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 manage, 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.
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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 explore the underlying factors 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 contribute to 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 contribute to 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 Explore for Cystic Acne
Functional medicine labs help practitioners personalize options for their patients. Below are some of the most common labs considered for patients experiencing cystic acne.
Comprehensive Stool Test
Comprehensive stool tests, like the GI-Effects, can identify and quantify gut dysbiosis and inflammation. Additionally, zonulin can be added to help identify increased gut permeability.
Insulin Resistance
Fasting blood glucose, insulin, and hemoglobin A1c (HbA1c) are helpful markers of blood sugar regulation and insulin resistance.
Hormone Testing
A DUTCH Complete 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.
Food Sensitivities
A food sensitivity panel helps identify foods in the diet that may be exacerbating intestinal inflammation, permeability, and dysbiosis.
IGF-1
IGF-1 can be measured in the blood; excess levels can contribute to excess sebum production and more severe acne.
How to Support Skin Health and Manage Cystic Acne
Dietary and hygiene habits, discussed in more detail below, can support skin health and may help manage cystic acne. Washing the face no more than twice daily with a mild facial cleanser and topical moisturizer helps keep the face clean. Washing the face too often with harsh chemicals can dry out the skin, potentially exacerbating inflammation and excess sebum production. An anti-inflammatory diet low in simple sugars and carbohydrates may also help reduce acne breakouts. (1)
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Conventional Approaches for Cystic Acne
Conventional approaches for cystic acne typically involve both topical and oral 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 help relieve the pain and size of the lesion. (8)
Functional Medicine Approaches to Support Skin Health Naturally
Based on an extensive intake and lab results, a personalized plan is considered. Below are some of the most common integrative approaches for individuals experiencing cystic acne.
Dietary Considerations for Cystic Acne
Low-glycemic diets that emphasize consuming foods less likely to raise blood sugar levels may help reduce total lesion counts and inflammatory lesions in individuals with cystic acne. Low-glycemic diets also have the benefit of increasing insulin sensitivity and may help reduce 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 explore 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 Support Skin Health
Berberine is an herbal compound that possesses anti-inflammatory and antibacterial properties. It is commonly used to support the body's defense against pathogenic infections, and its ability to also help manage blood sugar and improve insulin sensitivity makes it a potential option for addressing factors related to cystic acne. One study that used 600mg of dried barberry (a berberine-containing herb) daily for four weeks noted an improvement in total lesions and acne severity in adolescents with moderate-to-severe acne.
Supplementing antioxidants may help reduce inflammation and support skin health. 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, potentially resulting in hormonal imbalances and increased systemic inflammation. Avoiding environmental toxins from cleaning products, non-organic foods, and plastics may support liver function. Additionally, liver-supportive supplements and herbs like phosphatidylcholine, milk thistle, and artichoke may help support liver health and the optimal functioning of detox pathways.
Topical Options for Cystic Acne
Centella asiatica (Gotu Kola) is known for its potential to support wound healing and reduce inflammation. It can be applied topically to the skin to help manage residual scarring left by acne cysts and nodules.
Niacinamide (vitamin B3) applied to the skin topically may help reduce swelling and redness associated with acne to support skin tone and manage acne scarring. In addition, it may help control the amount of oil production by the sebum glands, potentially preventing new cystic lesion formation.
Applying tea tree oil to the skin may help reduce the number of lesions in those with acne. It has been shown to be more effective than placebo and is considered equivalent to conventional topical therapies, benzoyl peroxide and erythromycin.
Referral to An Integrative Dermatologist
Functional medicine practitioners usually have a list of other integrative specialists they refer to. In many cases, practitioners will work with an Integrative Dermatologist to provide a comprehensive approach to your care.
Summary
Cystic acne causes deep, painful lesions that can be challenging to manage. Often, without addressing underlying systemic factors, conventional approaches may not be successful in managing cystic acne in the long term. A functional approach to cystic acne considers factors like dysbiosis, blood sugar imbalance, and hormonal fluctuations that may contribute to inflammation and cyst formation for potential long-term support.
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