Acne

Adolescent F presents with gradual appearance of comedones, papules/pustules, and nodules on face. Denies use of androgens/steroids, isoniazid, lithium, phenytoin (Dilantin). Non-inflammatory nodules, inflamed comedones, and nodules noted on face, back.

  • Treatment

    • Stage 1

      • Noninflamed (blackheads and whiteheads)

      • Apply topical tretinoin 0.025% gel to acne lesions daily at bedtime

    • Stage 2

      • Inflamed comedones with few papules/pustules (pimples)

      • Apply benzoyl peroxide 10% gel sparingly twice daily; reduce frequency to once daily if excessive skin dryness occurs

    • Stage 3

      • Nodular lesions

      • Apply thin film of topical erythromycin 2.0% gel BID

    • Stage 4 refractory nodular/scarring acne: Start oral isotretinoin 1.0 mg/kg/day x 20 weeks and require pt

      • Enroll in iPLEDGE program

      • Obtain CBC, CMP, and fasting lipid panel

      • Obtain negative pregnancy test before starting medication and before each refill

      • Use two forms of birth control before engaging in sexually activity

    • Female: Consider combined oral contraceptives at any stage for improved acne control

  • Refractory acne: Refer to dermatology

  • Counseling

    • Pt counseled that acne is caused by bacterial infection with P. acnes

    • Pt informed that a minimum of 6-8 weeks is required to assess effectiveness of any one therapy

    • Pt advised that laser and light therapies are ineffective

    • Pt counseled that failure to comply with treatment may lead to continue acne and/or scarring

Acne.jpg

Notes

Acne formation.jpg

  • Rule out drug induced acne which may be caused by androgens/steroids, isoniazid, lithium, phenytoin (Dilantin)

  • Tretinoin = vitamin A derivative

  • Benzoyl peroxide (topical antiseptic)

    • Reduces risk for bacterial resistance when used with antibiotics

    • Pt may stop daily use once symptoms are controlled

  • Isotretinoin

    • Provider and pharmacy must be registered with iPLEDGE

    • Results

      • Long term remission in 40% of patients

      • 40% of patients controlled with topical therapy after course

      • 20% require re-treatment with isotretinoin