Acne and Acne Scar Treatment in Northern Cyprus

Correct treatment planning requires identifying the lesion type. The main categories used in clinical practice:

• Comedonal acne: Consists solely of blackheads and whiteheads, with no inflammatory lesions. The mainstay of treatment is a topical retinoid and an appropriate cleanser.
• Papulopustular acne (mild to moderate): Comedones, red papules and pustules appear together. A topical combination (retinoid plus benzoyl peroxide or antibiotic) is standard; a moderate-strength oral antibiotic may be added.
• Nodulocystic (severe) acne: Deep, painful nodules and cystic lesions predominate. The risk of scarring is high. Systemic treatment (most often isotretinoin) takes precedence; prolonged topical treatment alone is generally insufficient.
• Post-inflammatory hyperpigmentation (PIH): Brown marks that remain after a lesion heals. Particularly prominent in medium to darker skin tones (Fitzpatrick III–VI). Treatment follows a separate protocol targeting pigmentation.
• Post-inflammatory erythema (PIE): Red marks that persist after a lesion resolves. More common in lighter skin tones. Vascular laser or natural fading over time are the preferred approaches.
• Atrophic scars: Scars that leave depressions in the skin tissue. Divided into three subtypes: ice-pick (deep, narrow pits with sharp edges), boxcar (broad, square-edged craters) and rolling (undulating surface). Each subtype responds to different treatments — TCA CROSS for ice-pick; fractional laser and microneedling with subsision for boxcar and rolling.
• Hypertrophic and keloid scars: Raised scars. More common on the back, shoulders and jawline. Intralesional corticosteroid, silicone gel and laser options are used.

The first step in treatment is to classify the lesions present and plan which lesion type will be addressed and in what sequence. Scar treatment is not started while active acne remains uncontrolled — new lesions will simply produce new scars, and the investment is wasted.

The age of onset and distribution of acne provides clues about the underlying mechanism:

• Adolescent acne (ages 12–19): Triggered by the androgen surge of puberty. Tends to concentrate in the T-zone (forehead, nose and chin). The majority improve spontaneously in the early twenties; however, leaving severe presentations untreated is inadvisable because of the risk of permanent scarring.
• Adult acne (ages 20–40, particularly in women): Presents as deep papules along the jawline, around the mouth and on the neck. Flaring with the menstrual cycle is typical. Polycystic ovary syndrome (PCOS), insulin resistance and androgen imbalance are frequently associated. Topical treatment alone is often insufficient; hormonal therapy becomes relevant.
• Adult male acne: Severe presentations affecting the trunk and back; anabolic steroid or high-dose performance supplement use should always be explored. "Steroid acne" is a recognised clinical entity — no treatment will produce a lasting response unless use is discontinued.
• Late-onset acne (age 35+): New acne in a patient who previously had clear skin warrants endocrine evaluation. Adrenal or ovarian androgen excess, rapid weight change and newly started hormonal medication (certain progestins) should be investigated.

At Nis Clinic, the initial consultation covers in detail: age of onset, duration, relationship to the menstrual cycle, family history, current medications and supplements. Where indicated, joint assessment with an endocrinologist or gynaecologist is recommended — acne may begin as a skin problem but can sometimes reflect an underlying systemic condition.

Topical treatment is the cornerstone of acne management. It may be sufficient as monotherapy in mild presentations; it accompanies systemic treatment in moderate to severe cases; and in the maintenance phase after isotretinoin it helps prevent relapse.

• Topical retinoids (adapalene, tretinoin, trifarotene): First-line option for preventing follicular blockage. Mild redness and flaking during the first 4–6 weeks ("retinisation") is not a reason to discontinue. Contraindicated in pregnancy.
• Benzoyl peroxide (BPO) 2.5–5%: Antibacterial against C. acnes; it is one of the few molecules to which the bacterium does not develop resistance, making it valuable in every regimen. It may bleach towels and clothing — a typical split is retinoid in the evening and BPO in the morning.
• Topical antibiotics (clindamycin, erythromycin): Anti-inflammatory action. Never used alone — always combined with benzoyl peroxide to prevent resistance. Typical duration: 2–3 months.
• Azelaic acid 15–20%: Anti-inflammatory and effective on PIH. One of the few options that can be used during pregnancy and breastfeeding.
• Niacinamide and salicylic acid-based skincare: Categorised as support, not treatment; recommended as a complement alongside the primary topical plan.

Which topical agent is introduced and in what order depends on your skin's tolerance and lesion type. A patient who starts aggressively and abandons treatment does less well long-term than one who starts gently and maintains the course.

When topical treatment proves insufficient for moderate to severe or severe acne, oral medication is introduced.

