What is the best treatment for cystic acne?

Oral Isotretinoin is the Definitive Treatment for Cystic Acne

Oral isotretinoin should be prescribed immediately for all patients with cystic acne, as it is the only FDA-approved treatment specifically indicated for severe recalcitrant nodular/cystic acne and addresses all four pathogenic factors of the disease. 1, 2

Why Isotretinoin is First-Line for Cystic Acne

Isotretinoin is uniquely effective because it reduces sebaceous gland size and secretion, normalizes keratinocyte keratinization, decreases C. acnes indirectly, and possesses anti-inflammatory properties. 1 In clinical trials of treatment-resistant cystic acne, cystic lesions decreased by 17% at 1 month and 33% at 2 months with isotretinoin, while placebo patients worsened by 33% and 58% respectively—with 13 of 17 placebo patients requiring crossover to isotretinoin due to acne worsening. 1 Global acne experts universally agree that isotretinoin is the most appropriate treatment for severe or scarring acne. 1

Dosing Strategy

• Start at 0.5 mg/kg/day for the first month, then increase to 1.0 mg/kg/day as tolerated 2
• Target a cumulative dose of 120-150 mg/kg to minimize relapse rates 2
• Treatment duration is typically 15-20 weeks 1
• Daily dosing is preferred over intermittent dosing 3
• Always administer with food, as high-fat meals more than double both peak concentration and total exposure 4

Required Monitoring

Monitor only liver function tests, fasting lipid panel, and pregnancy tests—complete blood count monitoring is not needed in healthy patients. 1, 3

• Baseline: liver function tests, fasting lipids, pregnancy test for those with pregnancy potential 1
• Ongoing: pregnancy test every 30 days for females, repeat liver and lipid panels at least once during treatment 1
• Abnormal liver function occurs in 0.8-10.4% of patients, with only 0.9-4.7% requiring discontinuation 1
• Abnormal triglycerides occur in 7.1-39.0% and abnormal cholesterol in 6.8-27.2% 1
• Population-based studies have NOT identified increased risk of neuropsychiatric conditions or inflammatory bowel disease, so routine monitoring for depression or IBD is not recommended 3, 2

Mandatory Pregnancy Prevention

Isotretinoin is absolutely contraindicated in pregnancy due to teratogenicity. 1 All persons of pregnancy potential must enroll in the iPledge program with mandatory monthly pregnancy testing. 3, 2 Spironolactone crosses the placenta and may cause feminization of male fetuses in animal studies, so concurrent combined oral contraceptives are often indicated when using hormonal therapy alongside isotretinoin. 1

Adjunctive Therapies for Immediate Relief

Intralesional triamcinolone acetonide (2.5-10 mg/mL) provides rapid pain relief and inflammation reduction within 48-72 hours for individual large, painful nodules. 1, 2 This is particularly useful for nodules at high risk of scarring while isotretinoin takes effect. 3

For extremely severe cases with risk of isotretinoin-induced flares, systemic corticosteroids (prednisone 0.5-1 mg/kg/day) can be used temporarily while starting isotretinoin, with slow taper over several months. 1, 2

Hormonal Therapy Considerations for Female Patients

For female patients with hormonal patterns or premenstrual flares, spironolactone 25-200 mg daily can be used as adjunctive therapy alongside isotretinoin. 2 Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and can be combined with isotretinoin. 3, 2 No potassium monitoring is needed in healthy patients without risk factors for hyperkalemia. 3, 2

Critical Pitfalls to Avoid

• Never use oral antibiotics as primary therapy for cystic acne—they are inadequate for this severe form and only delay definitive isotretinoin treatment 3, 2
• Never delay isotretinoin initiation in patients with scarring or significant psychosocial burden 2
• Topical therapies alone are completely insufficient for cystic acne 2
• Do not use isotretinoin with tetracyclines (risk of pseudotumor cerebri), vitamin A (additive toxicity), methotrexate, or alcohol 1
• Avoid in patients with hypersensitivity to isotretinoin, vitamin A, or during pregnancy 1

Common Side Effects

Mucocutaneous side effects are nearly universal but generally resolve after discontinuation and rarely require stopping treatment. 1, 5 The most common include cheilitis, dry skin, dry eyes, dry nose, photosensitivity, and alopecia. 1 Musculoskeletal symptoms (arthralgia, back pain) and ophthalmic symptoms (dry eyes) are also frequent. 1 In severely affected patients, nonhealing erosions with granulation tissue may develop at sites of large cysts, which heal promptly after therapy completion. 6