How to Treat Cystic Acne

Almost all patients with this severe form of acne will require some form of systemic (oral) medication to control this condition. The goal of therapy is to minimize scarring. The choice of drug with which to begin treatment depends on the experience and preferences of the physician and patient.

• It is often warranted to try oral antibiotics initially (doxycycline [Doryx, Oracea, Monodox], sulfamethoxazole/trimethoprim [Bactrim, Sulfatrim], minocycline [Minocin]) for a limited period of time supplemented by a topical retinoid drug (Retin A, Differin, Tazarotene).
• Antibiotics probably owe much of their effectiveness to their anti-inflammatory characteristics rather than their antibacterial attributes.

Occasionally, cystic acne in female patients responds to oral contraceptives like Ethinyl estradiol/norethindrone (Ortho Tri-Cyclen) along with spironolactone (Aldactone), an antiandrogenic drug.

If this option is not successful, then the patient is started on isotretinoin (Claravis, Amnesteem, Absorica, Myorisan, Zenatane).

• Patients may benefit from a lower dosage initially, followed by an increase to the standard 1 mg/kg dose after about a month.
• Patients should remain on this dosage for at least six months to maintain a durable improvement.
• Rarely, a short course of oral steroids (prednisone) may be necessary to suppress the inflammation during the initiation of therapy.

Patients who are treated with isotretinoin will need to be enrolled in the iPLEDGE (http://www.ipledgeprogram.com) program as will the physician prescriber and the pharmacy provider. This requires monthly visits and laboratory work.

• Females of childbearing potential must be on some form of birth control and have negative pregnancy tests during the course of therapy because isotretinoin can damage exposed fetuses.
• There are a variety of other potential side effects produced by the drug.
• Isotretinoin, however, when used in appropriate patients, is a unique drug in that it offers a safe and effective "cure" for a noninfectious disease.

Singular, individual cysts can develop in association with moderate acne. These isolated cysts often respond to injections of a steroid suspension (Kenalog) directly into the cysts.

Severe cystic acne is a painful condition. People with severe cystic acne have multiple inflamed cysts and nodules. Source: Dr. P. Marazzi / Photo Researchers, Inc.

• Cystic acne is the most severe form of acne.
• Cystic acne is likely to produce scars.
• Cystic acne is treated aggressively.
• Topical medications and nonprescription medications are usually insufficient to control cystic acne.
• Aside from the face, cystic acne commonly involves the chest and back.
• Those afflicted have a predisposition for their acne to form deep, tender inflammatory fluid-filled cysts that tend to heal with scarring.

The cause of cystic acne is no different than typical acne.

• During puberty,
• hormonal changes occur that result in inflammation involving the sebaceous glands of the face, chest, and back.
• Family history of cystic acne.

There is probably a significant hereditary component that predisposes one to cystic acne. A family history of severe acne with scarring signals this predisposition.

The major symptoms and signs of cystic acne include

• red tender,
• elevated soft bumps on the face, chest, and/or back.
• Some of these may be surmounted by one or more pustules.
• Generally, such lesions are tender and painful.

Cystic acne is recognized by visual inspection of the typical inflammatory cystic lesions on the face, chest, or back of a teenager or young adult.

• There are no home remedies that are likely to have any effect on cystic acne.
• It is unwise to postpone treatment waiting for some nonprescription medication to produce improvement while scarring becomes worse.

• There is little that can be done to prevent the development of this severe form of the disease.
• It is important, as it is in any form of acne, to avoid manipulation of the lesion by the patient.

With aggressive treatment, the prognosis of cystic acne is excellent. But treatment must be instituted prior to the development of significant scarring, which is irreversible and permanent.