blocked sebum, creating inflammation within the follicle. The pore wall ruptures down and these inflammatory byproducts flood the surrounding skin eventually activating an acute inflammation that results in pain, swelling and redness as deep-rooted lesions of cystic acne.

Certain Key Triggers Of Cystic Acne

Hormonal Imbalance

Hormones ultimately control oil production. Hormone such as androgen is able to bind directly to receptors on the sebaceous gland and instruct the gland to release  the maximum amount of oil on the skin. Hormonal cystic acne is common during times of developmental changes such as puberty. This can continue for women even into adulthood. 

Changes in hormone levels due to the menstrual cycle, pregnancy, pre-menopause and various endocrine disorders (such as Polycystic Metabolic Ovary Syndrome or PMOS) will stimulate severe and repeated episodes of cystic flare-ups commonly. 

This specific kind of hormonal acne is seen as the painful cysts along the jawline, chin and neck, typically in the lower part of the face.

Genetics

Your genetic makeup influences your basic skin type, sensitivity of sebaceous glands, the ability of your skin to shed dead cells (keratinocytes) as well as the severity of your immune system’s inflammatory response to overgrowth of bacteria resulting in cystic acne. 

Mental Stress

During intense psychological or physical stress, the hypothalamus signals the adrenal glands to make cortisol. Cortisol is the body’s main “stress hormone”. Systemically, cortisol escalates inflammation. Locally, cortisol signals the sebaceous glands to secrete excess sebum. Neuropeptides released during stress augment neuropeptide-related neurogenic inflammation in skin, causing cysts to be inflamed, painful and slower to heal.

Environmental Stress

Environmental stress causes a collapse in the natural moisture defense layer and an increase in deep skin inflammation. External stressors like air pollutants, toxic heavy metals and even harsh UV rays can lead to free radical or Reactive Oxygen Species (ROS) formation on the skin barrier. They facilitate an oxidation process called lipid peroxidation that breaks down skin antioxidants.

Harsh high-humidity and high-temperature conditions force excessive and sticky oil production in the sebaceous glands. The oily sebum traps dirt and debris as soon as the skin is irritated to completely plug pores. The Cutibacterium acnes bacteria thrives comfortably in these conditions and multiply in an anoxic environment deep inside the hair follicle. This leads to painful deep tissue cysts called cystic acne.

Diet

For a while, people debated the impact of our food choices on acne that necessitates the research on the interrelation of diet with acne.What can actually wreak havoc on cystic acne is a diet high in glycemic load. Eating ultra-processed carbohydrates spikes our blood glucose levels sky-high and forces the pancreas to produce significantly high amounts of insulin and Insulin-like Growth Factor 1 (IGF-1). They elevate systemic inflammation and promote the formation of deep painful pimple with increased sebum release and delayed desquamation of the skin barrier.

Approaches To Prevent And Manage Cystic Acne Effectively

1. Topical Approach
2. Oral Approach
3. Surgical Procedures

Note This is for informational purposes only. For medical advice, diagnosis or personalized recommendations, consult a healthcare professional or a physician. 

Topical Approach

Alite Skincare’s science-based topical regimen is designed to address active breakouts by clarifying blockages from deep within their core, without compromising the skin barrier. To apply, begin by gently washing with a soap-free and hydrating solution such as the Alite Anti-Acne Face Wash formulated with ceramides and charcoal to expel impurities from the skin and regulating sebum on the skin.

Then use a small amount of Alite Anti Acne Gel to dispense onto the spot. The effective blend uses 5% Niacinamide PC, and 6% Silanediol Salicylate that allow it to penetrate deeper in the skin to fight acne. Later, apply noncomedogenic moisturizer such as Alite Spots Reduction Cream on those spots to effectively refine the pore and decrease painful inflammation. This will also boost the barrier repair of the damaged skin. It will function to actively reduce the formation of cystic acne, post-acne marks and subsequent scarring requiring cystic pimple treatment.

Oral Approach

Diet modification plays a key role in oral approach by reducing Insulin-Like Growth Factor-1 (IGF-1) with a simple and lower-glycemic load diet (reducing consumption of refined sugar and highly processed carbohydrate intake). A lower-glycemic load diet helps in preventing spikes of insulin which can consequently stimulate the oil glands in an effective way.

Reducing dairy and whey protein in your diet and increasing Omega-3 rich diet and zinc will further allow ultimate repair of your deep dermal tissues so that you are able to prevent post-acne scarring. For those who struggle with very deep, cystic forms of acne, it might be necessary to combat cystic acne with lifestyle and dietary modifications with the help of dermatologist recommendations.

Surgical Procedures

Management of Active Cysts

Corticosteroidal Injections

Acute, painful nodulocystic lesions will benefit greatly from direct intralesional corticosteroid injection (usually a diluted preparation of triamcinolone acetonide). As the injection directly goes into the center of the lesions through fine microneedles, the chemical  blocks the local, inflammatory and cellular process that is attacking the skin with immune cells and resulting in rapid shrinkage of swollen, deep cyst walls (usually within 24-72 hours). While this doesn't eliminate bacteria and sebum blockage within, it helps to reduce further significant tissue damage. Excessive dosage can lead to local atrophy or hypopigmentation, thus careful dosing by a dermatologist is essential.

