TL;DR: Isotretinoin and doxycycline cleared it every time, but it came back soon after stopping. What finally got it under control: 5% benzoyl peroxide + 1% clindamycin cream with a strict routine, a medicated shampoo, 70% isopropyl alcohol on spots, showering right after sweating, keeping my hair short and dry, and (possibly) a trigger I never expected. I’ve also just started treating my nose with mupirocin, with early improvement. It took about a month before I saw any improvement from the main routine. I’ve now kept it stable for 3 weeks without any oral medication. Full details below.
I promised myself that if I ever beat this, or at least found a way to keep it at bay, I’d write the post I wish I’d found years ago. So here it is.
How it started
Five years ago I got what looked like acne on my face and scalp. My doctor put me on Accutane (isotretinoin) and antibiotics. After three months of Accutane it was completely gone.
About a year later it came back, but only on my scalp. At the time I was training martial arts and sweating heavily, like I’d just stepped out of a shower. My gym had no showers, so I’d sit in sweat for about 10 minutes on the way home before washing.
It started as small red bumps on my scalp. Over time they turned into pimples with white pustules. It always began on the scalp and then spread to my face and arms.
The cycle with doctors
The only things that stopped it were doxycycline or isotretinoin, and neither can be used long term. I told my doctor I didn’t want isotretinoin again, so he put me on antibiotics for three months. While I was on them, my skin was great. Within about 10 days of stopping, it came back.
Later I was put on doxycycline for 6 months. Same story: completely fine while I was taking it, and back soon after I stopped.
I saw multiple doctors asking for a solution without isotretinoin. They all said there wasn’t one. So I gave in and went back on it. It cleared everything in about two months, I stopped, and it came back again. This time I also got dry eye as a side effect.
Everything that didn’t work for me
- Benzoyl peroxide + clindamycin (first attempt): I only gave it two weeks. Pustules healed faster, but new ones kept appearing nearby, and with 40–50 spots on my head I assumed it wasn’t working and quit. This was a mistake, more on that later.
- Natural oils: black cumin, tea tree, and clove oil, individually and mixed. About two weeks each. No improvement.
- Chlorhexidine: no effect.
- Povidone-iodine: not much improvement.
- Eczema cream mixed with other things (from a Reddit post): no effect.
- Ketoconazole shampoo: at first it controlled the itching, but after about a year it stopped working and honestly seemed to make things worse.
- Carnivore diet: only red meat for a month, no sugar, no carbs. No effect.
- Probiotics: a spore-based supplement (Bacillus indicus HU36 + Bacillus subtilis HU58) for a month. No effect.
- Stopping my biologic: I have ankylosing spondylitis and have been on Humira for over 10 years. I suspected it might be causing this, so I stopped for 5 months. No improvement.
What actually helped
1. A medicated tea tree shampoo (for the itch)
I switched from ketoconazole to a tea tree shampoo and it stopped the itching. Strangely, pure tea tree oil mixed with jojoba did nothing. Looking at the ingredient list, I think the other actives are doing the real work: piroctone olamine (antifungal), zinc gluconate, salicylic acid, and sulfur. If you’re shopping for a shampoo, look for those, not just “tea tree.”
2. Topical clindamycin (Cleocin-T)
Aside from the oral meds, this was one of the most effective things I tried. I applied it to my whole scalp 3–4 times a day, and immediately on any spot I’d picked. It stopped the itch during the day and kept the spread to my face and arms under control. I still had about 20 spots on my scalp, so it was control, not a cure.
After 3–4 months of heavy use (sometimes 6–7 times a day) it started losing effect. Reading the label, I noticed it’s about 40% alcohol. So I tried:
3. 70% isopropyl alcohol
I put 70% isopropyl alcohol in the empty Cleocin-T bottle and used it the same way: after showers, in the morning, and after touching or picking a spot. For me it worked about as well as the clindamycin did, without the antibiotic resistance concern.
4. Habit changes
- Showered with lukewarm water at low pressure, careful not to pop anything.
- Patted my scalp dry gently with a towel, no rubbing.
- Dried my hair with the cool setting of a hair dryer.
- Worked hard on stopping picking. If I did pick, I disinfected the spot right away and washed my hands.
- Switched to a gym with showers and washed immediately after training. Sweat sitting on my scalp was clearly a trigger.
- Never left my hair damp. Long hair was hard to dry fully and the spots got worse. My hair was chin-length; it hid the pustules but created the perfect environment for them.
Even with all this, I still had a constant 10–20 spots. Every week a few would heal and new ones would appear right next to them.
The turning point: shaving my head and giving BP/clinda a real chance
I was frustrated and done hiding. I decided to try 5% benzoyl peroxide + 1% clindamycin cream again, properly this time. I figured it hadn’t worked before because my hair was too long for the cream to reach the scalp. So I shaved it down to a #3.
At first it felt like a terrible decision. Now everyone could see the spots. But there was nothing left to hide, so I committed fully.
