Acne Vulgaris

Clinical Case Presentation

Acne
Acne Vulgaris
Vulgaris
Anna Katrina B. Balandra, RPh.
Danelle V. Bonite, RPh.
Glen Lester G. Chiong, RPh.
PATIENT PROFILE Name: Elaine Morgan
Age: 18
Sex: Female
Weight: 45 kg
Height: 5’2”
Chief Complaint
ACNE
 HISTORY OF Patient has a history of facial acne since age
15. She has completed a 3-month course of
PRESENT ILLNESS Minocycline in combination with Differin
(Adapalene) a month ago.
PAST MEDICAL HISTORY
•   Polycystic Ovary Syndrome 3 years ago
FAMILY HISTORY Parents are alive and well; two older
brothers (ages 21 and 25). Father had
acne with residual scarring.

Social History The patient is a graduating student. She

is sexually active and practices safe sex.
MEDICATIONS NONE

ALLERGIES NKDA
 REVIEW OF SYSTEMS/PHYSICAL
EXAMINATION
General survey
Alert, moderately anxious teenager in NAD. Has irregular menstrual periods and
mild hirsutism.

Vital signs
»BP – 110/70 mmHg
»RR – 15
»Temp – 37°C

HEENT
PERRLA, EOMI, fundi benign, TMs intact
 REVIEW OF SYSTEMS/PHYSICAL
EXAMINATION
Skin
Comedones on forehead, nose, and chin. Papules and pustules on the nose and malar area. A
few cysts on the chin. Scars on malar area. Increased facial hair.
Chest
CTA bilaterally
Cor
RRR without MRG, S1 and S2 normal
Abd
(+) BS soft, nontender, no masses
MS/Ext
No joint aches or pains; peripheral pulses present
Neuro
CN II-XII intact
LABORATORY RESULTS 1/4
RESULT NORMAL VALUE

Na 140 mEq/L 135 – 145 mEq/L

K 3.7 mEq/L 3.5 – 5.0 mEq/L

Cl 100 mEq/L 98 – 106 mEq/L

CO2 25 mEq/L 21 – 30 mEq/L

BUN 12 mg/dL 10 – 20 mg/dL

SCr 1.0 mg/dL <1.5 mg/dL

Glu 100 mg/dL 75 – 115 mg/dL

LABORATORY RESULTS 2/4
RESULT NORMAL VALUE

Hgb 13.0 g/dL 12 – 16 g/dL

Hct 38% 36 – 46%

Plt 300 103/mm3 150 – 350 103/mm3

WBC 7.0 103/mm3 4.5 – 11.0 103/mm3

LABORATORY RESULTS 3/4
RESULT NORMAL VALUE

AST 21 IU/L 0 – 35 IU

ALT 39 IU/L 0 – 35 IU/L

LDH 105 IU/L 100 – 190 IU/L

Alk phos 89 IU/L 30 – 120 IU/L

T. bili 1.0 mg/dL 0.3 – 1.0 mg/dL

Alb 3.9 g/dL 3.5 – 5.5 g/dL

FSH 30 mIU/mL 4.7 – 21.5 mIU/L

LH 150 mIU/mL 1.68 to 15 mIU/L

LABORATORY RESULTS 4/4
RESULT NORMAL VALUE

T. chol 170 mg/dL <200 mg/dL

LDL-C 90 mg/dL <130 mg/dL

Trig 90 mg/dL 35 – 135 mg/dL

HDL 45 mg/dL 30 – 75 mg/dL

DHEAS 221 mcg/dL 145 – 395 mcg/dL

Testosterone 2.3 ng/mL 6 – 86 ng/dL

Prolactin 15 ng/mL 0 – 20 ng/mL

PROBLEM IDENTIFICATION
1.A. Create a drug therapy problem list for this patient.
1.B. What signs and symptoms consistent with acne does this patient have?
1.C. How does polycystic ovary syndrome contribute to this patient’s acne and
other physical findings?
PROBLEM IDENTIFICATION
1.A. Create a drug therapy problem list for this patient.
Medication Problems
Oral antibiotics should be used for the shortest time possible to prevent
Antibiotics antibiotic resistance. Antibiotics may cause side effects, such as an upset
stomach and dizziness. These drugs also increase your skin's sun sensitivity.
The most common side effects of these drugs are weight gain, breast
Combined oral tenderness and nausea. A serious potential complication is a slightly
contraceptives increased risk of blood clots.

