I have treated acne for 6 months and it is still not clear. What next?

Escalate to the next step: if Isotretinoin has not been used yet, it is time to consider it. For women with acne, check a hormonal workup. If the lesions are not typical papules/pustules, it may be folliculitis or perioral dermatitis and the diagnosis needs to be reassessed.

What are the side effects of Isotretinoin?

Dry skin/dry lips (common), raised blood fats (LFT checked every 4-8 weeks), must not be used in pregnancy (can be fatal to the baby), temporary low mood, depression. Must be monitored by a doctor throughout.

My acne is not clearing but I do not want Isotretinoin. What are the options?

For hormonal acne: Spironolactone 100-200 mg/day or a Combined OCP (Drospirenone+EE) is effective in 60-85%. For truly inflammatory acne, no option matches Isotretinoin, but there is a reduced-dose protocol of 0.25-0.5 mg/kg/day if there are significant limitations.

Chronic Acne That Won't Clear: Refractory Acne Protocol by an IOD Faculty Dermatologist

6 days ago

1 min read

Acne for 2-3 years, tried many products, visited several clinics and still not clear? You may have Refractory Acne, acne that resists treatment and needs a specific protocol, managed by Dr. Patara Voravutinon, faculty member at the Institute of Dermatology (Outstanding Dermatologist 2025)

Why won't acne clear? 5 main causes

1. Hormonal causes not treated (PCOS, androgen excess, late-onset adrenal). 2. Not escalated to Isotretinoin. 3. Subclinical Demodex/Malassezia, not true acne. 4. Picking at pimples. 5. Acne fulminans / HS.

Refractory Acne Treatment Ladder

Step 1: High-strength topical retinoid (Tretinoin 0.1% or Adapalene 0.3%) + BPO 5%. Step 2: Doxycycline 100 mg BID for 3 months. Step 3: Spironolactone 100-200 mg/day (women) or OCP. Step 4: Isotretinoin 0.5-1 mg/kg/day for 6-9 months. Step 5: Acne scars: Fractional CO2, RF Microneedling, Subcision (Dr. Naphan Buarubporn, plastic surgeon).

Book a consultation

If you have treated acne for years without it clearing, do not keep going with the same treatment. LINE @siamderm to book a consultation with a specialist doctor

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Written by Dr. Patara Voravutinon, Dermatologist · Last reviewed July 16, 2026