Cystic Acne - Acne Cysts - Treatments

What is Cystic Acne?

Acne is the most frequently encountered skin disease in the globe, affecting up to millions of people all over the world. Acne typically starts during puberty and influences many young adults and adolescents. About 80 to 90% people by the age of 21 years are believed to have suffered from acne once. It can appear in any age and can continue into adulthood. It is a chronic disease characterized by inflammatory lesions such as pustules, papules, or cysts/nodules and closed or open comedones (whiteheads and blackheads). Although, no death occurs due to acne, but significant psychological and physical morbidity takes place e.g. poor self-image, anxiety, depression and permanent scarring.

In order to ensure proper acne treatment, one should know different types of acne and the one they are suffering from. There are various types of acne with different manifestations, causes and stages of life.

Acne Neonatum

Acne neonatorum affects approximately 20% of neonates. It is characterized by closed comedones which usually arise on the cheeks, nose, and forehead. It is because of activation of sebaceous glands by the infant or maternal hormone i.e. androgens. Pustules inflammatory papules, and open comedones can also occur.

Acne Infantum

Infantile acne generally develops in children above 1 month to 1 year of age and is more frequent in boys. It is not much harsh and resolves on its own within a few months.

Acne Vulgaris

Acne vulgaris affects about an average of 80% young people during puberty. It presents with pimples mainly on the face however they can also arise on the neck, back, upper arms and trunk. Acne vulgaris occurs chiefly in oily skin. Due to excessive sebum, the pores become clogged. Propionibacterium Acnes grows and utilizes sebum as food. There are four basic types of acne vulgaris and are differentiated pertaining to the severity of symptoms.  

  • Acne comedonica is the less severe type and is differentiated by the formation of blackhead and whiteheads or comedones.
  • Acne papulopustulosa is the medium to severe type and it pierces the deeper skin layers and presents with inflamed comedones in the form of pustules and papules.
  • Acne conglobata is the unusually severe type of acne that presents with pustules, abscesses, nodules and cystic acne. This form of acne can cause obvious skin scarring.
  • Acne fulminans, also known as acute febrile ulcerative acne or acne maligna is a very uncommon type of acne that occurs mainly in males of age 13 to 22 years. It is characterized by acute, hemorrhagic, ulcerating, and painful pimples. Systemic symptoms such as polyarthritis and fever may also occur with this acne. Acne fulminans is triggered by anabolic steroids because they lead to increase sebum level and colonization of Propionibacterium acnes. The use of isotretinoin especially if it is use in high doses while treating severe acne may also result in acne fulminans. It is also believed to be an autoimmune disease since immune complexes have been found in several patients suffering from acne fulminans.

Acne Tarda

If the acne occurs after puberty is over, then it is known as acne tarda or late onset acne or adult onset acne. It occurs mostly after the age of 24 and is common in females. Acne tarda is triggered by fluctuation in hormones during pregnancy, menstrual cycle and menopause and also by stress. Other causes linked to it are drugs, cosmetics, smoking and diet. Acne Tarda can also present as mild to severe to more severe acne.

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Symptoms

As already mentioned, acne is presented in various forms, chiefly papules, pustules, cysts and nodules. Other forms include open or closed comedones.

  • Papules: A papule is precisely any tiny, raised swelling on the skin differ in size from a pinhead to one centimeter.  It occurs when the follicle wall ruptures. With regards to acne, papule is a red colored bump that's swollen. Papules are generally painful as compared to blackheads or whiteheads but not as painful as cysts and nodules are. Papules can appear in cluster to form a popular rash.
  • Pustules: Pustules are filled with pus and are inflamed, small and blister-like lesions. They are usually tender to the touch and often hard in consistency. Pustules are mostly bigger in size as compared to the blackheads and whiteheads.
  • Cysts: Cysts are typically noncancerous growths and are caused by blocking of sebaceous glands or by infections. They contain a sac-like pocket filled with pus, substance, fluid or air. They can develop anywhere on the body. There are numerous diverse types of cysts.  Cysts become painful when they are infected. Cystic acne is painful, tends to crop up in individuals with oily skin.
  • Nodules: Nodular pimples or nodules are regarded as the most severe presentation of acne. Nodules differ from cysts in that they do not contain pus or fluid but they form a hard elevation deep in the skin. They are basically a growth of unusual tissues and are 1cm in size. They are sometimes painful to touch.
  • Whiteheads: Whiteheads or closed comedones are a mild variety of acne and are small, white bumps, round in shape and appear on the surface of skin. They are caused by dead skin cells and sebum.
  • Blackheads: Blackheads, as the name implies, appear black or dark small bumps on the skin and are mainly because of hormones that cause increased sebum production. They are composed of oxidized melanin and squeezing them can make them worse.

