History: This 14 y.o. boy has had acne for a year. He has painful lesions on the chest and back. Topical treatment and doxycycline has not been helpful. His father may have had similar lesions.
O/E: Small to moderate sized cysts on chest and back. There are hemorrhagic crusts and early scarring. Facial involvement less significant.
Clinical Photo(s)
Lab: Prior to initiating isotretinoin: CBC, Comprehensive Chem Panel, Fasting Lipids. (Women need two negative pregnancy tests 19 days apart)
Histopathology: N/A
Diagnosis or DDx: Acne, cystic.
Reason(s) Presented: This is the type of patient for whom isotretinoin should be the first line of therapy. Indeed, in patients such as this, it is often wise to treat with prednisone at the initiation of isotretinoin therapy to avoid a flare that may cause more scarring in the long run. In areas like Augusta, where access to dermatologists in limited, it would be important for this drug to be available from a non-dermatologist. Prescribing isotretinoin is not all that difficult; but one has to adhere to the iPledge program. The big risk with this drug is teratogenicity, so women of childbearing potential need to have pregnancy tests done before starting the medication and monthly while on it and one month after discontinuing therapy.
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