Acne Vulgaris

  • Core 1 (Pre-clerkship)
    • Integrative Systems
      • Dermatology 
        • Intro to Derm
        • Skin of Color
        • Acne
  • Core 2 (Clerkship)
    • Pediatrics - Well Child/Development Didactics
  • Core 3 (Post-clerkship)
    • Electives that may further knowledge: Pediatric dermatology, Dermatology

A 16-year-old male presents to the clinic for his annual well-child visit, expressing concern about painful bumps on his face that have developed over the past six months. On examination, he has multiple nodular and cystic lesions on his cheeks and forehead, with signs of inflammation and some scarring. Despite trying over-the-counter treatments, he feels self-conscious about his appearance and has started to withdraw from social activities. 

Onset and Duration:  

  • When did the acne first appear?  
  • How long has it been present?  
  • Is the acne worsening or improving? 
  • Does the acne coincide with the start of puberty or menstruation?  

Menstrual and Pubertal History (for females):  

  • Does acne worsen or improve during specific points in the menstrual cycle?  
  • Has puberty started? Are there any other signs of puberty, such as breast development, body hair, or menstruation?  

Family History:  

  • Do any family members have a history of acne or other related skin conditions? 

Medication history:  

  • Is the patient taking any medications and supplements (like progestin-only contraceptive agents or testosterone supplements) that may contribute to acne? 

Current and Previous Treatments:  

  • What treatments have been tried in the past, and what were the results?  
  • How well is the patient following the prescribed treatment plan?  

Lifestyle Factors:  

  • Skincare routine: What products are used for skincare?  
  • Diet: Are there any perceived dietary triggers for acne?  
  • Stress: Is the patient experiencing high levels of stress? 
  • Smoking: Does the patient smoke?  

Psychological and Social Impact:  

  • How does the acne affect the patient's self-esteem, confidence, and social interactions? 
  • Is the patient experiencing any mood changes or symptoms of depression related to the acne? 

Daily Activities:  

  • How does the acne impact daily activities, such as school, sports, or social interactions? 

Source: https://www.sciencedirect.com/science/article/abs/pii/S1751722222001834#:~:text=Around%2020%%20of%20adolescents%20will%20have%20moderate%20to%20severe%20acne.&text=History%20should%20include%20age%20of%20onset%2C%20initial,self%2Desteem%2C%20mood%20and%20daily%20activities%20including%20relationships/school/sport. 

  • Lesion Assessment: Identify closed comedones (whiteheads) vs. open comedones (blackheads) vs. papules vs. pustules vs. nodules vs. cysts 
    • Closed comedones (whiteheads): Noninflammatory; <5 mm; dome-shaped; smooth; skin-colored, whitish, or grayish papules 
    • Open comedones (blackheads): Noninflammatory, <5 mm papules with a central, dilated, follicular orifice containing gray, brown, or black, keratotic material 
    • Papulopustular acne: Inflamed, relatively superficial papules and pustules, typically <5 mm in diameter 
    • Nodular acne: Deep-seated, inflamed, often tender, large papules (≥0.5 cm) or nodules (≥1 cm) 
  • Scarring: Look for post-inflammatory hyperpigmentation or pitted scars (icepick, boxcar, rolling). 
  • Distribution: Note the location of lesions (face, chest, back, shoulders).  
  • Severity: Assess the extent of involvement (mild, moderate, or severe).  
    • While there is no universally accepted method of assessing acne severity, here are classifying characteristics from UptoDate: 
      • Mild acne vulgaris: 
        • Scattered, small (<5 mm) comedones, inflamed papules or pustules without associated scarring  
        • Limited skin involvement (involvement of one body area)  
        • No nodules  
        • No confluent skin involvement 
      • Moderate to severe acne vulgaris: 
        • Presence of nodules  
        • Involvement of multiple body areas with more than a few scattered lesions  
        • Associated severity  
  • Assess Tanner Stage 
    • Precocious puberty is the onset of Tanner 2 secondary sexual characteristics before 8 years of age in girls or 9 years of age in boys.  
  • Signs of Hyperandrogenism 
    • Hirsutism: Male pattern hair growth in women.  
    • Virilization: Development of male secondary sexual characteristics in women, such as male pattern baldness, clitoromegaly, and deepening of voice. 

Source: https://www.ncbi.nlm.nih.gov/books/NBK459173/ 

Treatment Plan based on Severity: 

  • Mild (comedonal ± few inflammatory lesions) 
    • First line 
      • Topical retinoid (e.g., adapalene, tretinoin) ± 
      • Benzoyl peroxide (BPO) ± 
      • Topical antibiotic (e.g., clindamycin) — always combine with BPO to prevent resistance 
    • Alternatives 
      • Azelaic acid (especially for sensitive skin or post-inflammatory hyperpigmentation) 
      • Salicylic acid as adjunct 
  • Moderate (more inflammatory lesions, some nodules) 
    • First line 
      • Topical retinoid + BPO + topical antibiotic or 
      • Oral antibiotic (e.g., doxycycline) + topical retinoid + BPO 
    • Considerations 
      • Limit oral antibiotic use to 3-4 months 
      • Evaluate for hormonal therapy in females (e.g., combined oral contraceptives, spironolactone) 
  • Severe (nodulocystic, widespread, scarring) 
    • First line 
      • Oral isotretinoin (iPLEDGE program in U.S.) 
    • Alternatives (if isotretinoin contra-indicated) 
      • Oral antibiotic + topical retinoid + BPO ± hormonal therapy (for females) 
    • Monitoring: 
      • Labs: Monitor lipid panel, liver enzymes, pregnancy test before/during treatment with isotretinoin 
      • Contraception: Required to be on two forms of contraception while on isotretinoin 
    • Psychosocial: Assess for psychosocial distress and signs/symptoms of anxiety and/or depression  

Additional Considerations: 

  • Signs of Precocious Puberty:  
    • Perform a comprehensive physical exam and Tanner staging.  
    • Obtain a bone age radiograph if hyperandrogenism is suspected.  
    • Refer to pediatric endocrinology for advanced evaluation if necessary.  
  • Signs of Hyperandrogenism:  
    • Consider screening for underlying disorders like congenital adrenal hyperplasia, polycystic ovarian syndrome (PCOS), etc. 

