Cystic acne doesn’t sit on the surface of your skin like regular acne. It involves lumps that form deep down under the skin that are often painful to touch. A single outbreak can last for weeks and can cause significant skin damage and scarring.
Over-the-counter products generally aren’t effective for cystic acne, and the treatments that do work require a prescription. Common cystic acne treatment options in Canada are stronger topical creams, a course of tablets, and for the most stubborn cases, a drug called isotretinoin.
Getting treatment for cystic acne doesn’t necessarily involve seeing a dermatologist. A family physician can diagnose cystic acne and start most treatments. The condition does usually respond to treatment, though improvement tends to build over months rather than days.
In this article, we cover what cystic acne is, what causes it, how to tell cystic acne apart from ordinary acne, and how it’s treated in Canada.
An Overview of Cystic Acne
Cystic acne is the same condition as regular acne, acne vulgaris, at its most severe grade. It occurs when many pustules come together to form nodules and cysts, which is where the medical name nodulocystic acne comes from. The Canadian clinical practice guideline describes severe acne as deep pustules and nodules that can be painful, can spread over large areas, and can damage the skin.
An acne cyst is a large, inflamed lump sitting deep in the skin, which is firm around the edges (and usually contains fluid in the middle). Dermatologists describe these lesions as nodules and pseudocysts — “pseudo” because an acne cyst isn’t a true cyst in the sense a doctor would normally mean.
What separates cystic acne from ordinary outbreaks is that a cyst usually never comes to a head. There’s nothing to squeeze out, a cyst won’t settle in a few days, and severe cystic acne tends to arrive in crops rather than one spot at a time. Left untreated, nodulocystic acne typically causes with scarring, which is why getting on top of it early matters.
How to Recognise a Cystic Pimple
You can usually feel a cystic pimple before there’s much to see. A firm, sore swelling builds under the skin over a day or two, and it’s often tender enough to notice when you lie on that side of your face.
Three things generally separate a cystic pimple from the spots you’re used to:
- Nothing comes to a head. A regular whitehead forms close to the surface and empties. A cyst sits deeper than that, below the level where a pore can open.
- Lasts weeks, not days. An ordinary pimple settles within a few days, whereas a single cystic pimple can still be there a month later.
- Genuine pain. Deep cystic acne is often sore to the touch rather than just tender, and the soreness can arrive before there’s anything to see.
Cystic acne also tends to appear in clusters rather than one spot at a time, most often on the face, jawline, neck, chest, and upper back.
Cystic Acne vs Nodular Acne
Nodular acne and cystic acne describe two lesion types that usually turn up together. A nodule is firm and solid under the skin, while a cyst is softer and feels slightly fluid. Both sit deep, both are graded as severe acne, and both are treated the same way.
What Causes Cystic Acne
Cystic acne starts in a similar way to ordinary acne. Sebaceous (oil-producing) glands are controlled principally by androgens, and the rise in those hormones through puberty increases how much oil the skin produces. At the same time, cells lining the hair follicle shed more than usual and stick together, forming a plug that traps oil behind it.
Bacteria are also thought to be involved in cystic acne. Research points to a loss of microbial diversity on affected skin, rather than a simple overgrowth of bacteria. Current thinking describes the role of bacteria in cystic acne as an imbalance in the skin’s own bacteria.
Cystic acne has a strong genetic link. In an Australian study of 4,491 twins and siblings, the heritability of acne severity was estimated at 0.85, meaning most of the variation between people probably traces back to genetics. Why one person’s acne turns cystic while another’s stays on the surface isn’t fully understood, but a stronger inflammatory response, the composition of skin oil, and which bacterial strains dominate all appear to be involved.
Cystic Acne Myths
Cystic acne isn’t a hygiene problem. Washing more often doesn’t clear it. And harsh scrubbing can actually help rupture an inflamed follicle rather than calm it.
Here are some other things commonly blamed for causing cystic acne that aren’t backed by evidence:
- Chocolate. No good evidence links eating chocolate to cystic acne.
- Greasy food. Eating oily food doesn’t produce oily skin.
- Vaping. Vaping’s impact on cystic acne has not been studied enough to prove a link.
Diet isn’t entirely irrelevant for cystic acne, though. In one large study, women who drank two or more glasses of skim milk a day were 44% more likely to have acne. There’s also some evidence that a low-glycemic diet may reduce the amount of acne you have. Both effects are modest, and neither explains cystic acne on its own.
Why Cystic Acne Appears on the Chin and Jawline
The chin and jawline are among the most common areas for a cystic acne outbreak, particularly in adult women. The reason can be hormonal, as for some people, oil glands in the lower face tend to respond strongly to androgens, the hormones that drive oil production. However, it’s important to note that most people with acne have normal androgen levels.
Cystic acne along the jawline is worth investigating further when it arrives alongside irregular periods or unusual hair growth. Together, those can point to an underlying hormonal cause such as polycystic ovary syndrome, which is a conversation to have with a doctor.
Cystic Acne Treatment: What a Doctor Can Prescribe
Over-the-counter acne products work at the surface of the skin and in the top of the pore. Cystic acne is inflamed well below that, which is why products that clear ordinary spots (like benzoyl peroxide and salicylic acid) usually make little difference to a cyst.
Cystic acne treatment usually means combining more than one approach, then stepping up if the first combination isn’t working well enough. A doctor will weigh how widespread the acne is, whether it’s likely to cause scarring, and recommend a treatment.
