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Cystic Acne



What is cystic acne?

Cystic acne is a form of acne associated with long-standing, painful nodules of the face, back of neck, chest, and back.

Adolescent acne goes through certain stages, each of which requires specific therapy. It starts with closed comedos (whiteheads), which may progress to open comedos (blackheads). Unless they are picked, popped, and manipulated, these would only rarely cause scarring. Some of these will progress to what is recognized as acne and, in turn, some of those into pustular acne. Pustules are more likely to scar, especially if they are "popped." Cystic acne is the final stage of progression of acne and left untreated is a significant source of acne scarring. As these are space-occupying collections of inflammatory material, scarring is predictable.

Cystic acne may involve the face, chest, back, or unique combinations of these. Cystic acne may also be part of a syndrome that involves some combination of acne on the face with draining lesions and boils of the scalp (dissecting cellulitis of the scalp), axilla (hidradenitis suppurativa), groin, or chest. Conglobate acne is a severe form that may present as a severe cystic acne of the face and trunk, which can also have systemic manifestations such as arthritis and other musculoskeletal problems.

Perioral dermatitis is an acne-like problem that usually affects young women and causes small papules on the chin, around the mouth, and along the jawline. Some of these papules may be deep-seated, but this usually does not cause the large, scarring nodules and cysts of true acne.


What are causes and risk factors for cystic acne?

There is a trend that if a parent or older sibling had significant scarring acne, you are more likely to develop it yourself. However, a family history of cystic acne is not universal, even in the most severe cases. Elevations in testosterone, either intrinsic to the body or extrinsic through the intake of anabolic steroids, may precipitate or worsen cystic acne. While most combination contraceptive pills will have a therapeutic benefit in acne, the progesterone-predominant contraceptive types such as progesterone-only mini-pills, progesterone implants, and progesterone-eluting intrauterine devices may worsen acne, although these may serve as effective contraception when isotretinoin use for acne is considered.


What are cystic acne symptoms and signs?

Cystic acne is characterized by long-standing, painful nodules of the face, back of neck, chest, and back. The nose may be spared or significantly involved with pustules and nodules. When these nodules finally recede, they usually leave behind scars. Individual scars may be the classic acne "ice pick" scars, but many of these aggregated together cause a more vermiculate or "worm eaten" scarring. This is especially likely on to occur on the cheeks. While starting as pus-filled pimples, these evolve to inflammatory red papules (bumps) and eventually once treated or in remission may settle down to pink spots.


How do health-care professionals diagnose cystic acne?

Cystic acne is usually diagnosed by its clinical appearance. Even if there are no active inflammatory nodules, pink scars may remain. Skin biopsy is not necessary unless it is suspected that the patient may actually have a folliculitis caused by yeast or a condition called eosinophilic folliculitis. Bacterial culture is rarely helpful as patients may respond to antibiotics to which they show resistance and not respond to antibiotics to which they show sensitivity.


Are there home remedies for cystic acne?

A variety of home remedies such as baking soda, various masks, apple cider vinegar, and tea tree oil have been recommended for cystic acne, and often one may find testimonials for these remedies online, especially on the web sites selling these supplements or alternative therapies. When put to scientific challenge, they are usually found to be ineffective and may only delay diagnosis and effective treatment.

Vitamin A orally or by injection has been used for acne with variable effects. Because isotretinoin is a vitamin A analog, extra vitamin A should not be taken while taking this drug because of the increased risk of vitamin A toxicity. Biotin, a vitamin cofactor, is necessary for healthy hair, skin, and nails, but any beneficial effects on severe cystic acne will be limited, especially if vitamin supplements are the sole therapy.

Diet may contribute to cystic acne as it may to other acne varieties. Rather than the "greasy food and chocolate" on which many blame their acne, it appears that milk, especially skim milk, worsens acne when not taken in moderation. Foods with a high glycemic index(that rapidly raise blood sugar) also are associated with acne flares. Other milk by-products, such as whey protein supplements, may worsen acne. Many patients who feel "sweating at the gym" is making their acne worse after working out should instead blame the protein shakes they consume after exercise. There is no good data at this time for the role that soy or almond milk may play in acne.

Although the mechanism is not clear, smoking may worsen acne of all types and is, in fact, one of the three primary risk factors for hidradenitis suppurativa. Most studies have examined cigarette smoking with the effect of cigars, smokeless tobacco, nicotinepatches, and "vaped" nicotine not being as well-defined.


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