Wednesday, May 22, 2024

Cystic Acne: How to Treat and Prevent Breakouts — Expert Tips

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As far as pimples go, those deep, cystic acne flare-ups are probably the most emotionally and physically taxing. If the brutal bumps had a theme song, it’d be the one from Jaws — and it’d start playing the moment you feel the telltale dull pain that signifies the arrival of a pimple under the skin.

Unlike whiteheads and blackheads, which eventually poke through the surface of your skin, cystic acne remains dormant, where it forms a minor mountain and then sits, stubbornly, for days or weeks. Aside from how little surface area those suckers tend to cover, the pain they cause makes them impossible to ignore. Press on one and it reverberates throughout your entire face.

Acne is the most common skin condition in the U.S., so it’s safe to say that dermatologists are extremely well-versed in treating it. Since cystic acne can be more challenging to clear than other types of acne, we suggest booking an appointment with your board-certified dermatologist to create a customized treatment plan or to inject and send any current cysts back to hell where they came from (more on that option, below). While you’re waiting for advice from your personal doctor, these cystic acne tips, product recommendations, and sample skin-care routines from expert dermatologists can help.


Meet the experts:

  • Joshua Zeichner, MD, is a board-certified dermatologist and director of cosmetic and clinical research at Mount Sinai Medical Center in New York City.
  • Michael I. Jacobs, MD, is a board-certified dermatologist and associate professor of Dermatology at Weill Cornell Medical College.
  • Brendan Camp, MD, is a board-certified dermatologist who practices at MDCS Dermatology in New York City.
  • Dr. Jeannette Graf, MD, is a board-certified dermatologist and assistant clinical professor of Dermatology at Mount Sinai School of Medicine.
  • Leyda Bowes, MD, is a Miami-based board-certified dermatologist.
  • Ife Rodney, MD, is a Maryland-based board-certified dermatologist.

In this story:

What is cystic acne?

While pimples come in many shapes, sizes, and forms, cystic acne is considered to be the most severe type of acne, according to Joshua Zeichner, MD, board-certified dermatologist and director of cosmetic and clinical research at Mount Sinai Medical Center in New York City. It’s characterized by the development of “tender, inflammatory nodules underneath the skin.”

You might have heard cystic acne breakouts referred to as blind pimples. They often happen along the chin, but can also emerge elsewhere on the face and even on the arms or back. They typically show up again and again in the same location, often based on your menstrual cycle. Unless you get treated, your first chin cyst will likely not be your last.

What causes cystic acne?

According to Sheila Farhang, MD, a board-certified dermatologist in Tucson, cystic acne is often caused by food triggers, stress, and hormones. Though it’s challenging to pinpoint exactly what causes acne on an individual basis, it’s unlikely that diet is the sole cause of severe acne, but according to Dr. Zeichner, certain foods “have been associated with the worsening of acne.” Those foods include skim milk, whey protein, vitamin B12 supplements, and foods that are high in sugar.

Lifestyle changes, like switching up your diet and reducing stress, can help clear skin. “The same hormones that prepare our bodies to deal with stressful situations also push our oil glands into overdrive,” which can cause breakouts, says Dr. Zeichner.

In addition, androgen hormones like testosterone also stimulate oil glands. “Because hormone levels go up and down during one’s menstrual cycle, acne may flare around the time of the period,” he says.

It’s extremely rare for dermatologists to give the go-ahead to pop any type of pimple. When it comes to cystic acne, not a single dermatologist we spoke with recommended doing so. “You increase your risk of infection and scarring,” says Michael I. Jacobs, MD, a board-certified dermatologist and associate professor of Dermatology at Weill Cornell Medical College. If you’re hoping to reduce the pain radiating from the cyst, Dr. Jacobs recommends gently pressing a warm, damp towel to the area a few times a day to help bring down inflammation.

How do you treat cystic acne?

Cystic acne is challenging to treat, and dermatologists typically recommend a combination of oral and topical prescriptions and lifestyle changes that we wish came in a prescription form, such as reducing stress. In short: Get thee to a dermatologist’s office, stat, as your typical acne skin-care routine might not cut it when it comes to treating cystic acne at home.

“Usually, people run to their dermatologist’s office for a quick cortisone injection to dry up those monsters within hours,” says Rachel Nazarian, MD, a board-certified dermatologist in New York City. But not everyone has the time (or money) to pop into a dermatologist’s office the moment you feel one coming on, and ad hoc injections won’t help treat or cure your cystic acne in the long term.

