Catherine E. Burns
Danielle J. Poulin
Sometimes a diagnosis seems to be quite apparent from the onset of the visit. Still, the provider needs to do the appropriate data collection via history and physical examination, consider alternative diagnoses, and plan care that is individualized to the patient—the “art of medicine.”
1. Apply the guidelines for management of acne to a teenage patient.
2. Discuss the impact of age upon the management plan.
3. Identify lifestyle factors that might affect the condition.
4. Discuss the cultural factors that might affect the management plan and the family’s understanding and compliance with the plan of care.
Case Presentation and Discussion
José Gutierrez is a 16-year-old Mexican American male who comes to your migrant clinic for a sports physical. He has recently joined the wrestling team at his high school. He is accompanied by his mother, who speaks mostly Spanish. She explains via his interpreting that she wants you to help José with his acne, which has been getting worse over the past year and he agrees, hesitantly, though in excellent English, that he doesn’t like the lesions on his face, chest, and back and would like help with this problem.
You ask Mrs. Gutierrez to wait in the waiting room while you talk with José about his health and complete the physical examination, assuring her that you will address the acne problem.
What questions will you ask José related to the acne problem?
Your symptom analysis reveals the following information: The lesions first appeared a year or two ago on his forehead. They seem to be getting worse and now are there all the time and have been appearing on his chest for the past 6 months. He has been showering daily, using Dial soap, but this doesn’t seem to help. He has also bought some acne medicine at a local pharmacy and has been using that but sees little improvement. He can’t remember what the name of the product is. His mother advises him to stop eating fries and chips but he hasn’t done that. She also wants him to use an ointment that she got from her sister in Mexico but it stings and makes his skin red and sore so he doesn’t use it.
What other questions do you need to ask José?
Before answering this question, here is some more information about acne that you need to consider.
Pathophysiology of Acne
Acne is a disorder of the pilosebaceous unit (PSU). Most often the PSUs of the face, chest, back, shoulders, and upper arms are affected. The unit is made up of a wide, stratified squamous epithelium-lined follicle, a rudimentary hair, and large, multi-lobulated sebaceous glands.
The pathogenesis involves androgen stimulation, which causes an enlargement of the sebaceous glands and an increase of sebum production. The androgens also stimulate hyperkeratosis of the follicle causing increased density of keratin and abnormal shedding of the epithelial cells lining the follicle. The combination of sebum and epithelial cell proliferation creates a microcomedone, a precursor to the visible acne lesion. As the microcomedone enlarges, it becomes a noninflammatory or inflammatory lesion.
The noninflammatory lesions are open or closed. Propionibacterium acnes (P. acnes) are anaerobic bacteria normally present on the skin. The closed comedones create the anaerobic environment with the sebum substrate that supports bacterial proliferation. The bacteria stimulate inflammation and weaken the follicular walls. When the walls break, the sebum spills out into the dermis where it causes additional inflammation and formation of a papule, pustule, or nodule. Multiple nodules and cysts can merge to form sinus tracts in the most severe cases (Gollnick, 2003; Kerkemeyer, 2005).
Scars occur in up to 95% of acne cases (Gollnick, 2003). Postinflammatory hyperpigmentation occurs with patients who are darker in skin color such as Hispanics.
Acne is the most common dermatologic problem affecting adolescents, with 80% affected at some point between 11 and 30 years (Paller & Mancini, 2006). It is also the most common dermatologic diagnosis among Hispanics (20.4%) (Halder & Nootheti, 2003). Acne occurs more frequently in adolescents, coinciding with puberty and the increases in androgen hormones. Some health problems associated with acne include XYY (Klinefeller Syndrome), hyperinsulinemia, insulin resistance, adrenal tumor, and pituitary tumor (Leonard et al., 2009; Paller & Mancini, 2006). Many medications can also trigger or exacerbate acne, including androgens, topical and systemic glucocorticosteroids, anabolic steroids, isoniazid, lithium, hydantoin, and gold (Cohen, 2005; Paller & Mancini, 2006). Other contributing factors include lotions, creams, or oils applied to the skin, which can be physically occlusive. Sports gear such as helmets or shoulder pads can also promote acne.
