Beyond the Blemish: Understanding and Managing Cystic Acne

 Cystic acne is a severe form of acne, distinct from other types such as blackheads, whiteheads, and smaller pimples (papules and pustules). It is characterized by deep, inflamed, and painful cysts beneath the skin surface, which are significantly larger and more likely to cause scarring compared to other acne lesions. Unlike typical acne which may affect only the surface layers, cystic acne involves deeper layers of the skin and results in widespread inflammation that is not limited to the area immediately surrounding the cyst.  

 These formative events begin with the development of a microcomedone that may progress to a closed comedone within the follicle under certain conditions. When the skin is compromised or inflamed, the integrity of the follicular lining can be weakened by the accumulation and pressure from sebum, keratin, and bacterial components. As these elements build up, the follicular wall may rupture, not only exacerbating local inflammation but also allowing the infection to escape the confines of the follicle and spread into the surrounding tissue. This breach leads to the formation of severe, painful, and swollen lesions typical of cystic acne, with deeper ruptures resulting in larger and more painful cystic lesions.

Simultaneously, the inflammatory response intensifies as immune cells infiltrate the area and release proinflammatory cytokines, further exacerbating skin pathology and contributing to the severity of acne. This persistent inflammation is crucial in the development of post-acne scarring and hyperpigmentation, posing a considerably higher risk of these complications compared to other types of acne.

Other dermatological conditions can often exhibit similar inflammatory and cystic features. Conditions such as hidradenitis suppurativa, folliculitis, and other acne imposters can mimic the appearance of cystic acne making treatment confusing and in some cases, detrimental if the skin has not been properly assessed.

Hidradenitis Suppurativa (HS) - This chronic skin condition is characterized by small, painful lumps under the skin, typically occurring in areas where the skin rubs together, such as the armpits, groin, and under the breasts. Unlike cystic acne, HS lumps are more likely to develop in these specific areas and can persist for years, worsen over time, and cause scarring.

Folliculitis - Often confused with acne, folliculitis is the inflammation of hair follicles and is usually caused by a bacterial or fungal infection. It appears as small, red, raised bumps or white-headed pimples around hair follicles — the key differentiator being the presence of hair in the center of these bumps.

Rosacea - This condition can sometimes appear similar to acne as it presents with redness and lesions which can appear nearly identical to acne.. However, rosacea typically affects the central face (cheeks, nose, chin, and forehead) and may be accompanied by visible blood vessels and skin sensitivity.

Keratosis Pilaris - Although not inflammatory like cystic acne, keratosis pilaris causes rough, small bumps on the skin. These bumps are usually white or red and don’t hurt or itch. They are often seen on the arms, thighs, cheeks, and buttocks.

A thorough client consultation and examination are paramount to distinguishing cystic acne from these conditions. During the initial consultation, it is important to ask about the duration of the skin issues, any family history of similar conditions, lifestyle factors, and previous as well as ongoing home treatments being used. A comprehensive examination should include assessing the lesion's location, distribution, type, and the presence or absence of systemic symptoms. Additionally, observing the skin’s response to treatments can provide valuable insights into the nature of the condition as it pertains to your clients skin. 

While hormonal fluctuations are commonly identified as a primary cause of cystic acne, it's important to take a deeper look at this perspective. More often, the progression of acne from its milder stages to more severe forms, such as cystic acne, is influenced significantly by external interventions, environmental irritants or the presence of inflammation either locally or systemically. Aggressive treatment methods, such as the excessive use of strong topical agents or harsh procedures like mechanical scrubs and chemical peels, can severely disrupt the skin’s natural barrier. This disruption leads to an overactive immune response, where the body, in an attempt to protect itself, sends inflammatory cells to the already compromised areas. This not only causes tissue damage and the formation of deep, painful cystic acne but also sets the stage for ongoing acne issues. By focusing on maintaining and restoring the health of the skin barrier and reducing inflammation, many cases of what appears to be hormonally-driven cystic acne can actually be mitigated or resolved, steering clear of the cycle of aggressive treatments and further skin damage.

