A 38-year-old woman presents with persistent facial acne that has worsened over the past six months.
She describes painful, red spots on her cheeks, jawline, and chin, with occasional pus-filled lesions.
She has tried over-the-counter products without relief.
She denies any systemic symptoms like fever or weight loss. Her periods are regular, and she has no known allergies.
She reports low self-esteem due to the acne affecting her appearance.
Allergies: None.
Past Medical History: None significant.
Medication History: No regular medications.
Social History: Non-smoker, occasional alcohol, works as a receptionist.
Family History: Mother had similar acne in her 30s.
Question: What is your next step in managing this patient?
Incorrect. Over-the-counter treatments are unlikely to help moderate to severe acne.
This approach may delay effective therapy and worsen the patient’s condition.
Outcome: She returns in six weeks with no improvement, feeling frustrated.
Incorrect. Oral isotretinoin is reserved for severe acne unresponsive to other treatments and
typically requires specialist supervision due to its significant side effects.
Correct! Topical retinoids combined with benzoyl peroxide are first-line for moderate acne.
They address multiple factors such as inflammation and plugged follicles.
Outcome: You advise the patient on correct application and provide safety-netting advice.
Scenario: Follow-Up in Primary Care
The patient returns six weeks later with minimal improvement. She has followed your instructions
but continues to have redness, pustules, and pain. She is frustrated and says, “Nothing seems to work.”
Question: What is your next step in managing this patient?
Incorrect. Simply increasing the retinoid strength won’t address ongoing inflammation.
Additional systemic treatment is now warranted.
Correct! Adding oral antibiotics helps reduce inflammation and is appropriate for
moderate acne that’s not responding sufficiently to topical therapy.
Outcome: The patient is started on a 12-week course of oral doxycycline. She continues the topical treatment.
Incorrect. Immediate referral is reserved for severe or truly treatment-resistant cases.
Oral antibiotics are the next logical step before referral.
Scenario: Referral to Secondary Care
The patient returns after three months with no significant improvement, despite adherence to combined
topical and oral antibiotic therapy. You discuss with your supervisor and refer her to dermatology.
In Secondary Care: A 38-year-old woman with treatment-resistant acne. She has painful lesions,
early scarring, and ongoing frustration about lack of improvement.
Question: What is your next step in managing this patient?
Incorrect. The patient has already failed these approaches. Further escalation is warranted.
Correct! Oral isotretinoin is the gold-standard for severe or treatment-resistant acne.
It requires close monitoring but offers significant improvement when other options fail.
Action: Counsel the patient regarding potential side effects, obtain informed consent, and organise baseline blood tests.
Incorrect. While hormonal therapy can be useful in some cases, this patient’s severity
and poor response warrant isotretinoin as the next step.
Case Conclusion
The patient starts oral isotretinoin with close monitoring. Within 3 months, her acne improves
significantly, with reduced inflammation and no new scarring. She expresses relief and gratitude,
saying, “I finally feel like myself again.”
You successfully managed a challenging case of treatment-resistant acne, demonstrating clinical
reasoning, adherence to guidelines, and appropriate escalation to specialist care.
