Treatment of Cystic Acne Lesions
For an individual cystic acne lesion, intralesional triamcinolone acetonide 2.5-10 mg/mL provides rapid pain relief and inflammation reduction within 48-72 hours, while simultaneously initiating systemic therapy based on overall acne severity. 1, 2
Immediate Management of the Individual Cystic Lesion
Inject intralesional triamcinolone acetonide 2.5-10 mg/mL directly into the cystic lesion to provide rapid pain relief and reduce inflammation within 48-72 hours, particularly for larger nodules at risk of scarring. 1, 2, 3
This adjunctive treatment addresses the immediate concern while systemic therapy takes effect over subsequent weeks. 1
Concurrent Systemic Treatment Based on Overall Disease Severity
The presence of cystic lesions indicates at least moderate-to-severe acne requiring systemic intervention:
For Moderate-to-Severe Inflammatory Acne (Multiple Cystic Lesions)
Initiate triple therapy: oral doxycycline 100 mg daily + topical retinoid (adapalene 0.1-0.3% or tretinoin 0.025-0.1%) + benzoyl peroxide 2.5-5% as the foundation regimen. 1, 2, 4
Doxycycline is strongly recommended with moderate certainty evidence as first-line systemic antibiotic therapy. 1, 2
Limit oral antibiotics to 3-4 months maximum to minimize bacterial resistance development. 1, 2, 4
Always use benzoyl peroxide concurrently with oral antibiotics to prevent antibiotic resistance—this is non-negotiable. 1, 2
For Severe, Treatment-Resistant, or Scarring Cystic Acne
Isotretinoin is the definitive treatment and should be initiated for severe nodular acne, treatment-resistant moderate acne after 3-4 months of appropriate therapy, or any acne with scarring or significant psychosocial burden. 1, 2, 5
Standard dosing: 0.5-1.0 mg/kg/day targeting cumulative dose of 120-150 mg/kg, with daily dosing preferred over intermittent dosing. 1, 2, 4, 5
Isotretinoin is the only single agent effective against all four pathogenic factors of acne (follicular hyperkeratinization, sebum production, bacterial proliferation, and inflammation). 6, 7
Monitor only liver function tests and lipids—CBC monitoring is not needed in healthy patients. 1, 2
Mandatory pregnancy prevention through iPledge program for persons of childbearing potential. 1, 2, 5
Population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease with isotretinoin. 1, 2
Hormonal Considerations for Female Patients
When cystic acne occurs in females with signs of hyperandrogenism or PCOS:
Endocrinologic testing is warranted for females presenting with clinical signs of hyperandrogenism including infrequent menses, hirsutism, androgenic alopecia, infertility, or truncal obesity. 1
PCOS diagnosis in adult females requires 2 of 3 criteria: androgen excess (clinical or biochemical), ovulatory dysfunction, or polycystic ovaries on ultrasonography. 1
Typical hormone-screening panel includes: free and total testosterone, DHEA-S, androstenedione, LH, and FSH. 1
Hormonal Therapy Options
Spironolactone 25-200 mg daily is useful for hormonal acne patterns, premenstrual flares, or those who cannot tolerate oral antibiotics. 1, 2, 3
No potassium monitoring needed in healthy patients without risk factors for hyperkalemia. 1, 2
Combined oral contraceptives reduce inflammatory lesions by 62% at 6 months and are conditionally recommended for inflammatory acne in females. 2, 7
Hormonal agents can be used as monotherapy for mild-to-moderate disease or as adjunctive therapy for more severe disease, particularly in patients with PCOS features. 1
Critical Pitfalls to Avoid
Never use topical or oral antibiotics as monotherapy—resistance develops rapidly without concurrent benzoyl peroxide. 1, 2
Never extend oral antibiotics beyond 3-4 months without re-evaluation, as this dramatically increases resistance risk. 1, 2, 4
Do not delay isotretinoin in patients with severe cystic acne, scarring, or significant psychosocial burden—early intervention prevents permanent scarring. 1, 2, 7
Do not underestimate severity when scarring is present—this warrants more aggressive treatment regardless of lesion count. 1, 3, 4