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  #1  
Old 06-15-2011
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Skin An Acne Treatment Question

A 17 yo girl comes to the office that her skin is “breaking out”. She has not prior h/o skin problems but has noticed that during the week before each menstrual cycle she develops red pustules on her cheeks, chin, and back. These changes improve over the course of the month, only to return prior to her subsequent menses. She has no other significant past medical history and never taken OCPs. She is thin and in no acute distress. All of her VS are normal and her PE is unremarkable except for numerous comedons around the cheeks and chin and scattered erythematous pustules on her cheeks & upper back. What’s the appropriate treatment ………
1. topical metronidazole
2. topical corticosteroid tx.
3. topical benzoyl peroxide
4. topical clindamycin
5. oral tetracycline
6. oral isotretinoin
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Old 06-15-2011
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4 - topical clindmycin i think if recurrent acne present

initial rx in acne if mild inflametion acne(comedon) like this case we start topical vit A if no response or reactivation we add topical AB or benzyl peroxide if no response we add oral AB
-oral vit A use in nodulcystic acne and if scar present
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  #3  
Old 06-15-2011
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confused between 3 , 4
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  #4  
Old 06-16-2011
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i think we start with topical benzoyl peroxide and then move to antibiotics if no improvement
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Old 06-16-2011
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Default acne case 1

A 15-year-old girl presents to her primary care physician because she has been experiencing a lesion on her face for the last 18 months. She states that she washes her face every day with a mild soap, but her lesion persists. Physical examination reveals occasional open and closed comedones over the entire face. There are no papules or pustules; no scars are visible. Which of the following is the most appropriate next step in the management of this patient?



Answer Choices
A. Oral doxycycline and topical tretinoin
B. Oral isotretinoin
C. Topical clindamycin
D. Topical tretinoin
E. Topical tretinoin and topical clindamycin
Explanation
Option D (Topical tretinoin) is correct. This patient has acne vulgaris. Acne vulgaris can be divided into four types. This patient has type I, which is primarily comedonal without papules or pustules. The treatment of choice is topical retinoids.

Option A (Oral doxycycline and topical tretinoin) is incorrect. Oral antibiotics and topical retinoids are the treatment for type III acne, which is primarily pustular acne, with associated papules and comedones. This acne is associated with scaring and typically affects the back, chest, and shoulders in addition to the face.

Option B (Oral isotretinoin) is incorrect. In patients who have nodules or nodulocystic acne accompanied by scaring, oral isotretinoin should strongly be considered as first-line therapy. This drug has many side effects, including hyperlipidemia and elevation of liver function enzymes. Nevertheless, it is a highly useful drug that is safe when appropriate monitoring is in place.

Option C (Topical clindamycin) is incorrect. Topical antibiotics, such as clindamycin, are not typically used in isolation anymore for the management of acne.

Option E (Topical tretinoin and topical clindamycin) is incorrect. This is the recommended therapy for patients with type II acne. Acne therapy is guided by the severity of the skin symptoms. Type II acne is defined as primarily papular acne with comedones and very little scaring. Thus, it would be the next stage of therapy should this patient's acne worsen.

High-yield Hit 1
ACUTE GENERAL Rx
Treatment generally varies with the type of lesions (comedones, papules, pustules, cystic lesions) and the severity of acne.
Comedones can be treated with retinoids or retinoid analogs. Topical retinoids are comedolytic and work by normalizing follicular keratinization. Commonly available agents are Adapalene (Differin, 0.1% gel or cream, applied once or twice daily), Tazarotene (Tazorac 0.1% cream or gel applied daily), tretinoin (Retin-A 0.1% cream or 0.025 gel applied once qhs), tretinoin microsphere (Retin-A Micro, 0.1% gel, applied at hs). Tretinoin is inactivated by UV light and oxydized by benzoyl peroxide, therefore it should only be applied at night and not used concomitantly with benzoyl peroxide. Tretinoin is pregnancy category C, tazarotene is pregnancy category X. Salicylic acid preparations (e.g., Neutrogena 2% wash) have keratolytic and antiinflammatory properties and are also useful in the treatment of comedones. Large open comedones (blackheads) should be expressed.
Patients should be reevaluated after 4 to 6 wk. Benzoyl peroxide gel (2.5% or 5%) may be added if the comedones become inflamed or form pustules. The most common adverse effects are dryness, erythema, and peeling. Topical antibiotics (erythromycin, clindamycin lotions or pads) can also be used in patients with significant inflammation. They reduce P. acnes in the pilosebaceous follicle and have some antiinflammatory effects. The combination of 5% benzoyl peroxide and 3% erythromycin (Benzamycin) or 1% clindamycin with 5% benzoyl peroxide (Benzaclin) are highly effective in patients who have a mixture of comedonal and inflammatory acne lesions.

From Ferri's Clinical Advisor 2006 by Ferri
High-yield Hit 2
Pustular acne can be treated with tretinoin and benzoyl peroxide gel applied on alternate evenings; drying agents (sulfacetamide-sulfa lotions [Novacet, Sulfacet]) are also effective when used in combination with benzoyl peroxide; oral antibiotics (doxycycline 100 mg qd or erythromycin 1 g qd given in 2 to 3 divided doses) are effective in patients with moderate to severe pustular acne; patients not responding well to these antibiotics can be switched over to minocycline 50 to 100 mg bid; however, this medication is more expensive.
Patients with nodular cystic acne can be treated with systemic agents: antibiotics (erythromycin, tetracycline, doxycycline, minocycline), isotretinoin (Accutane), or oral contraceptives. Periodic intralesional triamcinolone (Kenalog) injections by a dermatologist are also effective. The possibility of endocrinopathy should be considered in patients responding poorly to therapy.

