Another Case Study For Your Learning Pleasure

[blondy2061h, MSN, RN]

Patient is a 21 year old female in junior year of college. She has no chronic medical conditions and takes no medications on a regular basis. Her only surgical history is tonsillectomy as a toddler. She is being seen today for complaints of "acne." She was seen previously at her campus health center and was given a script for t-stat pads (erythromycin topical), which she has been using for two weeks and feels her condition has only worsened. She has also tried over the counter benzoyl peroxide face washes BID without aid. It is now winter break and she is home for three weeks from college. She states she feels tired following a busy exam week, but otherwise feels well. She would like her acne resolved before returning to campus!

Vital signs are normal. BMI 24 with a 5 pound weight loss noted since last visit 1 year ago. She attributes that to making healthier choices in campus dining. Physical exam is notable for scattered pustules ranging in size from 1-2cm across cheeks, forehead, chin, and shoulders. Some are erythemic, some white. Some have scabs, others are intact and fluid filled. None are actively draining.

What at should be the next steps for this patient?

[dudette10, MSN, RN]

Being an acute care nurse, derm is rarely seen inpatient. However, my son is currently in outpatient derm treatment for acne. So I only have his treatment regimen to go on.

PO abx is probably the next step with education on GI effects of broad-spectrum Abx. My son's concurrent topical regimen is so complicated that I wrote it down once, gave it to him, and he's responsible for following it. (He's 15, very motivated, and obsessively compliant with it...so no helicopter parenting necessary for this.)

Re-evaluate in 4 weeks.

[calivianya, BSN, RN]

I will say I have no idea about anything dermatology related, but that sounds like a totally whackadoo case of acne. It makes me wonder if you're trying to get at something else, especially mentioning the scabbed over parts and fluid filled parts...

Here is me going way out into left field - doesn't chicken pox mostly manifest on the upper body first? I would ask if the lesions are itchy, if she'd had chicken pox before, or if she'd received a vaccine. She'd be tired for sure if her body was fighting off a big viral infection, and chicken pox doesn't always have very many symptoms besides the blisters/rash. Viral infections like to make their way through crowded places like college dorms, so it's not unbelievable that if she'd never been exposed to chicken pox before, she'd be exposed in college. If it's possible she had chicken pox, I would tell her to stay home and rest until everything had crusted over and take benadryl for the itching.

[klone, MSN, RN]

This has been going on for >2 weeks, and presumably only on the face, so I would doubt varicella.

Culture the fluid from the pustules? I'm gonna go with GNF, tx would be Bactrim.

[MunoRN, RN]

If the condition worsened with erythromycin, which is effective against gram positive bacteria, then it's possible she as a gram-negative folliculitis, which could be potentially worsened by knocking out competing bacteria with erythromycin.

[Dogen]

Physical exam is notable for scattered pustules ranging in size from 1-2cm across cheeks, forehead, chin, and shoulders.

You meant mm, right? A 2cm pustule...

[blondy2061h, MSN, RN]

You meant mm, right? A 2cm pustule...

Yes, sorry.

Realistically, we have quite a range of sizes here from 1mm to 1 cm when including surrounding erythema and considering that some are multiple individual lesions conglomeratted.

[jadelpn, LPN, EMT-B]

I would most definitely get a derm consult, and see if a culture can be done.

I would not be quick to suggest an oral antibiotic regime, especially in the summer, when exposure to the sun can make things worse, even if it is incidental exposure. Additionally, not a huge fan of long term antibiotics in general.

What about birth control pills, as this can be hormonal. I would r/o PCOS as BMI is a bit high, and especially if there's other risk factors.

If one were to go the natural route, tea tree shampoo as a face wash can help if the cysts are seborrhea in nature.

And be sure that in an effort to clear skin, this patient doesn't go hog wild on the scrubbing, which can make things a LOT worse. Derm can make suggestions on a mild soap.

Also keep an eye on mental health. For some kids, acne of this nature can be depressing/stressing. And I gotta tell you, I am a HUGE makeup fan. There are so many options available now, I would also see about a foundation and application process that is going to cover all of it should it not go away by school time. And there's you tube galore on how one accomplishes this.

[klone, MSN, RN]

What about birth control pills, as this can be hormonal. I would r/o PCOS as BMI is a bit high, and especially if there's other risk factors.

I thought of this initially as well, but the OP stated a BMI of 24, with a 5-lb weight loss over the past year. Normally PCOS presents with obesity and weight gain/difficulty losing weight.

[blondy2061h, MSN, RN]

Excellent thoughts so far everyone! I will warn you that this turned out to be far from a typical case, which is of course, why it's interesting to share.

So our patient was started on oral minocycline daily and a retin A topical cream. She was educated on taking the antibiotic with food, increasing yogurt consumption to encourage probiotic use, avoiding peak sun hours outside, using sunscreen, and gentle face washing with a moisturizer afterward twice daily.

A follow up was scheduled for 2 and a half weeks later- just before she was to return to school. However, one week later she calls and asks to be seen for worsening skin lesions.

Now the areas on her cheeks have turned dark brown to purple and appear as thick plaques. There continue to be some areas with pustules on her chin and forehead, along with shoulders, but now there are new areas on her forearms as well with pustules.

The areas are non tender, not hot or cool to touch, and mildly itchy. She has had chicken pox in the past and blood work before she started college confirmed immunity to the virus.

At today's office visit her weight is down another pound and she comments that despite sleeping a lot since being home, she's still feeling tired.

Now what? What further history should be obtained?

[jifferte, BSN, MSN, RN]

Shot in the dark but I'd suggest a work up for lupus.

Sent from my iPhone using allnurses

[jadelpn, LPN, EMT-B]

Lupus, a strange presentation of herpes, shingles, psoriasis? Or even some sort of fungus/yeast? Along with the culture of fluid, a scraping of skin?

Because someone is immune to the chicken pox virus doesn't mean they can't get shingles. Plus, at 21 I would assume she received the chicken pox vaccine, which again doesn't mean that one can not get chicken pox, in my understanding.

Just to also throw it in there, allergies to anything....that have caused a skin reaction.

So what did the culture grow? Were labs drawn?

Now I can't wait to see what derm says......or how this was resolved.