A 13-year-old girl complains about “zits” on her face and shoulders. She has tried over-the-counter benzoyl peroxide to no avail, and has stopped eating chocolate and french fries on her mother’s advice. She has been invited to an upcoming school dance and wants to look her best. She complains about blackheads, but also lesions that are deep and painful.
What is the diagnosis?
What is the best treatment for her condition?
ANSWERS TO CASE 50: Acne Vulgaris
Summary: An adolescent girl presents with acne on her face and shoulders.
• Most likely diagnosis: Combination acne.
• Best therapy: First-line therapy includes antibacterial soap, keratolytic agent (benzoyl peroxide), comedolytic agent (tretinoin), and/or topical antibiotic (erythromycin). Oral antibiotics (tetracycline) are a secondary option. Isotretinoin (oral tretinoin) is reserved for severe, resistant nodulocystic acne.
1. Understand the various types of acne vulgaris.
2. Know the treatments for various types of acne.
3. Discuss the potential side effects of isotretinoin.
Acne vulgaris has the potential to be as damaging to the psyche as it can be to the skin. Managing acne successfully involves promoting patient understanding of the basics behind its development, creating thoughtful treatment regimens tailored to each patient, and periodically reassessing acne control in an effort to prevent possible emotional and physical scarring.
COMEDONE: Open comedones (blackheads) are composed of compacted melanocytes; closed comedones (whiteheads) contain purulent debris.
CYST: Dilated and often tender intradermal follicle.
PAPULE: Small, erythematous, and inflamed “bump” under the skin due to sebum, fatty acids, and bacteria reacting within a follicle.
NODULE:Papule greater than 5 mm penetrating deep into the dermis.
PUSTULE: Elevated focus of inflammation and purulent exudate around a comedone, occurring in the superficial dermis.
Pubertal hormonal surges lead to an increase in sebum production by sebaceous glands. Proliferation of the bacterium Propionibacterium acnes leads to distention of follicular walls, causing obstruction of sebum flow. Follicles reach a maximum capacity and rupture, releasing their inflammatory contents. Neutrophils and liposomal enzymes are released, causing further inflammation. Scarring and pitting often may result.
Acne lesions are categorized as inflammatory or noninflammatory. Noninflammatory lesions consist of open and closed comedones. Inflammatory lesions are characterized by the presence of papules, pustules, nodules, or cysts.
Treatment goals are elimination of lesions and diminishment of scarring (Table 50-1). Improvement may not be noticed for at least a month after therapy is initiated, with flare-ups possible during treatment. Patients should be discouraged from manipulating skin lesions because doing so will increase inflammation and promote scarring. The affected skin should be gently washed using antibacterial soap and rinsed well to prevent soap buildup on the skin surface. Scrubbing agents and harsh soaps should not be used, since they may stimulate more oil production and promote acne.
Table 50-1 • TREATMENT OF VARIOUS TYPES OF ACNE
First-line management should begin with topical benzoyl peroxide or a comedolytic agent such as a retinoid (Retin-A). The combination of benzoyl peroxide in the morning and a comedolytic agent at night may be effective when either alone has failed. Benzoyl peroxide must be washed off prior to application of tretinoin or the retinoid will be rendered ineffective. Benzoyl peroxide is bactericidal and keratolytic, causing follicular desquamation. It is available in over-the-counter preparations with variable uniformity, stability, and efficacy. Although these over-the-counter preparations eliminate bacteria at the skin surface, they do not have a carrier vehicle that allows deep follicular penetration. Therefore, 2.5% to 10% prescription preparations are preferable, with gels being more efficacious although more irritating at times; starting at the lowest concentration is recommended. A benzoyl peroxide wash is beneficial when lesions are widely distributed or when adherence to a treatment plan is problematic. Washes are applied in the shower and then rinsed off after approximately 30 seconds. Benzoyl peroxide can bleach fabric, so careful and thorough drying is recommended.
Topical tretinoin, a vitamin A derivative, inhibits the formation of micro-comedones and increases cell turnover. Therapy should begin conservatively at 0.025%, with 3 to 4 weeks allowed for accommodation. Patients should use a mild soap (Dove or Cetaphil) and allow the skin to dry 20 to 30 minutes prior to applying nightly tretinoin. Mild redness and peeling can occur, and patients should avoid sun exposure and use sunscreens. Adapalene 0.1% (Differin) is a retinoid formulation that causes less irritation and photosensitivity, has more activity, and can be used concomitantly with benzoyl peroxide preparations. A combination product combining adapalene and benzoyl peroxide (Epiduo Gel 0.1%/2.5%) is available. Tazarotene 0.1% (Tazorac) is a retinoid that is active against psoriasis. This agent is teratogenic and causes irritation, so it should be used with caution. Some believe that azelaic acid applied twice daily for 4 to 6 months may provide acne relief, especially for those sensitive to other agents, and theoretically can reduce scarring.
