- Cystic acne is a severe type of inflammatory acne characterized by large, painful cysts that develop deep within skin tissue
- If left untreated, the infection can cause extensive inflammation and scarring
- Cystic acne can be difficult to treat and typically requires a combination of topical and oral medications
Acne develops when hair follicles become blocked with dead skin cells, oil and debris to form noninflamed comedones. When Cutibacterium acnes bacteria accumulates and multiplies, this can lead to a severe infection that causes pus-filled cysts to form deep within skin tissue. Cystic acne typically develops in areas that have a large number of sebaceous (oil) glands such as the face, shoulders and chest; cystic acne on the upper back is another vulnerable area as sweat, bacteria and oils can easily become trapped in pores.
How to Identify Cystic Acne on the Back
You can identify cystic acne on the back by the extent of the inflammation.
Mild inflamed lesions will be red and swollen, and may contain pus due to the presence of C. acnes; they will form on the surface of skin and cause a mild to moderate degree of pain, itching and irritation.
These lesions are called papules, which are small red bumps that are pus-free; with greater infection pus-filled pustules will form which are typically painful and tender to the touch.
Cystic acne on the upper back is characterized by large, pus-filled cysts that form deep beneath the skin and appear as red, inflamed boils on the skin’s surface. These cysts represent a more severe level of inflammation; they may feel warm to the touch and cause greater discomfort and pain than acne pimples and lesions due to their size and the extent of the inflammation.
Itching and tingling may also be other uncomfortable symptoms.
Other areas you can get cystic acne
Causes of Cystic Acne on the Back
Cystic acne forms on the upper back due to the same reasons it develops elsewhere on the body: when pores become clogged with excess oil, dead skin cells and bacteria inflamed lesions form.
When left untreated, this infection can spread and penetrate into deeper layers of tissue causing widespread inflammation and extensive damage.
Multiple factors are at play in acne development, including inflammatory processes and follicular hyperkeratinization (abnormally rapid shedding of skin cells) but the key instigators are sebaceous glands as they can overproduce sebum due to specific causes:
- Hormonal changes that occur during puberty, the menstrual cycle, pregnancy and menopause cause excess sebum production and elevate the risk of cystic acne
- Chronic stress and anxiety release stress hormones called cortisol and androgen; this not only increases sebum production but causes greater levels of inflammation
- There is a strong genetic component to acne development as genes influence acne risk and severity, sebaceous gland activity and inflammatory response
- Diets that have a high glycemic load cause blood sugar to spike which triggers an immune response; this produces inflammation throughout the body as well as elevated sebum production
Cystic acne on the back can also form due to continuous heat, friction, pressure and irritation brought on by sports equipment, backpacks and too-tight clothing. This can trap perspiration, bacteria and oils on skin making it more vulnerable to a cystic acne breakout. When this occurs, this type of acne is called acne mechanica.
Treatment Options for Cystic Acne on the Back
As cystic acne is one of the most severe types of inflammatory acne, it needs to be managed through a multimodal approach which typically includes topical solutions and oral medications.
Medications are typically paired to achieve synergistic results or by using several medications to target different steps in the acne development process.
Topical treatments for cystic acne on the back are formulated to control acne-causing bacteria, reduce inflammation and clear skin of pore-blocking debris. You can choose among over-the-counter (OTC) skin care products or see your dermatologist for a stronger prescribed medication.
As the back is a hard-to-reach area, applying lotions and gels by yourself is easier with a back lotion applicator. This tool has a long handle with an applicator pad at the end, and can be found online or in store.
In addition, you can find the following medications in a body wash for ease of application in the shower or bath.
Benzoyl peroxide is a staple in treating mild-to-severe acne as it provides multiple benefits. It’s highly effective against inflammatory acne as it can kill acne-causing bacteria and penetrate deep to clear clogged pores of sebum, dead skin cells and debris.
Reducing levels of bacteria calms inflammation and redness and helps active breakouts heal.
Benzoyl peroxide is also absorbed into the skin making it an ideal choice to treat the deeply rooted cysts that form in tissue.
Benzoyl peroxide can be found in concentrations of 2.5%, 5.0% and 10%. One study demonstrated that a 5.0% concentration can kill C. acnes bacteria within 30 seconds. As side effects include dry skin, redness and peeling, a stronger formula may not be necessary, and in fact may cause greater irritation.
Azelaic acid is another effective choice to treat cystic acne on the back. It has bacteriostatic, anti-inflammatory, antioxidant and antikeratinizing properties to produce a number of positive effects.
It can prohibit the growth of bacteria, reduce inflammation, protect the skin from oxidative damage caused by free radicals and environmental aggressors, and exfoliate and slough off dead skin cells.
As azelaic acid is a gentle agent, it is best used for milder cases of cystic acne; it should also be paired with other acne medications such benzoyl peroxide or retinoids to achieve greater results. You can find it OTC in strengths ranging from 10%–12% and 15% or more with a prescription.
