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Section 1 Adolescent health Case 1 Erin Campbell

Instructions for the doctor Th is is a short case.

Please take a history from Erin, examine her face only, then outline the most likely diagnosis and negotiate a management plan with her.

Scenario

Erin Campbell is a 14-year-old girl who presents to you with moderate facial acne. Her mum has come with her to the surgery but lets Erin see you on her own.

Th e following information is on her summary sheet:

Past medical history Nil signifi cant

Medication Nil

Allergies Nil

Immunisations Up to date

Social history Lives with parents.

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Instructions for the patient Erin Campbell You are 14 years old and attend the local high school. Your zits dominate your life. Each morning your mum shouts at you to get dressed and ready for school while you stare at your zits in the mirror. You are convinced that you will never have a boyfriend like all your other friends. You used to take comfort in eating chocolate and cheese but have stopped since a friend said that was causing your zits.

You are embarrassed to be going to see the GP and hope the doctor will be kind.

Th e following information is on your summary sheet:

Past medical history Nil signifi cant

Medication Nil

Allergies Nil

Immunisations Up to date

Social history Lives with Mum.

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Suggested approach to the case Establish rapport with Erin

Open-ended questions to explore Erin’s concerns and expectations about her acne.

Specifi c questions Duration of acne

Location of acne

Impact of acne on social life and relationships

What has she tried so far as treatment?

What does she think causes the acne?

General health, e.g. are her periods regular?

Request permission to examine.

Examination Examine the face —confi rm acne —describe signs: comedones, pustules, erythema or scarring.

Management Explain medical understanding of cause of acne without using jargon

Reassure that diet is not proven to change acne

Reassure that acne can be controlled, should not stop her socialising

Advise against picking or squeezing

Off er treatment depending on what Erin has already tried

Advise regular washing with soap

Avoid oily or greasy skin preparations

Treatment takes 4–8 weeks to be eff ective, can combine topical and oral treatments

Reduce excess cells (hyperkeratinisation ) 1 Topical retinoids, azelaic acid

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Reduce bacteria (propioniobacterium acnes) Benzoyl peroxide, strength according to skin type Topical antibiotics (combine with Benzoyl peroxide to reduce antibiotic

resistance) 2 Oral antibiotics—tetracyclines not recommended until bone and teeth

development complete

Rebalance hormones (reduce androgen excess) Oral contraceptives containing an anti-androgen, such as cyproterone with

ethinyloestradiol

Reduce sebum hypersecretion Oral isotretinoin—high risk of teratogenicity

Arrange follow-up.

Case commentary

Adolescent acne is a common problem and can lead to physical and psychological scarring. 3 Refer to Figure 1, centre insert page A. 4 Myths about its cause abound but the doctor can reassure Erin that the acne is not her fault and is not related to junk food. However, there are other good reasons to encourage a healthy diet.

Typically many treatments will have been tried at home prior to consulting a GP. It is important to fi nd out what Erin has tried so you are off ering something new rather than a treatment that has already been tried and failed.

For some teenagers, the hidden agenda of an acne presentation is a request for contraception. Th is requires sensitive exploration. A phrase that I fi nd useful is: ‘Some people who come to see me know that the contraceptive pill helps with their skin; is this the case with you?’ Th e question about Erin’s periods is to assess the likelihood of polycystic ovarian syndrome.

Common pitfalls

Teenagers determine the severity and impact of their acne, not doctors. Th is case tests the doctor’s ability to practise in a patient-centred framework. Low marks will be given to doctors who dismiss Erin as having a few pimples which are insignifi cant and which she should learn to live with.

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References 1. Goodman, G 2006, ‘Managing acne vulgaris eff ectively’ , Australian Family

Physician , vol. 35, no. 9, pp. 705–8. 2. Laubscher, T, Regier, L & Jin, M et al. 2009, ‘Taking the stress out of acne

management’ , Canadian Family Physician , vol. 55, no. 3, pp. 266–9. 3. Goodman, G 2006, ‘Acne and acne scarring: the case for active and early

intervention’ , Australian Family Physician , vol. 35, no. 7, pp. 503–4. 4. Usatine, RP, Smith, MA & Mayeavz Jr, EJ 2009. Th e Color Atlas of Family

Medicine , McGraw-Hill, New York, NY, p. 439.