What is the skincare routine or treatment plan for my acne?

Question

Hello doctor,

I am a 26-year-old woman struggling with severe acne for the past year, and recently, my skincare routine has not seemed to help at all. I have been getting painful cystic breakouts on my cheeks and jawline, and my dermatologist said it may be hormonal acne. My latest blood tests showed total testosterone at 78 ng/dL and DHEAS at 395 µg/dL, which are both slightly elevated. My vitamin D level is low at 18 ng/mL, and my CRP is mildly raised at 9 mg/L, suggesting some inflammation.

I also have dark patches around my neck and underarms, and the doctor mentioned possible acanthosis nigricans, which made me worry about insulin issues. My fasting insulin came back at 22 µIU/mL, which is higher than normal. I have also been dealing with redness and burning after using even mild skincare products, so I am unsure if I have developed sensitive skin or rosacea. The scarring from old acne spots has made me self-conscious, and I have been avoiding social events. I tried Benzoyl peroxide and Adapalene, but my skin became very irritated. Could you please look at these symptoms and values and guide me on what skincare routine or treatment plan I should follow next?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Based on the symptoms and laboratory values you have shared, your acne appears to be driven by a combination of mild androgen excess and underlying insulin resistance, which is also suggested by the acanthosis nigricans and elevated fasting insulin level. These hormonal and metabolic factors commonly cause persistent jawline and cheek cystic acne. Your vitamin D deficiency and mildly elevated C-reactive protein indicate a background of inflammation.

The burning and redness after skincare products suggest that your skin barrier is irritated by Benzoyl peroxide and Adapalene, and there may also be a rosacea tendency. I will guide you about the treatment options and the skincare regimen to help manage it as much as possible.

For treatment, options like Spironolactone 50 to 100 milligrams daily can help stabilize androgen-related breakouts, and Metformin may be considered if insulin resistance is confirmed.

A short six to eight-week course of Doxycycline can help reduce active inflammation. You can start oral medications under the supervision of your dermatologist, and they will help for sure, as until you take systemic medicine, the root cause will be there, causing more acne flares. Once settled, you can stop oral medications and just switch to topicals. Start vitamin D3 supplementation at 50,000 International Units weekly for eight weeks and then continue with 2,000 International Units daily to improve immunity and keep acne flares at bay.

In the morning, use a gentle cleanser, Niacinamide 4 to 5 percent serum to help with redness, oil control, and barrier repair, a moisturizer for sensitive skin, and mineral sunscreen with a sun protection factor of 50 daily to avoid further pigmentation. At night, use a gentle cleanser and Azelaic acid 10 to 15 percent under the cover of moisturizer; it is anti-inflammatory and safe, and it treats rosacea while helping pigmentation when used three to four times a week initially.

Avoid Benzoyl peroxide, retinoids, scrubs, exfoliants, toners, vitamin C, and fragrances, as these can worsen irritation until your barrier stabilizes. After six to eight weeks, once sensitivity improves, a low-strength Adapalene 0.1 percent can be reintroduced gradually every third night, mixed with moisturizer.

For acne scarring, options include chemical peels, microneedling, subcision for deep scars, and laser resurfacing. Your dermatologist can recommend based on scar type, but these should be done only after control of active acne and after your skin barrier is repaired. Dietary changes like reducing high glycemic foods, improving sleep, staying active, and managing stress will also help.

I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.

Thank you.