Pediatric Primary Care Case Studies (123 page)

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Spergel, J. M., & Paller, A. S. (2003). Atopic dermatitis and the atopic march.
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British Journal of Dermatology, 135
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Chapter 31

The Teen Boy with Acne

Catherine E. Burns
Danielle J. Poulin

Sometimes a diagnosis seems to be quite apparent from the onset of the visit. Still, the provider needs to do the appropriate data collection via history and physical examination, consider alternative diagnoses, and plan care that is individualized to the patient—the “art of medicine.”

Educational Objectives

1.   Apply the guidelines for management of acne to a teenage patient.

2.   Discuss the impact of age upon the management plan.

3.   Identify lifestyle factors that might affect the condition.

4.   Discuss the cultural factors that might affect the management plan and the family’s understanding and compliance with the plan of care.

   Case Presentation and Discussion

José Gutierrez is a 16-year-old Mexican American male who comes to your migrant clinic for a sports physical. He has recently joined the wrestling team at his high school. He is accompanied by his mother, who speaks mostly Spanish. She explains via his interpreting that she wants you to help José with his acne, which has been getting worse over the past year and he agrees, hesitantly, though in excellent English, that he doesn’t like the lesions on his face, chest, and back and would like help with this problem.

You ask Mrs. Gutierrez to wait in the waiting room while you talk with José about his health and complete the physical examination, assuring her that you will address the acne problem.

What questions will you ask José related to the acne problem?

Your symptom analysis reveals the following information: The lesions first appeared a year or two ago on his forehead. They seem to be getting worse and now are there all the time and have been appearing on his chest for the past 6 months. He has been showering daily, using Dial soap, but this doesn’t seem to help. He has also bought some acne medicine at a local pharmacy and has been using that but sees little improvement. He can’t remember what the name of the product is. His mother advises him to stop eating
fries and chips but he hasn’t done that. She also wants him to use an ointment that she got from her sister in Mexico but it stings and makes his skin red and sore so he doesn’t use it.

What other questions do you need to ask José?

Before answering this question, here is some more information about acne that you need to consider.

Pathophysiology of Acne

Acne is a disorder of the pilosebaceous unit (PSU). Most often the PSUs of the face, chest, back, shoulders, and upper arms are affected. The unit is made up of a wide, stratified squamous epithelium-lined follicle, a rudimentary hair, and large, multi-lobulated sebaceous glands.

The pathogenesis involves androgen stimulation, which causes an enlargement of the sebaceous glands and an increase of sebum production. The androgens also stimulate hyperkeratosis of the follicle causing increased density of keratin and abnormal shedding of the epithelial cells lining the follicle. The combination of sebum and epithelial cell proliferation creates a microcomedone, a precursor to the visible acne lesion. As the microcomedone enlarges, it becomes a noninflammatory or inflammatory lesion.

The noninflammatory lesions are open or closed.
Propionibacterium acnes
(
P. acnes
) are anaerobic bacteria normally present on the skin. The closed comedones create the anaerobic environment with the sebum substrate that supports bacterial proliferation. The bacteria stimulate inflammation and weaken the follicular walls. When the walls break, the sebum spills out into the dermis where it causes additional inflammation and formation of a papule, pustule, or nodule. Multiple nodules and cysts can merge to form sinus tracts in the most severe cases (Gollnick, 2003; Kerkemeyer, 2005).

Scars occur in up to 95% of acne cases (Gollnick, 2003). Postinflammatory hyperpigmentation occurs with patients who are darker in skin color such as Hispanics.

Epidemiology

Acne is the most common dermatologic problem affecting adolescents, with 80% affected at some point between 11 and 30 years (Paller & Mancini, 2006). It is also the most common dermatologic diagnosis among Hispanics (20.4%) (Halder & Nootheti, 2003). Acne occurs more frequently in adolescents, coinciding with puberty and the increases in androgen hormones. Some health problems associated with acne include XYY (Klinefeller Syndrome), hyperinsulinemia, insulin resistance, adrenal tumor, and pituitary tumor (Leonard et al., 2009; Paller & Mancini, 2006). Many medications can also trigger or exacerbate acne, including androgens, topical and systemic glucocorticosteroids,
anabolic steroids, isoniazid, lithium, hydantoin, and gold (Cohen, 2005; Paller & Mancini, 2006). Other contributing factors include lotions, creams, or oils applied to the skin, which can be physically occlusive. Sports gear such as helmets or shoulder pads can also promote acne.

