Addressing Challenging Cases of Acne: Part 2

In a series of Dermatology Times Case-Based Roundtable® events, leading dermatologists and their local peers tackled some of the most challenging cases of acne. These gatherings provided an invaluable platform for collaborative discussion, innovative problem-solving, and the exchange of cutting-edge treatment strategies. Each session featured in-depth case presentations, allowing participants to delve into the complexities of acne presentations and explore various diagnostic and therapeutic approaches for diverse patient populations. These clinical insights from New York, Nevada, and Florida showcased the dermatology community’s collective expertise and dedication to improving patient care.

In a roundtable discussion held in Las Vegas, Nevada, a group of dermatology clinicians, including dermatologists, dermatology nurse practitioners, and dermatology physician assistants, convened to tackle some of the most challenging cases in acne management. James Del Rosso, DO, of JDR Dermatology Research, led this discussion, presenting a particularly challenging case of an adolescent girl with persistent acne. The case highlighted the complexities of acne treatment and the necessity for personalized, patient-centered approaches.

Tackling Persistent Acne in Adolescence

Del Rosso introduced the case of a 14-year-old girl with persistent acne. “This patient had been treated with conventional therapies but remained dissatisfied with her progress,” he explained. Initially, she had been using various over the counter topical treatments without success. When she sought medical intervention, she was prescribed topical clindamycin combined with benzoyl peroxide and, subsequently, oral doxycycline.

“From the start, she disliked benzoyl peroxide,” Del Rosso noted. “She had a strong aversion to it even as an over the counter medication, so we had to discontinue its use.” The patient’s acne primarily consisted of closed comedones, open comedones, and superficial inflammatory papules and pustules scattered across her face. Despite not having nodular acne, her condition was persistent and did not improve to her satisfaction over several months of treatment.

Navigating Diet and Preference Challenges in Treatment

The patient’s dislike for benzoyl peroxide posed a significant challenge. “We had to respect her preferences and not push her to use something she was uncomfortable with,” Del Rosso emphasized. Instead, the patient was treated with clindamycin and tretinoin, and oral doxycycline was added because of insufficient improvement. However, concerns about antibiotic resistance and the patient’s strict vegan, low-fat diet added layers of complexity to her treatment.

“When discussing options, we considered different topical therapies,” said Del Rosso. “But she was adamant about not using benzoyl peroxide, even in potentially less irritating formulations.” The team had to navigate these preferences while aiming to optimize her treatment outcomes.

Introducing Isotretinoin With Contraceptive Considerations

Given the patient’s lack of response to initial treatments and her consistent use of an intrauterine device that released levonorgestrel, the decision was made to start her on oral isotretinoin. “She was motivated and already had contraceptive protection, which made her a suitable candidate for isotretinoin,” Del Rosso explained. “We used a branded generic formulation based on the original Accutane, which requires high-fat intake for optimal absorption.”

Despite the challenge of her low-fat diet, the patient initially responded well to isotretinoin, achieving clear skin for nearly 1.5 years. However, her acne recurred, necessitating further treatment. A second course of isotretinoin at a higher dose provided another period of remission, but the acne returned after 2 years.

Considering Patients With Polycystic Ovary Syndrome

As the patient’s acne continued to recur, the discussion among clinicians turned to the possibility of underlying conditions, such as polycystic ovarian syndrome (PCOS). “There was debate about whether to conduct hormonal testing for androgens,” Del Rosso recalled. “Most of the group was not familiar with PCOS presenting in patients of low body weight and smaller physical size.”

Despite the patient’s lack of classical PCOS symptoms like hirsutism or alopecia, laboratory testing was conducted. “We tested for testosterone, androstenedione, and dehydroepiandrosterone-sulfate,” Del Rosso said. “She had her blood drawn during her menstrual period, which is ideal for these tests.” The results revealed elevated androgen levels, and a transvaginal ultrasound confirmed the presence of ovarian cysts, leading to a diagnosis of PCOS.

Pivoting the Treatment Plan

With the new diagnosis, the treatment strategy needed adjustment. “We considered using an isotretinoin formulation that does not depend on high fat intake for absorption,” Del Rosso explained. “But obtaining coverage for these formulations can be challenging.” The patient was also started on oral spironolactone, an anti-androgen medication, and the team discussed the potential benefits of topical therapies.

“We now have a topical androgen receptor inhibitor, clascoterone, which is FDA-approved for patients 12 [years] and older,” Del Rosso noted. “This patient could have been using it all along. It might have provided additional benefits alongside conventional agents like retinoids and benzoyl peroxide, although she wouldn’t use the latter.”

The Importance of Personalized Treatment

This case underscored the importance of a personalized approach in acne treatment. “Working with the patient to utilize treatments they feel comfortable with is crucial,” Del Rosso emphasized. “Pushing treatments they are reluctant to use can lead to non-compliance and suboptimal outcomes.” The clinicians agreed that patient preferences and lifestyle factors, such as diet and strict veganism, must be considered when designing treatment plans.

“Many were surprised by the PCOS diagnosis, especially in a patient who did not fit the classical visual textbook picture.” The case illustrated the necessity of considering underlying conditions in patients with recurrent acne and highlighted the evolving landscape of acne treatment options. “This was a very instructive case. It brought together considerations of optimizing topical therapy and evaluating androgen levels in patients with persistent acne. It was a great meeting with valuable input from various individuals, and I was happy to be able to facilitate this roundtable discussion,” Del Rosso concluded.