Review Question - QID 221211

This adolescent patient presents with acne vulgaris. Given that the family is planning to take a tropical beach vacation next week, doxycycline would be contraindicated due to the side effect of photosensitivity.

Acne vulgaris is characterized by comedones, pustules, and nodules in the distribution of hormone-sensitive sebaceous glands. This typically involves the face, chest, upper back, and upper arms. Post-inflammatory skin hyperpigmentation and scarring can also occur, leading to significant psychological distress. Diagnosis is clinical, and management of mild cases includes topical retinoids, benzoyl peroxide, or topical clindamycin. For moderate to severe cases, systemic agents such as oral tetracyclines, oral contraceptives, and/or spironolactone are added to topical therapy. Isotretinoin can also be used as monotherapy for severe acne vulgaris, although patients must have 2 negative pregnancy tests and use 2 different forms of contraception for at least 1 month prior to starting the medication due to its well-known teratogenicity. Doxycycline causes photosensitivity, which predisposes patients to sunburn.

Odorici et al. review the photosensitivity reactions that occur as a result of tetracycline use. They discuss how photosensitivity reactions are most commonly reported with demethylchlortetracycline and doxycycline. They recommend advising patients to avoid prolonged sun exposure while taking these medications.

Figure/Illustration A is a clinical photograph demonstrating comedones and nodules on the face (red circle). This appearance is classically seen in patients with acne vulgaris.

Incorrect Answers:
Answer 1: Azithromycin is a macrolide antibiotic that is occasionally used for the treatment of moderate to severe acne. However, its use is limited by rising rates of microbial resistance to this drug. Contraindications include hypersensitivity to azithromycin. Photosensitivity is a very rare complication of this medication compared to doxycycline. Side effects include diarrhea, nausea, and changes in taste.

Answer 2: Clindamycin is used in its topical preparation for the treatment of mild acne. It is well tolerated, but can sometimes cause skin irritation. Contraindications include a history of hypersensitivity to clindamycin, history of antibiotic-associated colitis, or ulcerative colitis. It does not commonly cause photosensitivity. An important side effect is watery diarrhea due to C. difficile infection.

Answer 4: Oral contraceptives are hormonal agents that reduce androgen action, which is useful in the treatment of moderate to severe acne. Contraindications to oral contraceptive use include a history of venous thromboembolism, smoking over the age of 35, and migraine with aura. They do not commonly cause photosensitivity. Side effects include an increased risk of thromboembolism.

Answer 5: Spironolactone is an anti-androgen agent that is used in the treatment of moderate to severe acne. Contraindications include hyperkalemia and Addison disease. It does not commonly cause photosensitivity. Side effects include gynecomastia and myalgia.

Bullet Summary:
Doxycycline is a tetracycline antibiotic used in the treatment of acne vulgaris that can cause photosensitivity as a side effect.