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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Understand risk factors and aggravating factors in the pathogenesis of acne vulgaris.

  • Understand the treatment strategies for acne, including appropriate situations for using nonprescription and prescription medications and use of topical and systemic therapies.

  • Educate patients with acne on systemic therapies.

  • Monitor the safety and efficacy of selected systemic therapies.

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PATIENT PRESENTATION

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Chief Complaint

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“I can’t stand this acne!”

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HPI

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Elaine Morgan is an 18-year-old woman with a history of facial acne since age 15. One month ago, she completed a 3-month course of minocycline in combination with Differin (adapalene). Her acne has flared up again, and she has again presented to her family physician for treatment.

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PMH

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Has irregular menses as a result of polycystic ovary syndrome diagnosed 3 years ago, which has not required medical treatment. However, it has resulted in an acne condition that was initially quite mild; she responded well to nonprescription topical products. In the last 2 years, the number of facial lesions has increased despite OTC, and, later, prescription drug treatments. Initially her physician prescribed Benzamycin Gel (benzoyl peroxide 5%/erythromycin 3%), which was beneficial, but this had to be discontinued because of excessive drying. Differin XP (adapalene 0.3% gel) was used next, and it controlled her condition for about 6 months; then the acne worsened and oral antibiotics were added. Most recently, she has received two 3-month courses of minocycline over the past year. She has also noted some scarring and cysts in the last few months.

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FH

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Parents alive and well; two older brothers (ages 21 and 25). Father had acne with residual scarring.

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SH

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The patient is under some stress because she is graduating in a few weeks. She wants to do well in school so she will qualify for the best colleges. Both of her brothers graduated with honors. She has been sexually active for the past two months, and her boyfriend uses condoms.

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Meds

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None currently

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All

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NKDA

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ROS

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In addition to the complaints noted above, the patient has irregular menstrual periods and mild hirsutism

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Physical Examination

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Gen
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Alert, moderately anxious teenager in NAD

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VS
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BP 110/70 mm Hg, RR 15, T 37°C; Wt 45 kg, Ht 5′2″

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Skin
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Comedones on forehead, nose, and chin. Papules and pustules on the nose and malar area. A few healing cysts on the chin. Superficial scars on malar area. Increased facial hair.

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HEENT
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