• Oral antibiotics (doxycycline 50–100 mg/day, occasionally minocycline): Reduce papular and pustular lesions through their anti-inflammatory action. Standard treatment duration is 3–6 months; beyond this, bacterial resistance and microbiome effects become a concern, so treatment is either stopped or transitioned to isotretinoin. Doxycycline increases sun sensitivity — timing is planned with Cyprus's climate in mind. Every antibiotic course must be paired with topical benzoyl peroxide; without this combination, resistance risk increases.
• Hormonal treatment — in female patients: Covered separately below.
• Isotretinoin (oral retinoid, "Accutane"): Covered in a dedicated section below.

The decision to start systemic treatment is made when topical therapy used consistently for three months has not produced an adequate response, when scarring is occurring, when there is meaningful psychosocial impact, or when a rapidly progressing nodulocystic picture is present. The rule "isotretinoin cannot be prescribed without first trying milder treatments" is not universally applicable under current guidelines — in severe, scar-producing acne, delayed treatment can lead to permanent damage.

Isotretinoin is an oral retinoid (a vitamin A derivative) and the only medication that targets all four mechanisms of acne simultaneously. It reduces the sebaceous gland, decreases follicular obstruction, lowers C. acnes colonisation and suppresses the inflammatory response. For severe nodulocystic acne and persistent moderate to severe acne unresponsive to other treatments, it is the most effective option available — producing long-term remission in a significant proportion of patients.

Typical use:

• Dose ranges from 0.3–1 mg/kg/day, adjusted to the patient's tolerance and target cumulative dose (typically 120–150 mg/kg).
• Treatment duration is 4–6 months; in severe cases it may be longer.
• Monthly review appointments and blood tests are standard.

Side effects and monitoring:

• Lip and skin dryness (cheilitis): Occurs in almost all patients. Managed with intensive moisturiser and lip care.
• Dry eyes and nasal dryness: Artificial tears and saline nasal spray are recommended.
• Raised liver enzymes and elevated lipids (triglycerides, cholesterol): Blood tests before starting and monthly throughout treatment are mandatory.
• Musculoskeletal aches: Particularly in the back and joints; usually mild. Temporary avoidance of strenuous physical activity is advised.
• Psychiatric effects: Depressive symptoms and mood changes have been described in the literature. The causal relationship has not been definitively established, but monthly questioning is carried out with every patient; where there is a pre-existing psychiatric history, treatment proceeds in collaboration with a psychiatrist.
• Bone density and long-term effects: Assessed in cases of prolonged high-dose use or repeated courses.

Pregnancy prevention programme — an absolute requirement:

Isotretinoin is a potent teratogen — its use during pregnancy causes serious congenital abnormalities. A pregnancy prevention programme is therefore mandatory for all female patients of reproductive age:

• Two separate pregnancy tests before starting treatment (one on the day treatment begins).
• Two effective, independent contraceptive methods throughout treatment (e.g. hormonal plus barrier).
• Continued contraception during treatment and for one month after the final dose.
• Pregnancy test at every monthly review.
• A signed informed consent form is retained on file.

This programme is not optional — it is a medical prerequisite for prescribing the medication. "I probably won't get pregnant" is not acceptable.

Who should not receive isotretinoin, or for whom it should be deferred:

• Women who are pregnant or planning a pregnancy
• Women of reproductive age unwilling to accept a contraception plan
• Active liver disease
• Uncontrolled hyperlipidaemia
• High vitamin A intake at the start of treatment (multiple supplement use)
• Concurrent use of tetracycline antibiotics (risk of raised intracranial pressure — this combination is contraindicated)

Isotretinoin is a prescription-only medicine in Cyprus and is only recommended for suitable patients within this programme. It is not a drug dispensed to every patient on grounds of "fast results"; in the right patient, however, it is one of the few treatments capable of bringing scar-producing acne under durable control.

Adult female patients with acne predominantly along the jawline, flaring with the menstrual cycle and carrying a suspicion of PCOS or androgen excess are suitable candidates for hormonal treatment.

• Spironolactone (25–100 mg/day): An aldosterone antagonist that blocks androgen receptors, reducing sebum production. It is an effective option for adult female acne in clinical practice. Side effects include menstrual irregularity, mild hypotension and, rarely, hyperkalaemia; potassium levels are monitored during treatment. Contraindicated in pregnancy. Not used in male patients (risk of gynaecomastia).
• Combined oral contraceptives (oestrogen + progestin): Effective in the right patient profile, particularly in those with a PCOS background. The progestin component should be anti-androgenic — preparations with androgenic progestins can worsen acne. Cardiovascular risk factors, migraine (particularly with aura), smoking and a history of thromboembolism are all assessed. A gynaecology referral is recommended.
• PCOS background: Where hirsutism, menstrual irregularity and weight gain are present, joint assessment with an endocrinologist or gynaecologist is required. Insulin sensitivity and metabolic management are just as important as acne treatment.