Use of anabolic steroids is relatively common among adolescents involved in sports (Vandenberg, Neumark-Sztainer, Cafri, & Wall, 2007). Anabolic steroid use may also cause weight gain, seborrhea, deepening voice, gyneco-mastia, and depression. There is an increased risk of acne when there are first-degree relatives with the condition. Environmental conditions can also contribute to acne. Working at a gas station or in a restaurant cooking fried foods are examples of risky environments.
Mexicans usually bathe or shower daily and may apply lotions to their skin (Guarnero, 2005); Hispanic males may use pomade when grooming their hair, a predisposing factor for pomade acne (Halder & Nootheti, 2003).
The Mexican American patient may seek the services of a curandera instead of or in addition to the services of Western healthcare providers. This may be true especially if the client lacks health insurance or access to Western health care (Guarnero, 2005). Lack of insurance, illegal status, and/or healthcare beliefs may lead the patient to self-treat acne with folk remedies (Guarnero) such as oregano (Howell et al., 2006).
The differential diagnoses for acne include cosmetic, mechanical, environmental, or drug-induced acne; rosacea; flat wart; milia; perioral dermatitis; and folliculitis. Other skin conditions common to wrestlers on sports teams include herpes gladiatorum, tinea corporis gladiatorum, and methicillin-resistant Staphylococcus aureus (MRSA) infections.
From the above review, some other information you should obtain from José includes the following:
• How much has he been wrestling recently? (Exposure to infectious agents)
• What head gear does he wear for wrestling? (Mechanical acne)
• Is he using any steroids to build muscle for his wrestling? (Steroid use)
• Is he taking any medications? (Drug-induced acne or drugs from Mexico)
• Is he working at a gas station, fast food restaurant, or elsewhere where oils are present? (Environmental factors)
• Does he use pomades to groom his hair (Halder & Nootheti, 2003) or other special soaps or cleansing products? (Cosmetic acne)
• Has he had any boils, other rashes, painful blisters, itching, or dryness? (MRSA, tinea, herpes)
• Have there been any other changes in his health—changes in weight, polydipsia, polyuria, polyphagia (Diabetes mellitus, adrenal tumor, insulin resistance), or hypertension? (Anabolic steroid use)
• Have they seen a curandera for this problem and, if so, what was recommended (Howell et al., 2006)? (Integrative medicine approach)
• Are any of his friends having similar problems, and are they having any success keeping acne under control? (Risk factors, peer influence for management)
• Is this problem making him feel self-conscious when he wrestles or elsewhere? (Self-esteem, embarrassment, possibility of limiting his sports participation)
• What is the family history of acne? (Risks, perceptions of care and outcomes)
José responds that he is not taking any medications or working. He has not had any other rashes, boils, or changes in his health. He uses a gel to groom his hair sometimes. He has not seen a curandera. Yes, some of his friends also have acne. One has seen a doctor and has some medications that are helping; others are just using over-the-counter treatments as far as he knows. For his wrestling, he wears ear guards that cover part of his cheeks and have a strap under his chin and through his hair but no other special gear. He has been wrestling all summer about twice a week to get ready for the wrestling season, but the coach checks out the team members’ skin to be sure they don’t have infections. He is embarrassed by the lesions, especially when he dresses for wrestling, but has not considered stopping the sport and doesn’t feel depressed because of his appearance.
Upon physical examination, you find that he has open and closed comedones on his face and forehead, back of the neck, and chest. There are also multiple papules and pustules in all stages of healing (> 40) and his skin is erythematous in the affected regions. There are no nodules, abscesses, or rashes consistent with MRSA, herpes gladiatorum, or tinea corporis. Height, weight, blood pressure, and the remainder of the physical examination are within normal limits for this Tanner stage 4 male. He does not have gynecomastia, hypertension, enlarged liver, edema, or other signs of anabolic steroid use or endocrine abnormalities.
Making the Diagnosis
This history and physical examination are consistent with a diagnosis of acne. He has papulopustular acne or inflammatory acne (Gupta et al., 2009) with pustules and lesions extending over a wide area but no nodules or cysts. Comedonal acne has more comedones with little inflammation. Nodular acne or nodulocystic acne has nodules along with the other lesions. Pomade acne would be more pronounced on his forehead (Halder & Nootheti, 2003), steroid-induced acne is more prominent on the trunk, shoulders, and upper arms (Lembo, 2006). A single lesion would be suggestive of another diagnosis such as a MRSA abscess or localized infection.
