Acne is the most common skin condition in the United States, affecting up to 95% of adolescents and 54% of adults. It can be a complex condition to treat, with medical costs associated with treatment estimated at over $1 billion.
Acne presents with different lesions, described as comedones, papules, pustules, cysts, and nodules. The most severe form of acne is called nodulocystic acne, characterized by deep, painful nodules and cysts within the skin.
What is Cystic Acne?
Cystic acne is the most severe form of acne. Oil and dead skin cells build up within the hair follicles deep within the skin, causing boil-like, painful cysts and inflammation.
What Does Cystic Acne Look Like?
Acne cysts look like red bumps under the skin and resemble boils. Cysts can vary in diameter, ranging from as small as a pea to as large as a dime. (1)
Acne nodules may accompany cysts, referred to as nodulocystic acne. Nodules appear very similar to cysts but are firmer because they do not contain fluid.
Cystic acne breakouts most commonly occur on the face but can also develop on the back, buttocks, chest, shoulders, upper arms, and neck (1).
Cystic Acne Symptoms
Cystic acne presents with pus-filled cysts deep within the affected skin area. Cysts appear inflamed with redness, oozing pus from a white-yellow head, and crusting. Acne cysts are commonly painful and tender to the touch. Cysts are more likely to become infected and cause scarring than other acne lesions. (1)
Severe acne is also associated with increased rates of depression, anxiety, poor self-image, poor self-esteem, and suicidal tendencies (2).
Causes of Cystic Acne
Acne develops at the skin's surface due to excess oil production, a buildup of dead skin cells, and bacterial growth within the pore. Factors that may increase the risk of developing acne include hormonal changes, family history of acne, certain medications, and adolescence. (3)
Functional medicine providers dive deeper into the underlying causes of acne, understanding that systemic internal imbalances may present clinically at the skin level.
Dysbiosis of the skin and gut microbiomes can lead to the overgrowth of organisms contributing to acne. Cutibacterium acnes, formerly Propionibacterium acnes, is the predominant bacteria implicated in acne development. However, millions of bacteria, fungi, and viruses compose the skin microbiota, and any disturbance can cause acne. Cosmetics, antibiotics, and environmental factors (e.g., temperature, humidity, sunlight) can disrupt the healthy balance of bacteria. (4)
Excess androgens (DHEA, testosterone, and DHT) binding to their receptors in sebaceous glands can upregulate gland function, producing extra oil. Additionally, fluctuations in estrogen and progesterone can contribute to cystic acne. Conditions such as PCOS and pregnancy are associated with an increased risk of cystic acne. (5)
Increased intestinal permeability caused by food sensitivities can cause skin inflammation. Cow's milk is the most researched allergen associated with an increased incidence of acne (10). This may be partly due to milk's ability to increase insulin-like growth factor-1 (IGF-1) levels, which can increase inflammation and sebum production (6, 7).
Insulin resistance is also thought to play a role in the development of acne. Higher fasting insulin levels and high-glycemic diets have been associated with severe acne. (6)
Functional Medicine Labs to Test for Root Cause of Cystic Acne
Functional medicine labs help practitioners personalize treatment options for their patients. Below are some of the most common labs ran for patients suffering from cystic acne.
Comprehensive Stool Test
Comprehensive stool tests can identify and quantify gut dysbiosis and inflammation. Additionally, zonulin can be added to help identify increased gut permeability.
Fasting blood glucose, insulin, and hemoglobin A1c (HbA1c) are helpful markers of blood sugar regulation and insulin resistance.
A DUTCH hormone test measures urinary metabolites of estrogens, progesterone, testosterone, and cortisol to assess how hormonal imbalances may contribute to acne.
A thyroid panel may also be beneficial to assess thyroid function, which can contribute to inflammation and sex hormone imbalances if not functioning optimally.
A food sensitivity panel helps identify foods in the diet that are exacerbating intestinal inflammation, permeability, and dysbiosis.
IGF-1 can be measured in the blood; excess levels can contribute to excess sebum production and more severe acne.
How to Prevent Cystic Acne
Dietary and hygiene habits, discussed in more detail below, can lower the risk of developing cystic acne. Washing the face no more than twice daily with a mild facial cleanser and topical moisturizer ensures the face stays clean. Washing the face too often with harsh chemicals can dry out the skin, exacerbating inflammation and excess sebum production. An anti-inflammatory diet low in simple sugars and carbohydrates can also reduce acne breakouts. (1)
Conventional Treatment for Cystic Acne
Conventional treatment for cystic acne typically involves both topical and oral treatment options. Topical therapies often include retinoids, benzoyl peroxide, azelaic acid, salicylic acid, and antibiotics. Oral medicines commonly prescribed include isotretinoin (Accutane), antibiotics, or hormonal therapy (i.e., oral contraceptive pill, spironolactone). For severe, painful acne breakouts, a dermatologist may administer a corticosteroid injection to the cyst to relieve the pain and size of the lesion. (8)
Functional Medicine Treatment to Heal Cystic Acne Naturally
Based on an extensive intake and lab results, a personalized treatment plan is prescribed. Below are some of the most common integrative treatment protocols for patients suffering from cystic acne.