"Hormonal acne" in male patients:

Spironolactone is not the hormonal treatment option in male patients. The key question in male patients is anabolic steroid, high-dose testosterone supplementation or performance-enhancing product use. "Steroid acne" is a severe presentation predominantly affecting the back and shoulders — no treatment will produce a lasting response unless use is discontinued. We approach this subject openly and without judgement; the goal of the conversation is to find a solution, not to pass comment.

Aesthetic methods serve two distinct roles in acne management: supportive during active acne and primary treatment in the scar phase.

Supportive applications during active acne:

• Superficial chemical peel (salicylic acid 20–30%): Salicylic acid is lipophilic and can penetrate the oily follicle; in superficial comedonal and mild inflammatory acne it accompanies medical treatment in sessions spaced 2–4 weeks apart. Glycolic acid is an alternative, but salicylic acid has a more suitable profile for acne.
• Extraction and open comedone clearance: Carried out under sterile conditions. Not performed when severe inflammatory lesions are present.

During active cystic acne, intensive mechanical procedures (aggressive microneedling, deep peels, ablative laser) are not undertaken — they create new inflammation and new scarring.

Scar treatment — after active acne is controlled:

Acne scar treatment begins once active acne has been controlled (generally after waiting 6 months from the completion of isotretinoin). A typical programme consists of 4–6 sessions over 6–12 months:

• TCA CROSS: Concentrated TCA (70–100%) is applied precisely to the base of ice-pick scars; new collagen formation raises the base of the scar. Not suitable for boxcar or rolling scars.
• Fractional laser (Er:YAG, CO₂ or 1,550–1,927 nm non-ablative): Columns of microscopic injury in the dermis stimulate collagen remodelling. The standard choice for boxcar and rolling scars. The risk of hyperpigmentation is higher in Fitzpatrick III–VI skin types; settings and patient selection are critical.
• Microneedling + platelet-rich plasma (PRP): Controlled micro-channels combined with platelet-rich plasma derived from your own blood. Less invasive than fractional laser; typically requires 4–6 sessions.
• Subsision: Releases fibrous bands tethering rolling scars from beneath using a fine needle. Combined with laser and microneedling.
• PIH treatment: Azelaic acid, triple cream (hydroquinone + retinoid + steroid), niacinamide and superficial peeling. SPF 50+ sunscreen used every day, year-round, is non-negotiable — no pigmentation treatment produces a durable result without it.
• PIE: Vascular laser (KTP 532 nm, pulsed dye 595 nm) or natural fading over time; sun protection is critical.

A realistic goal is 50–70% improvement. Promises of complete scar elimination are commercial claims, not clinical reality.

The pathway below is an example plan for a patient with moderate to severe acne and scarring; individual plans are developed at consultation. In mild presentations, the isotretinoin and scar treatment phases may not be required at all.

1. Month 0: Consultation, lesion classification, blood tests (for isotretinoin candidates), photographic baseline, start of topical treatment.
2. Months 0–3: Topical (adapalene in the evening, BPO in the morning) ± doxycycline 100 mg/day. Regular review and SPF 50+.
3. Month 3 review: If response is adequate, topical treatment continues and the antibiotic is stopped. If response is insufficient, isotretinoin is considered and the pregnancy prevention programme is initiated.
4. Months 3–8: Isotretinoin (in suitable patients), monthly review and blood tests.
5. Months 8–14: Topical maintenance, monitoring for new lesions; scar treatment is deferred until the skin has settled.
6. Months 14–24: TCA CROSS, fractional laser and/or microneedling + PRP sessions selected according to lesion type (4–6 sessions over 6–12 months).

The plan is given to you in writing; the goal and duration of each phase should be clear.

• Adolescent acne (ages 12–19): Candidates for topical treatment and, where necessary, oral antibiotics. In severe, scar-producing presentations, isotretinoin is considered; in this age group, blood monitoring and mood assessment take place with a parent present.
• Adult acne (ages 20–40): Hormonal evaluation becomes central; in female patients, spironolactone or combined oral contraceptives are discussed. Topical treatment forms the foundation at all ages.
• Female patients with a hormonal acne profile: Those with PCOS, hirsutism or menstrual irregularity; in conjunction with a gynaecology or endocrinology referral.
• Nodulocystic (severe) acne patients: Isotretinoin candidates — women who accept the pregnancy prevention programme and monthly monitoring, and patients outside reproductive age.
• Patients who have reached the scar phase: Active acne controlled for at least 6 months, with scars now stable. Suitable for fractional laser, TCA CROSS and microneedling + PRP.
• Post-inflammatory mark patients (PIH/PIE): Those able to maintain sun protection, candidates for topical pigmentation treatment and superficial peels where indicated.