 

Source: https://www.jaad.org/article/S0190-9622%2823%2903389-3/fulltext

  • Acne, even if it appears mild, can cause significant emotional distress, affecting self-esteem, confidence, and social interactions. This psychological burden may justify a more aggressive treatment approach, similar to that used for moderate to severe acne.  
  • Oral isotretinoin should be considered early for severe, nodular, or cystic acne, as it is the only medication that can permanently alter the natural course of acne and lead to long-term remission after stopping the treatment.  
  • A thorough evaluation of acne severity includes assessing lesion type (e.g., blackheads, whiteheads, papules, pustules, nodules), distribution, associated scarring, and impact on daily life and emotional well-being to guide appropriate treatment plans. 

Click the drop down to reveal the correct answers

Q1:A 16-year-old female presents with severe, nodulocystic acne that has not responded to oral antibiotics (e.g., doxycycline) and topical treatments (e.g., tretinoin). She has a history of persistent scarring and is frustrated with her acne. After a thorough discussion of potential risks, she is considered for isotretinoin therapy.  

Which of the following is NOT a necessary consideration when initiating isotretinoin treatment? 

  1. Baseline pregnancy test and contraception counseling 
  2. Liver function tests and lipid profile monitoring 
  3. Baseline EKG to assess for cardiac issues 
  4. Family history of depression or history of psychiatric disorders 

 

Q2: A 19-year-old male presents to your clinic with mild to moderate acne on his face, consisting primarily of comedones (both open and closed), along with a few papules. He has tried over-the-counter benzoyl peroxide with some improvement, but the acne persists.  

What is the most appropriate next step in the treatment of his acne? 

  1. Topical retinoid (e.g., adapalene) 
  2. Oral antibiotics (e.g., doxycycline) 
  3. Isotretinoin 
  4. Topical corticosteroid 

Answers: 

Q1: c. Baseline EKG to assess for cardiac issues 

A baseline EKG is not routinely required for isotretinoin therapy. While isotretinoin can have various side effects, cardiovascular effects like arrhythmias are not commonly seen. Routine EKGs are not needed unless the patient has a specific cardiovascular history or symptoms that warrant further investigation. 

Incorrect Answers:

a. Baseline pregnancy test and contraception counseling

This is essential for all females of reproductive age before starting isotretinoin. Isotretinoin is highly teratogenic, and a baseline pregnancy test is required. Additionally, monthly pregnancy tests are often mandated during treatment. Patients must be on two forms of contraception. Contraception counseling is critical to ensure effective birth control is used during treatment and for a period after treatment ends.

b. Liver function tests and lipid profile monitoring

Monitoring liver enzymes (AST/ALT) and lipid levels (cholesterol, triglycerides) is necessary before and during isotretinoin therapy because isotretinoin can affect liver function and lipid metabolism. These labs help ensure the patient can safely continue treatment.

d. Family history of depression or history of psychiatric disorders

There is a known association between isotretinoin and psychiatric side effects, including depression and suicidal ideation. Evaluating a patient's psychiatric history, especially any family history of depression or psychiatric disorders, is crucial to assessing risk and deciding on treatment. Patients with such a history should be monitored closely during therapy. 

 

Q2: a. Topical retinoid (e.g., adapalene) 

Topical retinoids are considered first-line treatment for mild to moderate acne. They work by increasing cell turnover, preventing the formation of comedones (the primary lesion in acne), and have anti-inflammatory effects. Adapalene (a third-generation retinoid) is commonly prescribed and is available over-the-counter in lower strengths or by prescription for higher doses. They are effective as monotherapy for comedonal acne or in combination with other agents like benzoyl peroxide. 

Incorrect Answers:

b. Oral antibiotics (e.g., doxycycline)

Oral antibiotics, like doxycycline or minocycline, are typically reserved for moderate to severe acne or when topical treatments (including topical retinoids) fail. They are used to reduce inflammation and bacterial load (P. acnes). However, oral antibiotics are not typically the first-line choice for mild to moderate acne, where topical treatments should be tried first.

c. Isotretinoin

Isotretinoin is a potent systemic treatment used for severe acne or cases where other treatments have failed. It is typically reserved for nodulocystic acne or persistent acne with scarring, not for mild to moderate cases. Starting isotretinoin in a case like this would be inappropriate and would expose the patient to unnecessary risks.

d. Topical corticosteroid

Topical corticosteroids are contraindicated in acne because they can worsen the condition. Although they have anti-inflammatory effects, corticosteroids can increase the risk of steroid-induced acne (rosacea-like acne) and should not be used in the routine management of acne vulgaris. 

Basic Dermatology: Acne and Rosacea (Cases and Questions) (American Academy of Dermatology)