We’re talking about blind pimples. You know, those large, inflamed, painful pimples under the skin? These can be particularly uncomfortable and oftentimes more difficult to treat than their more low-key cousins like blackheads, for example. There are many nuances to these breakouts that derms need you to know, so here we go. You can get cystic pimples on every area of the face, neck, back, and perhaps other parts of the body too—but they’re most common on the face. Cysts can be soft to the touch as well. “Pimples that arise deeper in the skin and do not always come to a head, lasting days, weeks, or months have a more inflammatory component and have the potential to scar more,” board-certified dermatologist Kseniya Kobets, M.D., MHS, FAAD, tells mbg. This is why this form of acne is taken so seriously. If you’re someone who menstruates, breaking out around your cycle might be another sign. According to a survey, almost two-thirds of acne-prone women report having flares before or on their menses2 (more specifically in the “late luteal phase of the menstrual cycle” or after ovulation and right before you start bleeding). Or, if you’ve recently started to feel the effects of menopause, your breakouts may be hormonal as well—yes, menopause acne is a real thing, and you can read more about it here if you’re curious. This is a very, very brief overview of hormonal breakouts—read more about causes, signs, and treatments here. This can include sex hormones like androgens, testosterone, and dihydrotestosterone (DHT) or stress hormones like cortisol. “Many of these hormones increase oil production and inflammation in the skin,” Kobets explains. If you know you’re predisposed to cystic acne (i.e., a close family member had or has acne), then it’s best to let your dermatologist know early on—this may influence their next steps or at the very least give them important context. A lack of sleep (which may be triggered by stress or, in turn, cause stress) also impacts your likelihood of experiencing breakouts. A lack of high-quality sleep creates stress in the body, which, as you now know, can manifest into more sebum production and more breakouts. Even if you don’t typically have acne-prone skin, a lack of sleep can contribute to what dermatologists refer to as “occasional acne.” What’s more, “Studies have shown that consuming low-fat or skim milk has been associated with a higher incidence of acne as compared to consuming whole milk or no milk at all,” board-certified dermatologist Ramya Garlapati, M.D., previously told mbg. The link is so strong, as demonstrated in this AAD study5—researchers found that women who drank two or more glasses of skim milk a day were 44% more likely to have acne than others. Sugar and dairy have a way of sneaking into your diet. Even if you aren’t deliberately drinking two glasses of dairy milk or consuming loads of sugar, these ingredients can be found in plenty of beverages (we’re looking at you, lattes), as well as premade foods. As you can tell, the gut and skin are incredibly connected. If you are predisposed to inflammatory skin conditions—whether it be acne, psoriasis, eczema, or something else, it’s important to take this connection even more seriously. This is why it’s so important to tend to the gut and treat acne from the inside as well as the outside—more on that to follow. Large, inflamed, painful pimples most often call for, “The big guns,” as Kobets puts it. This means prescription-grade products and treatments—here are a few worth noting. In fact, there’s been a decent amount of fearmongering over the years when it comes to isotretinoin. As Kobets says, “Many male and female patients with moderate to severe cystic acne tolerate oral isotretinoin without major effects.” However, a few drawbacks of taking isotretinoin include frequent doctor visits, strict contraceptive measures for those who could become pregnant while taking isotretinoin, and a long treatment course (typically around five to six months). There are some controversial side effects as well, “Skin dryness, cholesterol elevation, liver abnormalities, depression, and inflammatory bowel disease—the latter two are controversial on how much of increased risk there really is,” Kobets notes. Given all of the above, it only makes sense that isotretinoin is prescription-only. If you’re curious about isotretinoin, ask your doctor about eligibility, risks, and current formulations and research—as they’re up to date on all of the current medications and information. While spironolactone was originally used for heart failure and high blood pressure, it has proven to be an effective treatment for hormonal acne in women6, with minimal bothersome side effects. For men, a new form of hormonal acne treatment has hit the market in the past few years–referred to as Winlevi, or Clascoterone 1% cream. “While it has shown in vitro (which means in the lab) to be superior to blocking DHT7 (hormones that cause excess oil production and inflammation) in oil cells in the skin compared to spironolactone, we still have to see how it compares to oral spironolactone in the real practice,” Kobets says. To sum up, spironolactone may be the best oral medication available to treat female hormonal acne. However, Winlevi is another great option for men and for those looking to stick to topical treatment. “Cortisone shots are one of my favorite ’emergency’ treatments for active acne, especially for the pain and deep-seated cysts,” Kobets notes. It’s important to view cortisone shots as an emergency, and temporary treatment that can go alongside something more permanent and preventive like oral or topical medications. Cystic acne will not benefit from extractions on active cysts (as it is a blind pimple without a head), but your esthetician may be able to prevent some breakouts by clearing out dead skin cells and excess sebum before acne forms. Do be sure to let your esthetician know if you are on prescription medications or topicals beforehand, as that will change the sensitivity of your skin and thus the best facial practices and products for you. “It has anti-inflammatory, anti-pore clogging, and anti-scarring properties, and it helps heal up acne quicker, as well as helping the pigmentation,” Kobets says about the prescription-strength formulas. These formulas are strong, so it’s best to use them every few nights (or as directed by your derm). For non-prescriptions, there are many retinol serums and formulas out there. These aren’t FDA-approved to treat acne specifically, however using them will likely benefit the skin and heal clear up breakouts. (More on them in a second.) Plus, they have plenty of other healthy aging benefits. It’s also important to note that topical retinoids can be used alongside spironolactone but not in conjunction with oral isotretinoin (as your dermatologist will tell you). However, a proper at-home routine can still work wonders, especially for acne in its early stages. Here, a few ingredients that work best for inflammatory acne like blind pimples. Think of this as a launchpad for your acne journey, not the end-all-be-all. Perfecting 2% BHA Liquid Exfoliant. However, using a blend of AHAs and BHAs can tend to the skin from all angles. Don’t mix your AHA serum with a separate BHA serum. “Don’t DIY your acid combination,” board-certified dermatologist Whitney Bowe, M.D., FAAD, previously warned. “The acids need to be formulated in a way that makes them stable together.” Read: Don’t layer an AHA over a BHA—look for a product that has them both (like Bowe’s new Exfoliation Night serum). Here, a full guide to exfoliation and best products if you want to dive a bit deeper into this step. Tea tree has been shown to be an effective treatment for mild to moderate acne10 but likely will not clear cystic acne. It can be used in your face cleanser or a mild toner to help minimize oil on the surface, though. Read more about the gut and brain connection here and our list of the best probiotic supplements on the market here. Exercise produces endorphins12—chemicals in the brain that make you feel good—which help decrease tension, elevate mood, improve sleep, and boost self-esteem. Plus, it may double as a stress management technique. Also, prioritize healthy hormone habits when it comes to your food consumption—here’s how.