Salicylic acid is a beta hydroxy acid (BHA) prized for its strength in targeting excessive oil production—a prime component of acne development—and exfoliating away dead skin cells and debris from the skin. It is an appropriate choice for mild-to-severe cystic acne on the back.
This chemical exfoliant also has anti-inflammatory properties to calm irritation, itchiness and redness, and reduce swelling. It has also been shown to reduce sebum secretions, making this agent an effective acne preventative.
Several effective systemic medications are available by prescription to treat and control inflammatory acne symptoms.
Antibiotics and birth control
Antibiotics are a first-line treatment for moderate–severe cystic acne and are commonly prescribed along with benzoyl peroxide for enhanced results and to limit antibiotic resistance. They may also be used alongside other agents such as retinoids or isotretinoin for their combined effects.
Antibiotics such as second-generation tetracyclines (doxycycline, minocycline and sarecycline) can alleviate pain and inflammation by effectively killing acne-causing bacteria.
Since fluctuating hormones strongly influence acne development, birth control pills may be prescribed to help keep acne breakouts under control.
Isotretinoin is a retinoid that dramatically reduces sebum secretions, helps normalize proper skin shedding, inhibits bacterial growth and reduces inflammation. This prevents the formation of comedones (and ultimately, inflamed lesions) and alleviates redness and swelling of acne flare-ups.
Isotretinoin is reserved for difficult-to-treat cases of moderate acne and for severe cases of acne. Depending on the dose, most acne patients will be free of acne by the end of a 4–6 month treatment; however, this medication has a number of rare but serious side effects and patients must be monitored
Since fluctuating hormones strongly influence acne formation, regulating these hormones can treat and prevent acne from forming on the back. Birth control pills are frequently prescribed for women with hormonal acne seeking birth control.
Combined oral contraceptive pills (cOCPs), typically consisting of estrogen and progestin, act on androgen levels to effectively decrease sebum production. Multiple studies have demonstrated that these pills can decrease total acne lesion count, especially for inflammatory acne
Spironolactone is a medication that is used off-label to treat acne as it has antiandrogen benefits to normalize hormones and regulate sebum production.
It’s considered an important contributor to acne treatment as studies suggest that spironolactone may be similar in effectiveness to oral antibiotics and can also decrease the length of therapy in women with acne. Of equal importance is that this medication does not lead to bacterial resistance.
In addition to oral and topical medications, cystic acne can include professional in-office procedures. These are not first-line treatments but add-on procedures to help ease symptoms and inhibit recurring acne.
A medium to deep glycolic or salicylic acid peel can treat acne on the back by removing the top layers of damaged skin. This promotes new skin cell growth and boosts collagen production for healthier skin. These peels are also effective in treating acne scars, which commonly develop with cystic acne breakouts.
Laser treatments can effectively treat cystic acne on the back by speeding up healing of inflammatory lesions, killing bacteria and slowing sebum production.
Several lasers are used to treat acne lesions and scars, the most effective being pulsed dye lasers, the Nd:YAG lasers and diode lasers with moderate to significant improvements achieved after a series of sessions.
ND:Yag lasers can also reduce redness and improve the appearance of acne scars by 40%–50%.
When cystic acne on the book is unresponsive to conventional treatments, several other options are available in-office:
- Corticosteroid injections can speed up healing, relieve pain and reduce the size of large cysts
- Fluids can be drained from a cyst by using a fine needle
- A surgical blade can open the cyst and allow the fluids to drain
Popping Cystic Acne on the Back
Popping acne blemishes can spread the infection, worsen symptoms and inhibit healing.
Preventing Cystic Acne
You can help prevent cystic acne from developing on your back by making some simple lifestyle changes.
Diet is one of many factors involved in acne development. Studies show that people who consume low glycemic loads have reduced acne lesions compared to those who consume high glycemic loads. The same holds true for dairy consumption.
Increasing omega-3 and omega-6 fatty acid intake (in the form of fish and healthy oils) can reduce acne breakouts. Eating a diet rich in fruits and vegetables will support healthy skin and help protect skin as they contain powerful antioxidants.
Keeping a food diary and noting any connections between certain foods and acne outbreaks may help you eliminate acne triggers in your diet.
Skin care tips
There are some steps you can take to help prevent cystic acne on the back.
- It is vital to see your dermatologist if the first signs of back acne don’t respond to OTC treatments; you can prevent worsening symptoms and begin healing with a correct diagnosis and treatment plan
- Choose noncomedogenic sunscreen, and hair and body products that are formulated to not clog pores
- Wash your back regularly with a gentle medicated body wash; shower promptly after exercise to remove excess oils and perspiration
- Wash your bedsheets regularly as well as sleepwear to avoid grime, bacteria, dead skin cells and debris from accumulating and adhering to your skin
- Wear loose clothing when possible; tight clothes can trap moisture and bacteria against your skin
Inflammatory acne develops when sebum, dead skin cells and bacteria become trapped in pores. If left untreated, this infection worsens and spreads deep within tissue to form large pus-filled cysts. On the skin’s surface they will appear as red, inflamed boils.
