From Angela Palmer,
Your Guide to Acne.
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About.com Health's Disease and Condition content is reviewed by Kate Grossman, MD

Severe acne (Grades III and IV) is characterized by the presence of numerous papules and pustules, deep nodules, and pronounced inflammation of the skin. Cysts are often present as well. It is sometimes referred to as nodulocystic or cystic acne. Severe acne often occurs on other areas of the body, in addition to the face.

A dermatologist must treat acne of this severity. Severe acne can be difficult to control, and in most cases requires systemic medications in addition to topical treatments. Systemic medications work internally to improve the skin.

Oral Antibiotics

Oral antibiotics have been used to treat acne for many years. Like topical antibiotics, oral antibiotics work by reducing Propionibacteria acnes (the bacteria responsible for acne breakouts). They also help decrease inflammation of the skin. Patients are usually started on a high dosage and moved to lower dosages as acne improves. Oral antibiotics are used to treat moderate to severe acne, or persistent acne.

The most common oral antibiotics prescribed for acne treatments are:

• erythromycin
• tetracycline
• minocycline
• doxycycline

Oral Contraceptives

Oral contraceptives, also known as birth control pills, can be used to treat acne in women. A combination of estrogen and progestin, oral contraceptives work to reduce oil gland secretions by suppressing androgen hormones. They are a good choice for women with acne who need a form of birth control anyway. Oral contraceptives are used in conjunction with topical medications to treat severe acne.

Just a handful of birth control pills have been approved as acne treatments by the FDA, including:

• Ortho Tri-Cyclen
• Estrostep
• Yaz

However, birth control pills have been prescribed off-label to treat acne for many years. Most doctors agree nearly any formulation will give the same effect.

Isotretinoin

Isotretinoin, or Accutane as it is better known, is a vitamin A derivative. It works by shrinking the sebaceous glands, reducing the amount of oil found on the skin. This, in turn, reduces the amount of comedones produced. Isotretinoin is taken orally, under careful supervision of a doctor. Because of possible serious side effects, it is used only in cases of very severe or cystic acne after all other treatment options have been exhausted.

Isotretinoin is sold under the brand names:

• Accutane
• Amnesteem
• Claravis
• Sotret