Overview of Existing Acne Treatments

Oral Antibiotics are what some may say an over-prescribed therapy to reduce bacteria and inflammation. While generally effective in the short term, their prolonged use can lead to antibiotic resistance and disrupt the natural microbiome which has its own disadvantages on the skin.

Hormonal Therapy will be beneficial for acne driven by hormonal imbalances, especially in women. However, it requires careful monitoring and is not suitable for everyone, as it can have significant side effects.

Isotretinoin is often perceived as a powerful solution for severe acne, but it's crucial to understand its extensive range of potential long-term effects. Its mechanism—reducing sebum production and changing keratinization—can leave the skin extremely dry and fragile, impairing its ability to protect itself and heal. This disruption can lead to persistent dryness and increased susceptibility to scarring. Patients who undergo treatment with isotretinoin might experience a compromised lipid synthesis, making the ongoing management of acne particularly challenging due to the skin's weakened defense against minor infections and irritations.  Beyond the drawbacks affecting the skin, isotretinoin can also cause systemic issues including alterations in lipid profiles, potential liver enzyme elevations, and mood changes, which may contribute to psychological distress. These internal effects necessitate careful monitoring and consideration before starting treatment, underscoring the importance of evaluating all aspects of patient health.

Corticosteroid injections, while effective for reducing inflammation in severe acne lesions like cysts, can also contribute to scarring. Known as steroid atrophy, this side effect manifests as a depression in the skin where the injection was made, which can sometimes be permanent.

Chemical Peels are often touted for their immediate results in skin texture and appearance improvement. However, these treatments can significantly disrupt the skin's natural barrier. Studies, including those from 2012, have shown that Alpha Hydroxy Acids (AHAs) like glycolic acid work not merely by dissolving desmosomes (as previously thought) but by activating TRPV3 channels in keratinocytes, leading to an overload of calcium ions and subsequent cell death. This method, while effective in removing dead skin cells, is inherently pro-inflammatory and can exacerbate the underlying inflammatory processes of acne.

Beta Hydroxy Acids (BHAs) like salicylic acid are soluble in oil which allows them to penetrate follicles deeply, potentially also compromising the integrity of the skin, resulting in inflammation if used excessively. Moderation and careful management, using lower concentrations more regularly at home in conjunction with barrier supportive products, can help maintain the skin's integrity and prevent exacerbating issues.

Promising Non-Invasive Alternatives

Microcurrent is another modality showing efficacy towards acne management. A recent study in 2022 highlighted microcurrent's potential in reducing inflammation by modulating key signaling pathways and decreasing pro-inflammatory cytokines in acne models. Moreover, microcurrent treatments have been shown to alter the permeability and integrity of biofilms. Biofilms are protective layers formed by bacterial colonies like P. acnes on the skin, which shield the bacteria from treatments and contribute to persistent acne. By disrupting these biofilms, microcurrent enhances the effectiveness of acne treatments.

Galvanic Desincrustation Treatments offer a gentle yet effective solution for deep skin cleansing and maintenance. Utilizing a negative electrode to saponify sebum, these treatments facilitate the easier removal of comedones and are also effective against biofilms. By disrupting the biofilm structure, galvanic treatments can expose underlying bacteria to more effective eradication, aiding in clearer skin.

LED light therapy shows great promise when treating acne. Blue LED light effectively kills C. acnes bacteria by targeting the porphyrins that cannot survive in oxygenated environments. Red LED light helps reduce inflammation and accelerate healing, making the two combined an excellent option for managing acne with minimal side effects.

Ultrasonic Skin Spatulas are often used for extractions but work best when used immediately after galvanic treatments to remove softened debris. The mechanical action of the spatula enhances the clearing of pores, complementing the biofilm-disruption activities of the previous treatments.

