Severe Inflammatory Acne with Secondary Bacterial Infection in a 28-Year-Old Female

Case at a Glance

A 28-year-old female presented with a sudden onset of severe inflammatory acne characterized by painful pustules, facial swelling, and crusting over a three-week period, representing a significant departure from her baseline acne condition.

Patient's Story

The patient reported a 13-year history of mild to moderate acne since age 15. Three weeks prior to presentation, she experienced an acute exacerbation with large, painful pustules appearing suddenly on her forehead and bilateral cheeks. The lesions were associated with significant pain at rest, pruritus, and functional impairment affecting basic hygiene activities. She described morning periorbital edema, particularly affecting the left eye, and swelling around the nasal bridge. Yellow crusting was noted on the left cheek, with some lesions spontaneously rupturing during gentle cleansing.

Initial Assessment

Initial dermatological evaluation in June revealed acne conglobata. Bacterial culture identified Staphylococcus aureus sensitive to fusidic acid. Laboratory investigations showed vitamin D3 deficiency and elevated prolactin levels. Complete blood count, ESR, DHEA-S, and testosterone levels were within normal limits. ALT was mildly decreased at 8.9 U/L. Medical history included subclinical hypothyroidism with normal thyroid function tests not requiring treatment, and intermittent tachycardia previously evaluated by cardiology.

The Diagnostic Journey

Following initial treatment with topical fusidic acid (fucidin) twice daily for one week, the patient showed initial improvement. However, upon discontinuation of the antibiotic, there was rapid progression to severe inflammatory lesions. A second dermatological consultation at an emergency department resulted in empirical treatment with topical dermobacter and oral oxacillin 500mg every six hours without additional bacterial culture or laboratory workup.

Final Diagnosis

Acne conglobata complicated by secondary Staphylococcus aureus infection with inadequate bacterial eradication following initial antibiotic course.

Treatment Plan

Initial treatment consisted of topical fusidic acid for documented S. aureus infection with planned isotretinoin 10mg daily initiation. Following disease progression, treatment was modified to include topical dermobacter and systemic oxacillin therapy. Endocrinology referral was arranged to address vitamin D deficiency and hyperprolactinemia. Previous treatments included doxycycline and topical erythromycin with temporary response.

Outcome and Follow-up

At the time of case documentation, the patient showed no improvement on current antibiotic regimen after several days of treatment. Facial swelling and inflammatory changes persisted. Follow-up dermatology appointment was scheduled for reassessment and potential modification of treatment approach. Endocrinology consultation remained pending for evaluation of hormonal contributors.