Case Study: Resolving Persistent Cystic Acne in a 28-year-old Male

Chronic Acne and Its Long-term Impact

Acne vulgaris is one of the most common chronic skin conditions, affecting the pilo-sebaceous glands and carrying a significant physical and emotional burden. Ranked as the 8th most prevalent disease globally in 2010, acne can leave long-lasting scars, both physical and psychological. Over 40% of patients present with acne scarring at first consultation, and many report low self-esteem, social withdrawal, and impacts on academic or work performance.

At our clinic, we have treated thousands of patients over the years, ranging from mild breakouts to severe nodulocystic acne. In this case study, we share a real-world journey of a patient with persistent, treatment-resistant acne, and how we worked together to achieve successful outcomes.

Patient Profile: A 12-Year Struggle with Painful Breakouts

Patient Initials: NY
Age: 28
Occupation: Teaching professional
Condition Duration: 12 years

NY visited our clinic after experiencing painful, recurring breakouts on the cheeks, jawline, and back since adolescence. He had undergone multiple treatments, including oral doxycycline, topical adapalene, and benzoyl peroxide, which showed temporary improvement but failed to provide lasting relief. Breakouts would return, often more severe, once the treatment stopped.

NY expressed frustration with the cyclical nature of his acne and its toll on his self-esteem and social life. He reported no significant medical history, no current medications (aside from omega-3 supplements), and a family history of adult acne (his father had persistent acne with visible scarring).

He identified stress, lack of sleep, and sugary foods as triggers. NY does not smoke and has not used any other acne therapies recently.

Clinical Assessment: Severe Acne with Scarring

During NY’s initial consultation, a thorough dermatological assessment was conducted to evaluate the severity, distribution, and type of acne lesions, as well as the presence of any complications such as scarring. Understanding the clinical presentation in detail is essential for tailoring a treatment plan that is both effective and sustainable.

Examination Findings

The assessment revealed that NY has the following concerns:

• Acne involvement extending to the chest and back
• Inflammatory papules, pustules, comedones, and multiple cysts and nodules on the cheeks and jawline
• Oily skin with widespread acneiform lesions
• Visible erythema and severe atrophic scarring, particularly on the temples, cheeks, and jawline

No features suggestive of fungal folliculitis (itchiness) or rosacea (etelangiectasia, blushing episodes). Based on the clinical features and lesion morphology, NY’s acne was graded as Grade 4 (Severe) using the validated Investigator Global Assessment (IGA) scale as per below:

Table 1: Investigator Global Assessment (IGA) Scale for Acne  by US FDA

GRADE	CLINICAL DESCRIPTION
0	Clear skin with no inflammatory or noninflammatory lesions
1	Almost clear; rare noninflammatory lesions with more than one small inflammatory lesion
2	Mild severity; greater than grade 1; some noninflammatory lesions with no more than a few inflammatory lesions (papules/pustules only, no nodular lesions)
3	Moderate severity; greater than grade 2; up to many noninflammatory lesions and may have some inflammatory lesions, but no more than one small nodular lesion
4	Severe; greater than grade 3; up to many noninflammatory and inflammatory lesions, but no more than a few nodular lesions

Diagnosis: Severe Inflammatory Acne Vulgaris with Scarring

A diagnosis of severe inflammatory acne vulgaris was made. Other possibilities, including fungal folliculitis and rosacea, were ruled out based on the following clinical features:

• Absence of itching, telangiectasia, or flushing
• No signs of rosacea-specific triggers
• Presence of comedones and nodules

Personalised Treatment Plan: Starting Oral Isotretinoin

Given NY’s long-standing history and resistance to prior treatments, we recommended initiating oral isotretinoin therapy. This is the go-to treatment for severe acne and acne scarring, as per the American Academy of Dermatology guidelines.

Step 1: Baseline Testing

• Blood cholesterol and liver function tests were done and found to be normal.

