What is the recommended treatment for cystic acne?

Cystic Acne Treatment

For moderate-to-severe cystic acne, initiate oral doxycycline 100 mg daily combined with a topical retinoid (adapalene 0.3% or tretinoin 0.1%) and benzoyl peroxide 2.5-5% as first-line therapy, limiting antibiotics to 3-4 months maximum; for severe or scarring cystic acne, isotretinoin 0.5-1 mg/kg/day for 15-20 weeks is the definitive treatment. 1

First-Line Treatment for Moderate-to-Severe Cystic Acne

The American Academy of Dermatology recommends a triple-therapy approach combining oral antibiotics, topical retinoids, and benzoyl peroxide. 2, 1

Oral Antibiotic Component

• Doxycycline 100 mg once daily is the preferred oral antibiotic (can dose 100 mg twice daily on day 1, then 100 mg daily thereafter) 1
• Doxycycline and minocycline are more effective than tetracycline, with neither being superior to each other 2
• Limit duration to 3-4 months maximum to prevent bacterial resistance 2, 1
• Never use oral antibiotics as monotherapy—always combine with benzoyl peroxide to prevent resistance 2, 1

Topical Retinoid Component

• Apply adapalene 0.3% gel, tretinoin 0.1% cream/gel, or tazarotene 0.1% gel nightly 1
• Topical retinoids are essential as they address comedones, reduce inflammation, and resolve microcomedones 3
• Continue retinoid therapy indefinitely after antibiotic discontinuation for maintenance 1

Benzoyl Peroxide Component

• Apply benzoyl peroxide 2.5-5% gel in the morning (or use fixed-combination products with retinoid) 1
• Benzoyl peroxide prevents bacterial resistance when combined with antibiotics and has intrinsic antimicrobial activity 2, 3
• No bacterial resistance to benzoyl peroxide has been reported 3

Definitive Treatment: Isotretinoin for Severe or Scarring Cystic Acne

Isotretinoin is the gold standard for severe cystic acne and should be strongly considered for any patient with scarring or significant psychosocial burden, regardless of lesion count. 2, 1

Indications for Isotretinoin

• Severe cystic acne unresponsive to oral antibiotics after 3-4 months 1
• Any cystic acne with active scarring (scarring indicates need for aggressive treatment) 1
• Moderate-to-severe acne with significant psychosocial impact 2
• Treatment-resistant cystic acne 4, 5

Dosing and Duration

• Dose: 0.5-1 mg/kg/day for 15-20 weeks 1
• Use daily dosing rather than intermittent dosing 2
• Either standard isotretinoin or lidose-isotretinoin formulations are acceptable 2
• Always take with food as absorption is more than doubled with high-fat meals 6

Monitoring Requirements

• Baseline: liver function tests (LFTs) and lipid panel 2, 1
• During treatment: repeat LFTs and lipids at least once 2, 1
• Potassium monitoring is not necessary in patients without risk factors for hyperkalemia 2
• Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease 2

Pregnancy Prevention

• Mandatory for all persons of pregnancy potential (Category X) 2, 6
• Isotretinoin is absolutely contraindicated in pregnancy due to severe teratogenicity 6

Expected Outcomes

• Complete clearance achieved in 95-98% of patients with prolonged remissions lasting months to years after discontinuation 4, 5
• Remissions can persist for 20+ months after stopping therapy 5

Adjunctive Therapy for Individual Large Cystic Lesions

For rapid improvement of individual large, painful cystic nodules, inject intralesional triamcinolone acetonide 10 mg/mL (diluted to 5 or 3.3 mg/mL) to flatten lesions within 48-72 hours. 2, 1

Technique and Precautions

• Use intralesional corticosteroids as adjuvant treatment for larger papules or nodules at risk of scarring 2
• Caution: can cause local atrophy, pigmentary changes, and telangiectasias if overdosed 1
• Particularly useful for rapid pain relief and inflammation reduction 2

Maintenance Therapy After Clearance

After achieving clearance with oral antibiotics or isotretinoin, continue topical retinoid monotherapy indefinitely to prevent recurrence. 1, 3

Maintenance Regimen

• Preferred agents: adapalene 0.1-0.3% gel or tretinoin 0.025-0.1% cream/gel 1
• Benzoyl peroxide can also be continued for maintenance 3
• Topical retinoids are the cornerstone of long-term acne control 3

Hormonal Therapy Options (For Female Patients)

For women with hormonal components to their cystic acne, combined oral contraceptives or spironolactone can be added to the treatment regimen. 2, 3

When to Consider Hormonal Therapy

• Clinical signs of hyperandrogenism (hirsutism, oligomenorrhea, androgenic alopecia) 2
• Acne flares with menstrual cycle 2
• Can be used as adjunctive therapy with topical treatments 2

Critical Pitfalls to Avoid

Antibiotic Resistance

• Never extend oral antibiotics beyond 3-4 months—this dramatically increases resistance risk 2, 1
• Never use topical or oral antibiotics without concurrent benzoyl peroxide—resistance develops rapidly without it 2, 1, 3
• Avoid erythromycin and azithromycin except when tetracyclines are contraindicated (pregnancy, age <8 years) due to high resistance rates 2

Underestimating Severity

• Presence of scarring automatically indicates need for aggressive treatment (isotretinoin) regardless of total lesion count 1
• Psychosocial burden should lower threshold for isotretinoin use 2

Photosensitivity

• Doxycycline causes significant photosensitivity—counsel patients about strict sun protection and daily sunscreen use 1, 7
• Topical retinoids also increase photosensitivity 3

Isotretinoin-Specific Pitfalls

• Failing to take isotretinoin with food reduces absorption by more than 50% 6
• Inadequate pregnancy counseling and prevention in persons of pregnancy potential 2, 6