How to Treat Cystic Acne

Episode #107 / Oct 15, 2009

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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.

While many people assume that Cystic Acne should be treated by Accutane, that's not always the case. Dr. Schultz explains the different treatments available for Cystic Acne.

COMMENTS (8)

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Lorena on January 19, 2010 at 7:20pm

Hello!
I have mild moderate cystic acne... now I am using clyndamicin phosphate because the last time worked for me but this time is taking longer... im washin with Cetaphil and putting the lotion.
Should I exfoliate with glycolic acid???
My acne is the result of using birth control pills because Ive never had acne before..!
Im really worried and i dont know if i should do something else.... : S
Help!!

Neal Schultz, M.D. on January 26, 2010 at 3:49pm

@Lorena: It sounds like this flare-up is hormonally induced (birth control pills). Topical treatment often does not control hormonally-induced acne and you might consider discussing with your doctor changing your birth control pill or adding an antibiotic to help your cystic acne.

Dao on March 11, 2010 at 4:01am

Hi Dr. Schultz,
I have moderate cystic acne and you are right...they hurt a lot. I recently visited my derm and she prescribed me with Erythromycin Topical Soclution 2% and Minocin. Is that a good combination? Should I still use my daily regimen (Clinique 3 step system) along with them? Moreover, I believe to have combination skin and my breakouts can be crazy. Please help..

Neal Schultz, M.D. on March 11, 2010 at 3:19pm

@Dao: The Minocin and Erythromycin Topical Soclution 2% is a good combination, and does not preclude you from using your three step system, which is a good regimen to try to control your painful outbreaks. Also make sure your moisturizer for your dry areas is oil-free or water-based.

Melissa on April 21, 2010 at 2:36am

Hello, I have bad cystic acne. I was on tri-sprintec and it didnt work well. I was on ocella as well but i didnt like the side effects. I have also tried spironolactone. Do you know of any other BCs I could try for my acne bedsides yaz,yasmin annd ortho-tri cylen?

Neal Schultz, M.D. on June 6, 2010 at 8:22pm

@Melissa: Some other BCPs that are known to be helpful for acne include Estrostep, Alesse, Microgynon, Nordette, Levlen, Femodene, Femovan, and Ortho-Cept.

Marybell on June 22, 2010 at 7:03am

Hello Dr. Schultz! I am a 32 year old female who has suffered from cystic acne since the age of 17 yrs old. In my early 20's I took a combof of Minocin and Varidasa prescribed by a dermatologist near the U.S-Mexico border. It worked really well and I didn't have any flare ups for years until now that is. Now I'm getting the falre-ups again and don't know whether it would be safe to take the same combo pills again? No insurance makes it hard to go to a dermatologist in the states..help I'm desperate. Don't feel good about the cystic acne or the possible scarring.

Neal Schultz, M.D. on June 28, 2010 at 8:30pm

@Marybell: While the Minocin is generally safe when used as directed, I can not recommend the Varidasa as there is insufficient data on mechanism of action in acne or safety. If the Minocin by itself does not control your cystic outbreaks, an alternative consideration is a birth control pill that is helpful for cystic acne.

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