Acne develops inside skin pores, which are actually tiny hair follicles that have sebum (skin oil) producing glands attached to them. Acne lesions occur mostly on the face, neck, upper chest, back and shoulders where these follicles are most common. Both regular and cystic acne occur in these areas.
The difference between regular and cystic acne comes down to the types of lesions that each produces:
Regular acne: Regular acne consists of relatively small (under 5mm) whiteheads, blackheads, papules, and pustules. While regular acne can sometimes scar and can cause deep emotional distress, all of the lesions in regular acne tend to come and go relatively quickly, within weeks.
Cystic acne: Cystic acne can also come with all of the lesions of regular acne, and usually does, at an even higher number than seen in regular acne. But what makes cystic acne unique is that it also comes with nodules and/or cysts, which are larger (over 5mm), painful lesions that can last for months and frequently scar.
Regardless of the type or severity of acne, the same four factors lead to all acne lesions:
- Excess sebum (skin oil) production, which is controlled by androgens
- The release of inflammatory molecules in the skin
- Changes in the production of skin cells and keratin, from which skin cells are formed
- The presence of P. Acnes (acne bacteria) in the follicles
How some regular acne lesions become cystic acne lesions
All acne lesions start the same way, with a clogged pore. Sebum inside the clogged pore starts to build up and becomes either a whitehead, which looks like a very small white dot on the skin, or can become a blackhead, which looks like a black or brown dot on the skin.
A whitehead or blackhead can heal on its own and go away. However, sometimes, they erupt inside the follicle, leading to the development of inflamed, red pimples, that can fill up with pus and get a white or yellow center. Normally, these pimples heal on their own when the body either absorbs their contents or the contents drain to the surface of the skin.2
Sometimes a whitehead or blackhead erupts much more severely, however, and bursts deep in the skin, causing the body to overreact, producing a large, inflammatory reaction. This is where regular acne becomes cystic acne. When a whitehead or blackhead erupts severely like this, it almost always produces the cystic acne lesion called a nodule. A nodule is a large, inflamed and raised bump, larger than 5mm in diameter. It feels hard to the touch and is usually quite painful. The contents of a nodule can be absorbed by the body but sometimes the inflamed area is encapsulated, creating a pus-filled cyst. A cyst appears similar to a lesion and is also large, hard to the touch, and usually painful. Both nodules and cysts often cause scarring because the hair follicle in which the initial clogged pore was formed, as well as surrounding pores and skin structure, can be completely destroyed.2,3,4
Male hormones are to blame
Androgens, which are male hormones that are found in both males and females, are at the root of both regular and cystic acne. The higher the androgen level, normally, the more severe the acne can become. People with cystic acne tend to have high levels of androgens compared to people with regular acne, and especially compared to people with no acne.
Incidence, Gender, Genetics, and Race
U.S. census data showed that around 85% of people between 12 and 24 years old suffer from either regular or cystic acne at some point. The incidence decreases as people get older.
Both males and females can get both regular and cystic acne, but, as a whole, males tend to experience more cystic acne.5-6
As we can see in the following article published in 2013 in the British Journal of Dermatology, genetics also plays a part:
Research has also revealed a genetic link in the development and severity of acne. “Acne occurs earlier and is more severe in those with a positive family history. Several retrospective twin studies have found a possible genetic basis with familial clustering.” Based on the limited research we have thus far regarding ethnicity, the incidence of nodulocystic acne is also higher in Caucasians and Hispanics than in people of African descent.5
Treatment of Regular vs. Cystic Acne
Regular acne can be kept under control with proper topical treatment.
Cystic acne can also sometimes be kept under control through topical treatment. However, when nodules and cysts are widespread and actively scarring, it sometimes requires more aggressive treatment. Isotretinoin (Accutane) is the most reliable therapy for widespread and scarring cystic acne.7
Authors writing for the Journal of the German Society of Dermatology state:
“The multiple modes of action for isotretinoin…make this compound the single most effective in the treatment of severe recalcitrant nodulocystic acne, and in the prevention of acne scarring.”8
Isotretinoin acts on various levels, addressing all four factors which contribute to the development of acne. The following 2011 study published in the Clinical Evidence shows the power of isotretinoin:
After 20 weeks of treatment with isotretinoin, acne was eliminated in 85% of patients.1
However, isotretinoin is sometimes less effective if a person has abnormally high levels of androgens, particularly women. In that case, treatment to reduce androgen levels can be added, including oral contraceptives and/or specific anti-androgen medication like spironolactone or cyproterone acetate. As we see in the following study published in 2013 in the International Journal of Dermatology:
Researchers found that treatment with isotretinoin and anti-androgen therapy cleared acne completely in 91% of cases. In cases where this combined treatment only partly cleared the acne lesions, it was mostly in women with Polycystic Ovary Syndrome (PCOS), a condition that is characterized by excessive androgens.9
Isotretinoin side effects
Because of its side effects, doctors usually only prescribe isotretinoin for severe cystic acne or acne which does not respond to other treatments. You should understand the side effects before taking isotretinoin, so that you can make an informed decision. Most of the side effects are reversible, but some could be severe and long term. Isotretinoin is an oral medication that affects the entire body, and can change it permanently in unexpected ways. Side effects include, but are not limited to, dry skin and mucous membranes, joint pain, changes in vision, raised levels of cholesterol and liver enzymes, and an extremely high potential for severe birth defects when taken by pregnant women.4
Treatment to Reduce Androgen Levels. When blood tests confirm abnormally high levels of androgens, treatment that reduces androgen levels is sometimes an effective option for females with cystic acne. While this treatment has been studied in males as well, it is normally not prescribed to males because it can create feminizing symptoms, like enlarged breasts.
In a study investigating oral contraceptive and anti-androgen treatment, severe acne cleared or showed a marked improvement in 97% of women and 81% of men after six months.10
Anti-androgens are corticosteroid drugs, which have a range of side effects that should be considered even though the dosage needed to treat of acne is relatively low.6Oral corticosteroids are also on the World Anti-Doping Agency list of banned substances in competitive sport. You should discuss this with your doctor if you are a serious competitor, because you must avoid oral corticosteroids for at least a week leading up to a competition.10
If you have cystic acne, don’t wait too long to treat it because this form of acne is prone to scarring. Aggressively treat your acne with The Acne.org Regimen to get it under control. If your cystic acne is covering your face, back and chest, and is scarring, you may want to consult a physician and inquire about isotretinoin.