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A sign your cystic acne is hormonal is, in part, the placement of the majority of your pimples. If they run along the chin and jawline, they’re most likely to be hormonal. While plenty of face-mapping acne claims haven’t been borne out through studies, this one is backed by research1.

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.

Genetics do play a role in your likelihood of getting cystic acne3 as well, research shows. “Some patients who are already predisposed to acne with more oily skin or family history of acne can be more sensitive to hormones in the body,” Kobets says.

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.

Some hormones (including the stress hormone cortisol) can trigger the body to produce more sebum—aka the waxy, sticky stuff that keeps your skin moisturized. Too much sebum production has been linked to acne4, which is why you might break out when you’re stressed, too.

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 will increase cortisol levels, 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 you eat can have an impact on your skin as well, but it may differ from person to person. What we do know is that, according to the American Academy of Dermatology (AAD), a low glycemic index diet may lead to fewer pimples.

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 44% of 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.

“About 7 to 11% of people with inflammatory bowel disease (IBD), for instance, have psoriasis. Gut inflammation eventually can become systemic inflammation. And that, along with oxidative stress, blood sugar imbalances, and other problems, can all show up on your skin—especially if you are genetically predisposed to these conditions,” board-certified internist Vincent Pedre, M.D., once told mbg.

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.

If you want to prevent scarring, seeing a dermatologist is a must. Cystic acne can lead to post-inflammatory hyperpigmentation and indentation scars—both of which can be hard to treat and may impact your mental health and self-esteem even after the breakouts have cleared.

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.

While isotretinoin (formerly called Accutane) may be controversial in the beauty space, there’s nothing wrong with taking it—especially if you’ve tried everything else and want to finally clear up cystic breakouts.

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.

“For female patients with hormonal or cystic acne, especially when it is located on the lower part of the face, I believe oral hormonal blockers (anti-androgens), like spironolactone, are a great option if the patient is not planning to become pregnant any time soon,” Kobets notes.

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 can be administered by your dermatologist if a particular cyst is giving you trouble—whether the motive is to prevent scarring, clear up a pesky cyst before a big event, or just bring you some mental peace—these shots can be extremely helpful.

“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.

Acne facials (also called ‘decongestion facials’ or ‘deep cleansing’ facials) will often include extractions and high-frequency devices to kill acne-causing bacteria on site.

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.

“Any patient, male or nonpregnant females, should be using some type of topical retinol, preferably prescription,” Kobets says. Popular prescription-grade retinoids include Tretinoin and Tazorac, but there are over-the-counter options as well such as adapalene gel, retinaldehyde, and stronger forms of classic retinol.

“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).

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). 

As we mentioned, cystic acne is very difficult to treat from home. This might make you feel discouraged, but it may also bring you peace knowing that it’s not entirely your at-home routine contributing to your cystic breakouts.

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.

Using exfoliants in your skin care routine is a must, especially for acne-prone skin. BHAs, or beta-hydroxy acids (like salicylic acid), are typically most popular for acne-prone skin. However, using a blend of AHAs and BHAs is crucial to 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.

An increase in sebum generally leads to an increase in shine—which isn’t what everyone wants. Using skin care products with tea tree oil can help to minimize the oil thanks to its astringent properties. This may help mattify the skin and regulate oil, thus preventing more sebum buildup.

Tea tree has been shown to be an effective treatment for mild to moderate acne11 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.

• Keep your pores unclogged: Get acne facials, use topical retinoids, invest in acne-safe products, and try not to sleep in your makeup if you can. 
• Be consistent with your at-home skin care: Consistency is key—figure out what skin care schedule works for you and commit to it. May we suggest skin cycling? Everything you need to know here. 
• Evaluate your lifestyle habits: As mentioned above, there are so many more factors to consider than topical care. How much you sleep, how much you stress, and what you eat all impact your skin, so remember to work from the inside and the outside.

1.

Eat an anti-inflammatory diet.

2.

Skip skim milk and whey.

4.

Try your best to manage stress.

5.

Take probiotics for your gut flora. 

6.

Be mindful of hormone fluctuations. 

You’ll want to do your best to balance your hormones in your day-to-day life, starting with exercise.

Exercise produces endorphins13—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.