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A 17-year-old girl presents with red papules, pustules, and nodules on her face, shoulders, and back. She said that the condition started at around 13 and has progressively gotten worse. She has tried many topical agents including benzoyl peroxide, antibiotics, and retinoids with minimaleffect. In addition, she has also been prescribed oral antibiotics, also with minimal effects. Her father states that the condition is significantly affecting her self-esteem and also affecting her social interactions, often causing her to refuse invitations to participate in social events.


What is your diagnosis?


nodulocystic acne 1


nodulocystic acne 2


nodulocystic acne 3


 

Diagnosis:

Inflammatory nodulocystic acne

Discussion:  In cases like this, I have successfully used low-dose Accutane therapy.  This is a common practice in Europe and is gaining more popularity in the United States.  Because of I Pledge Program restrictions in females, two negative pregnancy tests separated by approximately five weeks are required for the initiation of isotretinoin therapy.  During this initial five-week period, I have patients use low-dose minocycline (50 mg in the morning with food), topical antibiotics, Cleocin, topical antiinflammatories, and Aczone.   I initiate weekly laser treatments with the Aramis erbium glass laser (1594 nm) treatments weekly.  This usually gives a good initial jumpstart to the treatment, and when the patients start the isotretinoin improvement continues. 

The other nice thing about the lower dose isotretinoin therapy is that one of the major side effects, drying, is dose dependent and is diminished.  Living in Minnesota, this is very important, especially during fall and winter when the relative humidity is extremely low.  Many patients who have had friends or family members treated with isotretinoin at standard American dosages are somewhat reluctant to try isotretinoin but are relieved to realize that although the drying will drying, it is usually not as significant as seen in the standard American dosing.  Also, the initial flare-up of acne is greatly diminished. 

If patients have severe nodulocystic acne, I will use a small dose of prednisone (20 to 30 mg q.a.m.) for the first two weeks of isotretinoin therapy.  The isotretinoin dosage I use is 0.25 to 0.50 mg/kg/day treated for 40 weeks.  I tell patients being on the standard dose or low dose, most clearing occurs around the end of three or four on the face with additional clearing on the chest and back to follow approximately one month after facial clearing.  We've treated hundreds of patients with this protocol with minimal complications. 

In patients of color, starting week 20 of isotretinoin therapy, I will initiate a topical lightening agent containing retinoids, steroids, and hydroquinone at 4% (commercially available as Tri-Luma).  It is important to note that in patients of color, with acne, one must carefully explain that we are treating two different conditions - the inflammatory nature of the disease but also the residual postinflammatory hyperpigmentation.  To patients, spots on the face are spots on the face, and they commonly call both the active lesions and the postinflammatory hyperpigmented macules acne.  As a result, if you can remove the inflammatory lesions but the patients still have brown spots on their face, they are still disturbed.  I tell them at the beginning of therapy, that I'm going to allow the first four months for their body to naturally lighten the dark spots but if there are any residual hyperpigmented macules at midway through the process, we will also initiate a lightening treatment.  Most patients find this both informative and comforting. 

In addition, I use increased emollient therapy recommending total body lotion application, especially after bathing or showering, and one more time a day equaling a minimum of two emollient treatments per day.  I would increase that if the patients were actively participating in sports, indicating that they should use an emollient lotion after every shower.  Additionally, I use Aquaphor for the lips on a regular basis.  I tell the patients to have small tubes available in the coat pockets, glove compartments, and lockers.  Even with these steps, some patients will develop a mild nummular xerotic eczema on their arms, which can be treated with hydrocortisone valerate 0.2% ointment applied twice daily for three days.  I use the same treatment on the lips in conjunction with Aquaphor for five days with extreme xerotic cheilitis.  Additionally in patients I see developing perlèche at the angles of the mouth, we treat with Alcortin t.i.d. for seven days. 

This treatment protocol has been extremely successful.  You will see the before and after pictures of this patient treated with a program similar to that described above and also a photograph of a patient with color with nodulocystic acne treated with this same protocol employing the Kligman-Willis formula using a combination cream containing topical retinoids, steroids, and 4% hydroquinone.  Of course, we routinely discuss with patients at every office visit that they should minimize fat intake and that if they start feeling sad or blue or if they develop a severe headache, stomachache or any GI problems, they should stop the medicine immediately and contact our office.  Additionally, we educate the patients on appropriate sun protection.  We also caution them that if they consume alcoholic beverages, a maximum of two per week is indicated.  Additionally, with females of childbearing age, even though they are on the I Pledge Program, we still reiterate that pregnancy is absolutely contraindicated.  We also follow the patients with monthly labs evaluating lipids, liver function tests, CBC, and in females of childbearing age, a pregnancy test. 

There are many options when it comes to treating patients with acne, and this is just one I have used very successfully in my practice over the years.  

 

Charles E. Crutchfield III, MD

 

References:

2010 American Academy of Dermatology Position Statement on Use of Accutane/Isotretinoin


Low-dose isotretinoin in the treatment of acne vulgaris 2006
"...At the end of the treatment phase, good results were observed in 94.8% of the patients aged 12 to 20 years, and in 92.6% of the patients aged 21 to 35 years. Failure of the treatment occurred in 5.2% and 7.4% of the two groups, respectively.

Acne vulgaris in the elderly: the response to low-dose isotretinoin 2002
"...patients respond well with few side-effects both in the long- and short-term to low-dose isotretinoin

Low-dose schema of isotretinoin in acne vulgaris. 2003
"...The low-dose schema produced fewer adverse effects and offered a very beneficial effect on pre-existing scarring. Our results confirm the beneficial effect of the low-dose schema


Efficacy of fixed low-dose isotretinoin (20 mg, alternate days) with topical clindamycin gel in moderately severe acne vulgaris. 2009
"...Six months of treatment with fixed-dose, alternate-day isotretinoin (20 mg) plus topical 1%clindamycin gel was found to be effective

Efficacy of low-dose isotretinoin in acne vulgaris. 2010
"...the efficacy and relapse rates of low-dose isotretinoin in mild to moderate grades of acne is comparable with the standard regimen

2009 Letter to Dermatology Acute Acne Flare following Isotretinoin Administration: Potential Protective Role of Low Starting Dose


Low dose, high rates of success Dermatology Times 2003
"...Ultra-low dose isotretinoin is all many acne patients need

Low-Dose Accutane Good for Mild Acne 2006

Low Dose Accutane, The new trend?
[a message board on the topic]
How to Get Rid of Acne Using Low Dose Accutane

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