Managing Triggers

Comedogenic Ingredients - When addressing comedogenic ingredients and their role in acne development, it’s crucial to understand their inherent properties and how they interact with acne-prone skin. Comedogenic ingredients often contain high levels of free fatty acids, which can irritate the pores. This irritation doesn’t simply block the pore mechanically; rather, it induces inflammation that leads to hyperkeratinization.  This response is akin to how skin reacts to a rash, where irritation causes dryness and flakiness inside the pore, leading to congestion. This is a critical aspect of comedogenicity that is often overlooked. When skin is already inflamed, such as in cases of cystic acne, it is hyper-responsive to any additional irritants. Thus, even minimal exposure to these ingredients can exacerbate acne. When managing acne, particularly severe or cystic types, it is essential to avoid all potential inflammatory triggers. Using even low concentrations of comedogenic ingredients can be risky. The goal in acne care should be to control and eliminate as many variables as possible to maintain clear skin, rather than risking the exacerbation of acne through unpredictable responses to such ingredients. This cautious approach helps to avoid a game of Russian roulette with the skin. 

Diet & Supplements - While there are an abundance of internal factors which can contribute to acne, many are bioindividual and better tolerated by some than others.  Some common identified supplements and vitamins include Biotin, B12, B6, Iodine and whey or forms of algae found in certain protein drinks.  Foods such as dairy, peanuts, fermented foods, cocoa/chocolate and saturated fats have all been linked to acne formation.  Sugar is a particularly important culprit as well as insulin promotes androgen synthesis, which can lead to excessive sebum production, a known correlate of acne severity. Hyperinsulinemia, or high insulin levels, can also cause increased proliferation and dysfunction of keratinocytes, which can lead to abnormal sebum production. 

Stress - a common dilemma is making the diet portion of treatment so stringent that it elevates stress levels so encouraging a fine balance is crucial.  The release of cortisol, often referred to as the “stress hormone” due to its increase in response to stress, has been shown to increase sebum, modulate the immune system and inflammatory pathways, weaken skin barrier function as well as influence glucose metabolism.  

The immediate results offered by more aggressive treatments can be compelling, but like using a hand grenade to clear weeds from a garden, they can be excessively harsh and may disrupt the delicate ecosystem of the skin. In acne treatment, this could mean achieving quick lesion clearance at the expense of long-term skin health, potentially exacerbating the underlying inflammatory process.

To truly manage acne, an integrative approach that considers both intrinsic and extrinsic factors contributing to inflammation is crucial. This approach generally involves:

Dietary Modifications: Identifying and eliminating foods that trigger inflammation can be pivotal. Partnering with a functional medicine practitioner can help in establishing any nutritional deficiencies or food sensitivities that may be exacerbating acne.

Fostering Sustainable Skin Health: Focusing on enhancing the skin's natural defenses through gentle, supportive skin care to ensure we are creating a healthy ecosystem for the skin to maintain its health in the future without professional intervention. 

Home Care Partnership: What a client exposes their skin to daily will make more of a difference than weekly treatments.  Home care should ideally be established before a client is seen for treatments to ensure the skin is in a state to maximize the benefits.

Ongoing Education: Ensuring your client is well versed in the many variables which can contribute to acne so that you can both manage them together is crucial. 

Mental Support: It’s important for practitioners to understand the psychological impact of acne on an individual’s life. The distress caused by acne can deeply affect a person's emotional well-being, making empathetic care crucial. While some patients may seek immediate relief through more aggressive treatments, providing comprehensive information and support allows them to make informed decisions that best suit their individual needs without judgment.

Ultimately, managing acne effectively requires a comprehensive strategy that combines treatment with lifestyle adjustments to mitigate the factors that exacerbate the condition. By adopting an integrative approach, practitioners can help their clients achieve lasting improvements in skin health and overall well-being. Central to this strategy is enhancing the skin's inherent ability to protect itself. Through an in-depth understanding of acne and the nuanced benefits and drawbacks of available treatments, practitioners can guide their clients towards methods that nourish and sustain skin health rather than relying on aggressive, short-term solutions. Despite the allure of immediate results, sustainable success in acne management is more effectively achieved by nurturing the skin's natural defenses and fostering its resilience. This approach ensures that treatments are both effective and nurturing, avoiding the potential long-term consequences of more aggressive therapies and helping clients maintain healthy skin over the long term.

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