Review Question - QID 217660

This patient with severe nodulocystic acne has trialed a course of doxycycline with minimal improvement. After appropriate counseling, the most appropriate step is the initiation of isotretinoin which first requires measurement of urine beta hCG level to rule out pregnancy.

Acne is a chronic skin condition characterized by inflammatory and non-inflammatory skin lesions including pustules, papules, cysts, and nodules that may occur on the face, back, chest, and upper arms. Acne occurs due to blockage or outlet obstruction of the pilosebaceous unit, forming comedones from increased sebum production and abnormal desquamation of keratinocytes and their accumulation. Physical exam may reveal erythematous papules, pustules, cysts, or nodules (inflammatory lesions) or comedones (non-inflammatory lesions which are dilated hair follicles filled with keratin, sebum, and bacteria). Treatment of mild comedonal acne involves benzoyl peroxide topical cream or washes and topical retinoids like tretinoin. Mild-to-moderate acne may be treated by antibiotics such as tetracyclines. Isotretinoin is a vitamin A analog that is used in cases of severe acne. Because of isotretinoin's teratogenicity, female patients who take the drug must first obtain a negative pregnancy test. Other adverse effects of isotretinoin include hypertriglyceridemia, idiopathic intracranial hypertension, hepatotoxicity, cheilitis, and photosensitivity. Due to these side effects, the use of isotretinoin is usually reserved for patients with severe acne, and frequent lab monitoring is required through a national drug registry and monitoring program called iPledge.

Leyden et al. discuss the use of isotretinoin in the treatment of acne and report that isotretinoin is the treatment of choice in cases of severe nodulocystic acne.

Incorrect Answers:
Answer 1: Continuation of doxycycline for 3 more months would be inappropriate in this case, as this patient has had minimal response to doxycycline. Doxycycline may be initially trialed for cases of moderate-to-severe acne; however, the drug should not be used for a prolonged course due to the risk of antibiotic resistance and associated side effects.

Answer 2: Initiation of a salicylic acid wash is inappropriate as salicylic acid is typically used in cases of mild or moderate comedonal acne. Salicylic acid would likely be ineffective in this case of severe acne that has failed to respond to benzoyl peroxide, tretinoin, and antibiotics.

Answer 3: Initiation of spironolactone is recommended for hormonal acne. For example, patients who report worsening of acne with the menstrual cycle may have a hormonal component behind the pathophysiology of acne. This patient reports severe acne that does not correlate with the menstrual cycle, making isotretinoin the preferred treatment.

Answer 5: Switching to minocycline is not recommended as this patient completed a course of doxycycline with no effect. In cases of moderate acne, systemic antibiotics are often used; however, in cases of no improvement, a "step-up" in therapy is recommended.

Bullet Summary:
Initiation of isotretinoin for severe acne refractory to other therapies requires measurement of urine beta-hCG to rule out pregnancy.