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.

Isotretinoin Failure

This 20-year-old woman has a 6 month history of cystic acne.  Although she has been on isotretinoin for three month her response has been poor and she continues to develop new lesions.  She started on 40 mg of isotretinoin a day but her acne flared and she was dropped to 30 and then 20 mg per day.  Due to her acne flare on isotretinoin, prednisone was started at 40 mg bid (tapered after two weeks).  She is on a combined oral contraceptive but it only has 20 mcg of ethinyl estradiol and spironolactome 100 mg per day.  She was also placed on desloratadine 5 mg a day, but that did not appear to help either. She is feeling discouraged, and sees a therapist for anxiety and that led to a prescription for BuSpar from her therapist.

EXAMINATION:  The examination shows a pleasant, outgoing woman.  She has acne with inflammatory and cystic features on the cheeks and forehead.  Back and chest are clear although she did have some acne on her shoulders that has resolved.  Her weight is 65 kg.  There is no hirsuitism or striae.

Photos 8.5.21(aftr 12 weeks of isotretinoin)

IMPRESSION:  This 20-year-old woman with severe inflammatory cystic continues to have active lesions after 3 months months on isotretinoin.  Her acne worsened significantly after her first month of isotretinoin at 40 mg a day.    

 

Photos Removed for Privacy Issue (for legitimate use please contact djelpernATgmail.com)

PLAN:  For the time being, we will continue prednisone at 20 mg a day for the next week and then drop, isotretinoin 20 mg a day, and continue spironolactone 100 mg a day.  I discussed with her either trimethoprim or Bactrim, but we are going to hold off on that, for the time being.    After a literature review,  an article about adding amoxicillin seemed promising.¹

          Questions:

1. At what point would you initiate a work-up for underlying endocrinopathy, such as Cushings?

2.  Have you treated similar patients who flared with isotretinoin and were difficult to control?

3. Have you had experience with adding amoxicillin in situations like this.

 

Reference:

Safety and effectiveness of amoxicillin in the treatment of inflammatory acne.  Guzman AK, Choi JK, James WD. Int J Womens Dermatol. 2018 Jun 8;4(3):174-175Free Full Text.
Comment from Dr. James:

Amoxicillin is a very good drug for acne. I would start at 500 mg tid, very few get any side effects other than of course possible drug eruption, but most have had penicillin in the past and know if they are allergic or not. At three months I would then go to bid. In the paper it was early in my using it, and I was giving it at lower doses, but I find higher dosing better and well tolerated.

You could also start at a lower dose with isotretinioin, sometimes with prednisone as well for the first three to six weeks, almost always tolerate it in this manner, but hard for those who have flared badly to want to take it again. Avoiding this bad flare is why when I use isotretinoin I start the first month at 20 mg per day, then increase. I have had to start at ten mg per day in some that have flared in the past, along with prednisone.

 

Cystic Acne vs. Filler Reaction

Presented by Dr. Kaare Nordqvist
Grand Forks, North Dakota

The patient is a 35 y.o. television news reporter in a Midwestern state.  For the past two yeas she has had inflammatory facial cysts.  She had acne when younger, but it was not like this.  Recently she’s been treated with intralesional triamcinalone, spironolactone (100 mg/d) and doxycycline 100 mg bid.  She has relocated to her family home in North Dakota due to Covid-19.

History: Anamnesis reveals that she had been receiving Restylane and Juvederm for the past two years for old acne scars.

It’s not clear that this pauci cystic diathesis was typical of her earlier acne.

O.E:  Deep cysts, 1.5 – 3 cm in diameter in cheeks, chin and nasolabial folds.  At any time there are no more than two to three lesions.  No other evidence of acne.

Clinical Images:

Diagnosis:  Are we dealing with pauci cystic acne or a reaction to HA fillers? It is known that injected material can migrate and the literature suggests that HA reactions may be more common after viral infections.

This young woman was on the television news nightly.  She is understandably concerned about these lesions and subsequent scarring once she in back in the public's eye.

References

1.Ofir Artzi  et. al. Delayed Inflammatory Reactions to Hyaluronic Acid Fillers: A Literature Review and Proposed Treatment Algorithm. Clin Cosmet Investig Dermatol. 2020 May 18;13:371-378. PMC

2. Katie Beleznay et al.  Delayed-onset nodules secondary to a smooth cohesive 20 mg/mL hyaluronic acid filler: cause and management. Dermatol Surg. 2015 Aug;41(8):929-39.

Maskacne

Then felt I like some watcher of the skies
When a new planet swims unto his ken…

 

The patient is a 35 yo OB/Gyn junior faculty with a 2 month history of “Maskacne.”  She uses a standard surgical mask for ~ 12 hrs a day. Her skin care regimen is: “wash with Aveno cleanser, apply Cerave moisturizer. If going out will apply Shiseido sunscreen as well. I try not to wear makeup under mask, but if I do it will be Tarte foundation and a blush
Night time: wash with Avene cleanser, sometimes apply toner, and followed by Cerave moisturizer."

Prior to Covid 19 she only used a mask in the OR and Labour & Delivery room but for the past 10 months she’s been masked 10 – 16 hrs a day.

O/E: Papules and pustules on the lower face.

 Diagnosis:  Acneiform eruption under a mask in a young woman with no previous history of inflammatory acne.

In the Differential Dx
1) Perioral dermatitis
2) Demodex folliculitis
3) Oil acne/Occlusive acne
4) Acne mechanica  (A report from the BMJ in 1976 is helpful.  Strangely, this entity has been understudied)

Has any reader had experience with Maskacne?  Your thoughts will be appreciated.

Addendum: I week after posting the patient writes "I just cleaned face without moisturizers this past week and it is improving everyday. Still doesn’t look great but the pustules are gone (photos below).

