Acne Scarring

The patient is a 26 year old man who presents to the office for evaluation of acne. He has struggled with acne on the face, back and chest since for over 6 years. He was previously prescribed a few different antibiotics over the past few years, however none of them have provided significant improvement in his acne. He had reactions to minocycline and doxycycline and therefore, his dermatologist recommended he stay away from these medications. Otherwise, he is a healthy man without any other concerns.

On exam, the patient has severe hypertrophic scarring on the chest and back. He has a couple active erythematous cysts on the back, chest and neck.

Assessment and plan: Hypertrophic and keloidsl acne scarring is difficult to treat. We  wonder if isotretinoin will trigger more scarring or whether it may actually help him.

Questions:

Is there a value to starting him on isotretinoin? With Prednisone?

His previous dermatologist used intralesional triamcinalone without benefit.

The patient may need to pay for procedures out of pocket; but his insurance will cover isotretinoin.

Painful Leg Ulcer in an Octogenarian

The patient is a, otherwise healthy 84 yo woman who had a squamous cell carcinoma of the left pretrial area in 2018 that was treated with radiation.  The area took 18 - 24 months to heal after XRT.  Due to concerns about a new crusted area at the site, it was biopsied in April 2023; but has not healed since then.  In August 2023, there was a 6 mm in diameter ulcer.  In July of 2024, she had moved to another state and a wound care physician re-biopsied the area and curretted it,  In the ensuing three months the ulcer has grown to its present size of 3.7 x 2.7 cm and is constantly painful.  (Both biopsies showed no evidence of cancer.)

She has good pedal and dorsals pulses and has had arterial and venous studies of her leg show normal findings. Ankle Brachial and Toe Brachial Indexes are normal.Wound cultures have repeatedly grown out a mixture of Pseudomonas, Coagulase Negative Staph and Strep species.

12.12.23

1.27.24

What is your diagnosis and what do you think is the best way to care for this ulcer?