Acne vulgaris in adolescents — branching viva

Opening — grade and name the disease

Open with the severity and the comedonal versus the inflammatory split, because the split drives the treatment. This 15-year-old has the open and the closed comedones, the inflammatory papules and pustules, and a few tender nodules on the jawline and the upper back — the moderate inflammatory acne vulgaris with some nodular disease. I grade on a reproducible scale and I record the proportion of the comedonal to the inflammatory lesions, and my first move is the psychosocial screen, because his withdrawal from swimming is the distress signal the lesion count hides. [1] [9]

Branch 1 — the topical ladder

Walk the examiner through your topical regimen. The foundation is the topical retinoid, because it fixes the microcomedone upstream. I use the adapalene 0.1 per cent as a thin film to the whole affected area at night, with the benzoyl peroxide 2.5 per cent by day, and I choose the adapalene over the tretinoin because the adapalene is photostable and combines safely with the benzoyl peroxide whereas the tretinoin is degraded by it. I counsel the dryness, the photosensitivity, and the sunscreen, and I review at six to eight weeks. [1] [2]

Branch 2 — the antibiotic stewardship

Explain when and how you add the oral antibiotic. For the many papules and pustules I add the oral doxycycline once daily for three months, but never alone — it travels with the topical retinoid and the benzoyl peroxide. The stewardship rule is the one the fellowship tests every year: never the antibiotic monotherapy, always pair it with the benzoyl peroxide to limit the resistance, cap the oral course at three to four months, and let the retinoid carry the maintenance. I never combine the topical erythromycin with the topical clindamycin, because the cross-resistance gives no added benefit. [1] [7]

Branch 3 — the isotretinoin candidacy

Define the isotretinoin triggers and the prerequisites. I refer for the severe 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 the weight-based daily dose and titrated toward the cumulative target that best predicts the durable remission. I stop the tetracycline first to avoid the benign intracranial hypertension, I baseline the pregnancy test in the female, the lipids, and the liver, and I counsel the teratogenicity and the mucocutaneous dryness. [5] [2]

Branch 4 — the fulminans curveball

Suppose instead he presents the sudden ulcerative nodules with the fever and the arthralgia — what changes? That is the acne fulminans, the dermatological emergency, and the protocol inverts. The systemic corticosteroid comes first — the oral prednisolone at the weight-based dose — to settle the systemic inflammation, and then the gradual low-dose isotretinoin is introduced as the inflammation resolves. I never start the full-dose isotretinoin or the oral antibiotic alone in the acute fulminans, because the flare can worsen, and I refer to the dermatology immediately. [1] [5]

Branch 5 — the female-pattern acne

If this were a girl with the jawline flare, the irregular menses, and the hirsutism, how would the plan change? I would recognise the hormonal, female-pattern acne of the polycystic ovary syndrome. I would add the anti-androgens — the combined oral contraceptive with the drospirenone or the norgestimate, and the spironolactone — to the continuing topical retinoid and benzoyl peroxide, and I would order the endocrine workup with the free testosterone, the dehydroepiandrosterone sulphate, and the 17-hydroxyprogesterone. The isotretinoin remains the definitive option for the refractory nodulocystic disease, with the pregnancy prevention throughout. [2] [9]

Closing — the maintenance and the safety-net

Close with the maintenance and the safety-net the examiner rewards. The topical retinoid continues long after the lesions clear, because the microcomedone recurs the moment the treatment stops, and the maintenance is the half of the treatment the adolescent underestimates. The mood and the scarring are reviewed at each visit, the early escalation triggers are the worsening nodules, the scarring, and the distress, and the clear pathway to the isotretinoin is named at the outset. [1] [9]