What Causes Cystic Acne?

Cystic acne is the most severe form of acne, creating painful, inflamed bumps deep beneath your skin's surface. Unlike regular pimples that appear near the surface, cystic acne develops when oil, dead skin cells, and bacteria become trapped deep within hair follicles, causing large, cysts that can lead to permanent scarring.

If you're dealing with large, painful bumps that linger for weeks or months, you're likely experiencing cystic acne. Understanding what triggers these deep breakouts is essential for effective treatment and prevention. While cystic acne involves multiple factors working together, the good news is that with proper treatment, most cases can be successfully managed.

What Is Cystic Acne?

Cystic acne occurs when bacteria gets into your pores along with oil and dead skin cells. This infection triggers an inflammatory response deep in your skin's middle layer, called the dermis. The result is a red, swollen, painful lump that can measure several millimeters across.

Cystic acne is more common in teenagers, but anyone can get it. It's more common in men than women, though women often experience cystic breakouts related to hormonal changes. The condition tends to run in families, suggesting a strong genetic component.

Main Causes of Cystic Acne

Hormonal Fluctuations

Hormones play a central role in cystic acne development. During adolescence, androgens (hormones present in both males and females) increase significantly. These hormones signal your oil glands to produce more sebum, the oily substance that keeps your skin moisturized.

When androgen levels go up, sebum production increases. This excess oil mixes with dead skin cells and blocks your pores. Research shows that acne is commonly triggered during adolescence by bacteria under the influence of normal circulating hormone levels.

For women, hormonal triggers include:

• Menstrual cycle fluctuations, especially the week before your period

• Polycystic Ovary Syndrome (PCOS), which causes elevated androgens

• Pregnancy and postpartum hormonal shifts

• Starting or stopping birth control pills

• Menopause and perimenopause

Genetic Predisposition

If one or both of your parents had severe cystic acne, you have a much higher chance of developing it yourself. Studies show that about two-thirds of people with acne report having at least one first-degree relative who also suffers from the condition.

Recent genetic research indicates that processes related to cell maintenance and cellular migration are particularly important in acne development. Your genes influence how your skin sheds dead cells, how much oil your glands produce, and how your immune system responds to bacteria in your pores.

Bacterial Infection and Inflammation

When your pores become clogged with oil and dead skin cells, bacteria can get trapped inside. The bacteria involved in acne, called Cutibacterium acnes (formerly Propionibacterium acnes), naturally lives on your skin. Under normal conditions, it's harmless.

However, when these bacteria multiply inside a blocked pore, they trigger your immune system to respond. This inflammatory reaction is what makes cystic acne so painful and severe. If the inflammation is intense enough, the follicle can break open into the deeper layers of skin, creating the large, painful cysts characteristic of severe acne.

The inflammation also activates enzymes that can destroy surrounding tissue, which is why cystic acne often leaves scars even after the breakout heals.

Excess Oil Production

Your sebaceous glands produce oil to keep your skin healthy and protected. But when these glands go into overdrive, the excess sebum becomes a problem. Too much oil mixed with dead skin cells creates a sticky plug that blocks your hair follicles.

Several factors increase oil production, including hormonal changes, stress, certain medications, and genetics. Some people simply have more active oil glands than others, making them more prone to developing cystic acne.

Risk Factors That Worsen Cystic Acne

Stress

Stress doesn't directly cause cystic acne, but it can make existing acne worse. When you're stressed, your body releases cortisol and other stress hormones that can increase oil production and inflammation in your skin.

Certain Foods

While food doesn't cause acne on its own, research suggests that certain dietary patterns may worsen breakouts in some people. Studies have found associations between acne and high consumption of dairy products and high-glycemic foods like white bread, sugary snacks, and processed carbohydrates.

These foods can cause spikes in blood sugar and insulin, which may increase inflammation and oil production. However, dietary triggers vary significantly from person to person.

Certain Medications

Some medications can trigger or worsen cystic acne, including testosterone, lithium, and corticosteroids. If you notice your acne worsening after starting a new medication, talk to your doctor about alternatives.

Who Gets Cystic Acne?

Cystic acne most commonly affects teenagers and young adults, with symptoms typically appearing during puberty when hormone levels surge. However, cystic acne can develop at any age, from children as young as 8 to adults in their 40s and 50s.

While severe cystic acne is more common in men, adult women often experience cystic breakouts related to their menstrual cycle, pregnancy, or hormonal conditions like PCOS. Women with acne along their jawline and lower face particularly tend to have hormonal triggers.

Treatment Approaches

Because cystic acne develops deep within your skin, over-the-counter treatments rarely work on their own. Professional treatment is usually necessary to clear cystic acne and prevent scarring.

Dermatologists typically recommend treatments that target multiple causes of cystic acne simultaneously. Options may include prescription topical medications to unclog pores and reduce bacteria, oral antibiotics to control infection and inflammation, hormonal therapies for women with hormone-related acne, or isotretinoin for severe cases.

According to current clinical guidelines, early and aggressive treatment of severe acne is important for preventing permanent scarring. The sooner you start effective treatment, the better your chances of clearing your skin without lasting marks.

When to See a Dermatologist

If you have large, painful bumps beneath your skin that don't respond to over-the-counter treatments, you should see a dermatologist. Cystic acne requires professional medical treatment to prevent scarring and manage symptoms effectively.

You should seek dermatology care if:

• You have deep, painful cysts that last for weeks

• Over-the-counter acne products haven't helped after 8-12 weeks

• Your acne is leaving scars or dark marks

• Your breakouts are getting worse or spreading

• Your acne is affecting your self-esteem or quality of life

Early intervention is crucial for cystic acne. According to the American Academy of Dermatology's clinical guidelines, dermatologists can successfully treat almost any case of acne. Don't wait until scarring develops or your acne becomes severe before seeking help.

Cystic acne results from a complex interaction of hormones, genetics, bacteria, inflammation, and excess oil production. While you can't change your genetic predisposition, understanding what causes your cystic acne helps you and your dermatologist develop an effective treatment plan. With professional care and appropriate treatment, most people with cystic acne can achieve significant improvement and prevent permanent scarring.