Follicular skin diseases
Acne case challenge 2
A 22-year-old student presents with longstanding acne, which has recently become more severe on his face, chest and back.
In case 1, which of the following skin lesions are clinically apparent?
#! Erythematous papules
Explanation: This patient has severe inflammatory acne affecting the face with nodules on his chest and back. These lesions are very prone to scar.
Which of the following management options is appropriate?
* Topical triclosan wash twice daily and review in 3 months
* Refer to a dermatologist for an urgent opinion
*! Minocycline 100mg twice daily and refer to a dermatologist with routine priority
* Prednisone 20mg daily for 2 to 6 weeks
Explanation: The student has severe nodulocystic acne and should be referred to a dermatologist for treatment. However, oral antibiotics should be prescribed in high dose (e.g. minocycline 200mg daily) to reduce the inflammation, as it is likely to be several weeks or months before the specialist appointment in most areas of New Zealand. As acne is one of the most common indications for referral to a dermatologist, this patient will be considered of routine priority unless there is some specific medical concern.
The patient fails to attend the appointment with the dermatologist (“Too busy”). Some months go by. He consults you again, this time complaining he feels unwell and his shoulders and knees ache. Examination reveals a fever but no obvious systemic cause for his illness. However, his acne is more severe than previously and there are some crusted erythematous plaques on his anterior chest and shoulders.
Blood count shows a leucocytosis 20x10^9^/l. The preferred diagnosis is:
*! Acne fulminans
* Staphylococcal skin infection
* Streptococcal skin infection
Explanation: He has acne fulminans, a rare complication of nodulocystic acne. It seems reasonable to prescribe an antibiotic for a few days, to cover Staphylococcal and Streptococcal infection. However, a phone call to the local dermatologist is mandatory so that he can be seen for specialist consultation within a few days.
The dermatologist treated the patient with oral prednisone 20mg daily and erythromycin 2g daily initially. Once the fever had settled, 10mg of oral isotretinoin daily was added (a small dose).
After some weeks of oral steroids and antibiotics, and six months treatment with isotretinoin, the acne completely cleared. However, the patient was left with severe scarring.
Which of the following may be used to treat acne scars?
#! Laser resurfacing
#! Intralesional triamcinolone injection
#! Repeated glycolic acid peels
Explanation: The treatment used depends on the site and type of the acne scarring. All treatment is rather disappointing! Laser resurfacing is used for extensive facial atrophic scarring. Intralesional steroid injection flattens out hypertrophic or keloid scars. Subcision is used to lift up ice-pick scars. Moderate depth or full-thickness chemical peels may be used as an alternative to laser resurfacing. However, glycolic acid peels are superficial and have little effect on true scarring because this is a dermal process. Repeated superficial peels can however improve overall appearance and are popular with patients because they are non-invasive and do not require ‘downtime’.
Refer to DermNet’s page on acne scarring for further information.