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Cystic Acne and Accutane

Updated: Jun 4, 2023

Cystic acne by definition has a serious potential for long-term scarring, discomfort, and psychological consequences to self-esteem. Read more...




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What is cystic acne?

Cystic acne is composed of nodules or cysts under the skin that can accompany comedones or clogged pores and inflammatory acne lesions. These can be painful, sore, tender to the touch, and take weeks to come to the surface. Cystic acne by definition has a serious potential for long-term scarring, discomfort, and psychological consequences to self-esteem.

What causes cystic acne?

Cystic acne is considered the most severe form of acne and often still has components of the others stages of acne including clogged pores or comedones and inflammatory lesions. Oil, sebum, bacteria, and an accumulation of keratin enter the pores and result in nodules developing. These can be gradual or sudden. In practice, I often come across patients that will say that it appeared to develop overnight. If it is not painful to the touch and just feels like a “marble stuck under a rug” it is likely packed with keratin or dead skin cells. When they develop suddenly and appear to balloon or swell, a bacteria such as Cutibacterium acnes may be triggering a response. Ultimately, hormones tend to be the most likely or common trigger of the constellation of events that culminate into cystic acne.

Should I try over-the-counter options to treat cystic acne?

Remember, cystic acne by definition, has a high risk of scarring. Time is of the essence. OTC options focus only on the surface and can rarely penetrate deep enough into the skin to really address your concerns.

What treatment options are available?

There is a range of options to consider in treating or addressing this type of breakout. I tend to tell my patients that it is my job to present each option, along with its potential risks and benefits, while I look to them to let me know which suits their particular needs and concerns as well as their risk tolerance. When it comes to cystic acne, topicals are rarely effective. There are some studies that have looked at the possibility of a Photodynamic therapy along with a photosensitizer called aminolevulinic acid or ALA applied prior to light therapy with some benefits. Although not as predictable in terms of outcomes and with variable insurance coverage, I have had some patients that consider this option. Topical therapy with one of the more potent prescription topicals called Tazarotene is worth considering for those avoiding oral therapy. However, again, given the topical formulation, it may have limited success. Cystic acne tends to respond faster and more predictably to oral medications.



What types of oral medications are available for cystic acne?

There are many topicals and options for oral antibiotics as well. However, these products work primarily by suppressing acne- it is almost as though they are buying time until we ‘outgrow’ it. These are not always long-term solutions. Oral antibiotics, such as Doxycycline, can help reduce inflammation and drainage associated with cystic acne lesions. It is primarily targeting inflammation and bacteria and not necessarily the keratin, oil, and sebum that contributed to the breakout. These will still need topical therapy in conjunction to help. Oral therapy with Accutane, or isotretinoin, is the only option that provides the potential for a long-term solution and potential ‘cure’ for acne. This medication has been around for a long time- first FDA approved in 1982 and has been available as a generic for over 15 years. It’s an oral medication taken daily for a specified window of time based on daily dosage amount, body weight, tolerance, and response to treatment. The average duration of treatment can be about 20 weeks. There are no special creams or cleansers- the medication alone addresses the breakouts. It works at the level of the oil gland to treat the underlying cause of acne which is an overproduction of oil or sebum. By reducing this, there is a lower likelihood to develop clogged pores that lead to inflammation that can lead to cysts that can lead to scarring.

But Accutane or Isotretinoin has side effects, right?

Accutane has a side effect profile that requires a detailed discussion with your Dermatologist to ensure it is the right choice for you. We monitor blood work when starting treatment but it is overall well tolerated. We have to make sure that female patients are not planning pregnancies during treatment and for 6 months after completion of therapy for risk to the fetus. Screening for depression prior to starting the therapy is performed. There are mixed studies on this potential side effect. Given the defined time course, more predictable response, and reduced risk of scarring, many patients opt for this option to reduce the long-term risk of scarring.

Aside from oral and topical options, any other choices?

Individual cysts or nodules can be injected with steroids to bring down inflammation and swelling associated with these. This only addressed individual lesions and not the overall tendency toward breakouts.

There are improving laser and light device options to address acne but can take repetitive treatments and sessions that can become costly.

What’s the bottom line when it comes to cystic acne?

The bottom line is that there is no reason to suffer or struggle with severe cystic acne when we have legitimate effective affordable options to treat it. There is no reason to work through expensive topicals and over-the-counter topicals that cannot get to the cause of this type of acne. There are a lot of false hope products or insincere marketing that claim results with particular products and do not acknowledge the oral medications these users may be on concomitantly. Talk to your Dermatologist before wasting time and money and the risk of scarring.


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