What causes cystic acne?


Despite the myth that acne only occurs during puberty, acne is a common skin condition that can affect anyone at any age. Acne can be categorized into three different groups (1):

  • Blackheads or whiteheads (comedones)

  • Raised lesions (papules, also known as skin lesions)

  • Pus-filled bumps (pustules)



Cystic acne is a severe form of pustules, which manifest as nodules (cysts). Nodules/cysts are inflamed, swollen bumps filled with excess pus. They are often large (approx. 5mm in diameter) and painful to touch (1, 2).



This article addresses the main causes of cystic acne and potential treatments. It can be challenging living with cystic acne, however, there are treatment options available. Please talk to your doctor or healthcare provider to discuss which options are best for you!


What causes cystic acne?

Androgen excess

The most common cause of cystic acne is hormonal imbalance, specifically androgen excess (5; 6). Androgens are a group of hormones, including testosterone, which regulate important growth processes in the human body (3). Testosterone is linked to increased production of sebum (oiliness) in the glands of the skin, known as sebaceous glands, which results in oily skin. Higher amounts of sebum on the skin can clog pores, leading to acne breakouts (4; 12). Pores are small, visible openings in the skin that secrete sweat and oil (p.s. it is normal to have visible pores!) (13). Therefore androgen excess, specifically high levels of testosterone, increase the likelihood of cystic acne. Additionally, for people with ovaries, androgen excess can lead to the development of Polycystic Ovarian Syndrome (PCOS); a common sign of PCOS is cystic acne (3).

If you feel like you have tried everything to clear your skin and nothing works, your cystic acne could be related to an internal hormonal issue. In this case, please consult with your doctor or healthcare provider about possible hormonal treatments. For example, you may be prescribed estrogen-only oral contraceptives (note: cisgender men are not prescribed hormonal birth control to treat acne).

Genetics

Cystic acne is more common in individuals with one or both parents who had or currently have cystic acne. This is especially the case for folks’ whose parent(s) have naturally oily skin types, since cystic acne is often caused by excess sebum (oiliness) which clogs pores (1).


Regardless of family history of cystic acne, individuals with an oily skin type experience more severe acne than individuals with other skin types, such as normal, combination, or dry (7). Everyone has different skin types and genetic makeups, therefore, a treatment that may work for your friend or a family member may not work for you. To learn more about your skin type, please visit your family physician or a dermatologist to explore options that are best suited to your skin.


Diet

Research related to the links between diet and acne are mixed. While large amounts of research have been conducted on dietary factors and their impacts on acne, there is no consensus on whether there is an effect or not. For example, a recent meta-analysis found lower glycemic index (GI) diets reduced acne severity. Higher GI diets did not affect acne severity at all, although most patients with severe (cystic) acne had high GI diets (8). Low glycemic index foods do not cause spikes in blood glucose (sugar) levels. High glycemic index foods cause quick increases in blood glucose levels. Examples of high GI foods include sugary foods, white bread, and white rice, while low GI foods include steel cut oats, apples, and most vegetables. It is possible that the increase in blood glucose levels may contribute to acne, although it is unclear how (14).


Additionally, a systematic review of acne treatments found that eating an “unhealthy” diet (e.g. consuming sugary foods, greasy foods, chocolate, or diary) was not linked with cystic acne (9). Researchers in this study suggested there are no strong correlations between diet consumption and worsened cystic acne, and addressing diet may be ineffective in treating cystic acne (1; 9).

Despite the mixed evidence, you may want to see if modifications to your diet will help with cystic acne. There is anecdotal evidence to suggest diet does impact acne, as some folks claimed their acne worsened when they ate fatty, oily foods (16). Since there is still a lack of clear research evidence, the best way to figure this out is to work with a registered dietitian, naturopath, family physician, and/or dermatologist to create diet options together.

Facial hygiene

Face-washing (or lack thereof) is cited as another cause for cystic acne. Especially for individuals with oily skin, washing your face twice a day is an important step for keeping oiliness - and therefore breakouts - to a minimum (9; 10). Using products such as facial cleansers, soap, masks, or toners, can reduce the amount of sebum on your skin, which ultimately reduces the occurrence of clogged pores and cystic acne (10).


A note on face-washing research: face-washing at least twice a day with a mild cleanser can reduce acne, while no face-washing can worsen acne (10). There is no evidence to suggest excessive skin cleansing worsens acne; however, it may irritate the skin which may worsen the appearance (as skin becomes redder and more swollen) (10). Additionally, an appropriate level of sebum is important to protect and moisturize facial skin, therefore excessive face-washing (e.g. four times a day) can result in side effects such as dry, cracked and/or bleeding skin or excess oil production, which can in turn worsen acne (7; 9; 10). The same principles apply to washing all skin areas, such as arms, chest, and back.


It is recommended to refrain from picking, popping or generally touching pimples (). Since pimples contain pus, oil, and other bacteria, popping them can spread that pus, oil, and other bacteria to surrounding pores on your face leading to more acne. Additionally, the natural oils, dirt, and bacteria on our hands can seep into our pores and cause and/or exacerbate existing acne (15).