Anti-androgen agents Possible side effects include breast tenderness and painful periods.
Potential side effects include ulcerative colitis, an increased risk of
depression and suicide, and severe birth defects. In fact, isotretinoin carries
such serious risk of side effects that all people receiving isotretinoin must
Isotretinoin
participate in a Food and Drug Administration-approved risk management
program.
PROBLEM IDENTIFICATION
1.B. What signs and symptoms consistent with acne does this patient have?
• Comedones on forehead, nose, and chin.
• Papules and pustules on the nose and malar area.
• A few cysts on the chin. Scars on malar area.
• Hormonal imbalance
PROBLEM IDENTIFICATION
1.C. How does polycystic ovary syndrome contribute to this patient’s acne and
other physical findings?
Polycystic ovary syndrome (PCOS) is a hormone imbalance that can cause
irregular periods, excess hair (hirsutism), and acne. For some women with PCOS,
this will cause glucose to increase in the bloodstream along with high levels of
insulin. High levels of insulin can increase the production of androgens such as
testosterone, in the ovaries. This contributes to excessive hair growth and acne.
DESIRED OUTCOME
2. What are the treatment goals for this patient?
The goals are to reduce the number and severity of lesions, slow disease
progression, limit disease duration, prevent formation of new lesions, and prevent
scarring and hyperpigmentation.
THERAPEUTIC ALTERNATIVES
3. What feasible therapeutic alternatives are available for management of this
patient’s acne and hyperandrogenism?
Alternative and integrative medicine approaches used in the treatment of acne
include fish oil, brewer's yeast, probiotics, oral zinc and topical tea tree oil. For
the hyperandrogenism due to having PCOS, the patients is advised to have dietary
changes such as eating whole food, balancing carbs and protein intake, eat food
that can fight inflammation, increase iron and magnesium intake, use supplements
such as inositol, chromium, turmeric, zinc, etc., and also to take some adaptogen
herbs. The patient is also advised to take probiotics, maintain a healthy weight,
reduce stress, and practice a good sleep hygiene.
OPTIMAL PLAN
4. What treatment regimen is best suited for this patient?
Due to her having more of a moderate type of acne and already experiencing
hyperandrogenism due to her PCOS, the patient is advised to take an Oral anti-
androgen with a topical retinoid or an azelaic acid with or without benzoyl
peroxide.
OUTCOME EVALUATION
5. How would you monitor the therapy you recommend for efficacy and adverse
effects?
Combination birth control pills that contain estrogen and progestin decrease androgen
production and regulate estrogen. Regulating your hormones can lower your risk of
endometrial cancer and correct abnormal bleeding, excess hair growth and acne. The amount of
hormone present varies from brand to brand. You can opt for low- or high-dose formulations.
Your doctor will help determine the right dosage for you. Patient may experience headaches,
mood swings, sore breasts and weight changes.

Topical retinoids are safe, effective, and economical for treating all but the most severe
cases of acne. They should be the first step in moderate acne, alone or in combination with
antibiotics and benzoyl peroxide, reverting to retinoids alone for maintenance once adequate
results are achieved. Side effects include erythema, xerosis, burning, and peeling. Retinoids
should be applied at night, a half hour after cleansing, starting with every other night for 1 to 2
weeks to adjust to irritation. Doses can be increased only after beginning with 4 to 6 weeks of
the lowest concentration and least irritating vehicle.
Continuation
Azelaic acid is an alternative to topical retinoids for maintenance therapy. Azelaic acid is
well tolerated, with adverse effects of pruritus, burning, stinging, and tingling occurring in 1%
to 5% of patients. Erythema, dryness, peeling, and irritation occur in fewer than 1% of patients.
Azelaic acid is available in 20% cream and 15% gel formulations, which are usually applied
twice daily (morning and evening) on clean, dry skin. Most patients experience improvement
within 4 weeks, but treatment may be continued over several months if necessary.

Benzoyl peroxide has an anti-inflammatory, keratolytic, and comedolytic activities, and is

indicated in mild-to-moderate acne vulgaris. Clinicians must make a balance among desired
concentration, vehicle base, and the risk of adverse effects, as higher concentration is not
always better and more efficacious. The main limitation of benzoyl peroxide is concentration
dependent cutaneous irritation or dryness. Development of contact dermatitis to benzoyl
peroxide should be monitored, with discontinuation of the medication in patients that develop
marked erythema and irritation with its use. Prior to using benzoyl peroxide, a test area should
be treated to monitor for tolerability and sensitivity.
PATIENT EDUCATION
6. How would you educate the patient about this treatment regimen to enhance
compliance and ensure successful therapy?
Patient must understand that mild irritation to the products may occur at first
as the skin is building its tolerance. If patient will opt for the use of azelaic acid
with or without benzoyl peroxide, she should limit her amount of UV exposure
and apply sunscreen to decrease the risk of developing phototoxicity and skin
irritation. Positive results of the therapy will not show overnight, so patient must
continue to medicate as recommended.
CLINICAL COURSE
Two months later, the patient has developed bloating, weight gain and increased
appetite, likely related to the therapy prescribed. She also reveals that her
maternal grandmother and aunt died of melanoma, and a friend told her that she
should not be using her new therapy.
FOLLOW-UP QUESTIONS
1. What is the most appropriate course of action?
Patient is advised to maintain a healthy weight and have dietary changes due
to her PCOS - balance carbohydrate consumption and protein intake. Try to
remember to watch your portion sizes and eat 5-7 servings of fruits and veggies
each day and don’t forget to exercise. Your appetite may increase or stay the
same. Side effects usually go away in the first three to four cycles (months). If
you do have side effects, you should talk to your health care provider. If the side
effects are very uncomfortable or if they don’t go away after three cycles, your
health care provider may switch you to a different pill.
Continuation
Patient may shift to isotretinoin use, which decreases sebum production,
inhibits P. acnes growth, and reduces inflammation. However, due to
teratogenicity, two different forms of contraception must be started in female
patients of childbearing potential beginning 1 month before therapy, continuing
throughout treatment, and for up to 4 months after discontinuation of therapy.