Facial Lesions in a Teenager
Author: Caden Carver, BS
Date: December 5, 2023
Case Presentation: A 15-year-old male is brought to the clinic by his mother for complaint of painful bumps on his face, chest, and back. She states the lesions first appeared approximately one year ago, but have progressively worsened since then. The patient notes that the bumps sometimes become larger and more painful if he forgets to wash his face after football practice. He has tried several “over the counter” acne products without any improvement. Physical exam reveals scattered open and closed comedones, inflammatory papules and nodules, and postinflammatory hyperpigmentation on the forehead, nose, and cheeks as shown above.
Question 1. What is the most likely diagnosis in this patient?
a. Rosacea
b. Acne vulgaris
c. Folliculitis
d. Molluscum contagiosum
Question 2. What are key components in the pathogenesis of this patient’s condition?
a. Poor diet, genetics, face touching, and comedogenic product use
b. Fungal colonization, excess sweating, and lesion picking
c. Androgen activation of sebaceous activity, hyperkeratinization, bacterial colonization, inflammation
Question 3. How would you classify this patient’s acne in terms of severity?
a. Mild
b. Moderate
c. Severe
Question 4. What features of this patient’s presentation support this?
a. Presence of inflammatory papules and nodules, presence of scarring
b. Age at onset
c. History of the patient
d. Failure to improve with over the counter products
Question 5. What is an important question to ask in order to accurately assess acne severity?
a. On a scale of 1-10, how severe would you rate your acne?
b. Is today a good day, bad day, or normal day for your acne?
c. Do your peers comment on your acne?
d. Do your parents or other family members also have acne?
Question 6. What is the most appropriate treatment regimen to initiate for this patient?
a. Topical retinoid
b. Topical antibiotic with benzoyl peroxide
c. Oral antibiotic
d. Choices a and b only
e. Choices a, b, and c
Question 7. At what time of day should the patient be instructed to apply the topical retinoid, and what things should the patient be counseled on regarding its use?
a. Morning; the medication requires routine laboratory monitoring
b. Morning; the medication should be used as a spot treatment and should immediately be used nightly
c. Before bed; apply a pea sized amount to the entire face, having caution for dryness and photosensitivity
d. Before bed; begin using the medication nightly to assess the patient’s tolerance
Question 8. The patient and his mother inquire how long the treatment will take to treat the patient’s acne. What do you tell them?
a. 1-2 weeks
b. 2-3 months
c. 6 months
d. 1-2 years
Question 9. The patient returns for follow-up as instructed, but is disappointed with the results. Physical exam reveals persistent inflammatory nodulocystic lesions. What is an acceptable next step?
a. Refer the patient to another dermatologist for a second opinion
b. Increase the concentration of benzoyl peroxide and return in 3 months
c. Obtain in-depth laboratory workup for underlying hormonal disturbance
d. Counsel the patient on isotretinoin therapy, including risks, benefits, alternatives, and length of treatment course
Question 10. What should the patient be counseled on with respect to isotretinoin therapy?
a. Possibility of dryness, muscle and joint discomfort, and mood changes
b. Treatment duration typically lasts around 6 months, but varies depending on individual response to therapy
c. Isotretinoin requires patients to enroll in a national monitoring database
d. Following one course of isotretinoin therapy, the patient will no longer need acne treatment
e. The patient should continue his current regimen of topical retinoid, topical antibiotics and benzoyl peroxide, and oral antibiotics while taking isotretinoin
f. All answer choices are correct
g. Choices a, b, and c
Answer Key: 1. b, 2. c, 3. c, 4. b, 5. a, 6. e, 7. c, 8. b, 9. d, 10. g
References:
1. Salem Y, Mija L, Nassim J, et al. Acne Vulgaris. Visual Dx. Accessed December 15, 2023. https://www.visualdx.com/visualdx/dxDetails.do?moduleId=101&diagnosisId=51027&age=4.
