An 18-year-old woman comes to the office for evaluation of acne. The patient is very upset about the acne scarring, which worsened since she started college. She has been very stressed by upcoming examinations and feels "exhausted" due to lack of adequate sleep. The patient has been using topical benzoyl peroxide and tretinoin for the past year. She was also prescribed an oral antibiotic but stopped taking it several months ago due to lack of improvement. The patient is sexually active with her boyfriend and uses an intrauterine device for contraception. Her periods are regular and last 5 days. She takes no other medications and does not use tobacco, alcohol, or illicit drugs. Physical examination shows nodulocystic acne with scarring on the face, chin, and upper back. The patient is interested in isotretinoin treatment. Which of the following is the best next step in management of this patient?

Question

An 18-year-old woman comes to the office for evaluation of acne.  The patient is very upset about the acne scarring, which worsened since she started college.  She has been very stressed by upcoming examinations and feels "exhausted" due to lack of adequate sleep.  The patient has been using topical benzoyl peroxide and tretinoin for the past year.  She was also prescribed an oral antibiotic but stopped taking it several months ago due to lack of improvement.  The patient is sexually active with her boyfriend and uses an intrauterine device for contraception.  Her periods are regular and last 5 days.  She takes no other medications and does not use tobacco, alcohol, or illicit drugs.  Physical examination shows nodulocystic acne with scarring on the face, chin, and upper back.  The patient is interested in isotretinoin treatment.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec160b_3c47_4e8b_9249_95a2ee94efa2_MD0001_00 Isotretinoin is a synthetic 13-cis-isomer of naturally occurring all-trans-retinoic acid (tretinoin), a derivative of vitamin A. It can be administered orally to treat severe acne associated with significant scarring. It is also indicated in patients who fail therapy with topical tretinoin/benzoyl peroxide and antibiotics. Retinoids inhibit follicular epidermal keratinization, thereby loosening the keratin plugs of comedones and facilitating their expulsion. They also reduce the size of sebaceous glands and inhibit sebum production. Isotretinoin is a potent teratogen and is absolutely contraindicated in pregnancy. Exposure to this medication can cause spontaneous abortion and a variety of severe fetal anomalies. A negative pregnancy test (urine or serum) is required prior to prescribing, and abstinence/contraception is recommended. Monthly pregnancy testing is required during treatment. An intrauterine device (IUD) is a long-term contraception method that is 99% effective and safe to use in women of all ages. It should not be discontinued in this patient (Choice C). Because no contraception method is 100% effective, condom use as a backup method is advised. (Choice A) Bone density testing is recommended in patients on long-term glucocorticoid therapy because these drugs increase bone resorption and reduce bone formation. Skeletal complications from isotretinoin therapy are rare. (Choices B and E) Pelvic ultrasound and serum testosterone are used to diagnose polycystic ovary syndrome (PCOS), a major underlying cause of acne. PCOS commonly presents with oligomenorrhea and hirsutism, which are absent in this patient. Pelvic ultrasound often reveals ovaries with multiple small cysts. Treatment with oral contraceptives restores menses and alleviates acne. (Choice D) Vitamin A deficiency is rare in developed countries. Unlike vitamin A, isotretinoin is not stored in the liver and is therefore not associated with toxicities seen with high-dose vitamin A intake. Serum retinol measurement is not indicated. (Choice F) Hypothyroidism commonly causes fatigue in addition to cold intolerance and constipation, but it does not cause acne. In addition, serum TSH would be elevated in a patient with hypothyroidism. Educational objective: Isotretinoin is used to treat severe acne with significant scarring. Pregnancy is an absolute contraindication due to the risk of teratogenicity. Sexually active women should be advised to use 2 forms of contraception and take monthly pregnancy tests. __________ References: Possible long-term teratogenic effect of isotretinoin in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/19961047) ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. (http://www.ncbi.nlm.nih.gov/pubmed/21691183)

An 18-Year-Old Woman Comes to the Office for Evaluation of Acne