A Challenging Case of Cystic Acne

Abstract:  28 yo woman with 3.5 month history of cystic acne

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.

Phtotos:

Labs:  None yet

Questions:
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?

References:
1. Psychiatric reactions to isotretinoin in patients with bipolar disorder.

Schaffer LC, Schaffer CB, Hunter S, Miller A.

J Affect Disord. 2010 May;122(3):306-8. doi: 10.1016/j.jad.2009.09.005.

Sutter Community Hospitals, United States. schafferpsych@sbcglobal.net

Conclusions: These results indicate that BD patients treated with isotretinoin for acne are at risk for clinically significant exacerbation of mood symptoms, including suicidal ideation, even with concurrent use of psychiatric medicines for BD. The clinical implications of this study are especially relevant to the treatment of patients with BD because acne usually occurs during adolescence, which is often the age of onset of BD and because a common side effect of lithium (a standard treatment for BD) is acne.  URL

2. [Retinoids: drug interactions]. [Article in French]

Berbis P.  Ann Dermatol Venereol. 1991;118(4):271-2.

Abstract There is little available literature on possible drug interactions involving retinoids despite their widespread use. Unlike some other molecules, the retinoids regardless of their generation do not entail a high risk of interference with other medications. A current study found that concomitant administration of etretinate did not significantly modify the timing or value of the peak serum level of 8 methoxy sporalene. Isotretinoin seems to have an inhibiting effect on certain microsomal hepatic and cutaneous oxydases. An isolated observation has been reported of reduced serum concentration of the antiepileptic Carbamazepine in a patient treated with isotretinoin for severe acne. The report, through unconfirmed, should prompt intensified monitoring of patients receiving antiepileptics and retinoids. Among potential pharmacodynamic interactions, studies with the most evident practical importance have assessed possible interference of orally administered retinoids with the efficacy of oral contraceptives (OCs). 1 study of isotretinoin and OCs concluded on the basis of serum levels of progesterone on the 21st or 22nd cycle day that there was no interference. Another study using the same evaluation criteria concluded that there is no interaction between the aromatic retinoids etretinate or acitretin and OCs. The use of low-dose progestins is however not recommended. A recent study on healthy volunteers demonstrated the absence of influence of acitretin on the efficacy of the antivitamin K agent phenprocoumon. The combination of cyclines with isotretinoin can cause intracranial hypertension and is formally contraindicated. Intracranial hypertension has also been reported with aromatic retinoids, which are not recommended. The combination of lithium and retinoids should also be avoided. Because of the additive effect of undesirable side effects, the combination of retinoids and potentially hepatotoxic molecules especially methotrexate and of isotretinoin and potentially photosensitizing molecules should be avoided..  URL.

3. Is thrombophilia testing useful?

Middeldorp S.

Hematology Am Soc Hematol Educ Program. 2011;2011:150-5. doi: 10.1182/asheducation-2011.1.150\

Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands.

Abstract: Thrombophilia is found in many patients presenting with venous thromboembolism (VTE). However, whether the results of such tests help in the clinical management of such patients has not been determined. Thrombophilia testing in asymptomatic relatives may be useful in families with antithrombin, protein C, or protein S deficiency or homozygosity for factor V Leiden, but is limited to women who intend to become pregnant or who would like to use oral contraceptives. Careful counseling with knowledge of absolute risks helps patients in making an informed decision in which their own preferences can be taken into account. Observational studies show that patients who have had VTE and have thrombophilia are at most at a slightly increased risk for recurrence. In an observational study, the risk of recurrent VTE in patients who had been tested for inherited thrombophilia was not lower than in patients who had not been tested. In the absence of trials comparing routine and prolonged anticoagulant treatment in patients testing positive for thrombophilia, testing for such defects to prolong anticoagulant therapy cannot be justified. Diagnosing antiphospholipid syndrome (APS) in women with recurrent miscarriage usually leads to treatment with aspirin and low-molecular-weight heparin (LMWH), although the evidence to support this treatment is limited. Because testing for thrombophilia serves a limited purpose, this test should not be performed on a routine basis.  Free Full Text.