Open comedones and inflammatory pustules


  • Acne vulgaris_1213 Derm Clinic

A man, aged 18 years, presented with complaints of severe acne on his face and upper back. He reported that he first developed mild acne at age 14 years, and it had gotten progressively worse. The patient had tried various OTC and prescription creams as well as oral doxycycline and oral minocycline for several months at a time with only mild improvement.

The patient’s father had a history of severe acne that resolved in his middle-age years and resulted in permanent scarring. Examination revealed scattered open comedones and numerous inflammatory pustules and papules, as well as hyperpigmented macules and atrophic scars.

HOW TO TAKE THE POST-TEST: This Clinical Advisor CME activity consists of 3 articles. To obtain credit, you must also read Localized vesicles on the trunk and Linear streaks on the trunk and extremities. Then take the post-test here .

In its milder form, acne vulgaris presents with comedones and few pustules or mildly inflammatory papules. Acne vulgaris is a very common condition, with up to 85% of teenagers affected to some degree.1 Cystic acne is much less common and...

Submit your diagnosis to see full explanation.

In its milder form, acne vulgaris presents with comedones and few pustules or mildly inflammatory papules. Acne vulgaris is a very common condition, with up to 85% of teenagers affected to some degree.1 Cystic acne is much less common and is characterized by larger inflammatory papules, cysts, and nodules that often resolve with permanent scarring. Practitioners should be able to recognize this variant of the disease early on and start appropriate treatment quickly to minimize permanent disfigurement.

Cystic acne is generally first seen in the middle teenaged years, coinciding with rises in hormone levels. Males appear to be affected more often, but young women may see a cyclical flare of papulopustular lesions in the week prior to menstruation.2 Cystic acne is also known to affect adults aged 20 to 35 years who have no prior history of acne.

Women with cystic acne should be evaluated to rule out a hyperandrogenic state.3 These patients should be asked about irregular menses, difficulty maintaining optimal weight, and hirsutism. An answer in the affirmative should prompt consideration of a referral to endocrinology to rule out polycystic ovarian syndrome or other disorders.

Acne education is vital to maximizing the potential for improvement. Patients should be instructed to wash their face daily with a gentle cleanser. Scrubs or other harsh cleansing products may irritate and dry out the skin and should be avoided. Noncomedogenic moisturizers, sunscreens, and cosmetics are recommended.

Isotretinoin is the most effective treatment for acne and the only acne treatment that can potentially induce disease remission. Isotretinoin inhibits sebocytes, decreases lipids, decreases inflammation, regulates keratinization, and decreases Propionibacterium acnes proliferation.4 This medication is indicated for severe nodular and cystic acne, as well as for less severe acne that is resistant to six months of oral and topical antibiotic use, acne that is psychologically distressing, acne that relapses after cessation of oral treatments, and scarring acne.

The usual dosage of isotretinoin is 0.5-1.0 mg/kg/day, in one dose or divided into two daily doses. The dose may be cautiously increased to up to 1.5 mg/kg/day in patients who do not respond to lower doses and who can tolerate the higher dose. To minimize side effects, start patients on 20 mg or 40 mg daily for the first month and then slowly increase to the desired dosage over the next month. The ideal desired cumulative dose is 120-150 mg/kg.

The typical course of isotretinoin treatment is 20 weeks; however, many researchers encourage treating until clinical resolution of acne. There are insufficient data to recommend a longer-term, lower-dose isotretinoin protocol. Many practitioners observe that lower doses (i.e., 0.1 mg/kg/day) appear to be as effective as higher doses in clearing acne;5 however, it is important to be aware that patients treated with lower doses have a significantly higher rate of relapse after stopping treatment.

Teratogenicity is the most concerning adverse effect of isotretinoin. The drug is contraindicated in women who are pregnant (Category X), and female patients need to be provided very clear information regarding this risk. In the United States, isotretinoin prescribers must be registered with the iPLEDGE program (, an FDA-approved a special restricted-distribution program. Female patients of childbearing potential must be using two forms of contraception for at least one month before, during, and one month after isotretinoin treatment. A negative pregnancy test is also required at least one month prior to the start of treatment, as well as monthly during treatment.

Common dermatologic side effects of isotretinoin include cheilitis, mucocutaneous xerosis, dermatitis, photosensitivity, exuberant granulation tissue, and acne flare. Many of these side effects can be alleviated with the use of emollients, artificial tears, and sun protection, and occasionally by reducing the isotretinoin dosage for the first few months.

Depression is a potential psychiatric adverse effect. Clinicians should screen patients at baseline for psychiatric disorders and at each follow-up visit for depressive or suicidal thoughts. While nausea is a potential GI side effect, isotretinoin’s association with inflammatory bowel disease is more controversial.6

Because isotretinoin therapy may cause lipid alterations, a lipid panel should be obtained monthly. Triglyceride levels >500 mg/dL should prompt a decrease in dosage along with appropriate therapy (conservative as well as pharmacologic, if indicated); levels >800 mg/dL require immediate cessation of therapy and evaluation for risk of pancreatitis.7

Liver enzymes should also be monitored monthly in patients taking isotretinoin. The medication should be stopped if there is a rise in liver enzymes three times greater than baseline values. Patients should be advised to avoid all alcoholic consumption to minimize the risk of hepatic toxicity.

The two most concerning isotretinoin drug interactions are tetracycline (Sumycin) and vitamin A. Clinicians should emphasize the importance of the patient informing all of his or her health-care providers of the fact that he or she is taking isotretinoin.

Relative contraindications for isotretinoin treatment include peanut allergy, paraben sensitivity, occupation as a pilot or taxi driver, leukopenia, and hepatic or renal disease.

The patient in this case was started on isotretinoin in compliance with the iPLEDGE program guidelines. During the first two months of treatment, the dosage was titrated slowly due to mildly elevated cholesterol levels, which normalized with lifestyle improvements. After six months of treatment, and having reached the desired cumulative dose of 120 mg/kg, the patient was acne-free and showed very significant improvement of scarring. The isotretinoin was stopped, and he was maintained on topical adapalene (Differin) gel nightly. The patient was very happy with the treatment results and reported that he felt like a new person, having an acne-free face for the first time since puberty.

Esther Stern is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J.


  1. Thiboutot D, Gollnick H, Bettoli V, et al. New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group. J Am Acad Dermatol. 2009;60(5 Suppl):S1-S50.
  2. Kligman AM. Postadolescent acne in women. Cutis. 1991;48:75-77.
  3. da Cunha MG, Fonseca FL, Machado CD. Androgenic hormone profile of adult women with acne. Dermatology. 2013;226:167-171.
  4. Ganceviciene R, Zouboulis CC. Isotretinoin: state of the art treatment for acne vulgaris. J Dtsch Dermatol Ges. 2010;8 Suppl 1:S47-S59.
  5. Strauss JS, Rapini RP, Shalita AR, et al. Isotretinoin therapy for acne: results of a multicenter dose-response study. J Am Acad Dermatol. 1984;10:490-496.
  6. Prevost N, English JC. Isotretinoin: update on controversial issues. J Pediatr Adolesc Gynecol. 2013;26:290-293.
  7. Jamshidi M, Obermeyer RJ, Govindaraj S, et al. Acute pancreatitis secondary to isotretinoin-induced hyperlipidemia. J Okla State Med Assoc. 2002;95:79-80.
Next hm-slideshow in Clinical Quiz