Here are the main cystic acne treatments available in Canada.
Prescription Topical Treatments
Prescription creams and gels are stronger than what’s sold on the shelf, and for cystic acne, they’re normally a core part of the plan. The usual options are:
Prescription creams and gels are generally used alongside oral medications rather than on their own.
Oral Antibiotics
Oral antibiotics can reduce the inflammation that drives cystic acne, and they’re almost always paired with a topical treatment rather than used alone. Pairing them improves how well they work and limits antibiotic resistance. Courses of oral antibiotics for cystic acne are deliberately time-limited, generally not exceeding 3 to 4 months.
Hormonal Treatment
For women whose cystic acne follows a hormonal pattern, a combined contraceptive pill is worth discussing. Some are approved for acne treatment by Health Canada. YAZ, for example, is indicated for treatment of moderate acne vulgaris in women 14 and over, who also want contraception. Because that approval covers moderate acne, a drospirenone pill is usually an addition to cystic acne treatment rather than the main part of it.
Isotretinoin
Isotretinoin, sold in Canada under brand names including Accutane, Epuris and Clarus, is the option for cystic acne that hasn’t responded to anything else. It’s usually taken as a course of capsules over several months rather than as an ongoing treatment. People taking isotretinoin need regular monitoring, which is why the Canadian guideline says prescribing should be limited to physicians who are trained and experienced in its use.
It’s important to note that “trained and experienced” in using isotretinoin doesn’t mean you can only get this treatment from a dermatologist. A family physician who prescribes isotretinoin regularly can start and monitor a course, so treatment can often begin without waiting for a specialist referral.
Treating a Single Painful Acne Cyst
One badly inflamed cyst can sometimes be treated on its own with a corticosteroid injection. Intralesional corticosteroids can be used alongside other treatment for larger acne lesions, though doctors use them carefully in people at high risk of scarring. Swelling and soreness usually settle within a few days of the injection.
How Cystic Acne Heals (and Why It Scars)
The majority of acne scars result from an inflammatory response destroying collagen fibres in the skin, and cystic acne produces exactly that kind of deep, sustained inflammation. Skin discolouration associated with acne often improves with time, but this may take months or longer.
Treating cystic acne early is the best protection against scarring. People with severe acne are about six times more likely to develop scars, and people who wait three years or more for effective treatment tend to experience more skin damage.
Scarring and distress are both reasons a doctor may decide to move faster when treating cystic acne. Isotretinoin is approved for severe or refractory acne in patients aged 12 and older with scarring or psychosocial distress, so how much cystic acne is affecting you personally is a valid reason to consider when evaluating treatment options.
Getting Treated for Cystic Acne in Canada
Cystic acne is diagnosed by looking at the skin and asking the patient about their experience with acne, which is work a doctor can do via telehealth or an in-person appointment. Family doctors can treat cystic acne, and a referral to a dermatologist is usually kept for acne that hasn’t responded to several courses of standard treatment.
If you’re in British Columbia, an appointment with an online Walk In doctor is covered by MSP, and a doctor can provide a prescription for acne treatment if it’s appropriate.
The cost of cystic acne treatment in Canada depends on which medication you’re prescribed, your insurance, and your pharmacy. Your pharmacist can price a prescription before you fill it, and it’s worth asking generic options available.
Frequently Asked Questions About Cystic Acne
What is cystic acne?
Cystic acne is the most severe form of ordinary acne, where inflammation goes deep enough that the follicle wall ruptures below the surface of the skin. The result is large, painful lumps that sit under the skin rather than coming to a head, which can last for weeks.
Can you shrink a cystic pimple overnight?
Nothing you can buy will reliably clear a cystic pimple by morning. A cold compress can take some of the swelling and soreness down for a while. The fast option that does exist is a corticosteroid injection from a doctor, which usually settles a single cyst within a few days.
Does cystic acne go away on its own?
Cystic acne can settle without treatment, but it often takes months or years, and cysts left to clear on their own are the ones most likely to scar. Actively treating cystic acne is both faster and better for your skin.
Do pimple patches work on cystic acne?
Hydrocolloid patches are designed to draw fluid out of a lesion that’s already open at the surface. A cyst has no opening, so there’s little for a patch to pull out. Patches may still stop you from picking at cystic acne, which could be helpful.
Can you prevent cystic acne?
Preventing cystic acne mostly means treating it properly. Ongoing treatment prescribed by a doctor is what keeps new cysts from forming once the current ones have cleared. Gentle skincare may help, but it doesn’t prevent cystic acne by itself.
How fast can cystic acne clear up?
Improvement is measured in months rather than days. Topical and oral treatments usually take several weeks before there’s a visible change, and hormonal treatment and isotretinoin both build over months. A single injected cyst is the exception, settling within days.
Want Help to Manage Cystic Acne?
Cystic acne responds to treatment, but not to the standard acne products most people try first. Cysts sit too deep for anything sold over the counter, which is why the treatments that work need a prescription.
A diagnosis is the first step in managing cystic acne. A family doctor can review your condition, identify what type of acne you are experiencing, and advise on treatment options. A specialist referral usually isn’t required, especially if you haven’t already tried several first-line treatments.
Cystic acne is the form of acne most likely to scar, and treating it early is the best protection against permanent marks.
Speak to a Doctor Online About Cystic Acne
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