Step 2: Initiating Low-Dose Isotretinoin

• Started on <0.5mg/kg/day due to concerns about tolerating side effects.
• Provided education on common side effects and precautions:
  • Lip balm, moisturiser, and broad-spectrum sunscreen to manage skin dryness
• Avoid alcohol and vitamin A supplements

Results Over Time: From Flare-Ups to Clear Skin

Tracking NY’s progress throughout treatment allowed us to monitor both clinical response and patient experience. Like many patients on oral isotretinoin, he experienced an initial flare, followed by steady improvement across multiple skin parameters. This timeline offers a closer look at the treatment milestones and long-term outcomes.

Weeks 1 to 2

• Expected initial flare-up of acne

Week 4 and Week 8

• Significant reduction in inflammatory lesions and comedones

Week 12

• Nodules and cysts resolved

Week 16

• Improved skin texture, reduced redness, and more even tone

End of Treatment (approximately 13 Months)

• Completed oral isotretinoin course
• Placed on topical retinoids for maintenance

Patient Feedback

• Reported high satisfaction with results
• Managed side effects well (dry skin, chapped lips)
• Experienced a boost in confidence, better mood, and more active social interactions
• Main inconvenience was abstaining from alcohol, which he coped with successfully

Clinical Insights: Why This Case Matters

NY’s treatment journey highlights several key considerations in the management of severe, treatment-resistant acne. It also reflects the importance of tailoring interventions to both clinical severity and patient lifestyle. The following insights provide context for decision-making in similar cases.

When Standard Acne Treatments Fail

Persistent acne that does not respond to oral antibiotics or topical treatments often leads to chronic inflammation and permanent scarring. Early escalation to oral isotretinoin can be critical to prevent long-term damage.

Weighing Benefits and Risks of Isotretinoin

While highly effective, isotretinoin can cause side effects:

• Common – dry skin, nosebleeds, muscle aches
• Lab-related – elevated cholesterol or liver enzymes
• Rare but serious – teratogenic effects (in women of reproductive age)

Contrary to popular concern, large population studies show no definitive link between isotretinoin use and increased risk of depression, anxiety, or inflammatory bowel disease. Nonetheless, it remains essential to screen and monitor patients based on individual risk factors and responses.

Managing Initial Flares

One of the most challenging aspects of isotretinoin therapy is the initial flare-up, which can discourage patients early on. Starting with a lower dose and using a short course of anti-inflammatory medication can help mitigate this temporary worsening and improve overall treatment tolerability.

Conclusion: A Clearer Path Forward

NY’s case is a testament to how evidence-based treatment, personalised care, and early intervention can lead to life-changing improvements in acne management. While severe acne can persist for years, the right treatment strategy can help patients achieve clearer skin and renewed confidence.

Reference

1. Hay RJ, Johns NE, Williams HC, Bolliger IW, Dellavalle RP, Margolis DJ, Marks R, Naldi L, Weinstock MA, Wulf SK, Michaud C. The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. Journal of investigative dermatology. 2014 Jun 1;134(6):1527-34.
2. Tan J, Kang S, Leyden J. Prevalence and risk factors of acne scarring among patients consulting dermatologists in the USA. Journal of drugs in dermatology: JDD. 2017 Feb 1;16(2):97-102.
3. Tan J, Beissert S, Cook-Bolden F, Chavda R, Harper J, Hebert A, Lain E, Layton A, Rocha M, Weiss J, Dréno B. Impact of facial atrophic acne scars on quality of life: a multi-country population-based survey. American journal of clinical dermatology. 2022 Jan 1:1-9.
4. Alsulaimani H, Kokandi A, Khawandanh S, Hamad R. Severity of acne vulgaris: comparison of two assessment methods. Clinical, Cosmetic and Investigational Dermatology. 2020 Sep 28:711-6.
5. Reynolds RV, Yeung H, Cheng CE, Cook-Bolden F, Desai SR, Druby KM, Freeman EE, Keri JE, Gold LF, Tan JK, Tollefson MM. Guidelines of care for the management of acne vulgaris. Journal of the American Academy of Dermatology. 2024 May 1;90(5):1006-e1.

Disclaimers

All patient information has been anonymised to protect patient privacy. No real names or initials are used; similarities are purely coincidental. Pictures in this article are for illustration purposes only. Individual results vary, and the example in the case study does not guarantee similar outcomes for other patients.

This case study is for informational and educational purposes only and does not constitute medical advice. Patients should always consult with a qualified healthcare professional for their specific condition.