How can I manage severe acne on my face and back that's causing pain and bleeding?

Management of Severe Inflammatory Acne with Pain and Bleeding

You need immediate triple therapy: oral doxycycline 100 mg daily combined with a topical retinoid (adapalene 0.3% or tretinoin 0.1%) applied nightly, plus benzoyl peroxide 2.5-5% gel applied in the morning. 1, 2

Immediate Treatment Plan

Your severe inflammatory acne with pain and bleeding indicates moderate-to-severe disease requiring aggressive systemic therapy, not just topical treatment. 1, 3

Core Triple Therapy (Start All Three Simultaneously)

Oral Antibiotic:

• Doxycycline 100 mg once daily for a maximum of 3-4 months 1, 2
• Clinical improvement typically begins within 1-2 weeks 1
• Critical warning: Doxycycline causes significant photosensitivity—you must use daily sunscreen and avoid prolonged sun exposure 3, 4

Topical Retinoid (Apply at Night):

• Adapalene 0.3% gel or tretinoin 0.1% cream/gel 2, 3
• Wait 20-30 minutes after washing before applying to completely dry skin 4
• Use only a pea-sized amount for the entire face; for back acne, adjust amount accordingly 4
• This addresses inflammation directly and prevents new lesions from forming 1

Benzoyl Peroxide (Apply in Morning):

• 2.5-5% gel or wash 1, 2
• Never skip this—it prevents antibiotic resistance, which develops rapidly without it 1, 2, 3

For Immediate Pain Relief

Intralesional Corticosteroid Injections:

• For individual large, painful, bleeding lesions, see a dermatologist for intralesional triamcinolone acetonide injections 5, 3
• These flatten painful nodules within 48-72 hours and prevent scarring 3

Critical Timeline and Monitoring

• Week 1-2: Expect initial improvement in pain and inflammation 1
• Week 3-6: You may see new breakouts—this is normal; continue treatment 4
• Week 6-12: Significant visible improvement should occur 4, 6
• Month 3-4: Reassess with your doctor; oral antibiotics must be stopped at this point to prevent resistance 1, 2

After Oral Antibiotic Completion (Month 3-4)

Mandatory Maintenance Therapy:

• Continue topical retinoid nightly indefinitely to prevent recurrence 2, 3
• Continue benzoyl peroxide in the morning 2
• Do not stop topical therapy once clear—acne will return 2, 7

If This Regimen Fails or You're Already Scarring

Isotretinoin (Accutane) is indicated if:

• No significant improvement after 3-4 months of triple therapy 5, 3
• You're developing scars (which your bleeding lesions suggest is likely) 5, 3
• The psychosocial burden is significant 5, 3

Isotretinoin is the only medication that addresses all four causes of acne and provides long-term remission in most patients. 5, 6 Standard dosing is 0.5-1 mg/kg/day for 15-20 weeks. 3 If you're female and of childbearing potential, mandatory pregnancy prevention through the iPLEDGE program is required. 5, 6

Absolute Contraindications to Avoid

• Never use oral antibiotics alone without benzoyl peroxide and retinoid—resistance develops within weeks 1, 2, 3
• Never extend oral antibiotics beyond 3-4 months without reassessment 1, 2
• Avoid harsh scrubbing, frequent washing, or picking—this worsens inflammation and bleeding 4
• Avoid astringents, alcohol-based products, and medicated soaps while on retinoids 4

Daily Skincare Routine

Morning:

• Wash gently with mild, non-medicated soap 4
• Apply benzoyl peroxide 2.5-5% gel 1, 2
• Apply oil-free (non-comedogenic) moisturizer with SPF 30+ sunscreen 4

Evening:

• Wash gently with mild soap 4
• Wait 20-30 minutes until skin is completely dry 4
• Apply topical retinoid (adapalene or tretinoin) 2, 3

Take oral doxycycline 100 mg once daily (morning or evening, with food to reduce stomach upset) 1

Expected Side Effects (Normal and Manageable)

• Mild redness, peeling, and dryness in weeks 1-4 from retinoid—this subsides as skin adjusts 4
• Increased sun sensitivity from both doxycycline and retinoid—daily sunscreen is mandatory 3, 4
• Initial "purging" with new breakouts at weeks 3-6—continue treatment through this phase 4

When to Seek Urgent Dermatology Referral

• No improvement after 3-4 months of triple therapy 1, 2
• Continued scarring despite treatment 5, 3
• Severe pain or bleeding that doesn't improve within 2 weeks 3
• Signs of infection (fever, spreading redness, warmth) 5

Your bleeding and painful lesions indicate you're at high risk for permanent scarring, which makes aggressive treatment non-negotiable. 5, 3 The combination of oral doxycycline, topical retinoid, and benzoyl peroxide is the evidence-based standard for your severity level and should provide significant relief within 1-2 weeks. 1, 2