A 47-year-old woman with a past history of adolescent acne asserts that her complexion is “worse now than during my teenage years.” Her skin has not improved following use of OTC acne preparations. She has neither signs nor symptoms of androgen excess (eg, hirsuitism).
Key point: Note that “active” lesions are covered by a bloody crust, and that saucer-shaped, hypopigmented scars are apparent. It is rare for acne of this severity to develop in normal, healthy adults.
Treatment: This picture strongly suggests patient manipulation of more minor lesions. The patient was given a topical benzoyl peroxide–clindamycin gel to apply at bedtime, but was also strongly admonished to stop picking or scratching at lesions. It was further suggested that she stop “examining” her skin with a magnifying mirror!
Note: When the clinical picture is unusual or improbable, always consider the possibility of factitious (self-induced) or self-worsened disease.