What are the risks of acne extraction during facial therapy?

Risks of Acne Extraction During Facial Therapy

Acne lesion extraction is a safe and effective physical modality for moderate acne when performed properly, with the primary risks being temporary post-inflammatory hyperpigmentation (lasting 1-3 months), potential scarring if performed incorrectly, and transient erythema. 1, 2, 3

Evidence-Based Risk Profile

Post-Inflammatory Hyperpigmentation (Most Common Risk)

• Post-inflammatory hyperpigmentation is the most frequently documented complication, occurring particularly in patients with darker skin tones and may persist for 1-3 months following extraction procedures 2, 3
• This hyperpigmentation resolves spontaneously but can be treated with azelaic acid 15-20%, which has specific lightening effects without causing additional irritation 3
• The risk increases when extractions are combined with other inflammatory treatments like photodynamic therapy 2

Scarring Risk (When Performed Improperly)

• Improper extraction technique can lead to permanent scarring, which is why the American Academy of Dermatology emphasizes that intralesional corticosteroid injections (not extractions per se) should be used judiciously for patients at risk of scarring 2
• The risk of scarring is minimized when extractions are performed by trained professionals using proper technique 4

Comparative Safety Data

• A randomized clinical trial of 128 patients demonstrated that acne lesion extraction was more effective and appeared safer than oral doxycycline, with prominent decrease in inflamed lesions at 6 weeks and decreased inflammatory marker (HIF-1 alpha) expression 1
• This study supports extraction as a viable alternative to systemic antibiotics, which carry their own risks including antibiotic resistance and gastrointestinal effects 1

Clinical Context and Proper Use

When Extractions Are Appropriate

• Comedone extraction is recognized as a legitimate physical therapy modality for acne treatment when used as part of comprehensive management 4
• Extractions should be combined with appropriate topical therapy (retinoids and benzoyl peroxide) rather than used as monotherapy 1

Risk Mitigation Strategies

• Use concurrent topical retinoids to prevent new lesion formation and maintain results after extraction 2, 5
• Apply azelaic acid prophylactically or therapeutically for patients at higher risk of post-inflammatory hyperpigmentation, particularly those with darker skin tones 3
• Avoid aggressive extraction techniques that increase tissue trauma and scarring risk 4
• Never combine extractions with topical antibiotics alone, as antibiotics have no role in post-inflammatory changes and only contribute to resistance 3

Critical Pitfalls to Avoid

• Do not perform extractions on severely inflamed nodular or cystic acne—these lesions require intralesional corticosteroids or systemic therapy instead 2, 6
• Never extract lesions without concurrent appropriate topical therapy (retinoid + benzoyl peroxide), as this leads to rapid recurrence 2, 1
• Avoid over-aggressive or repeated trauma to the same area, which significantly increases scarring risk 4
• Do not dismiss post-inflammatory hyperpigmentation as trivial—counsel patients that it may take 1-3 months to resolve and provide treatment options 2, 3