Use of anabolic steroids is relatively common among adolescents involved in sports (Vandenberg, Neumark-Sztainer, Cafri, & Wall, 2007). Anabolic steroid use may also cause weight gain, seborrhea, deepening voice, gyneco-mastia, and depression. There is an increased risk of acne when there are first-degree relatives with the condition. Environmental conditions can also contribute to acne. Working at a gas station or in a restaurant cooking fried foods are examples of risky environments.

Cultural/Ethnic Factors

Mexicans usually bathe or shower daily and may apply lotions to their skin (Guarnero, 2005); Hispanic males may use pomade when grooming their hair, a predisposing factor for pomade acne (Halder & Nootheti, 2003).

The Mexican American patient may seek the services of a curandera instead of or in addition to the services of Western healthcare providers. This may be true especially if the client lacks health insurance or access to Western health care (Guarnero, 2005). Lack of insurance, illegal status, and/or healthcare beliefs may lead the patient to self-treat acne with folk remedies (Guarnero) such as oregano (Howell et al., 2006).

Differential Diagnosis

The differential diagnoses for acne include cosmetic, mechanical, environmental, or drug-induced acne; rosacea; flat wart; milia; perioral dermatitis; and folliculitis. Other skin conditions common to wrestlers on sports teams include
herpes gladiatorum, tinea corporis gladiatorum
, and methicillin-resistant
Staphylococcus aureus
(MRSA) infections.

From the above review, some other information you should obtain from José includes the following:

•   How much has he been wrestling recently? (Exposure to infectious agents)

•   What head gear does he wear for wrestling? (Mechanical acne)

•   Is he using any steroids to build muscle for his wrestling? (Steroid use)

•   Is he taking any medications? (Drug-induced acne or drugs from Mexico)

•   Is he working at a gas station, fast food restaurant, or elsewhere where oils are present? (Environmental factors)

•   Does he use pomades to groom his hair (Halder & Nootheti, 2003) or other special soaps or cleansing products? (Cosmetic acne)

•   Has he had any boils, other rashes, painful blisters, itching, or dryness? (MRSA, tinea, herpes)

•   Have there been any other changes in his health—changes in weight, polydipsia, polyuria, polyphagia (Diabetes mellitus, adrenal tumor, insulin resistance), or hypertension? (Anabolic steroid use)

•   Have they seen a curandera for this problem and, if so, what was recommended (Howell et al., 2006)? (Integrative medicine approach)

•   Are any of his friends having similar problems, and are they having any success keeping acne under control? (Risk factors, peer influence for management)

•   Is this problem making him feel self-conscious when he wrestles or elsewhere? (Self-esteem, embarrassment, possibility of limiting his sports participation)

•   What is the family history of acne? (Risks, perceptions of care and outcomes)

José responds that he is not taking any medications or working. He has not had any other rashes, boils, or changes in his health. He uses a gel to groom his hair sometimes. He has not seen a curandera. Yes, some of his friends also have acne. One has seen a doctor and has some medications that are helping; others are just using over-the-counter treatments as far as he knows. For his wrestling, he wears ear guards that cover part of his cheeks and have a strap under his chin and through his hair but no other special gear. He has been wrestling all summer about twice a week to get ready for the wrestling season, but the coach checks out the team members’ skin to be sure they don’t have infections. He is embarrassed by the lesions, especially when he dresses for wrestling, but has not considered stopping the sport and doesn’t feel depressed because of his appearance.

Physical Examination

Upon physical examination, you find that he has open and closed comedones on his face and forehead, back of the neck, and chest. There are also multiple papules and pustules in all stages of healing (> 40) and his skin is erythematous in the affected regions. There are no nodules, abscesses, or rashes consistent with MRSA,
herpes gladiatorum, or tinea corporis.
Height, weight, blood pressure, and the remainder of the physical examination are within normal limits for this Tanner stage 4 male. He does not have gynecomastia, hypertension, enlarged liver, edema, or other signs of anabolic steroid use or endocrine abnormalities.

Making the Diagnosis

This history and physical examination are consistent with a diagnosis of acne. He has papulopustular acne or inflammatory acne (Gupta et al., 2009) with pustules and lesions extending over a wide area but no nodules or cysts.
Comedonal acne has more comedones with little inflammation. Nodular acne or nodulocystic acne has nodules along with the other lesions. Pomade acne would be more pronounced on his forehead (Halder & Nootheti, 2003), steroid-induced acne is more prominent on the trunk, shoulders, and upper arms (Lembo, 2006). A single lesion would be suggestive of another diagnosis such as a MRSA abscess or localized infection.