The Correct Answer is B!

A 22-year-old woman is evaluated for acne. She has experienced intermittent outbreaks since her teenage years, and she is a recent college graduate currently working as an assistant in a very fast-paced law firm. Because of her long work hours, she frequently finds herself eating fast food and unable to get proper exercise. She has been using over the counter topical salicylic acid products without any effect. On physical examination, she has both open and closed comedones on her face. There are no pustules or nodules present.

Which of the following is the most appropriate management strategy for this patient’s acne?

A. Avoidance of fatty foods
B. Topical retinoids
C. Oral tetracycline
D. Oral isotretinoin

Rationale:

Acne vulgaris is a common inflammatory disease involving the pilosebaceous structure of the skin. Four primary factors are involved in the pathogenesis of acne: increased sebum formation mediated by androgens, hyperkeratinization of the follicle, colonization of the follicle by Propionibacterium acnes, and inflammation. Exacerbating factors can include mechanical obstructions, anabolic steroids, corticosteroids, other medications, and endocrine disorders such as Cushing’s disease.

Treatment is based on determination of type and severity. There are two main types: comedonal acne and inflammatory acne. Inflammatory acne is further classified by severity: mild, moderate, and severe based on presence of papules, pustules, and nodules. In this case, the patient’s presentation is most consistent with comedonal acne, and topical retinoids (vitamin A derivatives) are the mainstay of treatment in this case.

Acne can be exacerbated by emotional stress. There is no definitive association between diet and acne, though low glycemic diet resulting in weight loss and reduction in insulin resistance has been shown to improve acne in young male patients.

Mild inflammatory acne is primarily treated with topical antibiotics; combination with topical retinoids and benzoyl peroxide may be even more effective. For moderate inflammatory acne, oral antibiotics, primarily tetracyclines, are the treatment of choice. With increased antibiotic resistance observed over the last few decades, more treatment failure has been seen especially with erythromycin. Topical therapies with antibiotics, retinoids, and benzoyl peroxide may reduce resistance. Finally, in severe inflammatory acne, oral isotretinoin can be used if other treatments have failed. Due to its serious effects such as teratogenicity and major depression, patients should be selected carefully.

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