Methyltestosterone Supplementation Most Likely Caused This Patient's Severe Acne Flare
The sudden progression from mild, well-controlled acne to severe nodulocystic disease in an 18-year-old college athlete is most consistent with exogenous androgen supplementation (Option D), as androgens directly drive all four pathogenic mechanisms of acne and can rapidly transform mild disease into severe nodulocystic acne. 1
Why Androgens Are the Culprit
Androgens such as testosterone have central roles in acne pathogenesis by stimulating sebaceous gland activity, increasing sebum production, promoting follicular hyperkeratinization, and creating an inflammatory milieu. 1 The dramatic transformation from 3 years of stable, topical-responsive mild acne to severe nodulocystic disease within just 2 months strongly suggests a new, potent androgenic stimulus rather than gradual disease progression. 1
- Severe nodulocystic acne developing in a young male athlete who recently started college (with access to performance-enhancing substances) fits the classic presentation of anabolic steroid-induced acne. 2
- The distribution pattern—face, neck, chest, and back—is characteristic of androgen-driven acne, as these areas have the highest density of sebaceous glands responsive to androgenic stimulation. 1
Why Other Options Are Unlikely
Dairy-free diet (Option A) would be expected to improve, not worsen, acne. Multiple observational studies demonstrate a positive association between dairy consumption (especially skim milk) and acne severity, with milk increasing insulin and IGF-1 levels that promote sebum synthesis. 3 Eliminating dairy should theoretically benefit acne control, making this option inconsistent with the clinical worsening. 3
Chlorinated pool water (Option B) lacks evidence as a significant acne trigger. While chlorine can cause folliculitis in some individuals, it does not typically induce severe nodulocystic acne, and the guidelines do not identify chlorinated water as a recognized acne exacerbating factor. 1, 4
Low-glycemic-index diet (Option C) is protective against acne, not causative. Dietary modifications including low-glycemic diets may provide benefit for acne treatment, as high-glycemic foods have been associated with worsening acne in susceptible individuals. 4, 5 Adopting this dietary pattern would not explain the severe flare. 3
Ultraviolet radiation (Option E) does not cause nodulocystic acne. While UV exposure can affect acne through various mechanisms, outdoor baseball practice would not trigger the sudden onset of severe nodulocystic disease. 1 Additionally, some acne treatments (like retinoids) increase photosensitivity, but UV itself is not a primary driver of severe inflammatory acne. 4
Clinical Approach to This Patient
This patient requires immediate isotretinoin therapy, as severe nodulocystic acne is a strong indication for isotretinoin regardless of prior treatment attempts. 1, 4 Isotretinoin is the only medication targeting all four pathogenic factors of acne and is specifically indicated for severe nodular acne. 1, 5
- Mandatory first step: Screen for and discontinue any anabolic steroid or testosterone supplementation. The American Academy of Dermatology recommends screening all acne patients for supplement use, particularly whey protein and performance-enhancing substances. 3
- Isotretinoin dosing should be 0.5-1.0 mg/kg/day targeting a cumulative dose of 120-150 mg/kg, with monitoring of liver function tests and lipids only (not CBC or routine depression screening). 1, 4
- Intralesional triamcinolone acetonide (10 mg/mL) can provide rapid relief for individual large, painful nodules while isotretinoin takes effect. 1, 4
Critical Pitfall to Avoid
Do not delay isotretinoin by attempting prolonged courses of oral antibiotics in severe nodulocystic acne. Oral antibiotics are inadequate for this severity and merely delay definitive treatment while increasing antibiotic resistance risk. 4 The presence of nodulocystic acne with high scarring potential mandates immediate isotretinoin consideration. 1, 5