What treatment options are available for recurring non-painful acne with white pus under the skin on the face, which started after stopping Hormone Replacement Therapy (HRT) two months ago?

Treatment for Hormone-Related Closed Comedones After Stopping HRT

Start immediately with adapalene 0.1% gel combined with benzoyl peroxide 2.5-5% as your foundation therapy, and strongly consider adding spironolactone 25-100 mg daily given the clear hormonal trigger of stopping HRT two months ago. 1

Understanding Your Acne Pattern

Your presentation—non-painful subcutaneous lesions with white contents (closed comedones) that began after discontinuing hormone replacement therapy—represents a classic hormonal acne pattern triggered by the withdrawal of exogenous estrogen. 1, 2 The timing (two months post-HRT cessation) aligns perfectly with the hormonal rebound phenomenon where androgens become relatively unopposed after estrogen withdrawal. 3, 4

First-Line Topical Therapy

Begin with adapalene 0.1% gel (available over-the-counter) combined with benzoyl peroxide 2.5-5%. 1, 2

• Apply adapalene in the evening to the entire affected area, not just individual lesions, as it prevents new microcomedones from forming. 1
• Apply benzoyl peroxide in the morning, or use a fixed-dose combination product for better compliance. 1, 2
• Adapalene is preferred over tretinoin because it can be applied with benzoyl peroxide without oxidation concerns and lacks photolability restrictions. 1
• Start with reduced frequency (every other night initially) if irritation occurs, then gradually increase to nightly as tolerance improves. 1
• Use daily sunscreen, as retinoids cause photosensitivity. 1

Hormonal Therapy: The Critical Addition

Given your clear hormonal trigger, spironolactone 25-100 mg daily should be strongly considered as first-line therapy alongside topicals. 1, 2

• Spironolactone is particularly effective for hormonal acne patterns, premenstrual flares, and post-hormonal therapy acne. 1, 2, 5
• Start at 25-50 mg daily and titrate up to 100-200 mg daily based on response over 3-4 months. 1, 2
• No potassium monitoring is needed in healthy patients without risk factors for hyperkalemia. 1, 2
• This addresses the underlying androgen-driven sebum production that became unmasked after stopping HRT. 3, 4

Alternatively, if you prefer or need contraception, combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and directly address the hormonal imbalance. 1, 2

If Moderate Inflammatory Component Develops

If your closed comedones progress to inflammatory papules or pustules despite topical therapy:

• Add a topical antibiotic (clindamycin 1% or erythromycin 3%) always combined with benzoyl peroxide to prevent resistance—never as monotherapy. 1, 2
• Fixed-combination products (clindamycin 1%/BP 5% or erythromycin 3%/BP 5%) enhance compliance. 1
• For moderate-to-severe inflammatory acne, oral doxycycline 100 mg daily or minocycline 100 mg daily can be added as triple therapy (oral antibiotic + topical retinoid + benzoyl peroxide), but limit to 3-4 months maximum. 1, 2

Adjunctive Options for Stubborn Lesions

• Azelaic acid 20% cream is particularly useful if you develop post-inflammatory hyperpigmentation or have sensitive skin, applied twice daily. 1, 6
• For individual large, painful nodules (if they develop), intralesional triamcinolone acetonide 10 mg/mL provides rapid relief within 48-72 hours. 1, 2
• Salicylic acid 20-30% chemical peels can provide intensive treatment for resistant closed comedones, though multiple treatments are needed. 1, 2

Maintenance After Clearance

Continue topical retinoid (adapalene) indefinitely after achieving clearance to prevent recurrence, as retinoids resolve microcomedones and prevent new lesion formation. 1, 2 Benzoyl peroxide can also be continued as maintenance. 1

Critical Pitfalls to Avoid

• Never manually extract ("pop") these lesions, as this increases inflammation, scarring risk, and potential infection. 1
• Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 2
• Don't apply retinoids to broken skin or areas with active wounds. 1
• Avoid alcohol-containing lotions or gels in favor of oil-in-water creams or gentle moisturizers. 7

When to Escalate

Reassess after 2 weeks for worsening or intolerable side effects, and after 8-12 weeks for efficacy. 1 If no improvement after 3-4 months of appropriate therapy, or if scarring develops, consider referral to dermatology for potential isotretinoin evaluation. 1, 8