Diet for Cystic Acne
Low-glycemic diets that emphasize consuming foods less likely to raise blood sugar levels effectively reduce total lesion counts and inflammatory lesions in patients with cystic acne. Low-glycemic diets also have the benefit of increasing insulin sensitivity and reducing androgen levels. (9)
Dairy intake (milk, yogurt, and cheese) is associated with an increased risk of acne for individuals aged 7-30 years. Based on this evidence, it may be beneficial to do a trial-elimination diet of dairy and other identified food sensitivities on testing.
It may take as long as 12 weeks to observe improvements in acne after initiating changes to dietary patterns (10).
Oral Supplements to Help Heal Cystic Acne
Berberine is an herbal compound that possesses anti-inflammatory and antibacterial properties. It is commonly used to treat pathogenic infections, but its ability to also reduce blood sugar and improve insulin sensitivity makes it a great holistic option for addressing the underlying causes of cystic acne. One study that used 600mg of dried barberry (a berberine-containing herb) daily for four weeks concluded an improvement in total lesions and acne severity in adolescents with moderate-to-severe acne.
Supplementing antioxidants can reduce inflammation and support the treatment of acne. People with acne are more likely to have vitamin E, A, and zinc deficiencies. Research also shows that supplemental zinc and vitamin A are correlated with improvements in the number of acne lesions as soon as four weeks after starting therapy.
Increased burden on the liver can slow down detoxification pathways, resulting in hormonal imbalances and increased systemic inflammation. Avoiding environmental toxins from cleaning products, non-organic foods, and plastics can improve liver function. Additionally, liver-supportive supplements and herbs like phosphatidylcholine, milk thistle, and artichoke can tonify the liver and support the optimal functioning of detox pathways.
Topical Treatments for Cystic Acne
Centella asiatica (Gotu Kola) effectively heals wounds, burns, and inflammation. It can be applied topically to the skin to treat residual scarring left by acne cysts and nodules.
Niacinamide (vitamin B3) applied to the skin topically reduces swelling and redness associated with acne to regulate skin tone and fade acne scarring. In addition, it can control the amount of oil production by the sebum glands, preventing new cystic lesion formation.
Applying tea tree oil to the skin reduces the number of lesions in those with acne. It has been proven more effective than placebo and is equivalent to conventional topical therapies, benzoyl peroxide and erythromycin.
Referral to An Integrative Dermatologist
Functional medicine practitioners usually have a list of other integrative specialist they refer to. In many cases practitioners will work with Integrative Dermatologist to give you a comprehensive approach to your treatment.
Cystic acne causes deep, painful lesions that can be difficult to treat. Often, without addressing underlying systemic factors, conventional therapy is unsuccessful at treating cystic acne in the long term. A functional approach to cystic acne addresses dysbiosis, blood sugar imbalance, and hormonal fluctuations at the root of inflammation and cyst formation for effective long-term solutions.
Lab Tests in This Article
1. Cystic Acne: What Is It, Symptoms, Causes and Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/21737-cystic-acne
2. Purvis, D., Robinson, E., Merry, S.E., et al. (2006). Acne, anxiety, depression and suicide in teenagers: A cross-sectional survey of New Zealand secondary school students. Journal of Paediatrics and Child Health, 42(12), 793–796. https://doi.org/10.1111/j.1440-1754.2006.00979.x
3. NIH. (2023, January 17). Acne. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/health-topics/acne
4. Skowron, K., Bauza-Kaszewska, J., Kraszewska, Z., et al. (2021). Human Skin Microbiome: Impact of Intrinsic and Extrinsic Factors on Skin Microbiota. Microorganisms, 9(3), 543. https://doi.org/10.3390/microorganisms9030543
5. Hormones and cystic acne: what you need to know. (2021, August 2). Nebraska Medicine. https://www.nebraskamed.com/dermatology/hormones-and-cystic-acne-what-you-need-to-know
6. Emiroğlu, N.İ., Cengiz, F.P., & Kemeriz, F. (2015). Insulin resistance in severe acne vulgaris. Postepy Dermatologii I Alergologii, 4, 281–285. https://doi.org/10.5114/pdia.2015.53047
7. Kim, H., Moon, S.H., Sohn, M.Y., et al. (2017). Insulin-Like Growth Factor-1 Increases the Expression of Inflammatory Biomarkers and Sebum Production in Cultured Sebocytes. Annals of Dermatology, 29(1), 20. https://doi.org/10.5021/ad.2017.29.1.20
8. AAD. Acne: Diagnosis and treatment. American Academy of Dermatology Association. https://www.aad.org/public/diseases/acne/derm-treat/treat
9. Pappas, A. (2009). The relationship of diet and acne. Dermato-Endocrinology, 1(5), 262–267. https://doi.org/10.4161/derm.1.5.10192
10. AAD. Can the right diet get rid of acne? American Academy of Dermatology Association. https://www.aad.org/public/diseases/acne/causes/diet