A 17-year-old girl comes to the office for follow-up due to worsening acne. The patient has scattered papules and pustules with mild-to-moderate redness on the cheeks. The lesions are not painful, and there is no scarring. The patient has been using topical tazarotene and benzoyl peroxide for 2 months without improvement and is concerned that the acne is getting worse. She is sexually active. Medical history is otherwise negative. On examination, she has moderate pustular acne with erythema on the cheeks. Which of the following is the best next step in management of this patient?

Question

A 17-year-old girl comes to the office for follow-up due to worsening acne.  The patient has scattered papules and pustules with mild-to-moderate redness on the cheeks.  The lesions are not painful, and there is no scarring.  The patient has been using topical tazarotene and benzoyl peroxide for 2 months without improvement and is concerned that the acne is getting worse.  She is sexually active.  Medical history is otherwise negative.  On examination, she has moderate pustular acne with erythema on the cheeks.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d370_9363_bc81_85311c46cf85_MD0003_00 This patient has worsening inflammatory acne vulgaris despite appropriate initial treatment. Acne is characterized by obstruction of the pilosebaceous follicle by the abnormal proliferation of keratinocytes (ie, hyperkeratinization) in association with the excessive accumulation of sebum. The resulting comedone is colonized by Cutibacterium acnes, which triggers an inflammatory response. hyperkeratinization Initial management of inflammatory acne includes a topical retinoid (eg, tazarotene, tretinoin), which inhibits comedogenesis, and benzoyl peroxide, which has bactericidal activity against C acnes. However, when this initial regimen is ineffective, a topical antibiotic (eg, clindamycin) may be added. Oral antibiotics (eg, doxycycline) are also effective and useful when topical agents are ineffective or impractical (eg, widespread inflammatory acne affecting the back). (Choice A) Androgens enhance sebum production and facilitate C acnes colonization. Spironolactone is an antiandrogenic agent that can be used to treat women whose inflammatory acne does not respond to topical treatment or who have androgen excess (eg, polycystic ovary syndrome). Because it can cause feminization of male fetuses, it is contraindicated in sexually active women who do not use contraception. This patient is not on maximum topical therapy; spironolactone is not indicated at this time. (Choice C) Topical hydrocortisone is a corticosteroid used to treat inflammatory dermatoses (eg, eczema, psoriasis) but is not indicated in acne. The inflammatory changes in acne are triggered by C acnes and usually improve with antibiotic therapy. (Choice D) Topical salicylic acid is a comedolytic agent that has mild anti-inflammatory properties. It can be considered for inflammatory acne in patients who do not tolerate retinoids; however, retinoids are more effective and generally preferred. (Choice E) Oral isotretinoin is typically used to treat severe, inflammatory nodulocystic acne, but it is teratogenic and can cause serious adverse effects (hypertriglyceridemia, pseudotumor cerebri); women who are sexually active must be on 2 forms of contraception. This patient's acne is not severe enough to warrant isotretinoin. Educational objective: Inflammatory acne is treated with topical retinoids and benzoyl peroxide. When this regimen is inadequate, the addition of topical or oral antibiotics is recommended. References: Acne vulgaris: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/31613567)

A 17-Year-Old Girl Comes to the Office for Follow-Up Due