Topical, rather than systemic, antibiotics are preferred because of their fewer side effects. Topical antibiotics (erythromycin, clindamycin) often are applied to affected areas twice daily or in combination with benzoyl peroxide or tretinoin. Long-term topical or oral antibiotic monotherapy is not recommended due to the potential development of bacterial resistance. Combination benzoyl peroxide and topical antibiotic preparations can be particularly beneficial, and do not typically promote resistance. Oral antibiotics are used when moderate to severe inflammatory and pustular acne does not respond to topical treatment. Tetracycline is the most frequently used oral antibiotic because it is inexpensive and has few side effects. To minimize the potential for antibiotic resistance, oral antibiotics ideally should be discontinued after a few months. Antibiotics, irrespective of the formulation, should be discontinued once inflammatory lesions are under good control.
Isotretinoinis the treatment of choice for severe, resistant nodulocystic acne. A 5-month course often clears a severe case of acne. It is highly teratogenic and has many side effects, including cheilitis, conjunctivitis, hyperlipidemia, blood dyscrasias, elevated liver enzymes, and photosensitivity. Lipid levels, liver enzymes, and complete blood counts should be monitored monthly during the course. Females should have a negative pregnancy test immediately before isotretinoin is initiated and should maintain effective contraception before, during, and after therapy. Prescribers and patients must be registered in the iPLEDGETM pregnancy prevention and risk management program.
Oral contraceptives (Ortho Tri-Cyclen) are approved for treatment of acne, and intralesional steroid therapy is sometimes used in unresponsive cases.
50.1 A teenager with severe cystic acne started using isotretinoin a month ago. Initially her acne worsened, but is now starting to improve. However, she reports “not feeling normal.” She does not want to go to school, cries frequently, and feels hopeless, but declares no suicidal thoughts. She also feels “achy” all over. Which of the following is the best course of action?
A. Continue isotretinoin and see her in follow-up in a week.
B. Prescribe an antidepressant.
C. Discontinue isotretinoin and refer her to a psychiatrist.
D. Decrease her isotretinoin dose to determine if the side effects resolve.
E. Counsel her that these symptoms will resolve over time.
50.2 A teenage boy complains of a several-week history of facial “zits” that are painful and itchy. There are no other breakouts. He has inflammatory papules and pustules in the beard and moustache area and has mild cervical lymphadenopathy. He occasionally works weekends on a farm. Which of the following therapies is appropriate?
A. Topical isotretinoin
B. Topical hydrocortisone
C. Oral antifungal
D. Topical mupirocin
E. Oral acyclovir
50.3 A 7-day-old infant is brought to clinic because of “pimples” on his cheeks and forehead. He is breast-feeding well, and the parents have no other concerns. The skin around the pimples and elsewhere is unremarkable, as is the rest of his examination. Which of the following is appropriate advice or therapy?
A. Recommend a different soap.
B. Prescribe topical triamcinolone.
C. Prescribe topical erythromycin.
D. Recommend no treatment.
E. Recommend more frequent bathing.
50.4 A 17-year-old girl is prescribed oral tetracycline, topical tretinoin, and topical benzoyl peroxide. She is sexually active and takes an oral contraceptive. You should counsel her to do which of the following?
A. Take the tetracycline with food or milk.
B. Use a second form of birth control in addition to her oral contraceptive.
C. Get some sun to help dry up her acne.
D. Avoid chocolate and fried foods.
E. Avoid sunscreen because it will irritate her face.
50.1 C. Depression is a rare side effect of isotretinoin, but it can be severe and suicides have been reported. Myalgias and arthralgias have also occurred. It would be best to stop the drug and have the patient evaluated for depression.
50.2 C. Tinea barbae is caused by various dermatophytes and closely resembles tinea capitis. It can be acquired through animal exposure and is more common in farmers. Topical antifungal preparations are ineffective; oral antifungals are required.
50.3 D. Approximately 20% of normal neonates develop at least a few comedones within the first month of life. The cause of neonatal acne is unknown, but has been attributed to placental transfer of maternal androgens, hyperactive adrenal glands, and a hypersensitive neonatal end-organ response to androgenic hormones. Such patients may be predisposed to adolescent acne. In most cases a prescription or change in skin care is not warranted.
50.4 B. Oral antibiotics may decrease the effectiveness of oral contraceptive pills. Tretinoin can lead to photosensitivity; patients should avoid sun exposure or use sunscreen. Diet has not been found to have an effect on acne. Tetracycline should be taken on an empty stomach; milk products bind tetracycline.
Acne is a disorder of the sebaceous follicle in which excess sebum, keratinous debris, and bacteria accumulate, producing microcomedones that may become inflamed.
Treatment of acne depends on its severity and distribution, and may involve a regimen of oral or topical agents, alone or in combination.
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