How can I treat cystic acne?

The best place to start is to consult with your primary care provider or ask to be referred to a dermatologist, who are experts in skin health.


As illustrated above, cystic acne is not caused by one specific issue - there could be many contributing factors to an individual’s cystic acne. With that being said, some of the most common treatments of cystic acne are (1; 5; 7; 11):

  • Estrogen-only oral contraceptive pills* (treats hormonal imbalances, specifically excessive testosterone, which targets excess oil production)

  • Spironolactone* (slows down body’s androgen production)

  • Oral isotretinoin* (reduces amount of oil produced by sebaceous glands)

  • Facial cleansing and treatment products containing benzoyl peroxide, retinoids, and/or salicylic acid (breaks down oil, dirt, and bacteria on skin before it clogs pores)

(* indicates treatments that are only available through prescription. A doctor must prescribe you these treatment options to access them.)

We understand that cystic acne can be painful, uncomfortable, and disempowering at times. We hope this article helps folks understand that acne is a common experience and that there are treatment options available. While there is a range of potential causes for cystic acne, it ultimately stems from excess oil on the skin that clogs pores and develops into acne. Whether androgen excess, genetics, diet, and/or facial hygiene issues contribute to excess oil, there are options available to help lessen and treat cystic acne.


While it may be hard to embrace cystic acne, it is possible! As someone who has struggled with cystic acne for over 8+ years, I have found that some days are easier than others, but I am grateful to have gone through this process as I’ve learned so much about skincare, self-love, self-care, and confidence. One of the most empowering influencers I’ve watched throughout my cystic acne journey is Cassandra Bankson - I highly recommend her YouTube channel here. For folks living with cystic acne, please know you are not alone. If you haven’t found a treatment yet, or haven’t had access to affordable treatment options, I hope this article provided helpful and accessible options for you. You & your skin are beautiful, no matter what! References

1. Heng AHS, Chew FT. Systematic review of the epidemiology of acne vulgaris. Nature. 2020 Apr;10(5754):1-19.

2. Daye M, Temiz SA. A case of nodular cystic acne treated with systemic dapsone. J Acad Res Med. 2020 Mar;10(1):103-5.

3. Hammes SR, Levin, ER. Impact of estrogens in males and androgens in females. J Clin Invest. 2019 May;129(5):1818-1826.

4. Li X, He C, Chen Z, Zhou C, Gan Y, Jia Y. A review of the role of sebum in the mechanism of acne pathogenesis. J Cosmet Dermatol. 2017 Jun;16(2):169-173.

5. Elsaie ML. Hormonal treatment of acne vulgaris: an update. Clin Cosmet Investig Dermatol. 2016 Sept;9:241-248.

6. Marynick SP, Chakmakjian ZH, McCaffree DL, Herndon JH. Androgen excess in cystic acne. N Engl J Med. 1983 Apr;308:981-986.

7. Mohiuddin, AK. A comprehensive review of acne vulgaris. J Clin Pharm. 2019 Jul;1(1):17-45.

8. Sakhaei R, Mohsenpour MA. Low glycemic load or index diet in association with acne vulgaris: a systematic review and meta-analysis. Critical Comment in Biomedicine. 2019 Dec;1(1):1-14.

9. Magin P, Pond D, Smith W, Watson A. A systematic review of the evidence for ‘myths and misconceptions’ in acne management: diet, face-washing and sunlight. Fam Pract. 2005 Jan;22(1):62-70.

10. Choi JM, Lew VK, Kimball A. A single-blinded, randomized, controlled clinical trial

evaluating the effect of face washing on acne vulgaris. Pediatr Dermatol. 2006 Sept;23(5):421-427.

11. Rademaker M. Isotreinoin: dose, duration and relapse. What does 30 years of usage tell us? Australas J Dermatol. 2013 Aug;54(3);157-162.

12. Straus JS, Kligman AM, Pochi PE. The effect of androgens and estrogen on human

sebaceous glands. J. Invest. Dermatol. 1962 Aug;39(2);139-155.

13. Kim BY, Choi JW, Park KC, Youn SW. Sebum, acne, skin elasticity, and gender difference – which is the major influencing factor for facial pores? Skin Res Technol. 2011 Dec;19(1):45-53.

14. Harvard Health Publishing. “Glycemic index for 60+ foods”. Harvard Medical School.

16 November 2021. Retrieved from: https://www.health.harvard.edu/diseases-and-conditions/glycemic-index-and-glycemic-load-for-100-foods.

15. Levitt S. “What to know before you pop a pimple”. WebMD. 2016 Jun 26. Retrieved

from https://www.webmd.com/skin-problems-and-treatments/features/pop-a-zit.

16. Magin P, Adams J, Heading G, Pond D, Smith W. The causes of acne: A qualitative study of patients’ perceptions of acne causation and their implications for acne care. Dermatol. 2006 Aug;18(4):344-370.



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