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.
These cases are very difficult. The key is to stop the acne process, so I would use a long course (1-2 yrs) of low dose isotretinoin - 10 mg/day, with cetirizine (antihistamine) 10 mg/day. Afer a year, if the keloids are still very thick, I would use intralesional steroid injections (hopefully he will be over actively growing phase, but I have seen them still growing in a 31 yr old).
ReplyDeleteA number of laser and radiofrequency devices have been used with success, but it is important to continue the isotretinoin as this helps withthe scar remodelling.
It is unlikely that it will help with atrophic scars, these could be surgically excised.
UV may help, even if it just gives a cosmetic tan. I think it too late for systemic steroids, but if you are worried by a possible isotretinoin-flare, then cover initially with 4-6 weeks of prednisone.