A 19-year old male presents with several comedones, papules, and pustules on face and trunk. The appropriate drug of choice for the patient would be:

Ans. b. Topical retinoic acid + Oral doxycycline (Ref. Fitzpatrick. 6/e p672-686; Rooks 8/e p42.17-42.70; Roxburgh 18/e p159-172; Harrison 19/e p351-352, 18/e p403-409)A 19-year-old male presents with several comedones, papules, and pustules on face and trunk. This is a case of inflammatory acne with comedones and appropriate drug of choice for this patient is a topical retinoic acid with oral doxycycline.In the given picture a patient is suffering from severe nodulocystic acne with pus filled lesions. Oral therapy with Isotretinoin is indicated is such a patient.IsotretinoinDoc for nodulocystic acne / severe acne.Side effects:Rash (MC)QTeratogenic (contraindicated in pregnancy)QHypertriglyceridemia (on prolonged use)treatment options for AcneDrug/AcneMildModerateSevere ComedonalPapular/PustularPapular/PustularNodularNodular/Conglobate1st ChoiceTopicalretinoidTopical retinoid +Topical antimicrobialTopical retinoid +Oral antibiotic +- BPOTopical retinoid + Oral antibiotic +- BPOOral isotretinoinAlternatives for FemalesTopicalretinoidTopical retinoid +Topical antimicrobialOral antiandrogen+ topical retinoid +- topical antimicrobialOral antiandrogen+ topical retinoid +- oral antibioticHigh dose oral antiandrogen+ topical retinoid +- topical antimicrobialAcne VulgarisChronic inflammatory disease of pilosebaceous unitsCharacterized by seborrhoea, open & closed comedones, erythematous papules & pustulesIn more severe cases nodules, deep pustules, pseudocysts & even scarring.Aggravating Factors:androgensSteroids (topical & systemic) in high dosesCosmetics, hair preparations, industrial compounds, lubricating & cutting oil.Friction & traumaDrugs: lithium, isoniazid, halogens, phenytoin & phenobarbitoneChlorinated naphthalenic compounds & dioxin (chloracne), pomades (pomade acne), topical steroid & other drugs (drug-induced acne)Clinical Feature:The self-limiting disorder primarily of teenagers & young adults.Earliest feature in the greasy skin (seborrhoea).Lesions consist of papules, nodules, pustules and comedonesQ.The clinical hallmark of acne vulgaris: comedones, closed (white head) or open (black head)Sandpaper comedones (multiple, very small whiteheads, frequently on fore head), macrocomedones (>1mm mostly whiteheads), submarine comedones (>0.5 cm in diameter & deeply situated) and secondary comedones (like chloracne and pomade acne) are other subtypes.Earliest lesions are generally mildly inflamed or non-inflammatory comedones on the forehead.MC location is the face (cheeks, chin, forehead & sides of nose) but shoulder, upper chest & back involvement is not uncommon.Most cases do not develop scarring.Treatment (Drugs)Antimicrobial agents reduce bacterial population;Comedolytic agents encourage the shedding of follicular homy plugs and remove the obstructionSebum production is decreased by biotrophic agents (directly) and antiandrogens (indirectly)Anti-inflammatory agents reduce the damaging effects of acne inflammation on skin.