Acute-onset Acne: A Mysterious Case
An acute outbreak on a formerly clear-complected young girl is suspicious for some notable features that are missing. Your Dx?
“I will give you a thousand dollars if you can show me how a piece of chocolate gets inside a zit.”
The first afternoon clinic patient is an 11-year-old girl whose chief complaint is an acute outbreak of acne on her forehead and nose.
Results of history and physical examination: patient is Tanner 1 in breast development; has not undergone menarche. Acne erupted abruptly 3-4 weeks ago and is limited to the face.
Visualized are non-inflammatory closed comedones about the nasolabial folds; on the forehead and temples are seen some inflamed papules.
Note closed comedones around the nasolabial area, eyes, and mouth; these are papular lesions with no central punctum.
Forehead: covered with inflammatory papules. Hair and facial skin are noted to be quite greasy.
Patient has been using "pomade" on her hair, face for 3-4 weeks, coinciding approximately with appearance of acne.
Known history: 11-year-old African-American female with no prior health problems; Tanner stage 1, no menarche. no dietary issues, no environmental contacts with grease.
Recent change: use of oily pomade on hair and face.
Differential diagnosis: Molluscum contagiosum, gram negative acne, staphylococcal infection, insect bites, acne vulgaris, pomade acne
Diagnosis: Pomade acne caused by occlusion of sebaceous glands by oily/greasy topical product. Unrelated to acne vulgaris; all races, age groups are susceptible; acne or acne-like lesions in a pre-pubertal child should make this diagnosis a consideration.
Treatment: for scalp, begin application behind hairline; for hair, apply only to ends, avoid scalp, forehead; use water-based pomade; d/c use if necessary.
Acne should clear without treatment over 6-8 weeks; or, treat like any other acne: benzoyl peroxide cleanse--> desquamative acne Rx --> dermatology consult. Antibiotics are NOT indicated.
"Do sodas, chocolate, and fried foods really play a role in causing acne," asks the new family practice resident over a lunch of sandwiches, chips, and soft drinks.Leaving the response to the old wives' tale hanging, Dr Schneider and his new resident proceed to meet the first patient of the afternoon -- an 11-year-old girl complaining of facial acne that she says came "out of nowhere."Close examination and a thorough history solve the mystery behind the acute breakout. The young girl's mother will have to take things from there. Your Dx?
