Objective To explore the effect of fire needle combined with oral administration of modified Xiaoyao powder on pigmentation and long-term recurrence in patients with cystic acne. Methods A total of 68 patients with cystic acne treated at Gusu District Pingjiang Street Loujiang Community Health Service Center from January 2024 to January 2025 were selected as the research subjects, and they were divided into the reference group and the study group by the random number table method, with 34 patients in each group. The reference group received conventional western medicine treatment, and the study group was treated with ffre needle combined with oral administration of modiffed Xiaoyao powder on the basis of the reference group. The clinical efffcacy, lesion severity, pigmentation and long-term recurrence were compared between the two groups. Results The total effective rate of the study group was higher than that of the reference group (P<0.05). The GAGS scores of the study group at 1 month and 3 months after treatment were better than those of the reference group (P<0.05). The MI and EI of the study group at 3 months after treatment were lower than those of the reference group (P<0.05). The recurrence rates of the study group during 3-month and 6-month follow-up were lower than those of the reference group (P<0.05). Conclusion Fire needle combined with oral administration of modiffed Xiaoyao powder can improve the clinical efffcacy of cystic acne, reduce lesion severity, relieve post-inffammatory pigmentation and lower the long-term recurrence rate.