 

Causes

Acne results when the pilosebaceous skin unit becomes clogged with bacteria, dead skin cells, and oil and is thus multifactorial in nature. The four major causative agents of acne are:

  • Colonization of bacteria named Propionibacterium acnes
  • Increased production of sebum by the sebaceous gland leading to oily skin
  • Changes in the process of keratinisation
  • Obstruction of sebum secretion

Hair follicles have sebaceous oil glands that secrete an oil called sebum, which lubricates and waterproofs the skin. When dead skin cells clog the exit of the hair follicle, the sebum builds up and hardens creating a plug made of dead skin and hardened sebum. The sebum oil secreted by hair follicles builds up to produce a bump so many of us are familiar with. Acne-causing bacteria, called propionibacterium acnes, is commonly present in hair follicles, but it’s usually secreted out before it has time to multiply. Trapped acne-causing bacteria inside a clogged pore then multiplies. The immune system then reacts to it by inflaming the surrounding area and sending white blood cells to take care of the bacteria. The inflammation swells the bump to be bigger and red in addition to more sebum oil building up.

In addition, evidence have shown that alteration in hormones levels, genetic, non-genetic and diet factors all can lead to the development of acne. Illness or stress may worsen acne. Females may also experience flares in their acne before their menstrual periods.

Acne Aestivalis

This form of acne develops following exposure to ultraviolet radiations. It is believed that free radicals generated by exposure to sunrays react with the emulsifiers present in the sun blocks and other cosmetic products. It frequently occurs in the armpits and the chest in the form of pustules and pimples while seldom appears on the face.  It causes pigmentation issues of the affected area.

Acne Excoriee

It is also known as picker's acne because it is the result of pimple popping or picking at the acne lesions. This form of acne is most common in teenage girls. The pimple popping exacerbates the acne and even leads to skin scarring, more pimples and, ultimately, more popping.

Acne Medicamentosa

As the name implies, it is the consequence of use of different medicines containing corticosteroids, lithium or barbiturates, or excess use of vitamin D and Vitamin B6 and B12 and occasionally by contraceptive pill. This type of acne generally improves after discontinuation of the causative medicines.  Acne medicamentosa is manifested in the form of painful pustules and nodules.

Acne Cosmetica

Acne cosmetica is also called make-up acne and cosmetic acne, and arises when comedogenic agents in some cosmetics react with the skin. These agents clog the sebaceous glands and cause acne. It usually subsides when the product’s use is discontinued.

Treatment

Acne is vexing whatever form it is in. Acne scars are even more troublesome and distressful.  Acne treatment must consist of safe management, lessening of the psychological burden via social and emotional help, and clearing mistaken beliefs regarding the disease. Acne treatment should begin earlier in order to reduce the possibility of scarring or unfavorable psychosomatic outcomes / psychological morbidity. It must target to decrease non-inflammatory acne that may lead to the inflammatory acne, diminishing the population of Propionibacterium Acnes and prevent acne scars. In addition, management should be according to the individual, the form and severity of acne and the person’s capacity to utilize medicine, and his/her psychological status.

Topical/ Local Treatment To Treat Mild Acne

The use of topical retinoids is preferred in the management of acne. They help to prevent the new pimple formation as well as decrease the number of pimples. Retinoids are especially useful for non-inflammatory acne. In fact, they also have anti-inflammatory properties and thus can be used for the management of inflammatory lesions. They can be use as a single therapy or can be combined with the antibiotics. Retinoids also show good results when they are used as maintenance following treatment.  In general, tretinoin and adapalene are best recommended topical retinoids. They work to correct skin cells and therefore indirectly help in improving the barrier function of these cells against pathogenic bacteria, UV radiation, heat, etc.