Staging the severity of the condition is important to select the appropriate management strategy. Acne is sometimes graded as mild if there are less than 15 lesions and mostly comedones. It is considered moderate if there are 15 to 50 papules and pustules and rare cysts. Severe acne is defined as a predominance of nodules and cysts. Acne fulminans is an acute disorder that requires intensive treatment. It is rare but would present with ulcerative, nodular lesions on the face and upper trunk accompanied by fever, leukocytosis, elevated sedimentation rate, and polyarthritis (Paller & Mancini, 2006).
Other diagnoses to consider but that do not fit this picture include folliculitis, perioral dermatitis, rosacea, and seborrheic dermatitis (Roebuck, 2006).
Do you need to do anything to confirm the diagnosis, such as laboratory studies?
No laboratory studies are recommended in general management of acne. Endocrine studies would be needed if an endocrine evaluation was merited based upon the physical findings.
Therapeutic plan: What will you do therapeutically?
The plan is determined by the type and severity of the acne and needs to be customized to improve the patient’s adherence to the plan. The goals are to:
• Decrease excess sebum
• Decrease the abnormal keratinization and desquamation in the pilose-baceous follicle
• Decrease the colony count of P. acnes
• Decrease inflammation
• Decrease the risks of scarring
Decreasing embarrassment and increasing self-esteem are also important goals.
You need to understand the various treatment options before you can create an individualized plan for this Hispanic adolescent. “Topical therapy is the standard of care for acne” (Strauss et al., 2007, p. 653).
The mainstay and first treatment of acne is a topical retinoid. Topical retinoids are also a mainstay of maintenance therapy. Their primary mechanism of action is normalization of follicular keratinization and perhaps facilitation of follicular penetration of other agents. These products help prevent microcomedones, the precursor of all the other lesions of acne. Retinoids are drying and somewhat irritating to the skin. Application on alternate nights or just two to three times per week is sometimes needed at the beginning of therapy (Roebuck, 2006). Retinoids should be applied to very dry skin to avoid the irritating effects. Alternative choices are azelaic acid or salicylic acid preparations, but these are less effective agents (Strauss et al., 2007).
Benzoyl peroxide is the next therapeutic agent commonly used for acne management. It serves as an antibacterial, comedolytic agent and oxidizing agent. It is available in a variety of concentrations and vehicles though there is little evidence to evaluate the efficacy of these different formulations (Strauss et al., 2007). Gels, topical cleansers, pads, and creams are all available. Benzoyl peroxide is the most common ingredient in over-the-counter acne products (Institute for Clinical Systems Improvement, 2006).
Topical antibiotics are used for moderate and severe acne conditions. Propionibacterium acnes is an anaerobic bacterium present in pilosebaceous follicles. The antibiotics reduce colonization and may possess direct anti-inflammatory effects. A combination of erythromycin or clindamycin and a topical retinoid are more effective than either agent alone. Combining either of these agents with benzoyl peroxide decreases bacterial resistance and enhances efficacy and again, combining the products is more effective than using either product alone (Strauss et al., 2007).
Oral antibiotics are considered the standard of care for moderate and severe acne and treatment-resistant forms of inflammatory acne (Strauss et al., 2007). Doxycycline and minocycline are more effective than tetracycline; minocycline may be more effective than doxycycline. Erythromycin should be used only in those who cannot use the tetracyclines because bacterial resistance is common. Trimethoprim-sulfamethoxazole can be used when the other antibiotics cannot be used. Azithromycin has also been used. There are no studies that support use of ampicillin, amoxicillin, or cephalexin according to the expert panel of the American Academy of Dermatology (Strauss et al.). Because antibiotic resistance is increasing and there are some side effects of antibiotics, they should all be used for as short a time as possible. Vaginal candidiasis is a problem for female patients with all the antibiotics. Doxycycline is associated with photosensitivity. Minocycline may cause pigment deposition in skin, mucous membranes, and teeth. Pigmentation may occur in acne scars, anterior shins, and mucous membranes. Autoimmune hepatitis and serum sickness-like reactions are all rare occurrences with minocycline (Strauss et al.).
