Life's Not so Simple with Asthma and Pimples

A 14-year-old girl presents with an outbreak of "zits" that she says is uncharacteristic for her.

Pertinent past history:

Asthma for 10-11 years; managed well with albuterol. Mother’s new husband moved in 6 months earlier-chain smokes in the house. Patient treated 3 weeks ago in ER for status asthmaticus followed by 1 week oral prednisone.

OTC acne product has controlled “pimples” in the past; she denies environmental influences, use of cosmetics, tobacco/marijuana, PHDs. Onset of outbreak is not consistent with typical acne progression.

Acne vulgaris starts as non-inflammatory comedones, followed by inflammatory lesions. The patient’s outbreak began as papules.

Note the wide distribution of monomorphous papules. This eruption began 2 weeks after the teen had taken prednisone for asthma exacerbation.

Patient’s back with monomorphous papular lesions, no comedones. Is this acne vulgaris, or an “acne look-alike?”

And the diagnosis is:

Acne fulminans, environmentally-induced acne (tobacco, cosmetics); contact-dermatitis induced acne from OTC acne medication; steroid-induced acne; Cushing’s disease.

Answer: E. Steriod-induced acne.

Follows steroid treatment of any kind by ~2 weeks; begins with monomorphous papules, “acne vulgaris in reverse.” May progress to open and closed comedones.

Acneiform eruptions may be also caused by: hormones, calcineurin blockers, anticonvulsants, psychotropics, antibiotics, among others.

Other substances (eg, halogens); exogenous factors (occupational exposures), acneiform folliculitis.

Treatment:

standard of care is topical desquamation, possibly antibiotics; dermatology consult recommended in severe cases.