Topical antibiotics are also applied to treat acne. They are primarily used for inflammatory acne of mild to moderate type. The most commonly prescribed topical antibiotics are erythromycin and clindamycin. In addition, Benzoyl peroxide also works against acne and is effective for mild acne treatment. It also does not develop resistance against acne causing bacteria.  For that reason its use is preferred in combination with oral and local antibiotics in order to reduce the risk of bacterial resistance. Additionally, these topical retinoids enhance the penetration of other local medications and also reduce the acne marks following the resolution of acne lesions. It is important to avoid heat and sun exposure while using retinoids because they can increase the sensitivity to sunlight.

In order to treat comedonic acne salicylic acid is used since it has anticomedonal properties. However, it is not as potent as topical retinoids but is still effective.

All these topical agents are available in different strengths and formulations. For oily skin drying preparations like gels, solutions and washes are preferred whereas for dry skin lotions, ointments, and creams are best suited.

Oral Therapies For Treatment Of Moderate Acne

Acne of moderate severity including some forms of acne vulgaris requires the use of oral antibiotics in addition to the topical one. The oral antibiotics having most effective results are erythromycin and tetracycline (such as minocycline and doxycycline). Mostly erythromycin is preferred where tetracycline is contraindicatory, for instance, in pregnancy, children younger than 8 to 12 years of age and during breast feeding. Tetracycline is considered first line and is also inexpensive. It is also chosen over erythromycin owing to the greater resistance reported with the erythromycin use. Trimethoprim/sulfamethoxazole is used as a third line agent when erythromycin or tetracycline is resistant or contraindicated.

Acne vulgaris is treated for up to three months depending upon the severity. If no or little response occurs, then alternative oral antibiotic is advised or topical retinoids are recommended for maintenance therapy. After resolution of acne antibiotic dose is reduced and topical therapy is advised for a longer duration.  Topical retinoids are enough to stop recurrence of acne in the majority of people especially if the acne is mild or moderate in severity. However, there is a severe form of acne which is not easily treated by oral antibiotics. How to get rid of such acne one needs to know about the vitamin A analogue, i.e. isotretinoin (accutane).

  • Treatment of Severe Acne

Isotretinoin (Accutane)

Persistent acne or severe acne that has shown poor response to combined topical and oral therapy necessitates treatment with isotretinoin (accutane). Isotretinoin is given orally and is FDA-approved for the management of severe intractable acne. It is a constituent of the retinoid class and is associated with vitamin A. Accutane can singly manage all the four major factors behind acne and also lead to everlasting remission. Dryness is a common accutane side effects but it is settled with treatment withdrawal or decreasing the dose.  This medicine is prescribed by dermatologists only and people should be informed about a pregnancy prevention program before its use.  A pregnancy test before treatment is compulsory since this medicine has harmful effects on the fetus. Other common accutane side effects are headaches, muscle pains, gastrointestinal upset, and dryness of eyes and of mucous membranes of nose and mouth. Laboratory monitoring of liver enzymes, fasting lipid profile, and a complete blood count is essential during therapy.

Hormonal Therapy

Hormonal therapy is also effective in severe form of acne such as cystic acne or nodular acne. Spironolactone, oral contraceptives, and a combination of ethinyl oestradiol and cyproterone acetate are all recommended hormonal therapies for the treatment of acne. Spironolactone decreases production of sebum and improves acne and is mainly reserved for females who cannot use isotretinoin. Oral contraceptives reduce the production of ovarian androgens and treats acne, particularly the nodular one. Estrogen containing oral contraceptives are generally considered for treatment of acne in females with perimenstrual flare-ups or adult-onset acne. Pregnancy should be avoided while using these hormonal therapies, especially with cyproterone owing to its potentially harmful effects on the fetus.

Light & Laser Treatment

In addition to treatment with medicines, acne at present can be treated by laser and light therapies. These include photodynamic therapy, pulsed-dye laser and visible light therapies. However, these are for short term acne prevention.

