acne treatment

How would you treat this teenage boy's cystic acne?

Alberta Children’s Hospital

Dr Barber is a consultant dermatologist at Alberta Children’s Hospital and clinical associate professor of medicine and community health sciences at the University of Calgary in Alberta.


A Photo Quiz to Hone Dermatologic Skills

Case: Deep acne nodules and cysts have been developing on this 15-year-old boy’s temples for the past year. He has been applying topical anti-acne therapy for almost 6 months because his mother is afraid of the adverse effects of systemic medications to treat his acne. His father has significant acne scarring on his face and back.

What treatment approach is likely to be most effective for this patient?





(Answer on next page)


Acne with scarring warrants early and aggressive therapy preferably with systemic medication.

Acne scarring is life-long and results in significant psychosocial impairment. For patients seeking my opinion on their acne treatment, my clinical approach is to carefully examine their skin for scarring related to their acne. If scarring is present, my treatment plan is to eradicate the inflammatory component of their acne as quickly and completely as I can; this will prevent further scarring. The cosmetic treatment of acne scarring is poor at best, thus prevention of scars is the only sensible option. 

The treatment of individual inflammatory acne cysts is straightforward. I inject the cyst with a solution of triamcinolone acetonide diluted to a concentration of 3 mg/mL. The cyst expands with the fluid until it blanches; I am careful to avoid rupture of the cyst. The cyst shown in Photo A was injected with about 0.5 mL of the corticosteriod solution and resolved within 24 hours. The major risk of injection is the development of atrophy and depressed scarring at the injection site. This is virtually always reversible, whereas scarring from the acne cyst is not.
The more important decision to be made for this teenage boy is how to manage his inflammatory scarring cystic acne. I begin with a frank discussion of the treatment options with the teen and his parents. The Internet, television, and social media have been their major sources of information on oral acne treatments. Patients and parents are often concerned about the following issues:
Isotretinoin – potential birth defects (a worry even among young men) and depression and possible association with inflammatory bowel disease.
Antibiotic therapy – potential drug allergy and long-term use—cost, effects, and antibiotic resistance.
Hormonal therapy (female patients) – adverse effects of thromboembolism, migraine, and weight gain.
After I address each of their concerns about the treatment options, I will usually recommend the use of isotretinoin to address the primary objective of acne therapy: to prevent scarring. Compared with other options, isotretinoin—despite its potential adverse effects—has the best chance for achieving long-term remission.

Photo B shows another 15-year-old boy with scarring from his cystic acne who is just completing a course of systemic isotretinoin. He has responded well to this treatment and will probably have prolonged remission. In my opinion, systemic treatment should be started as soon as it is established that acne is causing significant scarring. For both of the patients described, beginning systemic treatment earlier might have stopped the inflammation that led to the scars.