Cystic Acne
Cystic (nodulocystic) acne is the most severe form of acne, with deep, painful nodules and cysts that carry a high risk of permanent scarring, per the AAD 2024 Guidelines of Care for Acne Vulgaris.
Symptoms
Deep, painful, inflamed nodules and cysts, often clustered, frequently leaving scarring even after they heal.
Causes and risk
The same acne mechanisms (oil, clogged follicles, bacteria, inflammation) but more severe, often with a strong hormonal or genetic component and a family history of severe acne.
How it is evaluated
Diagnosis is clinical based on lesion depth and severity; the presence of scarring or a poor response to standard therapy typically prompts escalation to isotretinoin.
Treatment
Isotretinoin is the guideline-preferred treatment for cystic acne, taken via the FDA-mandated iPLEDGE program, which requires monthly pregnancy testing and contraception counseling for patients who can become pregnant. Baseline and peak-dose liver function and triglyceride checks are recommended rather than monthly monitoring, per current AAD guidance.
When to seek care
Sudden worsening with fever, joint pain, and ulcerating lesions (acne fulminans) is a dermatologic emergency requiring prompt treatment, sometimes with oral steroids alongside isotretinoin.