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Patient Story

A 16-year-old boy (Figure 96-1) with severe nodulocystic acne and scarring presents for treatment. After trying oral antibiotics, topical retinoids, and topical benzyl peroxide with no significant benefit, the patient and his mother request isotretinoin (Accutane). After 4 months of isotretinoin, the nodules and cysts cleared, and there remained only a few papules (Figure 96-2). He is much happier and more confident about his appearance. The skin fully cleared after the last month of isotretinoin.


Severe nodulocystic acne with scarring in a 16-year-old boy. (Used with permission from Richard P. Usatine, MD.)


A happier boy now that his nodules and cysts have cleared at the start of the fifth month of isotretinoin treatment. (Used with permission from Richard P. Usatine, MD.)


Acne is an obstructive and inflammatory disease of the pilosebaceous unit predominantly found on the face of adolescents. However, it can occur at any age and often involves the trunk in addition to the face.


Acne vulgaris affects more than 80 percent of teenagers, and persists beyond the age of 25 years in 3 percent of men and 12 percent of women.1

Etiology and Pathophysiology

The four most important steps in acne pathogenesis:

  1. Sebum overproduction related to androgenic hormones and genetics.

  2. Abnormal desquamation of the follicular epithelium (keratin plugging).

  3. Propionibacterium acnes proliferation.

  4. Follicular obstruction, which can lead to inflammation and follicular disruption.

Neonatal acne is thought to be related to maternal hormones and is temporary (Figure 96-3).


Neonatal acne in a healthy 2-week-old infant that resolved without treatment. (Used with permission from Richard P. Usatine, MD.)

Acne can be precipitated by mechanical pressure as with a helmet strap (Figure 96-4) and medications such as phenytoin and lithium (Figure 96-5).


Inflammatory acne showing pustules and nodules in a 17-year-old boy who uses a helmet while playing football in high school. (Used with permission from Richard P. Usatine, MD.)


Severe inflammatory acne in a young adult. His acne worsened when he was started on phenytoin for his seizure disorder. (Used with permission from Richard P. Usatine, MD.)

There are some studies that suggest that consumption of large quantities of milk (especially skim milk) increase the risk for ...

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