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Old 12-04-2011
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Skin Treatment of acne question

A 22-year-old woman comes to the office complaining of disfiguring acne of 3 year’s duration. She constantly breaks out with painful lesions that leave unsightly scars. Over the past year she has been on oral and topical antibiotics, benzoyl peroxide preparations, and topical retinoids with little improvement. Her past medical history is unremarkable. She has regular menstrual periods. Current medications include minocycline 100 mg PO bid, benzoyl peroxide 9% topically qd, and tretinoin 0.02% topically qd. The family history is significant for severe acne on the father’s side. On physical examination, the patient is in no acute distress. Vital signs are within normal limits. The patient has multiple comedones, inflammatory papules and pustules on the face, chest and upper back. She also has multiple tender, fluctuant nodules on the back. Interspersed with these acute lesions are many atrophic, rolled and punched-out scars. Otherwise, the examination is within normal limits. She should be told which of the following?

A. A topical antibiotic should be added to the regimen
B. Evaluation for isotretinoin treatment is indicated at this time
C. She has polycystic ovary disease
D. Intralesional steroids added to the regimen
E. The dose of minocycline should be increased
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Old 12-04-2011
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Evaluation for isotretinoin treatment is indicated at this time
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Old 12-04-2011
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evaluation of isotretinoin treatment at this time.
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Old 12-04-2011
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B. Evaluation for isotretinoin treatment is indicated at this time
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Old 12-04-2011
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B. Evaluation for isotretinoin treatment is indicated at this time
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B. Evaluation for isotretinoin treatment is indicated at this time
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Old 12-05-2011
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B. Evaluation for isotretinoin treatment is indicated at this time
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Old 12-05-2011
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The correct answer is B. Acne vulgaris is an inflammatory disease of the pilosebaceous follicle characterized by noninflammatory follicular papules or comedones, inflammatory papules, pustules, and nodules in its most severe forms. It is very common and affects up to 100% of people at some time during their lives. It is strongly influenced by genetic factors, although certain cosmetic agents, medications, and endocrine disorders (congenital adrenal hyperplasia, polycystic ovary disease) may trigger the development of acne. Treatment includes topical and oral antibiotics, topical benzoyl peroxide, topical and oral retinoids, and hormonal therapy. Isotretinoin is a systemic retinoid that is highly effective in the treatment of severe, recalcitrant acne, or disfiguring scarring acne. Isotretinoin is a teratogen, and pregnancy must be avoided during its use and for 1 month following cessation of use. Contraception counseling is mandatory, and two negative pregnancy tests are required prior to initiation of therapy. Baseline laboratory tests should also include a complete blood count and fasting lipid profile. Other potential adverse effects of isotretinoin include pseudotumor cerebri, vision impairment, headaches, myalgias, arthralgias, and depression; dry skin and cheilitis are nearly universal adverse effects
It is not recommended to use an oral and topical antibiotic at the same time because of a high risk of developing resistant bacteria. Therefore, it is incorrect that a topical antibiotic should be added to the regimen (choice A).
Polycystic ovary disease is characterized by hirsutism, obesity, oligomenorrhea, and severe acne. This patient has normal periods and no indication of hirsutism or obesity. It is highly unlikely that she has polycystic ovary disease (choice C).
Intralesional steroids (choice D) may expedite resolution of treated nodules and cysts in patients with acne; however, they have no influence on untreated lesions and do not affect further outbreaks. In a patient with severe acne, they are not very helpful.
The maximum dose of minocycline used in the treatment of acne is 100 mg give twice a day for a total daily dose of 200 milligrams (choice E). Higher doses than this are frequently associated with undesirable and/or detrimental side effects. If the patent does not respond to a reasonably long course of minocycline at this dose, it should be substituted with either a different systemic antibiotic or consideration for isotretinoin therapy.
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