Case Studies

Case 3 - A young man with spots leading to scarring

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This 22-year-old man presented with worsening spots with scarring on his face, chest and back since his mid teens. He did not feel the creams and antibiotic tablets his GP prescribed 6 months ago had improved his rash. He was a sports enthusiast and was otherwise well.

• (a) What is the most likely diagnosis?

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  Acne

• (b) What are the hallmark clinical features of this condition?

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  Closed and open comedones, papules, pustules, nodules and cysts.

• (c) What are the potential complications of this skin disease being left untreated?

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  Scarring, psychological impact.

• (d) What is the aetiology of this skin condition?

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  The aetiology of acne is multi-factorial. These include hyperkeratinisation and shedding of the epidermis around the hair follicles, androgen-stimulated increased production of sebum and proliferation of Propionibacterium acnes leading to dermal inflammation.

• (e) What possible underlying causes should be considered as a cause of this rash in individuals with severe and/or treatment-resistant disease?

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  Polycystic ovarian syndrome, ingestion and/or injection of anabolic steroids.

• (f) How would you manage this patient?

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  The treatment of acne depends on its clinical severity. This patient has evidence of severe acne with inflammatory papules, pustules and extensive scarring which has not responded to the topical treatment and oral antibiotics prescribed by his GP. Therefore, oral isotretinoin 0.5–1 mg/kg/day for 4–6 months should be considered as the next treatment option for this patient.

• (g) What other treatment option is available for a female patient with this disease?

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  An anti-androgen combined with oestrogen in the form of the oral contraceptive pill (e.g. Dianette®) can be used in female patients with moderate to severe acne, provided there are no contraindications for this treatment to be used in the individual patient.

• (h) What special precautions should be taken in females with this disease being considered for systemic therapy?

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  Females of child-bearing age being considered for oral isotretinoin should be counselled about its teratogenic effects and advised on the use of a reliable mode of contraception.