What it is
The visit starts with an examination that records which lesion types are present, how widely, and what has already been used — including creams bought without a prescription and unlabeled mixed creams. The plan is usually topical, with oral treatment added when the disease is widespread or when every lesion is leaving a mark or a scar behind it.
What this page covers
- Acne consultation, grading and baseline clinical photography
- Comedonal acne (blackheads and whiteheads)
- Inflammatory papulopustular acne
- Nodulocystic acne
- Adult female and hormonal acne, with androgen and PCOS screening where the history indicates it
- Truncal acne of the back, chest and shoulders
- Acne mechanica and folliculitis under a niqab, mask or tight scarf
- Acne excoriée (picking-driven acne)
- Pomade and cosmetic acne at the hairline and temples
- Drug-induced and steroid acne from unregulated mixed creams (الخلطات), supplements and anabolic agents
- Malassezia (pityrosporum) folliculitis, which is mistaken for acne and does not respond to acne treatment
- Gram-negative folliculitis after prolonged antibiotic use
- Topical retinoids, benzoyl peroxide, azelaic acid, clascoterone, dapsone gel and fixed combinations
- Topical and oral antibiotic courses with antibiotic stewardship
- Oral isotretinoin, with pregnancy-prevention counseling, side-effect management and laboratory monitoring
- Combined oral contraceptive and spironolactone for hormonal acne
- In-clinic comedone extraction
- Intralesional triamcinolone for a single inflamed cyst
- Superficial salicylic and mandelic peels as an acne adjunct
- Post-inflammatory hyperpigmentation (the brown marks) and post-inflammatory erythema (the red marks) after acne
- Post-acne scarring assessment and handover to the scar plan
- Skincare, cleanser, makeup and sunscreen counseling; an honest diet, dairy and supplement discussion
- Acne fulminans and acute severe flare, seen the same day
Who it suits
- Anyone whose spots are inflamed and leave a dark mark or a scar behind each one — here treatment starts earlier rather than waiting to see whether it settles on its own
- Anyone who has worked through pharmacy products, a relative's prescription, or a lightening mixture with nothing written on the tube, and wants to know what is actually going on. Bring everything you have used, in its packaging
- Anyone with deep tender nodules on the cheek, jawline, back or chest who has already been through more than one antibiotic. This pattern scars while it is being treated, so delay is itself a risk, and oral treatment is discussed early rather than after several rotations
- An adult woman whose spots sit on the lower face and jawline and flare before her period — particularly alongside irregular periods, increased hair growth or thinning at the scalp, where the questions go wider than the skin
- Not you if what you have is small, itchy, uniform pustules on the forehead, upper back and chest with no blackheads or whiteheads among them. That is often Malassezia folliculitis: it is mistaken for acne, it does not respond to acne treatment, and the antibiotic prescribed for the acne often makes it worse. Say so at the visit so it can be looked for
When we advise delaying or not treating
- Pregnancy, planning a pregnancy, or breastfeeding: isotretinoin is out in all three. In pregnancy and while you are trying to conceive, topical retinoids are not used and doxycycline is not given. While you are breastfeeding, each medicine is decided one at a time with your own doctor rather than assumed to be safe or assumed to be barred. Azelaic acid is one of the few agents that can be continued in pregnancy, after a discussion with the obstetrician looking after you. Tell us before the prescription, not after it
- Doxycycline and the rest of the tetracycline family are not given to young children
- Spironolactone is prescribed for women and requires reliable contraception because of the risk to a male fetus; it is not used in pregnancy. It also raises potassium, so blood pressure and a potassium blood test belong with it — say whether your kidneys have ever been a concern, and list every other medicine and supplement you take, because some of them raise potassium too. A combined oral contraceptive does not suit a history of clot, migraine with aura, uncontrolled blood pressure, smoking past the relevant age threshold, or breastfeeding in the early months, and blood pressure is checked before it is started and while you are on it
- Skin thinned by a mixture, or by a topical steroid used for a long stretch: peels, microneedling and laser are deferred until the skin barrier recovers. Stopping the steroid all at once sets off a rebound flare, so it is withdrawn on a plan and by degrees
- Peels are deferred on isotretinoin, on an active cold sore, on skin that has just been threaded or waxed, and where diabetes is uncontrolled or healing is poor
- A request for a facial program or a run of device sessions while the acne is still scarring: we decline to make that the treatment. The medical plan is written first, and in-clinic sessions have a place after it if they add anything. A month spent on a cosmetic program instead of a prescription is a month in which a scar is drawn that no device later erases
- A request to treat the marks first and leave the spots: resurfacing is not started while acne is active, because each new inflamed lesion resets the mark. And much of what is called scarring at a first visit is pigment or redness that settles without any device; examination separates the two, and the plan then moves to acne scar treatment or to post-inflammatory pigmentation
- A request to repeat an isotretinoin prescription with no blood tests, no review and no contraception plan: we decline. The tests and the review are part of the medicine, not paperwork attached to it
- Squeezing or forcing inflamed cysts, here or at home: it is not done. The cyst ruptures deeper, and both the inflammation and the scar are worse for it. A steroid injection into one cyst is a bridge before an occasion, not a treatment for acne, and it is not repeated into the same lesion at short intervals
- If you or your family have G6PD deficiency (التفول), say so — it changes some of the medicines that can be offered
Possible effects
Stated in full, because the decision is not sound without them. Acne medicines work, and each one carries something you should be told before you start it rather than after.
