17-Year-Old Female with Hormonal, Cystic Acne – Follow-Up Evaluation
At Reena Jogi MD, Village Dermatology in Katy, Texas and Houston, Texas, we frequently see adolescents and young adults experiencing persistent acne even after completing isotretinoin (Accutane). This case highlights the evaluation and management of a 17-year-old female presenting with a 5-week flare of cystic, hormonally driven acne, despite prior isotretinoin therapy.
Patient Overview
The patient is an established dermatology patient who previously completed a full isotretinoin course in June of this year. She now presents for evaluation of worsening acne on the cheeks, jawline, and right nasal sidewall.
Recent History
Acne worsening over 5 weeks
Characterized by deep, cystic lesions
Had stopped birth control for 2 weeks post-Accutane, then resumed Avaine 0.1 mg
Using:
OTC benzoyl peroxide 5% spot treatment
Topical tretinoin 0.025% nightly
Juice cleanses attempting natural acne improvement
Declines restarting isotretinoin
Interested in alternative medical acne therapies
Clinical Examination
A focused examination of the face revealed:
Inflammatory papules and pustules
Comedonal papules
Cystic nodules along jawline/cheeks
Acne present on the right nasal sidewall
The patient appeared alert, oriented, and in no distress. A dermatoscope was used during evaluation.
Assessment
1. Hormonal, Cystic Acne
Diagnosis: Acne vulgaris
Given the pattern of deep cystic breakouts following temporary discontinuation of OCPs, the flare was deemed hormonal in nature.
Why the Flare Occurred
Hormonal shifts after stopping OCP
Increased oil production post-Accutane
Underlying hormonal sensitivity
Tretinoin alone insufficient for cystic lesions
Management & Treatment Plan
Medication Strategy Chosen
The following options were discussed:
✔ Restarting isotretinoin – patient declined
✔ Topical regimen
✔ Oral antibiotics (short term adjunct)
✔ Switching to a more acne-friendly OCP such as Yaz – patient declined
✔ Hormonal therapy with spironolactone – patient agreed
After counseling, the patient elected to:
Start:
Clindamycin 1.2% / Benzoyl Peroxide 5% (Benzaclin) QAM
Continue tretinoin 0.025% at bedtime
Skin Care Routine (Provided to Patient)
AM Routine
Wash with gentle cleanser
Apply Benzaclin
Apply broad-spectrum sunscreen
PM Routine
Gentle cleanser
Apply tretinoin pea-sized
Moisturize
Take spironolactone (1 tab AM and PM; may combine after 1 week)
Spironolactone Counseling (Reviewed in Detail)
Can improve hormonal acne over 8–12 weeks
Possible side effects:
Breast tenderness
Menstrual irregularity
Dizziness / low blood pressure
GI upset
Elevated potassium (rare in teens)
Must avoid pregnancy
Safe for long-term use with monitoring
Benzoyl Peroxide Counseling
May bleach towels/pillowcases
May cause dryness or irritation
Reduce frequency if too irritating
Retinoid Counseling
Apply to completely dry skin
Expect initial dryness and purging
Use non-comedogenic moisturizer
Follow-Up Plan
The patient was instructed to:
Continue the new regimen consistently for 3 months to judge improvement
Follow up in 1 year if stable
Return sooner for:
Worsening acne
New cystic flares
Intolerable side effects
Concerns regarding spironolactone or topicals
Discussion
This case demonstrates how hormonal fluctuations can trigger significant acne flares—even after completing Accutane. Young female patients in Katy and Houston, Texas often benefit from a combination of:
Hormonal therapy (spironolactone)
A supportive OCP regimen
At Reena Jogi MD, Village Dermatology, our goal is to create individualized acne care plans that address both inflammation and hormonal factors, helping teens and young adults achieve clearer, healthier skin.
