Introduction

Acne vulgaris is a chronic inflammatory disorder of the pilosebaceous unit, presenting with comedones, papules, pustules, nodules, and post-inflammatory sequelae. Moderate to severe acne, especially when involving inflammatory lesions on the cheeks and jawline, often warrants systemic therapy to prevent scarring and psychological morbidity. Isotretinoin remains the most effective disease-modifying agent, while adjunctive antimicrobials and topical retinoids offer synergistic benefit.

Case Presentation

A 24-year-old female presented with a 6-month history of worsening inflammatory acne predominantly affecting the cheeks and mandibular area, associated with tenderness, flares during menses, and developing post-inflammatory erythema and hyperpigmentation.

Clinical examination revealed multiple inflammatory papules, pustules, nodules, and a few cystic lesions, consistent with Grade 3–4 acne vulgaris. No history of drug triggers, anabolic agents, or endocrine symptoms. No history of any menstrual irregularities.

Pathophysiology

Acne arises from four interacting mechanisms:

1. Follicular hyperkeratinization → comedone formation
2. Sebaceous hyperactivity (androgen mediated)
3. Cutibacterium acnes colonization
4. Inflammatory cascade → papules, pustules, nodules

Isotretinoin uniquely targets all four, reducing sebaceous gland size and altering keratinocyte differentiation, leading to long-term remission.

Treatment Approach

Systemic Therapy

Topical Regimen

• Adapalene 0.1% at night (alternate nights initially)
• Niacinamide 4–5% mornings for barrier repair and inflammation
• AHA-based cleanser (Ahaglow) once daily to support comedolysis

Adjunctive Modalities

Evidence-supported clinical add-ons explained as options:

Topical Options:

• Benzoyl peroxide (2.5–5%) to prevent resistance
• Clindamycin short-course spot therapy
• Zinc-based soothing gels
• Post-treatment PIH therapies (azelaic acid, tranexamic acid, kojic acid)

Hormonal Therapies (for appropriate candidates):

• Combined OCPs
• Spironolactone
• Cyproterone acetate

Procedural Modalities:

• Chemical peels (salicylic/glycolic)
• Comedone extraction
• Photodynamic therapy
• IPL for erythema
• Microneedling for scars (after isotretinoin window)

Clinical Course

At 2 months, the patient demonstrated:

• Marked reduction in inflammatory lesions
• Smoother texture
• Diminished erythema
• No new nodules

First Visit

Multiple inflammatory papules, pustules, and nodules with post-inflammatory erythema

Two Months Into Treatment

Marked reduction in inflammation, improved texture, and minimal new lesions

Treatment continued with isotretinoin dose escalation toward cumulative target.

Conclusion

This case highlights the successful management of Grade 3/4 inflammatory acne using systemic isotretinoin, pulse azithromycin, and topical retinoid-based combination therapy, achieving significant improvement within two months and preventing long-term scarring. A personalized, layered therapeutic strategy remains the gold standard for durable clearance and restoration of skin confidence.