Solomon Sallfors: Ambulatory Morning Report 1: Acne

Chief Complaint: Acne

HPI: 22 yo woman without pertinent past medical history, presents for treatment of acne. She
has had acne since young teenager. She had used topical OTC medications for years without
improvement. Her skin becomes very dry with these agents. The acne causes her significant
social embarrassment preventing her from engaging in activities. She worries about permanent
scarring. She has never used tobacco, uses only oral contraception for medication, and has no
family or personal history of cancers or coagulopathy. Shes heard about something stronger a
doctor can prescribe.

Meds: Oral contraceptives. Surgeries: None. Allergies: None. FMHX: No breast or uterine
cancer. No coagulopathy. PMHx: None. OB/GYN: Menarche at 14yo. Periods fairly regular and
without complaint. SOCIAL: No Alc/tob/drugs. College student majoring in business. ROS:
Neg except as in HPI.

PE: Vitals: 115/75, 75HR, 12RR, O2Sats 98%, Temp 88.9. Gen: Well developed, well nourished
woman who looks her stated age, thin, well kept and appropriately dressed, in no apparent
distress. HE: Normocephalic,atraumatic, sclera non-icteric, conjunctiva non-injected. Neck:
supple, trachea mid-line. CV: Normal S1/S2. No murmur. Resp: CTAB, no wheeze or rales.
Neuro: Normal behavior, emotional state, and cognition. Moves all limbs, sensation grossly
intact. Musculoskeletal: Nl size, tone, and ROM in major muscle groups. Major joints are non-
tender and non-swollen. PSYC: no anhedonia, no worthlessness. Skin:Normal turgor, warm and
non-diaphoretic without excessive oil or dryness. Raised papular lesions erythematous to purple
in color diffuse over maxillary areas of face, 2-5 mm in diameter, with some evidence of scarring
in the form of depressions. Lesions not especially prominent on jaw line. Same lesions on her
back. Other systems normal.

Diagnosis: Acne vulgaris of severe intensity with nodules and scarring.

Treatment: Four targets

Follicular hyper- Increased sebum Propionibacterium Inflammation

proliferation and production acnes
abnormal
desquamation

Topical retinoids Oral isotretinoin Benzoyl peroxide Oral isotretinoin

Oral retinoids Hormonal therapies Topical and oral Oral tetracyclines

antibiotics
Azelaic acid Topical retinoids
Azelaic acid
Salicylic acid Azelaic acid

Hormonal therapies
Solomon Sallfors: Ambulatory Morning Report 1: Acne

Comedonal acne can be treated with topical retinoids as well as OTC benzoyl peroxide, azelaic
acid, and salicylic acid.

Moderate to severe inflammatory acne can be treated with the above plus an oral antibiotic
(12-18 wks). Topical benzoyl peroxide will decrease the risk of antibiotic resistance.

Severe, recalcitrant, nodular acne are generally treated with oral isotretinoin. 50% curative.

Other considerations:

Hormonal acne: Women with signs of hyperandrogenism should be evaluated for underlying
endocrine disorders. Hormonal therapy can be a useful addition to a therapeutic regimen for
moderate to severe acne vulgaris in women with or without hyperandrogenism. Spironolactone
can be used for this type.
Solomon Sallfors: Ambulatory Morning Report 1: Acne

Our Patient: Patient chose to start isotretinoin in combination with others. A pregnancy test
today was negative. Shes on oral birth control and will choose another. Shell return to clinic in
7 days for blood work including a second pregnancy test. Shell register for iPledge, an online
support and information system to track her adherence to the regimen. She will return to clinic
monthly for each prescription and a new pregnancy test.