Hormonal agents may also be helpful in treatment of acne among women. These decrease androgen levels and thus the production of sebum. Oral contraceptives, spironolactone, and cyproterone acetate are among these types of agents. Oral corticosteroids used in short courses of high dose may be beneficial in patients with highly inflammatory disease but are not considered mainstays of treatment (Strauss et al., 2007).
Oral isotretinoin, a vitamin-A derivative, is approved for treatment of severe acne. It can also be used in less severe cases where either physical or psychological scarring is occurring. It is a potent teratogen and has many other serious adverse effects so it should only be prescribed by physicians knowledgeable in its administration and monitoring. Female patients must participate in the iPLEDGE program (http://www.ipledgeprogram.com). Mood disorders, depression, and suicidal ideation have been reported in addition to other effects summarized in Table 31-1.
The summary of a plan for management of acne of different types and in different levels of severity is found in Table 31-2.
In José’s case, it would be appropriate to prescribe a topical retinoid, benzoyl peroxide, and a topical antibiotic. You choose adapalene 0.1% cream because it is effective and has fewer problems with burning and drying than other agents, and 1% clindamycin with 5% benzoyl peroxide (Duac gel), which should be easy for him to use. You prescribe the adapalene for use at night. The Duac can be applied after the adapalene. Use of an oral antibiotic such as doxycycline is also an option, but you choose to begin more conservatively and then see if it should be added to the regimen later.
Educational plan: What will you do to educate him and his mother about acne and its management?
Points to make through discussion include:
Explain the diagnosis and its pathophysiology, chronic nature, and need for maintenance after it is brought under control.
Explain the use of the various agents you are prescribing: adapalene 0.1% cream, 1% clindamycin with 5% benzoyl peroxide (Duac), and their side effects.
Reassure them that acne is very treatable but results may not be apparent for 6 to 12 weeks. He will need to be patient until the improvements begin.
Alert him that an increase in the number of lesions is common as all the developing ones in the skin layers emerge, but this effect will subside as the lesions are eliminated.
Warn him that some mild irritation and drying may occur at the beginning of treatment, but this response should subside over time.
Advise him to:
- Avoid harsh cleansers and wash with mild soap and water morning and night.
- Use a noncomedogenic sunscreen to minimize sun exposure and photosensitivity and a noncomedogenic moisturizer if needed to combat dryness.
- Avoid over-the-counter acne products at the same time as the prescription ones are being used.
- Avoid oily pomades and keep his hair off his face.
- Avoid squeezing or manipulating the lesions because this will increase infection in the skin.
Assure Jose and his mother that most foods are not related to acne.
Tell him that his acne is not directly related to his wrestling contact with other students, but his ear guard may be a source of some acne lesions on his cheeks. Wrestling, however, can lead to other skin infections and he should watch for any other lesions that are different from the acne ones he currently has.
Table 31–1 Therapeutic Agents Used for Acne
Table 31–2 Outline of Care for Acne
When do you want to see this patient back again?
Generally you want to see new patients beginning acne management in about 6 weeks to assess response to medications and to support the patient as he takes on this new management regimen. You may need to increase the level of care, reduce it, or move to a maintenance program after initial success.
José and his mom seem to understand the regimen as explained and ask appropriate questions. You choose to get a translator for your discussion with the mother so that José is not expected to fulfill that role. You also hand him the prescriptions to give a nonverbal gesture of your trust in him as the primary manager of his condition and his ability to make decisions.
When he returns in 6 weeks, his face and chest have only 15 papules and pustules but there are still many comedones. You congratulate him on his care of his condition and he seems pleased with the progress, although he doesn’t like the dryness of his skin and he didn’t like the emergence of so many pustules during the first few weeks of the treatment. He does not have more lesions on his cheeks where the ear guards were in place. You elect to continue the treatment for another 6 weeks and then reassess his progress.
Key Points from the Case
1. Guidelines simplify the care of acne. They are based on the severity of the condition.
2. Treatment of acne in a teen requires understanding physiology, activities, cognitive development and experience, and the role of provider as advisor, not director, for care.
3. Activities such as sports or after-school work could influence the development and severity of conditions such as acne and need to be considered in assessment and planning for care.
4. Treatment of acne can be influenced by cultural beliefs and practices as with any healthcare problem. Awareness and openness to other approaches to management is helpful.
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