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You probably aren’t doing anything wrong.
This is what Dr. Amy Wechsler told me when we talked on the phone. "The reason most women get cystic acne is a hormonal imbalance. There's nothing you can apply topically to fix it, you really need to seek the help of a dermatologist." She explained that the first thing she does for patients afflicted with nodule-like blemishes, especially around the jawline and lower face, is check for poly-cystic ovarian syndrome, or PCOS, which causes an increase in testosterone. Other ways to detect PCOS: extra hair growth in areas it shouldn't be growing, weight gain, irregular periods and trouble conceiving. Still, even if PCOS isn't the cause, it's something happening internally, brought on by anything from genetics to stress to poor sleeping habits.
Don't be afraid of Accutane.
Depending on her diagnosis, Dr. Wechsler prescribes oral medication; she's a big fan of Accutane for very severe cases. When I mentioned some bad press on the drug, she was quick to defend it: "I think [Accutane] has been vilified by the media, but it's only a problem taken if you’re pregnant—it causes birth defects. So long as you're off it for one full menstrual period before conceiving, it's fine." Later that same day, on a call with Dr. Brant, he agreed. "Accutane is a great drug," he told me in between bites of his lunch. (Famous dermatologists—they're just like us!)
Look for powerful ingredients.
Over-the-counter retinol (unblocks pores and promotes skin cell turnover), salicylic acid (an anti-inflammatory that soothes redness) and benzoyl peroxide (kills bacteria) can help—if not totally clear—acne of all types. For more severe cases, Brant recommends prescription retinoids, particularly Differin: it’s one of the least irritating options out there.
Have a good spot treatment for emergencies.
Drying creams and masks will not completely clear your face but they will help to shrink blemishes. Jean's best over-the-counter suggestion is Umbrian Face Clay from Fresh (the tube of paste, not the bar): "It really helps most anyone’s skin.” (I’ve been using it myself for the last couple weeks and it has, as promised, helped a great deal: my smaller blemishes have disappeared and the bigger ones are less red, less painful, less hard to cover up with foundation.) Chanel’s Masque Déstressant Pureté Purifying Cream Mask also makes skin smoother and matte-r, in the most rich, luxurious way. And in just ten minutes! (I’d like to tell you I use that time to run around my apartment and do chores, but I prefer to lay back on my bed, eye closed, and pretend I’m at a French spa.)
Never, ever—EVER—try to pop a cystic pimple.
I'll be the first to admit that I've broken this rule, and more times than I'd like to admit. But Dr. Brant told me that squeezing a headless blemish will just push the infection deeper. In the longterm, that means a Groundhog's Day kind of situation for certain areas of your face: those spots will keep getting the same pimples over and over again. Then, the only way to stop the cycle is to have a doctor manually open the clogged pore and squeeze out the guck. (It's about as fun as it sounds.)
Your conditioner could be causing you to break out.
Deeply moisturizing hair products often contain shea butter and mineral oil, which seal up pores and cause dirt to get trapped. This, however, shouldn't lead to Sophie's Choice between your hair and face. Dr. Brant says being more diligent will minimize clogging: pay attention in the shower as to which lotion/scrub/wash goes on where! Don't let your blowout fall all over your face!
Drug-free treatments do exist.
Although Megan O’Neill, Lucky’s associate beauty editor, also suffers from cystic acne, she’s going to all-natural route and seeing an ayurvedic doctor. "It goes a lot slower [than prescription medicine], but it's working," she says. Ayurvedic, if you don't know (I didn't), means "traditional medicine" in India, and focuses on creating balance within the body. For Megan, that means eating totally organic with a heavy emphasis on produce, although sugar, dairy and other treats are still allowed. "It's not about totally cutting things out, but living a balanced life. My doctor keeps saying that it sucks that I have to pay him for such simple advice, but modern day people have forgotten how to eat and that's why we break out!"