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What is Cystic Acne and How to Treat it

Dermatology Weekly Flash Briefing – How does cystic acne differ from comedonal acne? We often treat cystic acne with the oral medication isotretinoin (also known by its trade names Oratane, Accutane, Nimegen) which is effective but has certain side effects as well. In this flash briefing, Dr. Teo Wan Lin shares on the causes of cystic acne and when treatment with Isotretinoin is indicated.

Ep 17: Cystic Acne – What is it & How to Treat it

Hi guys and welcome to this week’s dermatology flash briefing. We are going to be talking about cystic acne in this episode. As well as the medicine Isotretinoin, also known by its trade name Accutane or Oratane. 

Cystic acne vs acne

In terms of cystic acne, the key features that differentiate it from typical comedonal or other types of inflammatory acne, is it’s tendency to form large, painful cysts. These cysts fill with pus, may bleed and cause significant pain and psychosocial distress. The most severe type of cystic acne is acne fulminans. This sometimes can lead to sepsis – were the bacteria spreads to the skin infection systemically via the bloodstream. Sufferers of acne fulminans can feel a lot of distress. Because, they wake up with blood and pus from the lesions on their pillowcase. They also experience significant pain and psychosocial distress from the cosmetic disfigurement. 

What causes cystic acne? 

Cystic acne is actually the same in terms of pathogenesis when comparing with comedonal, inflammatory types of acne. Apart from the fact that individuals with cystic acne are probably genetically predisposed to the condition. Whereas, in people who suffer from comedonal or papular types of acne, they may be experiencing a physiological change in their bodies. For example, during puberty – which leads to the onset of pimples. If an individual in your family has had a history of cystic acne, especially if they’ve been on treatment with a medication known as isotretinoin, it is highly likely that if you suffer from acne, that your acne can be severe as well. 

How to treat cystic acne

In terms of effective treatments, it’s important to highlight that when an individual is diagnosed with cystic acne, most dermatologists would recommend starting on this medication known as isotretinoin. However, there are contraindications to this medication. If you are pregnant, breastfeeding, or planning conception, we do not prescribe isotretinoin because it is keratogenic – category X. This means that it can cause fetal abnormalities. In individuals with pre-existing liver disease or if they are hepatitis B carriers, it’s important that we carry out a thorough evaluation. Preferably in conjunction with an attending gastroenterologist to ensure that there isn’t underlying liver disease that would cause further abnormalities to arise during Isotretinoin treatment. If you have a history of familial hypercholesterolemia, which is high cholesterol inherited on the basis of genetics, then treatment of isotretinoin may be a bit tricky because of the side effects is that it increases your cholesterol levels. 

Other treatments for acne 

Berberine is a botanical-derived phytochemical popular for it’s effectiveness in treating acne. It is a traditional Chinese herb derived from Berberis Vulgaris, Phellodendron Amurense and other plants. It targets mechanisms in acne formation in 4 main ways. Firstly, berberine promoted bacterial killing in macrophages immune cells, 

Berberine has also demonstrated anti-inflammatory activity by inhibiting release of proinflammatory cytokines and regulating signaling pathways that can lead to inflammation. It also reduces oxidative stress and upregulates the body’s natural antioxidants. Lastly, berberine also prevented androgen (hormones that stimulate the sebaceous gland leading to more sebum produced) synthesis, and decreased sebum production by suppressing lipogenesis of sebaceous glands in our skin. 

Antibacterial acne face wash can also help treat your acne. Use of medical grade honey in advanced wound dressings is prevalent. Because, of its innate ability to modulate the immune cells and mitigate inflammation. Additionally, it also has antibacterial and antifungal effects. It also functions as a humectant, meaning that it traps water under your skin, preventing transepidermal water loss.

