How to manage cystic acne without facial scarring?

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Cystic acne comes under acne vulgaris grade 4. The generation they present as large inflamed pus-filled nodules which later develop into cysts along with draining sinuses. Treatment of severe acne includes,

1. We need to counsel the patient that severe acne can be treated entirely within six to eight months of treatment with little scarring.

2. We can use a combination of oral antibiotics like Azithromycin 500 mg thrice a week initially for a minimum duration of six to eight weeks but can be continued maximum up to 12 to 14 weeks and oral Isotretinoin dose 0.5 mg per kg body weight to a maximum of 1 mg per kg body weight.

3. Isotretinoin is a retinoid which acts on all significant factors involved in the pathogenesis of acne vulgaris and helps in complete remission in most cases. Dermatologists can prescribe it, and a pregnancy prevention program like iPLEDGE should be followed. Signed consent should be obtained, confirming that the patient knows not to get pregnant during therapy and for four weeks afterward. A pre‐treatment pregnancy test and routine blood investigation like liver function tests, lipid profile is required, and monthly pregnancy testing along with LFT and lipid profile throughout treatment is advised.

The patient should be explained of minor effects of Isotretinoin, such as dryness and soreness of eyes, skin, oral mucosa, nasal mucosa, muscle aches and pains, hypertriglyceridemia. Mucocutaneous drying can be managed by emollients and tear substitutes. A rare complication of Isotretinoin therapy is pseudotumor cerebri, and benign intracranial hypertension with papilloedema has been reported when combined with oral Tetracyclines. Initially, you can use oral steroids to reduce the flare of acne. Atrophic scarring can be treated with laser resurfacing, dermal collagen injection like fillers. Hypertrophic scarring can be treated by chemical peels, microdermabrasion, intralesional Triamcinolone injection, and surgical excision.

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