Objective To analyze the effect of acne pricking combined with red light irradiation and Periplaneta americana wet compression on skin physiological parameters in elderly patients with perianal acne inversa. Methods A total of 80 elderly patients with perianal acne inversa admitted to Beijing Anzhen Hospital Affiliated to Capital Medical University Nanchong Hospital from December 2022 to December 2024 were selected, and they were divided into the reference group and the observation group according to different treatment methods, with 40 patients in each group. The reference group received acne pricking combined with red light irradiation, and the observation group received acne pricking combined with red light irradiation and Periplaneta americana wet compression. The skin physiological parameters, lesion score, clinical efficacy and adverse reaction rate were compared between the two groups. Results After treatment, the porphyrin index, erythema index, heme, transepidermal water loss rate and sebum secretion of the observation group were lower than those of the reference group, and the skin elasticity index and skin stratum corneum hydration were higher than those of the reference group (P<0.05). The lesion score of the observation group after treatment was lower than that of the reference group (P<0.05). The total effective rate of treatment in the observation group was 97.50%, which was higher than 77.50% in the reference group (P<0.05). The incidence of adverse reactions in the observation group was 2.50%, which was lower than 42.50% in the reference group (P<0.05). Conclusion Acne pricking combined with red light irradiation and Periplaneta americana wet compression has an ideal clinical effect in the treatment of elderly patients with perianal acne inversa. It can effectively improve skin physiological parameters, reduce lesion score and the incidence of adverse reactions.