A 15-year-old boy comes to the office for a follow-up visit regarding acne. He first developed acne a year ago and has tried over-the-counter acne washes with no improvement. His first visit for acne was 3 months ago, at which time he was prescribed a topical retinoid and benzoyl peroxide for inflamed papules and pustules on his cheeks and forehead. The patient says, "I've been using these 2 ointments every day. Do you think I should keep using them? Sometimes my face gets red and stings a little. I don't feel like my skin looks much better than before." He takes no other medications and always uses an oil-free, non-comedogenic sunscreen when outdoors. He has no allergies. Skin findings on examination are shown below. Which of the following is the most appropriate next step in management of this patient?

Question

A 15-year-old boy comes to the office for a follow-up visit regarding acne.  He first developed acne a year ago and has tried over-the-counter acne washes with no improvement.  His first visit for acne was 3 months ago, at which time he was prescribed a topical retinoid and benzoyl peroxide for inflamed papules and pustules on his cheeks and forehead.  The patient says, "I've been using these 2 ointments every day.  Do you think I should keep using them?  Sometimes my face gets red and stings a little.  I don't feel like my skin looks much better than before."  He takes no other medications and always uses an oil-free, non-comedogenic sunscreen when outdoors.  He has no allergies.  Skin findings on examination are shown below.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be69_adef_8f63_39821c2f3579_MD0005_00 This patient has inflammatory acne vulgaris that is unresponsive to initial therapy (topical retinoids and benzoyl peroxide). Many patients with inflammatory acne often require the addition of topical antibiotics (eg, erythromycin, clindamycin). By decreasing skin colonization with Cutibacterium acnes, topical antibiotics decrease inflammation in acne vulgaris. Oral tetracycline antibiotics (eg, doxycycline, minocycline) are indicated in patients with severe or nodular acne and for acne unresponsive to topical antibiotics. Oral antibiotics are also considered for patients with widespread acne (eg, on the back or upper arms) that makes topical therapy impractical. Neither topical nor oral antibiotics should be used as monotherapy (Choice E) due to rising antibiotic resistance. (Choice A) Spironolactone can be used as an adjunctive treatment for acne in women due to its anti-androgen effects, though antibiotic therapy is usually tried first. Spironolactone is generally avoided in men due to its side effect of gynecomastia. (Choice B) Topical organic acids (eg, salicylic, azelaic, glycolic) are most useful for noninflammatory/comedonal acne. This patient's worsening inflammatory acne (given the presence of pustules and papules) warrants more aggressive therapy. (Choice D) Isotretinoin is an oral retinoid that greatly diminishes sebum secretion but is used primarily in patients with extensive nodulocystic acne who have failed other treatment regimens or have significant scarring. This patient has not yet used topical or oral antibiotics and does not have scarring. Educational objective: Initial treatment for inflammatory acne includes topical retinoids and benzoyl peroxide. Antibiotics (topical or oral) can be added for refractory or more severe cases of inflammatory acne. References: Guidelines of care for the management of acne vulgaris. (http://www.ncbi.nlm.nih.gov/pubmed/26897386)

A 15-Year-Old Boy Comes to the Office for a Follow-Up