From Ferri's Clinical Advisor 2006 by Ferri
High-yield Hit 3
Isotretinoin is indicated for acne resistant to antibiotic therapy and severe acne; dosage is 0.5 to 1 mg/kg/day in 2 divided doses (maximum of 2 mg/kg/day); duration of therapy is generally 20 wk for a cumulative dose ≥120 mg/kg for severe cystic acne; before using this medication patients should undergo baseline laboratory evaluation (see "Laboratory Tests"). This drug is absolutely contraindicated during pregnancy because of its teratogenicity. It should be used with caution in patients with history of depression. In order to prescribe this drug, physicians must be a registered member of the manufacturer's System to Manage Accutane-Related Teratogenicity (SMART) program.
Azelaic acid is a bacteriostatic dicarboxylic acid used to normalize keratinization and reduce inflammation.
Oral contraceptives reduce androgen levels and therefore sebum production. They represent a useful adjunctive therapy for all types of acne in women and adolescent girls. Commonly used agents are norgestimate/ethinyl estradiol (Ortho Tri-Cyclen) and drospirenone/ethinyl estradiol (Yasmin).
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  #6  
Old 06-16-2011
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Default acne case 2

A 20-year-old man presents to his primary care physician with an 8-year history of acne. He has undergone several years of therapy with little benefit. He is concerned about his appearance and worries about his long-term appearance. Physical examination reveals numerous nodulocystic lesions over the face, neck, shoulders, and back. There is extensive atrophic depressed scarring in the affected areas. What is the most appropriate next step in the management of this patient?

Answer Choices
A. Oral doxycycline
B. Oral isotretinoin
C. Topical clindamycin
D. Topical tretinoin
E. Topical tretinoin and topical clindamycin
Explanation
Option B (Oral isotretinoin) is correct. Acne vulgaris can be divided into four types; and this patient can be considered to have the most severe form, type IV. In patients who have nodules or nodulocystic acne accompanied by scaring, oral isotretinoin should strongly be considered as first-line therapy. This drug has many side effects, including hyperlipidemia and elevation of liver function enzymes.

Option A (Oral doxycycline) is incorrect. Oral antibiotics and topical retinoids are the treatment for type III acne, which is primarily pustular acne, with associated papules and comedones. This acne is associated with scaring and typically affects the back, chest, and shoulders in addition to the face.

Option C (Topical clindamycin) is incorrect. Topical antibiotics, such as clindamycin, are not typically used in isolation anymore for the management of acne.

Option D (Topical tretinoin) is incorrect. This is the management of type I acne, which is primarily comedonal without papules or pustules. The treatment of choice is topical retinoids.

Option E (Topical tretinoin and topical clindamycin) is incorrect. In type II acne, there is primarily papular acne with comedones and very little scaring. The lesions are usually confined to the face. A topical retinoid and topical antibiotic is useful therapy.
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  #7  
Old 06-16-2011
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Default

Quote:
Originally Posted by aghammoud85 View Post
A 17 yo girl comes to the office that her skin is “breaking out”. She has not prior h/o skin problems but has noticed that during the week before each menstrual cycle she develops red pustules on her cheeks, chin, and back. These changes improve over the course of the month, only to return prior to her subsequent menses. She has no other significant past medical history and never taken OCPs. She is thin and in no acute distress. All of her VS are normal and her PE is unremarkable except for numerous comedons around the cheeks and chin and scattered erythematous pustules on her cheeks & upper back. What’s the appropriate treatment ………
1. topical metronidazole
2. topical corticosteroid tx.
3. topical benzoyl peroxide
4. topical clindamycin
5. oral tetracycline
6. oral isotretinoin
Mild-moderate acne vulgaris-so

Topical benzoyl peroxide to start with, then topical antibiotics!
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  #8  
Old 12-01-2011
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This is a pretty old question (before 2003).
Now, the first step in management is Topical Vit A


An Acne Treatment Question-acne-treatment-table.png
click image to enlarge
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  #9  
Old 02-02-2012
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Wats bpo ?? benzoyl peroxide ??
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Old 02-03-2012
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Quote:
Originally Posted by dr.dhruvdesai View Post
Wats bpo ?? benzoyl peroxide ??
Yes!
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  #11  
Old 02-22-2012
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I support cool atomic. Benzoyl peroxide is perfect start to fight with acne. BP produces powerful anaerobic antibacterial activity which is beneficial to reduce acne.
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Old 02-23-2012
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just to summarize treatment as per new guidlines.i guess the order is correct...

comedones - topical vitamin A

pustular - topical vitamin A and topical antibiotics
nodular - topical vitamin A and oral antibiotics and Benzoyl peroxide

cystic - oral vitamin A
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  #13  
Old 03-23-2012
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Smile Excellent case! Could u please tell what the answer is? Than you

Thanks for this post. Its a great way to integrate acne rx!
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I think starting from benzoyl peroxide would be a good treatment for a beginning. If condition doesn't improve then antibiotics can be used.
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Old 02-04-2014
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i think we ll start with topical vit A
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  #16  
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Acne is a very common skin disorder. It can be due to various environmental condition or hormonal changes in the body. There are various skin products available to reduce acne and its scars.
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  #17  
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Acne is a common, in fact, predominant skin disorder that affects all nations, races and genders regardless of their ethnic backgrounds geographical location or environmental conditions.


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Post RE: Best derm source for USMLE

Checkout the book "Dermatology for the USMLE" in Amazon.

Cover all derm topics for the boards, excellent source to score high. It has HIGH quality pics for every disease you may encounter in the USMLE's.

Bought it in amazon 5 months ago, it is awesome. A must have...
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