Best Treatment for Very Severe Acne

Grade 4 Nodulo-Cystic Acne Best Treatment Tips



The best treatment for very severe acne or grade 4 nodulo-cystic acne is mainly systemic medications. Dermatologist Dr.Hanish Babu provides expert advice on the best treatment for very severe acne.

Clinical Picture of Very Severe Acne

(Grade 4 Nodulo-cystic Acne)

Tips on the Best Treatment for Severe Acne

  • Treatment is usually instituted with Minocycline 50-100 mg twice daily for 1 month  duration. Topically Isotretinoin gel 0.05% in the night and Clindamycin solution are advised.
  • After 4 weeks, if the lesions are responding, continue with once daily Minocycline for another  month.
  • After 2 months of Minocycline, I shift the patient on to daily dose of Doxycycline 100 mg.  The topical applications are continued till complete remission, then the frequency is reduced.
  • If there is no improvement in males even after 1month of the above trials, then, only then, do I advice Isotretinoin, a 20 weeks' course at a dose of 1 mg/kg body weight per day.
  • Female patients in the child bearing age group are  treated with Minocyline for 1months and then Doxycycline for another 1months, and then, if there is no improvement,  isotretinoin is advised.  See special precautions on Isoretinoin.
  • If there is collection and oozing of pus, I usually drain the pus to assist the healing process. This will also help in reducing the chance of severe scarring. In non-infective sebaceous cysts and nodules, a few judicious intralesional triamcinolone injections under antibiotic cover will work wonders in clearing the lesions faster than usual.
  • For the explosive onset of  nodulo cystic acne known as pyoderma faciale, a course of systemic steroid is very effective along with antibiotic coverage. Infact, this is one situation where systemic steroid helps resolve a facial emergency.

Practical Points on the Best Treatment for Very Severe Acne

  • All the above  medications should be taken under the guidance of a dermatologist only. The information given here is only for educational purpose and cannot  replace personal consultation with your acne physician! (See disclaimer).
  • Topical Tretinoin may cause irritation due to excessive peeling in individuals with sensitive skin. The following steps are advised to minimize this adverse effect:
    • Apply tretinoin only at night
    • Use a water based sun screen during daytime
    • In the first week, apply the Tretinoin gel/cream for 2 hours and wash off with water. If the skin is tolerating the application well, overnight application can be started from the second week onwards.
  • Also see the acne best treatment principles and acne best treatment general advices  to supplement the tips for very severe acne best treatment given on this page.


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