Is this 15-year-old patient's acne cyclic and would initiating birth control (BC) be beneficial, given the patient and mother's denial of sexual activity, and the mother's request for a refill of the patient's acne medication, likely isotretinoin (Accutane)?

From the Guidelines

The patient's acne management should be prioritized with a review of her current medication regimen and assessment of acne severity, and consideration of hormonal therapy may be beneficial, but only after a thorough evaluation of her condition, as recommended by the guidelines of care for the management of acne vulgaris 1. The patient is a 15-year-old female presenting today with her mother for acne management. The patient has a history of acne for which she was previously prescribed medication. Her mother is requesting a refill of the acne medication. Additionally, the mother is inquiring if the patient's acne could be cyclic acne related to hormonal fluctuations and is interested in starting the patient on birth control to help manage this condition. Both the patient and her mother deny that the patient is sexually active. The mother appears to be seeking birth control solely for acne management purposes rather than contraception. Some key points to consider in the management of acne include:

• The use of benzoyl peroxide, topical retinoids, and topical antibiotics as first-line treatments for acne, as recommended by the guidelines 1.
• The consideration of hormonal therapy, such as combined oral contraceptive pills, for patients with acne that is suspected to be related to hormonal fluctuations, as conditionally recommended by the guidelines 1.
• The importance of assessing acne severity and pattern to determine the most effective treatment approach, as emphasized by the guidelines 1.
• The need to review the patient's current acne medication regimen and response to previous treatment to determine the best course of action, as suggested by the guidelines 1. It is also important to note that the guidelines recommend against the use of topical antibiotic monotherapy and emphasize the importance of combining topical therapies with multiple mechanisms of action to optimize efficacy and reduce the risk of antibiotic resistance 1. Overall, a thorough evaluation of the patient's condition and a review of the current guidelines for acne management will be necessary to determine the best course of treatment for this patient.

From the FDA Drug Label

Isotretinoin must only be prescribed to patients who are known not to be pregnant as confirmed by a negative CLIA-certified laboratory conducted pregnancy test. The patient is a 15-year-old female with a history of acne, and the mother is requesting a refill of acne medication and inquiring about the possibility of starting birth control. Key points:

• The patient and mother deny the patient being sexually active.
• The FDA drug label for isotretinoin emphasizes the importance of pregnancy prevention and the use of two forms of effective contraception simultaneously for patients who can become pregnant.
• The label also requires a negative pregnancy test before initiating isotretinoin therapy and monthly pregnancy tests thereafter. Considering the patient's age and denial of sexual activity, cyclic acne is a possible diagnosis, but it is not directly confirmed by the information provided. To determine the best course of action, a thorough history of present illness (HPI) should be taken, including:
• Onset and duration of acne symptoms
• Severity of symptoms
• Previous treatments and responses
• Menstrual history (if applicable)
• Sexual activity and contraceptive use (if applicable) Given the patient's denial of sexual activity, birth control may not be immediately necessary, but it is essential to discuss pregnancy prevention and contraception options with the patient and her mother, as the patient is approaching an age where sexual activity may become more likely. It is crucial to follow the guidelines outlined in the FDA drug label for isotretinoin, including obtaining a negative pregnancy test and counseling the patient on pregnancy prevention, if isotretinoin is prescribed 2, 2.

From the Research

History of Present Illness

The patient is a 15-year-old with a past medical history of acne. The patient's mother is requesting a refill of the acne medication and is wondering if the patient's acne is cyclic. The mother would like the patient to start birth control (BC) pills, but both the patient and mother deny the patient being sexually active.

Acne Treatment Options

• Topical therapies such as retinoids, benzoyl peroxide, and azelaic acid are first-line treatments for acne vulgaris 3
• Combination therapy with adapalene gel and doxycycline has been shown to be effective in treating severe acne vulgaris 4
• Anti-inflammatory dose doxycycline plus adapalene 0.3% and benzoyl peroxide 2.5% gel is a safe and effective treatment option for severe acne 5
• Adapalene 0.1%-benzoyl peroxide 2.5% fixed-dose combination gel with doxycycline hyclate 100 mg is a effective and safe combination therapy for severe acne vulgaris 6

Considerations for Birth Control

• There is no direct evidence in the provided studies to support the use of birth control pills for acne treatment in this patient
• However, combination oral contraception (COC) has been associated with reductions in inflammatory lesions in patients with acne vulgaris 3

Treatment Recommendations

• The patient's acne treatment should be based on the severity and type of acne, as well as the patient's medical history and preferences 3, 4, 5, 6, 7
• The use of birth control pills for acne treatment should be discussed with the patient and mother, taking into account the patient's denial of sexual activity and the potential benefits and risks of hormonal therapy 3