If left untreated, cystic acne on the back can become severe and cause tissue damage and scarring.
Fortunately, there are several treatment options available. Due to the severity and difficulty in treating this form of acne, combined therapy is typically considered.
Oral and topical medications, including antibiotics, can alleviate pain and inflammation by killing bacteria, reducing sebum production and clearing pores of debris.
Benzoyl peroxide, azelaic and salicylic acid are all tried-and-true agents that can effectively clear inflammatory cystic acne. Antibiotics also kill bacteria and oral birth control can help prevent acne by regulating hormones.
Chemical peels and laser treatments can play a supportive role in acne treatment; the former removes damaged skin and the latter can speed up healing, kill bacteria and reduce sebum production.
If you feel OTC treatments are not effective in treating acne on your back, see a dermatologist. They will examine your skin and determine the best treatment for your needs.
- Lambrechts IA et al. In: Lall N. Exploiting Medicinal Plants as Possible Treatments for Acne Vulgaris. Elsevier; 2018;117-143. https://www.sciencedirect.com/science/article/pii/B9780128124758000044
- Makrantonaki E, Ganceviciene R, Zouboulis C. An update on the role of the sebaceous gland in the pathogenesis of acne. Dermatoendocrinol. 2011;3(1):41-49. doi:10.4161/derm.3.1.13900
- Heng AHS, Say YH, Sio YY, Ng YT, Chew FT. Gene variants associated with acne vulgaris presentation and severity: a systematic review and meta-analysis. BMC Med Genomics. 2021;14(1):103. Published 2021 Apr 13. doi:10.1186/s12920-021-00953-8
- Tallarida RJ. Quantitative methods for assessing drug synergism. Genes Cancer. 2011;2(11):1003-1008. doi:10.1177/1947601912440575
- Sagransky M, Yentzer BA, Feldman SR. Benzoyl peroxide: a review of its current use in the treatment of acne vulgaris. Expert Opin Pharmacother. 2009;10(15):2555-2562. doi:10.1517/14656560903277228
- Boonchaya P, Rojhirunsakool S, Kamanamool N, et al. Minimum Contact Time of 1.25%, 2.5%, 5%, and 10% Benzoyl Peroxide for a Bactericidal Effect Against Cutibacterium acnes. Clin Cosmet Investig Dermatol. 2022;15:403-409. Published 2022 Mar 10. doi:10.2147/CCID.S359055
- Matin T, Goodman MB. Benzoyl Peroxide. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 10, 2022. PMID: 30725905. https://www.ncbi.nlm.nih.gov/books/NBK537220/
- Fox L, Csongradi C, Aucamp M, du Plessis J, Gerber M. Treatment Modalities for Acne. Molecules. 2016;21(8):1063. Published 2016 Aug 13. doi:10.3390/molecules21081063
- Lu J, Cong T, Wen X, et al. Salicylic acid treats acne vulgaris by suppressing AMPK/SREBP1 pathway in sebocytes. Exp Dermatol. 2019;28(7):786-794. doi:10.1111/exd.13934
- Zhang L, Shao X, Chen Y, et al. 30% supramolecular salicylic acid peels effectively treats acne vulgaris and reduces facial sebum. J Cosmet Dermatol. 2022;21(8):3398-3405. doi:10.1111/jocd.14799
- Baldwin H. Oral Antibiotic Treatment Options for Acne Vulgaris. J Clin Aesthet Dermatol. 2020;13(9):26-32. PMCID: PMC7577330. https://pubmed.ncbi.nlm.nih.gov/33133338/
- Layton A. The use of isotretinoin in acne. Dermatoendocrinol. 2009;1(3):162-169. doi:10.4161/derm.1.3.9364
- Salvaggio HL, Zaenglein AL. Examining the use of oral contraceptives in the management of acne. Int J Womens Health. 2010;2:69-76. Published 2010 Aug 9. doi:10.2147/ijwh.s5915
- Barbieri JS, Choi JK, James WD, Margolis DJ. Real-world drug usage survival of spironolactone versus oral antibiotics for the management of female patients with acne. J Am Acad Dermatol. 2019;81(3):848-851. doi:10.1016/j.jaad.2019.03.036
- Jih MH, Kimyai-Asadi A. Laser treatment of acne vulgaris. Semin Plast Surg. 2007;21(3):167-174. doi:10.1055/s-2007-991185
- Gozali MV, Zhou B. Effective treatments of atrophic acne scars. J Clin Aesthet Dermatol. 2015;8(5):33-40. PMID: 26029333. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4445894/
- Kucharska A, Szmurło A, Sińska B. Significance of diet in treated and untreated acne vulgaris. Postepy Dermatol Alergol. 2016;33(2):81-86. doi:10.5114/ada.2016.59146
- Baldwin H, Tan J. Effects of Diet on Acne and Its Response to Treatment [published correction appears in Am J Clin Dermatol. 2020 Dec 26;:]. Am J Clin Dermatol. 2021;22(1):55-65. doi:10.1007/s40257-020-00542-y