Acne vulgaris in adolescents — formative SAQs

SAQ 1 — A 15-year-old boy with moderate inflammatory acne

Stem. A 15-year-old boy presents with a one-year history of open and closed comedones across his forehead and cheeks, now with increasing red papules and pustules and a few tender nodules on his jawline and upper back. He has become withdrawn and has stopped swimming. He has tried over-the-counter washes without success. Outline your assessment and your stepwise management. (10 marks, 15 minutes) [1] [2]

Assessment (3 marks). Take the onset, distribution, flare factors, prior treatments and adherence, the menstrual question is not applicable, the family history of severe or scarring acne, the diet and the cosmetics, and — above all — the psychosocial impact, because his withdrawal from swimming signals the distress that the lesion count hides. Examine and grade the severity on a reproducible scale, record the proportion of the comedonal versus the inflammatory lesions, look for the early atrophic scarring and the post-inflammatory hyperpigmentation, and note the truncal involvement. Screen the mood and self-harm risk. The diagnosis is clinical and no routine test is needed. [1] [9]

Mild-to-moderate rung (2 marks). Begin the topical retinoid — the adapalene 0.1 per cent gel as a thin film to the whole affected area at night — and the benzoyl peroxide 2.5 per cent by day. Counsel the dryness, the photosensitivity, and the sunscreen, and warn that the adapalene, not the tretinoin, is the photostable retinoid that combines safely with the benzoyl peroxide. The improvement is judged at six to eight weeks. [1] [11]

Moderate inflammatory rung (3 marks). Because he has the many papules and pustules and the tender nodules, add the oral doxycycline 50 to 100 mg once daily for three months alongside the topical retinoid and the benzoyl peroxide — never as the monotherapy. State the antibiotic stewardship: always pair the antibiotic with the benzoyl peroxide to limit the resistance, cap the oral course at three to four months, and let the retinoid carry the maintenance. Review at three months. [1] [7]

Escalation (2 marks). Define the triggers for the oral isotretinoin and the dermatology referral: the nodulocystic disease, the scarring or the high scar risk, the failure of three months of the combination therapy, and the significant psychosocial impact. The isotretinoin is started at 0.5 mg/kg per day toward 1.0 mg/kg per day with the cumulative 120 to 150 mg/kg target; stop the tetracycline first, baseline the pregnancy test in the female, and the lipids and the liver, and counsel the teratogenicity. Give the safety-net for the mood and the follow-up. [2] [5]

SAQ 2 — A 16-year-old girl with treatment-resistant jawline acne

Stem. A 16-year-old girl has acne concentrated along her jawline and lower face, worse premenstrually, that has not responded to three months of a topical retinoid and benzoyl peroxide and a course of oral doxycycline. Her periods are irregular and she has noticed increased facial hair. Discuss the likely diagnosis, the investigations, and the additional therapy. (10 marks, 15 minutes) [1] [9]

Diagnosis (3 marks). The distribution on the jawline and the lower face, the premenstrual flare, and the resistance to the standard topical and oral antibiotic therapy mark the hormonal, female-pattern acne. The irregular menses, the hirsutism, and (often) the acanthosis nigricans complete the polycystic ovary syndrome picture, and the hyperandrogenism is the engine of the treatment resistance. The severe, sudden, or resistant female acne with the menstrual irregularity and the hirsutism warrants the endocrine workup. [2] [9]

Investigations (3 marks). Order the early-morning free testosterone, the dehydroepiandrosterone sulphate, the luteinising hormone and the follicle-stimulating hormone, and the 17-hydroxyprogesterone to exclude the non-classic congenital adrenal hyperplasia. A pelvic ultrasound may support the polycystic ovarian morphology but is not diagnostic alone. Markedly elevated androgens or the rapid virilisation raises the androgen-secreting tumour and the paediatric endocrinology referral. [1] [11]

Additional therapy (4 marks). Add the anti-androgens to the continuing topical retinoid and benzoyl peroxide. The combined oral contraceptive — the ethinylestradiol with the drospirenone or the norgestimate — and the spironolactone 50 to 100 mg per day, titrated toward 200 mg, are the hormonal mainstays. Counsel the contraception, the spironolactone potassium monitoring, and the three-month review. If the disease remains the nodulocystic and the scarring, the oral isotretinoin remains the definitive option, with the pregnancy-prevention programme and the lipid and liver monitoring. Address the psychosocial impact throughout. [5] [9]