HPI: The patient's mother contacted us regarding her daughter, a 28 yo woman with severe cystic acne for over three months. She has had acne in the past, but has also enjoyed long acne free periods as well. No recent changes in medications. The patient has a complicated medical and psychiatric history. She has had a diagnosis of bipolar illness disease (BPD) for greater than ten years. She has two children but her pregnancies were possibly complicated with hypercoagulation secondary to Protein S (history vague). She has been hospitalized for psychiatric disease. Presently, shes care for her children and is in school hoping to get a degree in social work. She is on a host of medications which include lithium, a mini OCP (progesterone only because estrogen is contraindicated due to Protein S). She is understandably depressed as a result of her acne.
O/E: The patient is a sad looking woman who sat in the waiting room with a baseball cap low on forehead and head bowed. She has cores of small to moderate cysts covering face. Back and chest clear. She is aesthenic.
Labs: None yet
It seems that periodically something triggers her acne. What are your thoughts?
Workup: Which serum androgens should be ordered? I am considering Total and Free Testosterone and DHEA-S.
Management: Since estrogenic OCPs are contraindicated and tetracyclines have interactions with lithium, what is best approach?
Lithium and progesterone both can cause acne flares. Do they act synergistically?
I started her on amoxicillin 500 mg tid until I get some better ideas.
There is a worrisome article on the use of isotretinoin in patients with BPD. (Ref 1) Do you believe this?
1. Psychiatric reactions to isotretinoin in patients with bipolar disorder.