In cystic acne, usually you need internal treatment. In cystic acne, you get red, swollen, large cysts—usually on the face, sometimes on the upper back and the upper chest. But it’s not just the fact that you have these unattractive cysts that’s the problem. They hurt, and the reason that they hurt is because they’re so large and they’re so deep. As the cyst gets larger and larger, it stretches the skin over it, and stretching the skin, stretches the nerves. That’s what makes the nerves fire. If you stretch pain nerves, you'll make them fire and that’s what causes pain. Also, the fact that they’re so deep also pushes on pain fibers and causes them to fire and create pain. It’s the same depth that’s causing this problem that’s also responsible for the fact that topical medications for blackheads and whiteheads and even superficial pus pimples don’t work, and that’s why you need to have internal treatment. We discussed how Accutane is really a great miracle cure for really bad cystic acne, but most people with cystic acne don’t need Accutane. Most people will improve with oral antibiotics—sometimes for two weeks, sometimes for three weeks. And sometimes the first antibiotic doesn’t work, and your dermatologist will give you a second antibiotic. But usually antibiotics will be helpful. But when they’re used for acne, it’s very different than having antibiotics for a cold or a sore throat because, in those cases, when you’re finished with your infection, you stop the antibiotic abruptly, not with acne. With acne, we gradually reduce the dose of the antibiotic from three times a day, to twice a day, to once a day and, by gradually reducing it, we fool the body into thinking it’s still having the medication, and that’s how, when you finally do stop the antibiotic, you have a sustained improvement, and you don’t have to keep taking antibiotics
If antibiotic treatment doesn’t help men, they then have the option of going to Accutane. But women have another choice. If antibiotics don’t help women, they can take birth control pills. Because birth control pills that are estrogen-dominant tend to help acne, and there are a least a half-a-dozen on the market which are very, very helpful. So if women have a need for contraception and acne, estrogen-dominant birth control pills are a perfect choice. But the important thing to remember here is that, if you do have cystic acne, see your dermatologist. There are oral medications that will control this problem and you no longer need to have these unattractive painful cysts.