- Oral isotretinoin causes severe birth defects. It is not started until pregnancy has been excluded, and the contraception plan is agreed and already in place for a period before the first capsule rather than begun on the day the medicine is dispensed. Pregnancy is then avoided throughout the course and for a period after stopping that your prescriber sets, with repeated pregnancy testing. A capsule is never given to a sister, a cousin or a friend however similar the spots look, and is never taken from someone else's box. Blood donation is not permitted during treatment or for a period afterwards
- Isotretinoin — what is expected, and what is reported at the time: dry lips, eyes and nose, and minor nosebleeds in air conditioning, are close to universal and are managed with moisturizing rather than by stopping the drug; sun sensitivity is marked here in every season. But a change in night vision, a change in mood, withdrawal or hopelessness, severe headache, muscle pain or bowel symptoms are reported immediately and not held over until the next appointment
- Isotretinoin — what pauses while you are on it: waxing and threading, dermabrasion, ablative laser and elective skin surgery are deferred during the course and for a period afterwards set by the prescriber. A tetracycline antibiotic — doxycycline among them — is not taken alongside isotretinoin, because the combination is linked to raised pressure inside the head, so tell any doctor who offers you an antibiotic that you are taking it. Blood tests before and during are not optional, and the course is not continued on repeat prescription without review. Absorption depends on the fat in the meal, so the capsule is taken with a proper meal, and the Ramadan plan is worked out with the doctor before the month begins rather than improvised in its first days
- Oral antibiotics: tetracyclines raise the skin's sensitivity to sun, which counts in Jeddah and during Hajj and Umrah. They are swallowed with water and sitting upright. An oral antibiotic is given alongside a topical retinoid and benzoyl peroxide rather than on its own, so the result holds once the course ends. A review date is set on the first day so the course does not drift into months; long repeated courses are what produce gram-negative folliculitis — a sudden crop of pustules, or deep tender lumps, around the nose and mouth — and Malassezia flares
- Topical retinoids: dryness, redness and flaking at the start, and a flare of small spots in the first weeks that is expected and does not mean failure. They raise sun sensitivity, so they are used at night with sunscreen every day. Too much product irritates, and irritation on deeper skin turns into pigment. They are paused on an area due to be threaded or waxed, because they let skin lift with the hair
- Benzoyl peroxide: it irritates at higher strengths, so we start lower or use the wash-off form. It bleaches towels, bedding, headscarves and prayer garments — we say so before it is dispensed, not after something is ruined
- A topical antibiotic on its own: it drives resistance, and it is one of the common reasons acne stops responding after a while. It is used alongside benzoyl peroxide or a retinoid, and as a phase of the plan rather than as the plan
- Steroid injection into an inflamed cyst: too strong or too much leaves a dent and a pale patch that is very visible on deeper skin and can take months to fill. So it is used sparingly and not repeated into the same lesion at short intervals
- Superficial peels and in-clinic extraction: post-inflammatory pigmentation is the expected complication in deeper skin tones, which is why the depth stays conservative. Forceful extraction leaves a mark that outlasts the comedone it removed, and inflamed cysts are not extracted at all
A note on darker skin
On Fitzpatrick III to VI the problem is rarely the spot alone; it is what the spot leaves behind. Every inflamed lesion can leave a dark mark that outlasts it by months, which is why treatment is started earlier and eased off slowly rather than stopped in the first clear week. Irritation itself turns into pigment, so retinoids and benzoyl peroxide are started at low strength and built up, peel depth stays conservative, and scrubs, harsh exfoliants and forceful extraction are left alone because they add color on top of color. Sunscreen here is part of the treatment, not decoration laid over it. And not everything left behind is brown: pink and red marks are dilated vessels rather than pigment, lightening creams and pigment lasers do nothing for them, and they are counted and treated separately. Aggressive lightening or a harsh peel can darken the skin further instead of clearing it, and the marks fade slowly once the acne is quiet — any date put on them is a guess.
