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I went through your query and understood your concern. According to the history and image provided, it looks like acne vulgaris grade 4 (attachment removed to protect the patient's identity). Acne appears due to multiple factors, including hormonal changes, climate changes, dietary modifications, genetic factors, usage of various skin products, and gynecological conditions like PCOS (polycystic ovarian syndrome), which presents with menstrual irregularities most often, but sometimes the menstrual cycle may be regular as well. To manage severe acne, I suggest you consult a gynecologist in person. For the time being, I suggest you to follow the instructions mentioned below. Use a face wash that contains a combination of Salicylic acid 2 % and Glycolic acid (AHA glow S foaming face wash). Apply twice daily, massage gently in a circular motion for one minute, and wash it off. Use Peroclin gel (Clindamycin and Benzoyl Peroxide) 2.5 % in the morning after cleaning with the face wash. Apply them only on the acne lesions. Use Aziderm (Azelaic Acid)) 10 % cream and apply a very thin layer on the affected area at night on alternate days. Make sure your face is cleansed and dried well. Your hands and face should be dry without any moisture. Apply the cream in a pea-sized quantity only on the affected areas in a very thin layer. Do not use it all over the face, and do not use it in large quantities since it is a strong medication and may cause irritation. Take tablet Ascorbic acid (antioxidant) 500 mg, which is chewable. It should be taken after food twice daily for two months. Avoid sweets, oily and fried food, milk and dairy products, and red meat. Include a lot of fruits and vegetables in your diet, and adequate water intake is recommended. I suggest you visit a gynecologist for consultation and management of PCOS, as without eliminating the root cause, the management of acne may be time-consuming. ILS (intralesional steroid injections) may also be done at a dermatologist clinic for cystic acne for faster reduction. Also, facial chemical peels with Glycolic acid are done in sessions of two weeks to one month for at least six sessions, and laser therapy is done in sessions as well. These procedures help in better recovery. Again, kindly consult a dermatologist in person to undergo these procedures. Kindly consult a specialist, talk with them and take the medications with their consent. Acne may be on and off depending on hormonal changes, climate, and dietary changes. Therefore, external factors like diet can be managed. However, hormonal factors being internal can be challenging to manage. Therefore, management of acne may have to be done frequently till the acne lesions reduce their appearance. To achieve this, consistency is the key. I hope this has helped you. Take care.