I have acne that turns into pustules. What treatment suits me?

Question

Hello doctor,

I have acne mainly on my cheeks and jawline. It usually starts as blackheads or closed comedones and then turns into painful red pustules. Recently, my skin became very sensitive, itchy, flaky, and red, and the pimples feel hard and pointy when touched.

I used a Salicylic acid cleanser, Mandelic acid serum, Clindamycin gel, and a gentle moisturizer, but activities seem to irritate my skin and worsen redness. My chin and nose are mostly clear.

Hot showers and touching my face make it worse, and new pustules sometimes appear overnight. I am worried about ongoing inflammation, blackheads triggering more acne, and barrier damage.

Painful inflammatory acne on cheeks and jawline with redness, pustules, blackheads, itching, and flaking for the past few weeks. Acne worsened recently and became more sensitive and irritated. I have had mild to moderate acne before, but it was never this severe.

My diet is irregular and not well-controlled. My menstrual cycles are regular. I am unsure if this could be hormonal or PCOS-related acne, as I have never been diagnosed with PCOS. No major past skin disease.

I would like guidance on a gentle treatment plan and whether I need any prescription medication.

Please suggest.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Based on your history, pictures (the attachments were removed to protect the patient's identity), and the description, you are having moderate to severe inflammatory acne involving the cheeks and jawline, with associated skin barrier damage and irritant dermatitis.

The acne begins as closed comedones and blackheads that rapidly progress into painful, red pustules and firm, tender lesions. Recently, your skin has become highly sensitive, itchy, flaky, and erythematous, which strongly suggests that repeated use of active ingredients has compromised the skin barrier.

It is significant that your chin and nose are largely unaffected, while the cheeks and jawline have been mostly affected. This implies that the process is primarily inflammatory and could even be hormonally driven, although it is not the usual PCOS acne because of your normal menstrual cycles and absence of any history of PCOS.

Your increasing acne during hot showers and constant touching means that inflammation and barrier disruption play a more important role in your acne compared to uncontrolled sebum production.

New pustules appearing overnight are common in inflamed acne and do not mean that your skincare is failing, but rather that the skin is in a reactive state.

At this stage, continued use of Salicylic acid, Mandelic acid, or other exfoliating agents is likely exacerbating redness and sensitivity, preventing proper healing.

Follow a minimal and consistent routine to calm inflammation and allow your skin barrier to recover as follows:

In the morning, wash your face gently using a mild, non-foaming cleanser with lukewarm water; avoid scrubbing or using hot water.
After patting the skin dry, apply moisturiser containing Ceramide 3, Petrolatum, and Glycerin in a thin layer over the entire face to restore the skin barrier and reduce dryness and irritation.
After applying the moisturizer, you will apply a broad-spectrum sunscreen (SPF of 30 or more), using a light, non-comedogenic formula. Sunscreen application is very important, even if you are indoor because the inflammation and post-acne lesions are exacerbated by sunlight exposure.
Avoid touching your face, picking lesions, or washing repeatedly. Do not use any exfoliating products, acids, face masks, or spot treatments during the day.
Keep showers lukewarm and avoid letting hot water hit your face directly, as heat aggravates redness and acne inflammation. In the evening, cleanse again with the same gentle cleanser and allow the skin to dry completely for 15 to 20 minutes.
Apply Benclin gel (benzoyl peroxide) at bedtime in a thin layer all over the face, pea-sized only, not as a thick coat. This helps control inflammation and bacteria without over-irritating the skin.
After 10 to 15 minutes, apply moisturiser containing Ceramide 3, Petrolatum, and Glycerin again to maintain hydration and reduce dryness caused by the gel.

This regimen should be followed consistently for at least two to three weeks. To benefit more effectively from oral Isotretinoin, you may need a prescription, as it cannot be started without the proper screening of blood tests and contraindications like pregnancy and hepatitis.

Using too many active ingredients can actually make your skin worse, so please make it and keep it gentle.

Feel free to contact me for a proper consultation so that we can decide if you are a candidate for oral Doxycycline or oral Isotretinoin, as you need oral medication. Otherwise, this kind of moderate to severe acne will end up in very bad scarring.

I hope this helps.

Thank you.