Treatment for Cystic Back Acne After Nexplanon
For cystic back acne that developed after Nexplanon implantation, the recommended treatment is a combination of topical retinoid with benzoyl peroxide, with the addition of oral doxycycline if the acne is moderate to severe. 1, 2
Understanding the Connection
Nexplanon (etonogestrel) is a progestin-only contraceptive implant that can sometimes trigger or worsen acne due to its androgenic effects. Cystic acne on the back is particularly challenging because:
- The skin on the back is thicker
- The area is harder to reach for treatment application
- Cystic lesions are deeper and more inflammatory
Treatment Algorithm
Step 1: First-Line Therapy
- Topical combination therapy 1, 2:
- Adapalene 0.1% gel (better tolerated than other retinoids)
- Benzoyl peroxide 2.5-5% wash or gel
- Apply once daily in the evening after gentle cleansing
Step 2: For Moderate to Severe Cases
- Add oral antibiotic therapy 1:
- Doxycycline 100mg once or twice daily for 8-12 weeks
- Always use with topical benzoyl peroxide to prevent bacterial resistance
- Limit antibiotic use to 3-4 months maximum
Step 3: For Severe or Resistant Cases
- Consider hormonal therapy (since acne appeared after Nexplanon) 1:
- Spironolactone 50-200mg daily (for females)
- Combined oral contraceptives (if switching from Nexplanon is an option)
Step 4: For Very Severe or Scarring Cases
- Isotretinoin (0.25-0.4 mg/kg/day) 1, 3:
- Reserved for severe, scarring, or treatment-resistant acne
- Requires monitoring of liver function tests and lipids
- Mandatory pregnancy prevention for women of childbearing potential
Practical Application Tips
For hard-to-reach areas like the back:
- Use applicators with extended handles for topical treatments
- Consider spray formulations of medications when available
- Benzoyl peroxide washes may be easier to apply in shower
Managing side effects:
- Start with lower concentrations of topical retinoids to minimize irritation
- Apply moisturizer to reduce dryness and irritation
- Benzoyl peroxide may bleach clothing and bedding
Important Considerations
- Never use topical antibiotics as monotherapy due to risk of bacterial resistance 1, 2
- Evaluate treatment response after 8-12 weeks 1, 4
- Consider intralesional corticosteroid injections for large, painful nodules for rapid improvement 1
- Maintenance therapy with topical retinoid should be continued after clearing to prevent recurrence 4
When to Consider Alternative Diagnoses
If the acne is not responding to appropriate therapy after 12 weeks, consider:
- Gram-negative folliculitis (may require culture)
- Pityrosporum folliculitis (especially if monomorphic)
- Other causes of deep nodular lesions on the back
When to Consider Removal of Nexplanon
If the cystic acne is severe, persistent, and significantly impacting quality of life despite appropriate treatment, discussing alternative contraceptive options may be warranted, particularly if the acne developed or worsened after Nexplanon placement.