• Pregnancy: Tretinoin, adapalene (including topical formulations), isotretinoin and spironolactone are contraindicated. Options during pregnancy are very limited (azelaic acid, limited topical erythromycin, gentle cleansers). Treatment is deferred where possible until after delivery and the end of breastfeeding.
• Breastfeeding: Isotretinoin and tetracycline-class antibiotics are contraindicated. Any medication to be used is selected in consultation with the treating clinician and a paediatrician.
• Active liver disease: Isotretinoin is deferred; topical treatment and safer systemic options are assessed.
• Uncontrolled hyperlipidaemia: Internal medicine evaluation and lipid profile control are required before isotretinoin.
• Psychiatric history: If isotretinoin is planned, joint monitoring with a psychiatrist is arranged; management takes place within the ongoing patient–clinician relationship, not only when the drug is stopped.
• Perioral dermatitis, rosacea, folliculitis: Conditions that resemble acne but require entirely different treatment. Applying an acne protocol following an incorrect diagnosis can worsen the underlying condition. Differential diagnosis is therefore carried out at the initial examination.
• Suspicious squamous lesions: Skin lesions that are long-standing, asymmetric or prone to bleeding are not acne — biopsy and histopathological examination are required. "Every red mark is acne" is an unacceptable clinical error.
• Dermatitis or eczema history: Topical agent selection and starting doses are adjusted to account for this sensitivity; an aggressive start may flare the condition.
• Scar treatment under the age of 18: Invasive scar treatment is typically deferred while active acne continues and the face is still growing; a patient and staged approach is preferred.
• Fitzpatrick IV–VI skin types: The risk of hyperpigmentation with fractional laser and medium to deep chemical peels is elevated; settings and practitioner experience are critical factors.

A clinic that can also say "this is not right for you" or "not now — later" is a clinic that produces lasting satisfaction. Offering an unsuitable treatment delivers short-term income and long-term problems.

Acne does not fit neatly within a single specialty. Topical and systemic treatment is the domain of dermatology; scar treatment (TCA CROSS, fractional laser, microneedling) draws on surgical-aesthetic expertise; hormonal background requires the perspective of endocrinology and gynaecology. At Nis Clinic, treatment is managed by Op. Dr. İbrahim Meyzin from a plastic surgery perspective, with dermatology collaboration engaged at every stage that requires it. A plastic surgery foundation is particularly relevant in scar treatment — facial anatomy, wound-healing dynamics, scar biology and laser safety are fundamental to this discipline. When hormonal assessment or medication selection is needed, joint decisions are made with dermatology and endocrinology colleagues. We do not follow the "one doctor knows everything" model; we follow the "right question to the right specialist" model. Member of the Cyprus Turkish Medical Association (CTMA), Registration No. 969.

Full doctor profile: Op. Dr. İbrahim Meyzin

Two marketing narratives are common in the market: "laser cleared the acne scars in one go" and "one antibiotic course is enough". Neither is correct in isolation. Laser performed while active acne is uncontrolled creates new inflammation; antibiotics alone reach the bacteria but do not resolve hyperkeratinisation and lead to resistance.

The Nis Clinic approach:

• First priority — control active acne: Topical foundation plus systemic or hormonal treatment where required.
• Prevent new scar formation: In severe presentations, not delaying isotretinoin in suitable candidates.
• Scar treatment after active treatment is complete: Different methods are planned together according to lesion type (ice-pick / boxcar / rolling / hypertrophic / PIH / PIE). Treating all scar types with a single tool does not work.
• Long-term maintenance: Acne is a chronic condition. After treatment, topical maintenance and lifestyle advice reduce the risk of relapse.

Your plan will not be the same as someone else's — and it should not be. A written treatment plan, with the goal and duration of each phase, is shared with you.

The multistage nature of acne treatment cannot be captured in a single fee. At Nis Clinic, the package is broken down by phase; each phase carries a clear price and timeline. Approximate ranges:

Pricing varies according to the medications and products used, number of sessions, device parameters and combination planning. Blood tests and medication costs are generally not included in the package — these are billed separately by the external laboratory or pharmacy. A personalised plan and written price confirmation are provided after consultation; there are no hidden charges.

Acne treatment is typically managed as outpatient follow-up and does not require a medical tourism package; monthly review appointments can be conducted online (Zoom or WhatsApp video call). In-person attendance at the clinic is required for scar treatment sessions. Related pages: Chemical peel, PRP, Mesotherapy, Pigmentation treatment, Op. Dr. İbrahim Meyzin profile, Contact, Book a consultation.