A 15-year-old, previously healthy girl comes to the office due to "spots" on her face. About a year ago, the patient started having tiny bumps on her forehead; they have progressively increased in number and size. She has used several over-the-counter facial cleansing products without relief. The patient does not use tobacco, alcohol, or illicit drugs and is not sexually active. Physical examination shows an oily complexion and the findings seen in the image below:
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Which of the following is the best next step in management of this patient?
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This patient has noninflammatory, comedonal acne on the forehead; the treatment of choice is a topical retinoid. The pathogenesis of acne involves the following:
Hyperkeratinization leads to keratin plug formation in the hair follicles, preventing sebum flow from the follicles to the skin surface. When the keratin plug is hidden under the skin, it is called a closed comedone, like those seen in this patient. In contrast, when the keratin plug is exposed at the follicular orifice, it is called an open comedone; melanin and oxidized sebum give open comedones a dark color. Comedone formation (ie, comedogenesis) is the initial step in acne pathogenesis.
Cutibacterium acnes, which is part of the skin flora, relies on sebum as a nutrient source. As the bacterium proliferates, it triggers an inflammatory response that leads to formation of the red papules and pustules seen in inflammatory acne.
Ongoing inflammation leads to follicle rupture, releasing additional proinflammatory substances and leading to the formation of nodulocystic acne.
Topical retinoids inhibit comedogenesis by normalizing keratinization; decreasing epithelial cohesiveness, which facilitates desquamation and prevents follicular plugging; and increasing epithelial turnover, which facilitates the extrusion of comedones. Because retinoids inhibit comedogenesis, the first step in acne pathogenesis, they are also used as part of a multiagent therapy for inflammatory acne.
(Choice A) Despite coverage in the lay media, chocolate has not been shown to promote acne formation.
(Choice B) Patients with oily skin are generally advised to use water- or gel-based cleansers. Cream-based cleansers contain higher oil content and are comedogenic.
(Choice C) Estrogen-containing oral contraceptives have an antiandrogenic effect that inhibits sebum production. They are commonly used for women with moderate/severe inflammatory acne, especially those who have premenstrual acne flares. However, they are not recommended for noninflammatory comedonal acne.
(Choice D) Oral antibiotics (eg, tetracyclines) effective against C acnes are used to treat moderate/severe inflammatory acne or acne that is widespread (eg, on the back), making the application of topical therapy impractical.
(Choice E) Topical corticosteroids are used in a variety of inflammatory dermatoses (eg, contact dermatitis) but are not indicated for acne. The inflammation seen in acne is triggered by C acnes; therefore, antibiotics are part of the multiagent regimen for inflammatory acne.
Educational objective:
Topical retinoids are first-line treatment for noninflammatory, comedonal acne. They inhibit comedogenesis by normalizing keratinization, decreasing epithelial cohesiveness, and increasing epithelial turnover.