Reference:
1. Yu J, et. al. Occupational dermatitis to facial personal protective equipment in health care workers: A systematic review J Am Acad Dermatol. 2021 Feb;84(2):486-494. PMC Full Text.

2. Jillson OF, Perioral dermatitis. Cutis 1984 Nov;34(5):457-8.

3. Khalifa E Sharquie  et. al. Topical therapy of acne vulgaris using 2% tea lotion in comparison with 5% zinc sulphate solution. Saudi Med J. 2008 Dec;29(12):1757-61. PMID. (See Prof. Sharquie's comment on this patient.
Conclusion: Two percent tea lotion was a good alternative remedy to be used in the treatment of acne vulgaris, and was much superior than topical 5% zinc sulphate solution.

4. Acne mechanica. BMJ 1976 Jan 17;1(6002):130.  PMC1638630 Free Full Text

Neonatal Acne

Presented by Dr. Henry Foong, Ipoh Malaysia

21 day old boy

normal full term delivery

breast feeding

1 week history, initially forehead then spread too cheeks and nose area

mother is healthy and asymptomatic.

O/E: symmetrical/bilateral vesicles/ pustules/ papules/comedone on affected areas

 Dx: neonatal acne/ cephalic pustulosis

A benign condition.  i think it revolves with our treatment

Treatment:  reassurance!!

Comment by a pediatric dermatology colleague: "Neonatal acne is a common newborn eruption, and it can be seen in about 20% of healthy babies. The scalp, face, neck and back and chest are commonly affected, and open comedones are usually absent as this finding would make one consider infantile acne. The lesions are usually not present at birth, but typically appear within the first 2-4 weeks of life, and generally improve by about 4-6 months of age. This condition is self-limited, however, one can consider topical antifungal or low potency topical corticosteroid if the parents seek for medical treatment. Usually reassurance would comfort the parents." [The role of P. ovale is considered]

Reference:

Neonatal Malassezia furfur pustulosis.

Rapelanoro R, et. al.

Arch Dermatol. 1996 Feb;132(2):190-3.

Abstract

BACKGROUND:

Papulopustular eruptions of the face in neonates are frequently referred to as neonatal acne or sebaceous miliaria. Our findings suggest that there is an association between this type of eruption and Malassezia furfur infection.

OBSERVATIONS:

Direct examination of pustule smears showed M furfur yeasts in eight of 13 cases involving neonates with erythema and papulopustules of the face, neck, and scalp (mean age at onset, 22 days [range, 7 to 30 days]). The pustules were predominantly neutrophilic. Treatment with 2% ketoconazole cream applied topically twice daily was effective in 1 week.

CONCLUSION:

Malassezia furfur is frequently associated with a common nonfollicular pustulosis of the newborn, probably improperly termed neonatal acne.

Florid Acneiform Eruption

Presented by: 
Marina Delgado, M.D.
Apache Junction, Arizona

The patient, a 21 woman  with a 9 year history of acne is studying in Arizona.  Her acne, present since age 12, was relatively quiescent until it flared three months ago when she was doing research in Southern China.  In the past, she had been treated with topicals, antibiotics and oral contraceptives.  None were effective; but her acne was not florid as it is now.

10.9.2016

 After treatment with prednisone and isotretinoin.

5.12.2017

Photos are presented with the young woman's consent.
 
One of our pediatric dermatology colleagues suggested that this woman has pyoderma faciale.

We recommended isotretinoin plus prednisone but, because of iPledge, the patient has to wait a month to qualify for isotretinoin.

Have you managed similar patients?  What suggestions do you have?  What do you see as the role for prednisone and how long shoould it be continued?

References:

1. Pyoderma faciale: Successful treatment with isotretinoin

Victor J. Marks, Robert A. Briggaman

J Am Acad Dermatol 17, 1062–106. 1987  PDF.

2. Henry Foong. Pyoderma faciale, Virtual Grant Rounds in Dermatology, October 2001.

3.

Combination of low-dose isotretinoin and pulsed oral azithromycin in the management of moderate to severe acne: a preliminary open-label, prospective, non-comparative, single-centre study.  De D1, Kanwar AJ. Clin Drug Investig. 2011;31(8):599-604.

RESULTS: Sixty-two (93.9%) of 66 eligible patients had complete clearance of disease activity after a mean treatment duration of 21 weeks. The mean total cumulative dose of isotretinoin was 49.6 mg/kg. Seven (11.3%) patients had a relapse of disease during the post-treatment follow-up period. Fifty-three adverse effects were observed. Three patients had initial aggravation of disease that was managed with prednisolone and disappeared with continuation of treatment.

CONCLUSION: A combination of low-dose isotretinoin and oral azithromycin pulse is effective in severe acne and has a reasonably acceptable adverse-effect profile and low post-treatment relapse rates.  Abstract.

 

Excoriated Acne with Hyperpigmentation

A 37 yo Haitian woman was seen complaining about hyperpigmented lesions on face and back.  By history, these followed acne which she has excoriated.  Her health is good otherwise and she takes no medication by mouth.

O/E:  Hyperpigmented papules and macules on face and torso in a young woman with Type V skin.  Some lesions show mild excoriation.

Clinical Photos:

Diagnosis:  Post-inflammatory hyperpigmentation in excoriated acne.

Comment:  In my area, we have few patients with Type V and VI skin.  This is a common problem, but I do not have much experience treating it.  What is your protocol?  I started her on tretinoin 0.05% cream as this may be covered by her insurance.

Note:  A Pubmed search for hyperpigmented acne scars retrieves only three references and all are to laser surgery which this patient can not afford. This problem must be extraordinarily common; yet the biomedical literature is strangely silent about it.