In her practice, Dr. Farhang begins treatment with topical prescriptions and conversations around lifestyle changes, then moves on to oral medications if needed. “Topical treatments could include a combination of benzoyl peroxide and/or prescription antibiotic cream if multiple whiteheads in the morning, along with prescription dapsone (Aczone) cream if the target area is less oily and has more adult inflammatory lesions, like hormonal cysts along the jawline,” she says. In the evening, she often prescribes a retinoid to help increase cell turnover, which helps diminish acne and neutralize any hyperpigmentation from previous breakouts.

In terms of over-the-counter treatments, Dr. Zeichner says the best way to treat acne is to use “different ingredients that work differently and complement each other.” He recommends a two-pronged ingredient approach, focusing in on salicylic acid and benzoyl peroxide. To prevent irritation when using the latter, make sure you prime the skin with a light moisturizer first, he says, then spot-treat the cyst with a super-thin layer of the lowest percentage of benzoyl peroxide.

If, after three months, there has been no improvement (or if you already have permanent acne scarring) your dermatologist may prescribe spironolactone, an oral medication for those with adult acne, which helps “block the excess hormones that [increase oiliness] and cause cystic acne,” says Dr. Farhang.

Does drinking water help cystic acne?

There’s good news and bad news: “Drinking water will help keep you hydrated and may improve your skin’s health, but it is unlikely to clear cystic acne on its own,” explains Dr. Camp. “Cystic acne is primarily related to hormonal factors, genetics, and inflammation,” he says, none of which can be changed by water consumption alone.

Which products help treat cystic acne?

Start with an oil-free cleanser.

“Think of your cleanser not as a true wash, but rather as a short-contact therapy,” Dr. Zeichner suggests. For this reason, he typically recommends that patients with cystic acne use cleansers that contain high concentrations of salicylic acid, a beta hydroxy acid (BHAs) that helps shrink cystic pimples by removing excess oil, sloughing off dead skin cells, and drying them out.

Typically, salicylic acid concentrations range between 0.5 to two percent, and if you’re prone to cystic acne, Dr. Zeichner recommends looking for a cleanser that leans toward a higher concentration. A couple of great 1.5 to 2 percent salicylic acid-based cleansers include La Roche-Posay Effaclar Medicated Acne Face Wash and Murad Clarifying Cleanser.

La Roche-Posay Effaclar Medicated Gel Acne Cleanser

Murad Clarifying Cleanser

If your skin is both acne-prone and sensitive, higher concentrations of salicylic acid could be overdrying. In that case, cleansers that contain lower concentrations (0.5 to 1 percent) of the ingredient include Aveeno’s Clear Complexion Foaming Cleanser and Burt’s Bees’ Natural Acne Solutions Purifying Gel Cleanser.

Aveeno Clear Complexion Foaming Cleanser

Burt’s Bees Natural Acne Solutions Purifying Gel Cleanser

If your skin prefers it when you steer clear of salicylic acid overall, Dr. Jacobs likes the classic CeraVe Acne Foaming Cream Cleanser, which is formulated with 4% benzoyl peroxide, another acne-fighting ingredient. Jeannette Graf, MD, a board-certified dermatologist and assistant clinical professor of Dermatology at Mount Sinai School of Medicine, is a fan of the stronger PanOxyl Acne Foaming Wash, which contains 10% benzoyl peroxide. “It helps clear existing acne and prevent new acne from starting. It also contains moisturizers to prevent the skin from becoming too dry from use,” she says.

CeraVe Acne Foaming Cream Cleanser

PanOxyl Acne Foaming Wash

Dr. Zeichner says to apply your cleanser and let it sit while you sing the alphabet before rinsing it off. “The cleanser needs enough contact time with the skin for the active ingredients to exert their effects.”

Follow up with an oil-free moisturizer.

People who are prone to cystic acne should still use a facial moisturizer regularly in order to maintain a healthy skin barrier. “Patients who are prone to cystic breakouts should use oil-free, noncomedogenic moisturizers to hydrate their skin,” says Maryland-based board-certified dermatologist Ife Rodney, MD.

However, she notes that non-comedogenic products won’t necessarily treat your breakouts — they just won’t contribute to the problem. That said, choosing a moisturizer that contains ceramides, niacinamide, or hyaluronic acid can be especially helpful. “These ingredients help to reduce redness and inflammation and restore the skin’s protective barrier. This is important because many acne-fighting active ingredients tend to be drying and irritating to the skin.”

