Objective To investigate the efficacy of fire needling combined with pulsed laser and erythromycin ointment in treating cystic acne， as well as its impact on the levels of serum follicle-stimulating hormone （FSH）， luteinizing hormone （LH）， and estradiol （E2）， and skin lesions. Methods A total of 204 patients diagnosed with cystic acne and admitted to the Geriatric Hospital Affiliated to Wuhan University of Science and Technology between July 2022 and December 2023 were included in this study. By using a random number table method， they were divided into four groups： the control group， which received fire-needling treatment； combination group 1， treated with fire needling plus pulsed laser； combination group 2， treated with fire needling plus erythromycin ointment； and combination group 3， treated with fire needling， pulsed laser， and erythromycin ointment. With a treatment course of one month， all groups underwent three courses of treatment. Propensity score matching （PSM） was employed to match the clinical data at a ratio of 1∶1∶1∶1. The efficacy， sex hormone levels before and after treatment， severity of skin lesions， skin barrier function， and adverse reactions were compared among the groups. Results Before PSM， a total of 204 patients were included in the study， with 51 cases allocated to each group. After PSM， each group was composed of 40 patients， and their baseline data were comparable （P > 0.05）. There were significant differences in the clinical effective rates among the groups. Specifically， the effective rate in combination group 3 was 92.50%， which was significantly higher than that in the control group （65.00%） and combination group 2 （75.00%） （P < 0.05）. Nevertheless， there was no statistical difference when compared with combination group 1 （85.00%）. After treatment， the serum levels of FSH， LH， and E2 increased in all groups. Among them， combination group 3 showed the highest levels of these hormones （P < 0.05）. Additionally， the skin lesion scores of all groups decreased after treatment， and combination group 3 had the lowest scores （P < 0.05）. Regarding skin physiological parameters， after treatment， the stratum corneum water content increased in all groups， whereas the transepidermal water loss （TEWL）， the content of mucins and proteins related to desquamation， and skin erythema （a value） decreased. Combination group 3 had a higher stratum corneum water content than the control group， lower TEWL than the control group and combination group 2， a lower a value than the other three groups， and lower content of mucins and proteins related to desquamation than the control group （P < 0.05）. The adverse reactions that occurred during treatment included itching， redness， swelling， and mild bleeding. The incidence of adverse reactions in combination group 3 was the highest， reaching 20.00%. However， there was no significant difference in the incidence of adverse reactions among the four groups （P > 0.05）. Conclusions The combined use of fire needling， pulsed laser， and erythromycin ointment is effective in treating cystic acne. It can improve patients' sex hormone levels and skin lesions without a significant increase in adverse reactions， which demonstrates favorable clinical application value.