Incision and Drainage 

A sterile I&D Incision and Drainage procedure is usually performed on larger, tense, fluctuant cysts that aren’t being responsive to previous treatment. A board-certified dermatologist will make a tiny opening in the epidermal layer of skin with a sharp scalpel or surgical needle and squeeze to release trapped pockets of debris including pus,blood, and the remnants of dead skin cells. The procedure to release the deep tissue pressure is quick and will halt the migration of the inflammation to other areas of skin and this protects other healthy dermal tissue. It is absolutely vital that I & D be done by skilled medical care providers. 

Note Trying to poke at an infected, unformed sac usually releases and drives its contents deeper, causing further damage and a higher incidence of infection and scarring. Avoid touching the cysts or any other acne lesions with unclean hands and maintain proper hygiene around the affected area.

Cryotherapy

The treatment with cryotherapy exploits freezing temperature application to an active lesion. It is usually using liquid nitrogen or solid carbon dioxide - to create a vascular- mediated injury that will eliminate the microvasculature supplying hyper-inflamed cystic lesions. The cycle of ice application and thaw-out will result in some mild scaling and sloughing of superficial tissue destroyed in the course of freezing, thereby flattening these painfully deep nodules as well as causing the destruction of the blood vessels frequently feeding eruptive cysts. Lastly, conditions brought on by the intense cold are unfavorable for growth of C. acnes that can also reduce significant acne-causing bacterial population.

Laser Treatment

Laser treatments for active cysts are designed to utilize light and heat to address the dermal process of inflamed lesions. For targeted intervention with the active cyst inflammation, this photo-thermal energy works by targeting micro-blood vessels. Specialized vascular lasers like the PDL or a specific Gold Toning approach are utilized to provide photo-thermal energy that deactivates the micro-vasculature thereby diminishing redness, discomfort and the inflammation process. In addition, utilization of long-wavelength lasers such as the 1064 nm Nd:YAG system to directly target and impact the  sebaceous gland activity. The moderate heat produced inhibits overproduction of sebum and neutralizes excess oil and by stimulating C. acnes through photoexcitation. This dual targeted process impacts the inflamed lesions, increases turnover time in the tissue and halts progressive structural damage.

Prevention of Future Cystic Acne

Comedone Extraction

Comedone extraction is a non-inflammatory preventative treatment that can help keep pimple precursors away. Your dermatologist will place a sterile instrument around blackheads and whiteheads with the correct technique using even pressure and squeeze out the hardened oil plug (sebum and keratin). Getting the comedones out before they have a chance to block the pores prevents the anaerobic conditions required for the overgrowth of C. acnes bacteria, as the bacteria’s expansion could damage and break the pore wall to cause deep cysts. Regularly scheduled extractions along with your topical treatments will help clear pores.

Chemical Peels

Chemical peels help to keep cystic acne away because they use strong chemical exfoliants like salicylic acid or glycolic acid to help to completely break down sticky cellular bonds. The salicylic acid component in your chemical peels helps keep your skin fresh promoting skin renewal process as it helps break down the excess sebum and dead cells at the blocked pores. This exfoliates the cellular buildup and also removes dull skin preventing potential severe inflammatory flares.

Laser Therapy

Preventive laser therapy focuses on permanently altering the deep structural causes of chronic acne. Non-ablative fractional lasers and targeted photodynamic therapies (PDT) deliver thermal energy deep into the dermal layers where oil glands are present. This heat shrinks hypertrophic sebaceous glands. This permanently lowers excess oil production in a very effective way. Additionally, specific light wavelengths neutralize C. acnes populations within the pores. This dual action addresses both excess oil and bacterial overgrowth. This shifts the skin's microenvironment away from chronic inflammation, reducing the frequency and severity of future deep-tissue cystic flares.

Post-Cystic Scar Management

Subcision

Subcision is the gold standard surgical method of treating depressed rolling acne scars that result from severe cystic inflammation. Normally, the dense fibrous band of collagen is left where your deep cysts damaged the healthy skin tissue. It pulls your epidermal level down in between the deep tissues. During the subcision technique, a trained professional inserts a sharpened needle with a curved tip under the skin where the scar is. This specialized needle is then maneuvered horizontally to release the stretched out fibrotic bands that were pulling the skin down from above. The results are immediate elevation of the skin surface. Your body’s wound repair process also begins with this controlled process under the skin, and new collagen production naturally fills in the depressed acne scar.

Punch Excision

This treatment is intended for treatment of deep, thin acne scars like ice pick scars and deep boxcars that surface treatments can’t correct. The dermatologist takes a very precisely matching object into the skin and severs down to remove the entire damaged tissue from the surrounding skin. The edges of resulting space are then neatly brought together with tiny sutures in natural skin lines to close it up. By doing this, one removes an uneven and deep pit for a flat and very narrow linear scar that is almost invisible. Later on, this linear scar can be completely concealed within the rest of the face skin with further laser treatment.

Wrapping Up

Cystic acne is a deep acne that can lead to pain, scarring and emotional problems. It often comes from a mix of sebum buildup, blocked pores, bacteria, hormones, genetic predisposition, stress, surroundings and food. Since it forms under the skin, it usually requires more than just regular cystic acne home remedy and skin treatments.

Important aspects of cystic acne that are discussed above include using Alite Skincare on the skin, making changes to eat foods with a low glycemic index and getting procedural aid from a physician for active cysts. Subcision and punch excision might be useful for the management of post-cystic acne scars. If you are struggling with moderate to severe acne, it is best to get help from a dermatologist to get the right plan for prevention and effective management.