Afterwards
- Use the plan as it is written, in the amount you were shown, at the time of night you were told. Dryness, flaking and a flare of small spots in the first weeks are part of the road, not proof that it is failing — do not stop over them
- Sunscreen every day, in a texture you will tolerate under makeup and in the heat. Irritation and inflammation both turn into color on this skin
- Do not pick and do not squeeze. Much of what stays on a face afterwards is picking damage rather than the severity of the acne
- Set aside a light-colored towel and pillowcase if you are using benzoyl peroxide; it bleaches fabric
- If you are on isotretinoin: take the capsule with a proper meal, as you were instructed, and settle the Ramadan plan with the doctor before the month starts
- Come to the review with everything you are using, in its packaging, including the mixture if there is one
- And report straight away: any possibility of pregnancy; a change in mood, withdrawal or hopelessness; severe headache; a change in night vision; muscle pain or bowel symptoms; or a sudden crop of pustules or deep tender lumps around the nose and mouth after a long antibiotic course
Honestly
Acne is controlled rather than cured, improvement is counted in months and an early flare of small spots is expected rather than a sign of failure; on Fitzpatrick III–VI the dark marks left behind outlast the spots by months, and no honest plan puts a date on them. Facials and in-clinic light sessions are support alongside a medical plan, not a replacement for one — a patient sold a course of facials for scarring acne loses the months that mattered.
Common questions
My friend has leftover isotretinoin capsules from her course and offered me some. Can I take them?
No — not one. Isotretinoin causes severe birth defects. It is not started until pregnancy has been excluded, and it comes with a contraception plan, pregnancy testing and monitoring bloods, none of which exist in a box that has moved from one hand to another. Blood donation is also not permitted during the course or for a period after it. And the fact that it suited her does not mean it suits you; spots that look alike are not the same condition.
I am pregnant, or planning to be soon. What is out and what is left?
Say so at the start of the visit, not after a prescription is written. Isotretinoin is out, topical retinoids are not used, doxycycline is not given, and neither is spironolactone. What remains is still workable — azelaic acid among it — and is decided together with the obstetrician looking after you. Acne can be treated in pregnancy, with different medicines.
I use a lightening mixture from a shop, or a cream with no name on the tube. Should I stop it?
Stop it — but not abruptly and not on your own, and bring the tube with you. Mixtures containing a steroid produce a uniform spread of spots and thin the skin, and stopping all at once sets the skin off again, so it looks as though the new treatment caused it. It is withdrawn by degrees, and peels, microneedling and laser wait until the skin has recovered.
I want laser or facial sessions for the marks now.
Not while the acne is active. Each new lesion resets the mark, and much of what looks like a scar at a first visit is pigment or redness that settles without any device. We control the acne first, then separate color from depth on examination, and move on to acne scar treatment or post-inflammatory pigmentation. A facial program sold in place of a prescription does not stop what is leaving the scar.
I am taking doxycycline. Is there anything to watch?
Yes. It raises your skin's sensitivity to sun, which is felt in Jeddah and during Hajj and Umrah, so sunscreen and shade are not optional extras. Take it with a full glass of water, sitting up rather than lying down. And the course has a review date from day one; letting it run on for months is what brings out a sudden crop of pustules or deep tender lumps around the nose and mouth, or itchy small bumps on the forehead and back — and the answer then is to change the plan, not to add more antibiotic.
When will I see a difference?
Not in days. We set a review appointment so the difference is measured on photographs rather than on impression, and small spots may appear early on, which is expected. The dark mark stays after the spot has gone and fades slowly afterwards; we will not give you a date, because we do not have one.