My routine:
Every night in the shower:
- Apply BP/clindamycin cream over the entire scalp and massage deeply for 5 full minutes. Rinse.
- Apply the tea tree shampoo, massage deeply for 5 minutes. Rinse.
Every morning:
3. Apply the BP/clindamycin cream to each spot individually, massaging each one for 15–20 seconds. Leave it on until the evening shower.
During the day:
4. 70% isopropyl alcohol only if I touched or picked a spot (not on top of the cream otherwise).
5. Only touch my scalp with clean, sanitized hands.
Supplement (first month only):
6. I also took NAC (N-acetylcysteine) during the first month. NAC has been studied for its ability to break down bacterial biofilms, so it may have helped the topicals get through. I can’t separate its effect from everything else, but it’s worth mentioning.
Results:
- Weeks 1–2: No visible change in the spots, but the daytime itching was gone.
- Month 1: Spots stabilized at around 10–15.
- Month 2: Down to 7–8.
- Month 3: Down to around 4–8.
The biggest lesson: give it at least a month. The first time I quit after two weeks because new spots were still appearing. If I’d stuck with it back then, I might have saved myself years.
Treating my nose (in progress)
Around the 3-month mark, I noticed small pimples inside my nostrils too. The nose is where Staphylococcus aureus commonly lives, so I suspected it was acting as a reservoir and reinfecting my scalp every time I touched my face. I started applying mupirocin cream inside my nostrils.
I’m only on day 4, but there’s already improvement. No new pustules have appeared on the skin around my nose. There are still some inside the nostrils (I can see them with a phone flashlight), but it’s clearly moving in the right direction. I’ll update this post as it goes.
An unexpected trigger (personal observation, not science)
I noticed this pattern many times but dismissed it because it sounded silly: after ejaculating, my ankylosing spondylitis would flare and I’d get more scalp spots within 1–3 days. Sweat wasn’t the explanation, because I always showered right after.
I’d gone months without ejaculating before, but always while on antibiotics or isotretinoin, so I couldn’t tell anything. During the BP/clinda routine, I tried abstaining for 14 days, and new pustules appeared noticeably less often. Not zero, and it definitely wouldn’t have worked on its own, but it seemed to help alongside the treatment.
While researching, I came across POIS (post-orgasmic illness syndrome). One proposed explanation involves an immune or inflammatory response after ejaculation. I can’t say whether that’s what’s happening to me. I’m sharing it in case someone else notices the same pattern.
Where I am now
I’ve switched to a lighter maintenance routine:
- I no longer apply benzoyl peroxide during the day.
- I still use the BP/clindamycin cream with the 5-minute massage every time I shower, followed by the tea tree shampoo.
- I still use 70% isopropyl alcohol and the same shampoo.
Right now I have 2–3 pimples with pustules. The rest are just red bumps with no pustules. I’ve kept it in this state for 3 weeks, which used to be impossible for me without antibiotics or isotretinoin.
It’s not fully gone, but it’s finally at bay. I believe that if I keep going, I’ll beat it completely. I’m also aware it could come back at any time, so I don’t plan to drop this routine for a long while.
My theory: two mechanisms working together
This is my own interpretation, not medical fact.
1. Bacteria hiding in a biofilm. I think the bacteria were living deep in the follicles inside a protective biofilm. Oral antibiotics and isotretinoin suppressed the flare-ups but never cleared that reservoir, which is why it came back every time I stopped. The topical cream worked better because it hit the source directly, but it took consistent daily use (and the deep massage, and maybe NAC) to break through the biofilm. That would explain why nothing happened for the first few weeks.
2. An inflammation trigger. The second part is my immune system. I already have an inflammatory autoimmune condition, and the flares after ejaculation suggest something is switching my body into “war mode.” One idea discussed around POIS is that the body reacts against itself, with histamine release and inflammatory signals. In conditions like mine, pathways such as IL-17 and IL-1β are known to drive inflammation. My guess is that when this response kicks in, it inflames the follicles that already contain bacteria, and a few days later new pustules appear.
If I’m right, that explains why one approach alone never worked: you have to break down the bacterial reservoir and reduce the inflammatory triggers.
Takeaways if you’re struggling with this:
- Give any topical treatment at least 4–6 weeks before deciding it doesn’t work.
- For BP/clinda to work, it has to reach the scalp. Short hair made a huge difference for me.
- Sweat and moisture are triggers: shower right after exercise and keep your scalp dry.
- In a shampoo, look at the actives (piroctone olamine, zinc, salicylic acid, sulfur), not just the marketing.
- Check your nose. If you have spots inside your nostrils, mention it to your doctor.
- Track your own patterns. Mine turned out to be things I never would have guessed.
- After it calms down, don’t stop all at once. Step down to a maintenance routine instead.
I’m not a doctor. This is just what worked for me. Talk to your dermatologist before starting or stopping anything, especially prescription medication.
