Visual Diagnosis: What's the Diagnosis?

Column Author & Editor: Sean Reynolds, MBBCH | Associate Program Director, Pediatric Dermatology Fellowship

Case 1:

A 15-year-old male presents for evaluation of “zits.” He reports a one-year history of developing pimples on the cheeks, forehead and chin area. He is using an over-the-counter non-medicated facewash without improvement. He denies using anabolic steroids or supplements. He is not using any oral or topical steroids. He reports similar but less numerous lesions on the chest and back. He denies picking at his acne.

Question #1 - How would you grade the patient’s acne?

1. A) Clear
2. B) Almost clear
3. C) Mild
4. D) Moderate
5. E) Severe

1. D) Moderate

In January 2024, the American Academy of Dermatology (AAD) published their updated Guidelines of Care for the Management of Acne Vulgaris. The guidelines recommend that appropriate management of acne begins with an assessment of severity. Many scales are available, but one of the more commonly used is the Physician Global Assessment Scale of Acne, which allows acne to be graded from 0 (clear) to 4 (severe) as outlined in the table below.

Physician Global Assessment Scale of Acne.

From the above photo we can see inflammatory papules, pustules, open (blackheads) and closed (whiteheads) comedones on the cheeks, forehead and chin. Because more than half (but not all) of the patient’s face is involved and there are no obvious nodules or cysts, this patient’s acne would be classified as moderate. Mild-moderate cases can most often be managed with topical treatments while moderate to severe cases are more likely to require systemic treatments such as oral antibiotics, hormonal agents or isotretinoin. Of note, the guidelines recommend that patients with scarring or significant psychosocial burden from their acne should be considered to have severe disease and be considered candidates for systemic treatment.

Question #2: Of the following treatment options which would be the most appropriate treatment for this patient?

1. A) Topical clindamycin
2. B) Topical tretinoin, combined benzoyl peroxide-clindamycin gel
3. C) Oral doxycycline
4. D) Topical hydrocortisone ointment

1. B) Topical tretinoin, combined benzoyl peroxide-clindamycin gel

Of the options listed, this is the most appropriate choice for several reasons. The recently published guidelines issued a number of good practice statements and recommendations to aid clinicians in treating patients with acne. When it comes to topical treatments for acne, the guidelines recommend multimodal therapy combining agents with different mechanisms of action to improve efficacy, such as a topical retinoid, topical antibiotic and topical benzoyl-peroxide in option B. In addition, the guidelines also advocate for the use of fixed-dose combination products, which combine benzoyl peroxide, retinoids or antibiotics into a single formulation and which have been shown to improve compliance and efficacy. While topical clindamycin and oral doxycycline may be appropriate for this patient as part of a treatment regimen, the guidelines specifically recommend against using antibiotics (both topical and systemic) as monotherapy for acne and instead recommend using them with topical benzoyl peroxide to reduce the incidence of antibiotic resistance. Finally, option D is incorrect as, while intralesional steroids can be helpful for larger acne cysts or nodules, topical steroids are not helpful and can result in steroid-induced acne.  

Case 2:

Case 2 is a 14-year-old boy who presents for evaluation of the lesions shown. He started developing acne about six months ago but this acutely worsened over the past month. He is using a benzoyl peroxide wash but no other treatments for his acne. He denies using anabolic steroids or supplements.

Question #3 What is the most likely diagnosis?

1. A) Isotretinoin-induced acne fulminans with systemic symptoms
2. B) Non–isotretinoin-induced acne fulminans with systemic symptoms
3. C) Non–isotretinoin-induced acne fulminans without systemic symptoms
4. D) Isotretinoin-induced acne fulminans without systemic symptoms

1. C) Non–isotretinoin-induced acne fulminans without systemic symptoms

This patient is a young male presenting with very severe and extensive acneiform lesions with large areas of ulceration and crusting. These features should raise concern for acne fulminans. 

Acne fulminans is a variant of acne in which there is (often abrupt) severe worsening of acne lesions with extensive ulceration and hemorrhagic crust that can result in significant and disfiguring scarring. In severe cases, patients may develop systemic symptoms including fevers, joint pain, and osteolytic bone lesions, and they may occasionally require hospitalization. Acne fulminans can be triggered by starting isotretinoin in at-risk patients (most commonly younger male patients with severe nodulocystic or extensive acne). It is classified according to whether or not it was isotretinoin induced and whether or not the patient has systemic symptoms. In this case, the patient was not taking isotretinoin and does not have systemic symptoms, so he has non–isotretinoin-induced acne fulminans without systemic symptoms. Systemic symptoms are much less common in isotretinoin-induced acne fulminans.

Question #4 What is the next best step in management of this patient?

1. A) Oral steroids
2. B) High-dose isotretinoin
3. C) Oral doxycycline and isotretinoin
4. D) Topical tretinoin, benzoyl peroxide and clindamycin

1. A) Oral steroids

Patients with acne fulminans should be referred to a dermatologist. The cornerstone of management of acne fulminans is systemic glucocorticoid treatment until ulceration and crusting improves. If it is isotretinoin induced, this is temporarily held until the lesions start to improve. While the condition can be induced by isotretinoin, most cases will require reintroduction of the medication at a low dose that is gradually increased while steroids are tapered. The isotretinoin is continued for several months and typically leads to long-term remission. High-dose isotretinoin is not appropriate as it can worsen acne fulminans. Oral doxycycline and isotretinoin are not typically used simultaneously as they can cause pseudotumor cerebri. The topical treatments listed in D are unlikely to be helpful in a patient with acne fulminans.

Acne Treatment Tips:

• The new AAD Guidelines of Care for the Management of Acne Vulgaris provide a helpful framework for treating patients with acne.
• Compliance with topical treatments may be improved by having patients place their topical medications next to their toothbrush/toothpaste, setting reminders, and using fixed-dose combination products.
• Post-inflammatory hyperpigmentation can be a bothersome side effect of acne and is typically most severe in patients with skin of color. Topical retinoids can be helpful in treating the hyperpigmentation. Tinted sunscreen can help block visible light which also plays a role in preventing post-inflammatory hyperpigmentation from acne.
• Regarding isotretinoin treatment, population-based studies have not identified increased risk of neuropsychiatric conditions or inflammatory bowel disease in acne patients undergoing treatment with isotretinoin. For persons of childbearing potential, pregnancy prevention is mandatory while taking isotretinoin.
• Acne fulminans is a severe inflammatory variant of acne with extensive ulcerated lesions and hemorrhagic crusting. A patient who develops acne fulminans should be promptly referred to dermatology for further management.

References:

1. Habeshian KA, Cohen BA. Current issues in the treatment of acne vulgaris. Pediatrics. 2020;145(Suppl 2):S225-S230. PMID: 32358215. doi:10.1542/peds.2019-2056L
2. Reynolds RV, Yeung H, Cheng CE, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2024;90(5):1006.e1-1006.e30. PMID: 38300170. doi:10.1016/j.jaad.2023.12.017
3. Cho SI, Yang JH, Suh DH. Analysis of trends and status of physician-based evaluation methods in acne vulgaris from 2000 to 2019. J Dermatol. 2021;48(1):42-48. PMID: 33180351. doi:10.1111/1346-8138.15613
4. Greywal T, Zaenglein AL, Baldwin HE, et al. Evidence-based recommendations for the management of acne fulminans and its variants. J Am Acad Dermatol. 2017;77(1):109-117. PMID: 28619551. doi:10.1016/j.jaad.2016.11.028