Miscellaneous Therapies for Acne Treatment

These include:-

  • Acupuncture
  • Chemical peels (retinoic acid & glycolic acid)
  • Intralesional steroids (triamcinolone injections)
  • Electrocauterization 
  • Biofeedback-assisted relaxation
  • Microdermabrasion
  • Removal of comedones
  • Filler
  • Surgical techniques (subcision and punch excision)

Treatment Of Acne Scars

Acne can sometimes lead to scarring of the skin and dark sports which are stubborn and not easy to vanish. Pimple popping can also cause scarring. These dark spots or acne scars are a consequence of inflammation that enhances increased production of pigment. They can last for many months and are mostly more annoying than the acne itself. These are best treated with above mentioned procedures.

  • For atrophic scarring dermal collagen injection and laser resurfacing are preferred techniques.
  • For hypertrophic scarring cryotherapy, microdermabrasion, use of silicone gels, intralesional steroid injection, chemical peels, excision, and topical corticosteroid creams are recommended.

How To Get Rid Of Acne With Natural Ingredients

There are various proven natural alternatives that help to get rid of acne and acne scars. For example;

Essential oils Use: A large number of essential oils are available with anti-inflammatory and antibacterial properties that can assist in clearing up acne quickly. Oils of lavender, rose, clove and cinnamon have properties to fight against acne bacteria. Likewise, lemongrass and rosemary have also shown to be effective in preventing acne. Gels comprising sweet basil, acetic acid, and orange essential oils help in healing of pimples.

  • Green Tea: It can also be applied to the skin besides drinking it. It consists of tannins and flavonoids, and both offer protecting effects from acne causing bacteria and inflammation. Green tea is rich in such an antioxidant which has demonstrated to reduce sebum formation, fight inflammation, and prevent the growth of Propionibacterium acnes in individuals with acne-prone or oily skin.
  • Aloe vera gel:  when applied to the skin promotes healing of lesions, decreases inflammation and fights bacteria.
  • Application of Papaya: Papaya comprises an enzyme which is known to reduce the inflammation. It also facilitates controlling of pus formation in acne.
  • Baking Soda: It is a renowned home remedy for clearing up the pimples. Baking Soda offers antiseptic properties, works against bacteria and fungus and even removes excess oil. It also causes new skin cells growth and makes skin softer. It is quite beneficial for oily skin.
  • Cinnamon and honey mask:  Owing to anti-inflammatory, antioxidant, and antibacterial properties, this mask may prove helpful in preventing acne when applied to it. Honey is also helpful in oily skin as it sucks moisture from the skin devoid of restoring it.
  • Blackheads Removal Techniques: Blackheads can be removed naturally at home. For example application of vinegar and cornstarch on the blackhead affected area can help remove them. Likewise, lemon, rose water, honey and baking soda when applied work as blackhead removal agents.

 

Dietary Modification

Dietary modification is also required such as avoiding foods with a high glycemic index, while consuming more foods containing omega-3 fatty acids and using fewer dairy products. The use of zinc, probiotics, and seaweed can also helps in removing acne.

Decrease stress

A number of studies have shown that acne flares with stress. In order to reduce stress, one should seek help from the healthcare provider, perform relaxation techniques and bring change in lifestyle.

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Post Treatment Prevention

  • Get good advice and recommendations on the application of sunscreens, cosmetics, hair gels and moisturizers, since some formulations are oily and can cause acne or aggravate existing acne.
  • Popping pimples, squeezing, and manipulating can cause additional problems. Pimple popping makes the pimple become highly inflamed.  Avoid this. Pimple poppers suffer from exacerbation of acne as well as scarring in the long run.
  • Popping or squeezing blackheads with unhygienic hands and scapulas should be avoided.
  • Rinse the face with water twice daily and abstain from harsh scrubbing.  Aggressive scrubbing can spread acne further.
  • Opt for makeup or any skin product that is categorized as "noncomedogenic," signifying it should not lead to acne. 
  • Consume fresh vegetables, fruits and whole grains and exercise regularly.
  • Refrain from too much sunlight exposure.

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