Case 81
Acne vulgaris
Presented by Aletheia Vinson
10/15/2014
HPI – History of present illness
M.E., 21 yo woman with Hx of facial
acne since age 18
Presents with acne flare up
Also c/o irregular menses and facial
hair
Just completed 2.5 month course of
500mg erythromycin (antibiotic)
BID, and topical adapalene gel
0.1%
PMH – Past medical history
No other chronic medical conditions
No other acute or recent illnesses
First case of acne 3 years ago responded
to:
Topical 0.5% salicylic acid daily
Topical 2.5% benzoyl peroxide twice daily
Past 2 years, facial lesions have
increased and worsened
Comedones to pustules and nodules with
scarring
Acne stages/types
Pilosebaceous unit hair follicle and oil gland
Causes of Acne
1.
Plugged follicles from dead skin cells
2.
Inflammation of skin surrounding follicle
3.
Increased sebum production
4.
Propionibacterium acnes
(P. acnes) within follicle
- leads to inflammation
(PMH)
Medications
Oral tetracycline (500 mg BID)
Beneficial for 10 months
Doxycycline (100 mg BID) and
clindamycin (150 mg BD)
Suspected resistant strain of
P. acnes
Not successful
FH & SH
No FH of cystic acne
Both parents and older brother alive and well
Non-smoker, no alcohol or IVDA
Work, school, extracurricular activities
Sexually active in 3 year monogamous
relationship
No condoms, oral contraceptives or diaphragm
Enjoys movies, jogging, racquetball,
canoeing, reading
Pelvic Exam
Meds / Allergies
No vaginal
discharge or
lesions
Cold medications
and naproxen
Make her “feel
irritable”
LMP 5 days ago
Abnormally light
flow
Physical Exam & Lab Tests
General: alert,
moderately anxious, slim,
NAD
HEENT
Pupils 3 mm
bilat/reactive
Visual acuity 20/20
bilat
Funduscopic exam
normal
EOMI
TMs intact
Mucous membranes
moist and pink
Vital signs:
BP 115/75
T 98.6 F
P 80
Wt 114 lbs
RR 14
Ht 5’4”
Neck
Supple, no JVD,
thyromegaly,
carotid bruits or
adenopathy
Lungs CTA bilat
Vital signs normal?
HR, RR, P, T all normal
BMI = (weight kg)/(height
m)^2
= 19.6 HEALTHY WEIGHT
Heart, abdomen, MS/Ext
RRR, no m/r/g
S1 and S2
Abd soft, no
palpable masses
NT/ND, no HSM,
(+) BS
No joint or muscle
aches or pains
Peripheral pulses
strong, 2+
(-) CCE
Strength 5/5 bilat
Full ROM
Neurological Exam
A&Ox3
No signs of local deficit
(-) Babinski reflex bilat
Patellar DTRs active and equal
bilat
CNs II-XII intact
Sensory intact
Normal gait
Skin
Warm and dry
No rashes, tumors,
moles or bruises
Normal turgor
Facial hair prominent
Closed and open
comedones on
forehead/chin/cheeks
Pustules/cystic
nodules on nose and
chin
Inflammatory or non-inflammatory?
2 Types of acne:
Non-inflammatory =
comedones - whiteheads or
blackheads
Inflammatory = papules or
pustules
Papule, red tender bump
Pustule, red tender bump
with whitish center
Questions
•
Major concerns with prescribing:
1.
•
•
2.
•
•
•
Minocycline? Oral antibiotic
Risk of cholecystitis with low
HDL
Embryo- and fetotoxicity
Isotretinoin? Oral vitamin A
derivative
Very effective acne medication
Highly fetotoxic, severe birth
defects
Pt not using contraceptives
Laboratory Test Results
Na
139 meq/L
Plt
290,000/mm cu
LDL
120 mg/dL
K
3.0 meq/L
WBC
6,000/mm cu
HDL
41 mg/dL
Cl
101 meq/L
AST
20 IU/L
Trig
100 mg/dL
HCO3
24 meq/L
ALT
38 IU/L
DHEAS
31
micrmol/L
BUN
11 mg/dL
Alk phos
79 IU/L
Testosterone
150 ng/d:
Cr
0.9 mg/dL
T. bilirubin
0.9 mg/dL
Prolactin
16 ng/mL
Glu,
fasting
90 mg/dL
Alb
3.8 g/dL
FSH follicular
10 mU/mL
Hb
17.5 g/dL
T. cholesterol
175 mg/dL
Hct
49%
MRI
Abd, right
2 cm mass
adrenal
8 Abnormal findings
1.
Prominent facial hair
2.
Abnormally light menstrual period
3.
Low potassium (>3.5 meq/L) - 3.0
4.
High hemoglobin (<15.5 g/dL) - 17.5
5.
Low HDL (>50 mg/dL) - 41
6.
High DHEAS (<12micromol/L) – 31
7.
Testosterone (<75 ng/dL) – 150
8.
MRI abdomen – 2.0 cm mass,
superior pole, right adrenal
What condition is suggested?
Hyperandrogenism
Overproduction of male
hormones
Testosterone stimulates
sebaceous glands
Excess sebum = acne flare up
Abnormal hematology?
Patient’s hemoglobin and hematocrit
resemble male levels
Consistent with high testosterone levels
Hormone secreting adrenal tumor
Low HDL not consistent with
diagnosis
Likely dietary/behavioral, not hormonal
Lipid profile is healthy, but HDL “good
cholesterol could be higher
Why would stress affect her acne?
Adrenal cortex
makes:
Glucocorticoids
Stress response
DHEA and sex
hormones
Mass may
cause excess
production of
both
Why aren’t acne meds working?
The likely cause of her acne
is hormonal, not bacterial
Adrenal tumor producing
excess corticosteroids and
androgens
Therefore antibiotics
ineffective
Possible cure: tumor excision