Persistent Severe Acne in Young Adult with Treatment Challenges

Case at a Glance

A 27-year-old East Asian female presents with lifelong severe facial acne that has been refractory to multiple treatment modalities. The patient has a strong family history of severe acne and experienced significant adverse effects during isotretinoin therapy, including alopecia and psychiatric symptoms.

Patient's Story

The patient reports onset of acne at age 7 with progression to severe facial involvement over the past several years. She describes a strong family history, with her physician brother requiring three courses of isotretinoin and maintenance doxycycline therapy, and paternal history of severe acne. The patient also has seborrheic dermatitis of the scalp with generalized xerosis affecting extremities. She works in a high-stress legal profession and expresses concern about treatment sustainability and cost-effectiveness.

Initial Assessment

Physical examination revealed severe inflammatory and comedonal acne across the face. Patient demonstrated excellent skincare compliance with a comprehensive multi-step routine including retinoid therapy. Medical history significant for psychiatric conditions including suicidal ideation. Current medications include dextroamphetamine 15mg daily, mirtazapine 7.5mg nightly, and various supplements. Known drug allergy to cefaclor causing cutaneous reactions.

The Diagnostic Journey

Previous treatments included systemic antibiotics (effective during adolescence but lost efficacy upon re-treatment at age 23), spironolactone (no significant improvement), and isotretinoin 20mg daily. The isotretinoin trial was complicated by rapid-onset alopecia with visible balding requiring cosmetic camouflage, and concerning psychiatric deterioration in a patient with underlying mental health vulnerabilities. Dose reduction to 20mg twice weekly was attempted, but treatment was ultimately discontinued due to patient's travel and missed follow-up.

Final Diagnosis

Severe persistent acne vulgaris with familial predisposition, complicated by isotretinoin intolerance manifesting as significant alopecia and psychiatric adverse effects. Secondary diagnoses include seborrheic dermatitis and generalized xerosis cutis.

Treatment Plan

Dermatology consultation recommended exploring low-dose isotretinoin maintenance therapy (5-10mg daily) as suggested in specialist response, potentially combined with hormonal therapy including appropriate oral contraceptives and optimized spironolactone dosing. Current retinoid therapy may be upgraded to higher concentration (0.1% tretinoin). Close monitoring for adverse effects, particularly psychiatric symptoms, with multidisciplinary approach involving mental health providers.

Outcome and Follow-up

Patient seeking guidance for treatment optimization with emphasis on sustainable, effective therapy that balances efficacy with tolerability. Long-term management strategy needed given chronic nature of condition and previous treatment challenges. Regular dermatologic follow-up recommended with consideration of alternative therapeutic approaches if standard treatments remain problematic.