Treating Severe Inflammatory or Cystic Acne

When acne does not respond to the standard one-two punch of topical retinoids and oral antibiotics, patients have two other choices: the drug isotretinoin, or Accutane, or one of several procedure-based treatments for acne that involve using laser or light treatment to reduce inflammation and kill acne-causing bacteria.

Accutane is an extremely powerful treatment for acne, often clearing up severe, scarring breakouts that had not responded to any other treatments within a matter of a few months.

But it also carries with it a host of risks and side effects, including inflammatory bowel disease, ulcerative colitis, liver damage, bony malformations, depression, and a virtual certainty of severe birth defects for the babies of women who take Accutane while pregnant.
In 2005, the FDA established an online tracking database, called iPledge, and now requires all patients to sign onto the database to continue receiving their prescriptions. The iPledge system requires women to submit two negative pregnancy tests before they can receive an initial prescription for isotretinoin. Women must also undergo a monthly pregnancy test before each refill. Men are also tracked because of Accutane’s depression risk.

"Anyone taking Accutane really needs to be counseled properly about all of these risks,” says Alexiades-Amenakas.  The drug also impairs wound healing, so if a patient with severe cystic acne begins taking the drug, those cysts typically resolve with scars. "It gets rid of the underlying problem, but you’re almost guaranteed to heal with scars if you’re at that level of inflammation when you start taking Accutane."

The alternative to Accutane for people with severe, stubborn acne, is a treatment involving laser/light therapy. The two main options are:

Photodynamic therapy. "In this technique, we apply a prescription liquid to the patient’s face, chest, or back -- wherever the acne is -- and then apply a light or laser to activate the medicine," Taub says. "Not only does the medication kill bacteria -- which is less important, because bacteria will come back -- but over a few months, it also reduces the size and activity of the oil glands."

Isolaz. This treatment combines a vacuum with a broadband light. The vacuum cleanses pores and extracts excess oil, while the light helps destroy the acne-causing bacteria as well as reducing the activity of the oil gland.

"For people with the most severe acne who’ve failed other treatments, I usually count on Accutane or laser treatment," says Taub.