Cystic Acne: Best Treatments for Severe Nodular Acne Without Accutane

Accutane is a life-saver for many acne sufferers. I've seen countless examples of faces more red than normal color and more bumpy than flat. These individuals are as disfigured as a burn or trauma victim, but with several months of Accutane use, they have mild or no acne. Due to the possibility of serious side-effects, Accutane should be reserved for only severe acne or moderate acne that's recalcitrant (resistant) to other treatments.

It's my hope that with the assistance of their dermatologist, every acne sufferer will make an informed decision about Accutane treatment, a decision that isn't based on fear or desperation but on carefully weighing the risks and benefits. In the vast majority of cases, Accutane doesn't cause serious side-effects, so the wide-spread fear created by the mainstream media is irrational and detrimental to decision-making.

However, if Accutane isn't a possibility, there are still options. There's a group of leading acne doctors and researchers called the Global Alliance to Improve Outcomes in Acne. Every several years, they release a set of recommendations for acne treatment based on all research up to that point. Accutane works so well because it's the only medicine that attacks all four causes of acne: increased oil production, hyperkeratinization of the pore, growth of acne bacteria, and inflammation. If Accutane isn't a possibility, the Global Alliance suggests a topical retinoid + benzoyl peroxide + an oral anti-biotic, but this combination only treats three causes as it doesn't have an effect on skin oil production. Women can take a high dose anti-androgen (like spironolactone) in addition to the medicines listed above, in which case they're treating all four causes.

Benzoyl peroxide is available over the counter; however, the benefit isn't concentration-dependent. In other words, 2.5% benzoyl peroxide works as well as 10%, but the higher concentrations can cause more irritation. The next question becomes which topical retinoid and which oral anti-biotic are the best. All the research I've read suggests that adapalene is the most effective topical retinoid with the least side-effects. The other retinoid, tazarotene, might be considered for particularly oily skin.

The use of the antibiotic, tetracycline, is somewhat outdated do to the higher effectiveness of the second generation antibiotics: doxycycline and minocycline. Studies have failed to show a difference in effectiveness between the two, so side-effects are the main consideration. Both medicines can cause nausea, vomiting, diarrhea and candidiasis. Both may also cause benign intracranial hypertension, which manifests mainly as headaches but also as nausea, vomiting, dizziness, lethargy, and vision problems; of course, let your doctor know immediately if you're experiencing these symptoms. These medicines aren't recommended for children due to the potential for staining teeth blue. Finally, both can be associated with esophageal ulcers.

Enteric-coated doxycycline is probably the better choice; the enteric coating helps prevent nausea. From 1966 to 2003, there were only 130 reported cases of serious side-effects with doxycycline worldwide; the major issues were gastrointestinal (55%) and light sensitivity (36%). With minocycline, there were 333 reported cases including 28% lupus like syndrome, 15% hyperpigmentation, and 11% vestibular effects. Minocycline can have very serious side-effects that should be thoroughly discussed with your doctor before taking.