A 32-year-old woman returns to the office due to acne. For the past 3 months, the patient has been applying topical clindamycin, benzoyl peroxide, and tretinoin on the face and neck, with only partial improvement. In addition, she has been using a salicylic acid-containing gel cleanser morning and evening. The acne tends to worsen before menses, which occur every 28-30 days and last 5-7 days. During menses, the patient also craves chocolate, sometimes eating multiple bars a day. Medical history includes recurrent vaginal candidiasis and a bilateral tubal ligation. Examination reveals comedones, papules, and pustules on the lower cheeks, chin, and neck but no scarring. Facial and body hair distribution is normal. Which of the following is the most appropriate next step in management of this patient's acne?

Question

A 32-year-old woman returns to the office due to acne.  For the past 3 months, the patient has been applying topical clindamycin, benzoyl peroxide, and tretinoin on the face and neck, with only partial improvement.  In addition, she has been using a salicylic acid-containing gel cleanser morning and evening.  The acne tends to worsen before menses, which occur every 28-30 days and last 5-7 days.  During menses, the patient also craves chocolate, sometimes eating multiple bars a day.  Medical history includes recurrent vaginal candidiasis and a bilateral tubal ligation.  Examination reveals comedones, papules, and pustules on the lower cheeks, chin, and neck but no scarring.  Facial and body hair distribution is normal.  Which of the following is the most appropriate next step in management of this patient's acne?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be6c_e245_8f63_6365abcea70b_MD0005_00 This patient has moderate inflammatory acne that has responded inadequately to maximal topical therapy. Systemic treatment is warranted; options include hormonal therapy and oral antibiotics. Evidence comparing relative efficacy is limited, and the choice depends on acne characteristics, patient preference, and comorbid conditions. Hormonal therapy (eg, estrogen/progestin oral contraceptives) works best for acne that exhibits premenstrual flares and is located on the lower face and neck, as in this patient. Estrogen functions as an antiandrogen and suppresses production of sebum, which occludes hair follicles and promotes Cutibacterium acnes proliferation. Patients with concurrent menstrual irregularities or hyperandrogenic states (eg, polycystic ovarian syndrome) may derive additional benefits. In contrast, oral antibiotics (eg, doxycycline, minocycline) eradicate C acnes and diminish C acnes-triggered inflammation. However, tetracyclines are potentially teratogenic, and concurrent use of effective contraception is required for women of childbearing potential. In addition, oral antibiotics can increase the risk of vaginal candidiasis, which makes them a less-than-ideal choice for patients, such as this one, with a history of recurrent candidiasis (Choice D). (Choice B) Progestin-only oral contraceptives are not recommended for treating acne because of the androgenic effects of progestins used in these pills. (Choice C) Despite coverage in the lay media, chocolate has not been shown to promote acne formation. (Choice E) Salicylic acid-containing gel cleansers are recommended for acne. Salicylic acid is comedolytic, and gel-based vehicles have low oil content, making them less comedogenic than cream-based cleansers. However, exfoliating facial scrubs are not recommended because the mechanical trauma can worsen inflammatory acne. Educational objective: Combined estrogen/progestin oral contraceptives suppress sebum production and have antiandrogenic effects. They can be used to treat moderate inflammatory acne, especially for patients with premenstrual acne flares and acne on the lower face and neck. References: Acne vulgaris: diagnosis and treatment (http://www.ncbi.nlm.nih.gov/pubmed/31613567)

A 32-Year-Old Woman Returns to the Office Due to Acne