For a niacinamide-spiked option, Brendan Camp, MD, who is board-certified in both dermatology and dermatopathology and practices at MDCS Dermatology in New York City, suggests Paula’s Choice Clear Oil-Free Moisturizer. Dr. Jacobs is a fan of the lightweight and creamy Tula Skincare Breakout Star Acne Moisturizer. “It has active ingredients azelaic and salicylic acids which are good for clearing acne and improving skin texture,” he says.

Paula’s Choice Clear Oil-Free Moisturizer

Tula Skin Care Breakout Star Acne Moisturizer

Finish with a medicated spot treatment to kill the bacteria.

Benzoyl peroxide works by lowering levels of acne-causing bacteria on the skin, thereby reducing inflammation, which is why Dr. Zeichner recommends using the ingredient as a spot treatment. Skin-care products come in 2.5, 5, and up to 10% concentrations of benzoyl peroxide, but you don’t necessarily have to max out on it. “Studies have shown that even low concentrations of benzoyl peroxide are as effective as higher concentrations, but are associated with less dryness of the skin,” he says.

Dr. Zeichner recommends looking for leave-on acne spot treatments with 2.5% benzoyl peroxide, such as Paula’s Choice Clear Daily Skin Clearing Treatment. Dr. Camp suggests Neutrogena Rapid Clear Stubborn Acne Spot Treatment Gel, which kicks the active ingredient up to 10%. He advises his patients to leave the gel on overnight.

Neutrogena Rapid Clear Stubborn Acne Daily Leave-On Mask

Paula’s Choice Clear Regular Strength Daily Skin Clearing Treatment

For painful cystic acne, top it off with a hydrocortisone cream cocktail to reduce redness and inflammation.

“Hydrocortisone cream is not designed to be an acne treatment, and will not prevent acne,” says Dr. Jacobs. “But if you have a cystic pimple that is inflamed and red, hydrocortisone cream may help with the redness and swelling.” (Keep in mind that hydrocortisone should not be used during pregnancy.) He suggests Cortizone-10 Sensitive Natural Skin Cream.

Cortizone-10 Sensitive Natural Skin Cream

For the peskiest of big pimples, like cystic acne on the chin, combine a hydrocortisone cocktail as a leave-on spot treatment. Dr. Zeichner recommends a hydrocortisone cream to reduce inflammation, a 2% salicylic acid product to dry out excess oil (we like The Ordinary’s Salicylic Acid 2% Masque), and then benzoyl peroxide to kill acne-causing bacteria. “Put a drop of all three in the palm of your hand, mix them together, then apply,” he says.

The Ordinary Salicylic Acid 2% Masque

For those with skin that’s not sensitive or doesn’t get easily dried out, another combo option is to swap in a sulfur-spiked treatment in place of the salicylic acid. “The combination of these three over-the-counter products — a sulfur-containing mask (try Sunday Riley’s Saturn Sulfur Acne Treatment Mask), a benzoyl-peroxide cream (we love Clearasil’s Daily Clear Acne Treatment), and a mild cortisone salve — usually proves very effective when mixed and applied two to three times a day over the cyst for seven to 10 days,” says board-certified dermatologist Leyda Bowes, MD, who is based in Miami.

Sunday Riley Saturn Sulfur Spot Treatment Mask

Clearasil Daily Clear Acne Treatment Cream

When all else fails, color-correct the cyst.

When your cystic acne persists despite your very best efforts, Dr. Nazarian recommends using makeup with a slight green tint to help mask redness and blend your pimple into your natural skin tone. Try Lancôme Idole Ultra Wear Camouflage Corrector, applying a thin layer over the cyst before reaching for your concealer and foundation.

How long does cystic acne take to go away?

Any individual breakout may take between one and three weeks to heal, says Dr. Graf. As for cystic acne overall, it “may last months or years,” says Dr. Camp.

“Factors like age, hormonal changes, medications, skin-care routine, and overall health,” determine how long untreated cystic acne can go on, Camp says. There’s no countdown clock to the moment when skin stops breaking out. Though the nodules are often “most commonly associated with young people, especially teenagers who have fluctuating hormones, there are many women in their 30s who develop cystic acne for the first time, having never had teenage acne,” says Dr. Jacobs.

Waiting until your skin magically clears isn’t a risk that dermatologists want their patients to take. “I do not suggest waiting until it phases away, particularly because cystic acne can cause severe and permanent acne scarring,” says Dr. Farhang.

Acne scarring can be more challenging and expensive to treat than the acne itself — better not to scar in the first place than to have to treat a scar after the fact, right? — so as soon as you feel those telltale bumps under the skin, try to get right to your doctor.


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