Objective To compare the effects of Yiqing Tablets and self-made Xiaocuo decoction on the efficacy and safety in the treatment of moderate to severe facial acne. Methods A total of 80 patients with moderate to severe facial acne admitted to Taizhou Fourth People's Hospital from March 2023 to November 2024 were selected as the research subjects. According to the random number table method, they were divided into the control group and the observation group, with 40 patients in each group. All patients was treated with fire needle and fusidic acid cream. On this basis, the control group was given Yiqing Tablets, and the observation group was given self-made Xiaocuo decoction. The clinical efficacy, TCM syndrome scores and adverse reactions were compared between the two groups. Results The total effective rate of treatment in the observation group was 87.50%, which was higher than 67.50% in the control group (P <0.05). After treatment, the TCM syndrome scores in the observation group were lower than those in the control group (P <0.05). There was no significant difference in the incidence of adverse reactions between the two groups (P >0.05). Conclusion For patients with moderate to severe facial acne, using self-made Xiaocuo decoction on the basis of conventional treatment with fire needle and fusidic acid cream can better improve their clinical symptoms, ensure the curative effect and medication safety, and is worthy of clinical application.