Isotretinoin side effects

Apart from that isotretinoin is actually very effective. Some of the problems that arise during treatment would be dryness of the lips and the eyes. A condition of the lips known as cheilitis – a more severe form of lip eczema may arise from Isotretinoin treatment. Because, one of the primary ways Isotretinoin works is by suppressing the sebaceous glands. The lips are considered a mucocutaneous type of skin, which means that it is thinner and more fragile. Isotretinoin can cause the development of lip eczema. Hence, it is important to ensure proper lip care. This is more than just applying Vaseline or Paraffin, but using a ceramide or phytoceramide formula that repairs the lip barrier. 

Treating side effects of Isotretinoin

In my practice we use one that is based on the phytoceramides derived from plant seed oils. Also, an anti-inflammatory formula with grape seed oil. There are antioxidants that function in a way that mimics the activity of a mild steroid. All this can be very helpful in preventing lip eczema from arising during the course of treatment.

Another moderate contraindication would be an individual with pre-existing eczema. If you have severe eczema, then you should not take Isotretinoin. However, if your eczema is mild or moderate, and is currently not flaring up, then your attending dermatologist may consider giving you the medication. However, it’s important to note that a good 70-80% of patients with pre-existing history of eczema, when they start on Isotretinoin, will experience a flare-up of the eczema. Most dermatologist’s will be very aware of that. Prompt management either in terms of reduction of dose of Isotretinoin, and or treatment of the concomitant eczema with a topical steroid and wet wrap treatment is necessary to bring it under control. 

Is isotretinoin safe in breastfeeding or pregnancy? 

The answer is a clear no. However, after you complete the course of isotretinoin, we typically state that it is safe to commence conception about a month after stopping the medication. This is because that is when all the medications wash out. 

How does Isotretinoin affect your skin? 

It is a medication with a near 100% cure rate, primarily because of its ability to block oil production. But this cure rate is very much dependent on the individual’s ability to tolerate the medication. Photosensitivity is one major side effect that comes on an individual who starts taking Isotretinoin. Isotretinoin works by way of cumulative dosing.This means that you have to reach a cumulative target dose based on your body weight in order for it to be effective. Rather than taking it once a day for a period of a month or 2 months or 3 months. It means that your photosensitive side effects are also dose-dependent.

In a tropical country like Singapore, right at the equator, we get 100% of the sun’s UV rays. That also means that you can develop a lot more of photosensitive side effects. In my practice, I have not been able to give doses higher than 30/40mg simply because of the amount of UV exposure Singaporeans come into contact with. If you look at the studies done in European countries or in the US, we find that the doses are a lot higher. Other than if you were a heavier weight and you need to reach the target dose faster, the other limiting factor is how your skin is able to tolerate that level of medication.

Does Isotretinoin cause acne scars?

In terms of acne scars, when you start taking Oratane, while your pimples are sure to resolve and come down, you’ll find that if you had severe cystic acne before starting Isotretinoin, these areas will turn into red scars. Isotretinoin does worsen the appearance of scars, as your skin will appear more fragile. There might be a lot more redness, or telangiectasia which is the appearance of blood vessels on your face. Partly due to the photosensitive side effects as well as the breakdown of the ceramide barrier function of the skin. Because of the way isotretinoin works, it’s very important that while you are on it, you replace your moisturizer with one that contains the optimal lipid balance.  A prescription emollient device, or PED, is a type of moisturiser that behaves like a mild steroid. This is because it contains anti-inflammatory ingredients such as botanicals.

Is Isotretinoin safe? 

Yes, Isotretinoin for acne is safe. It is an important treatment for individuals with cystic acne. Because, unfortunately, this type of acne does not respond well to any other type of therapy. After treatment of a combination of lasers, light therapy, oral antibiotics, it will still be recalcitrant. You will probably save yourself a lot of time and money, as well as the cosmetic disfigurement that comes with acne scarring if you are put on isotretinoin and monitor for side effects. I feel that this is a very effective treatment for individuals with cystic acne. 

Well that’s it for this week’s dermatology flash briefing. Remember follow us on Spotify, Apple podcasts or wherever you get your podcasts. You can find me on Instagram @drteowanlin where I give regular updates on the latest podcast episodes. Thank you for joining us and see you guys next time.