Once upon a time the appearance of a pimple meant to die a little death.
Then we got older and more pressing life problems forced blemishes to make room. We gained perspective, but never forgot the lesson learned at age 13: Zits are created far from equal.
Regular zits can still be knocked out with weapons from an arsenal of benzoil peroxide, a salicylic acid toner, maybe a tube of Australian tea-tree extract for the green at heart. But the cystic zit!
The cystic zit.
The king of blackheads, the emperor of white heads and lord of all red bumps is evil incarnate. If in doubt recall the 1989 classic "How to Get Ahead in Advertising" -- the film about the murderous boil that sprouts on the neck of a young executive.
And as in the movie, a cystic zit can throw an otherwise rational adult into a rage.
And in our rage and pain we do exactly what dermatologic surgeon Min-Wei Christine Lee, director of the East Bay Laser and Skin Care Center in Walnut Creek, Calif., says not to. We attack the growth with fingernails and sewing kit needles, we bloody bathroom tissues, we burn the wound with pure alcohol and pronounce victory.
Of course there will be a scar, but in the moment of triumph we don't care; we've released the pressure that makes the boil -- to use the British word, so much more mature-sounding than pimple! -- so sore to the touch and so difficult to stop touching.
Not surprisingly dermatologists disapprove of the above and have alternate suggestions. What follows is a summary of data, in Q & A form, shared with ABC by a panel of top skin experts who spoke to us by phone and e-mail.
Besides Lee, we have Dr. Sandra Read of Washington, D.C., a member of the board of directors of the American Academy of Dermatology; Dr. Theresa Pacheco, associate professor in the Department of Dermatology at the University of Colorado-Denver; Dr. Jeffrey M. Weinberg, director of the Clinical Research Center of the Department of Dermatology at St. Luke's-Roosevelt Hospital Center in New York; and Dr. Richard Granstein, chairman of the Department of Dermatology at Cornell University.
Q: What is cystic acne? A: Acne starts with a clogged follicle that becomes infected. That's a white or black head. Sometimes inflammation occurs and it becomes rounder and redder. A cyst is what may happen if left untreated. They can grow several centimeters in diameter, and are often painful to the touch.
Q: What causes the infection? Dirt? A: Acne has many causes, and the cause will differ from person to person. Dirt is not one of them, however, so scrubbing your skin with a pumice stone will only bring you more pain. The main causes stem from hormones, which is why people typically notice outbreaks during puberty, periods, and pregnancy.
That said, if a patient noticed that she breaks out after eating a certain food, Lee would tell her to avoid that food, which may serve as a hormonal trigger. Still, she says, researchers have not yet discovered a "direct and universal correlation between any one food and acne."
Q: But what about the purported link between milk and cystic acne?
A: Says Pacheco: "A recent study, based on a survey of 47,335 women, did find a positive epidemiological association between acne and consumption of partially skimmed milk."
The researchers hypothesize that the association may be caused by hormones such as several sex hormones and bioactive molecules.
It is plausible that hormones given to cows could somehow be related to the development of acne -- but it is unlikely that this is the only cause, she says, adding that it is not "unreasonable to ask a patient to refrain from consuming partially skimmed milk products if they report that such food affects the severity of their acne."
Adds Weinberg: "This is controversial, but at this point, it is at least worth asking patients with acne if they have high dairy consumption, and thinking about lowering it, especially in resistant cases."
Q: Nothing works on my cysts. What should I do?
A: Go to a dermatologist; most insurance plans will pay for office visits. Retin-A is but one of several useful topical medications. Antibiotics may also be prescribed. A drug called Accutane belongs to the strongest class of drugs and is prescribed for relatively short-term use.
Q: I don't like the idea of being on antibiotics indefinitely, and I heard that Accutane can cause severe depression.
A: If you have any sort of psychological disorder (or plan on getting pregnant) no responsible doctor would prescribe Accutane for you. That said, Weinberg emphasizes that Accutane is "safe and effective, despite the bad press," but adds that "We need new subantimicrobial antibiotics with high potency."
Says Pacheco: "It's regulated through a government-mandated drug safety program and can be used safely when monitored appropriately. I have not had a complications to date."
Of course, you can also get a quick fix by having your most painful zits lanced and injected with a steroid.
Q: Can't I just lance them myself?
A: You'll risk scarring. If you do nothing to a cystic zit, there's a good chance it will leave a scar. If you try and pop it yourself, you're nearly guaranteed. According to Reed, only a dermatologist knows what individual zits will benefit from the needle and which will just get more infected. Moreover, it takes skill to do it correctly.
Says Granstein: "Lancing may not always be the best thing to do for acute lesions. Injection of a small amount of a corticosteroid (usually triamcinolone) leads to rapid and effective improvement. Patients should never open them at home due to the risk of scarring and infection."
Q: What else is there?
A: Thermage, a relatively new procedure developed to tighten the skin with heat with a radio frequency device has shown promise, says Lee.
Laser technology -- not just for zapping scars, but for penetrating individual zits and killing the bacteria with light -- is the most exciting development to date.
Yet Pacheco predicts that laser and light device will have only an adjunctive role in treatment.
Besides, she says, at this time insurance won't cover it.