AcneNet This Month
November 2000

Cysts are relatively uncommon in acne, a fact that does not comfort the person with cystic acne. When a cyst is as large as several centimeters in diameter, it is a prominent feature on the face as seen in these two photos:

(Photos used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides and the Sulzberger Institute for Dermatologic Education)

Even when cysts occur on areas other than the face, for instance on the chest:

or the shoulders:

(Photos used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides and the Sulzberger Institute for Dermatologic Education)

they limit the person’s ability to wear clothing such as off-the-shoulder gowns and swim suits. In addition, cysts may be painful.

A cyst may be unmarkedly inflammatory. An inflammatory cyst may arise from a papular or nodular acne lesion, or occasionally from a type of cyst not usually associated with acne (an epidermal cyst). In fact, the nodular cyst of acne is not a true cyst which an abnormal dilatation of a normal skin structure. The acne cysts are really nodules of inflammation.

A cyst may appear to be filled with thick, yellow pus-like fluid. This is usually an inflamed and infected cyst. If an attempt is made to drain such a cyst, it should be done in a physician’s office under sterile conditions, not in front of a bathroom mirror.

Cysts may occur singly, or may be widespread over the face, neck, scalp, back, chest and shoulders. Cysts occurring close together may sometimes coalesce, producing boggy areas undermined with tunnels, cell destruction and inflammation—the condition called acne conglobata, discussed next.

Severe nodulocystic acne usually requires an aggressive treatment regimen that may include isotretinoin and antibiotics, or intralesional steroids that "melt" the cyst over a period of 3 to 5 days. Some very large follicular cysts that do not respond to medications may require drainage and surgical excision.

Acne conglobata is a chronic and severe form of acne vulgaris. Burrowing abscesses commonly result in deep, irregular scarring. The condition may be preceded by unhealing cystic, papular or pustular acne that rapidly deteriorates. Occasionally acne conglobata flares up in acne that had been dormant for many years.

Males are more likely than females to have acne conglobata; the age of onset is usually between 18 and 30 years. The cause of the condition is not well understood.

The person with acne conglobata usually also has a significant number of conspicuous lesions that appear to be blackheads, often occurring in pairs or groups on the neck, arms, chest and/or buttocks. These apparent blackheads are really the openings of epithelial sinus tracts. Inflammatory nodules often form around the grouped "blackheads", increasing in size until they break down and exude pus. Crusts may form over deeply ulcerated nodules.

Isotretinoin is the usual treatment of choice for acne conglobata. Antibiotics may also be prescribed. Even after effective treatment the patient should have regular checkups by a dermatologist for any signs of recurrence. The patient may also wish to consult with the dermatologist about treatment of scars.

A small number of patients experience one or more recurrences of severe acne after an effective course of treatment. Nothing could be more discouraging for the patient who has followed all of the physician’s instructions and complied with directions for taking medication. If the patient with recurrent severe acne has been under treatment by a non-dermatologist, consultation with a dermatologist would be warranted.

A dermatologist will try to identify the cause of recurrence after severe acne has been effectively treated. For example, microbiologic investigations may try to identify a bacterial organism that could be an underlying cause of recurrence. Sometimes what appears to be recurrent severe acne is actually another condition called folliculitis that is caused by infection of follicles by staphylococci or other organisms.

Recurrences usually require adjustments in therapy and trials of various combinations of isotretinoin and antibiotics. At the first sign of recurrence the patient should see the dermatologist and begin a treatment regimen. As discouraging as recurrences may be, the patient should continue to follow a treatment plan to keep the acne under control and minimize scarring.

Last month’s question was:

Answer:   There is no evidence that diet is a cause of acne, or that dietary alterations or supplements can effectively treat acne.

A relationship between diet and acne is one of the most persistent myths. There just is no good evidence that acne is caused by what you eat or don’t eat, or that acne can be made better or worse by what you eat or don’t eat. Almost everyone has heard that if you have acne you should not eat chocolate—but there is no persuasive evidence of any relationship between chocolate and acne. Pizza, hot dogs, tacos and fast foods in general are often blamed for causing acne—but, just as with chocolate, the evidence is lacking for any relationship between these foods and acne. It has been suggested that one reason that the myths about chocolate, fast foods and acne are so persistent is that teenagers are heavy consumers of these foods—and the ‘teens is when acne usually appears. The association between adolescence and acne has nothing to do with diet, however. 

Health food stores and herbalists often promote dietary and herbal treatments for acne. However, since diet is not a cause of acne, there is no reason to expect that any dietary manipulation can be a treatment for acne.

Whether or not you have acne, a daily diet should meet recommendations for good general health. If you do have acne, good general health and good skin care will contribute to the effectiveness of recommended acne treatments.