33-Year-Old Female with Adult Acne — Successfully Managed with Tretinoin, Clindamycin, and Spironolactone
Background
A 33-year-old female presented to Reena Jogi MD Dermatology in Katy, Texas for evaluation and management of moderate acne affecting the face. The patient reported a history of pimples and comedonal breakouts, which had persisted despite prior treatments, including a completed course of isotretinoin (Accutane).
She noted that her acne flared after discontinuing oral birth control pills. At the time of her visit, she was using tretinoin cream but continued to experience new inflammatory lesions.
Examination
A comprehensive skin examination, including facial and scalp evaluation, revealed:
Inflammatory papules and pustules
Comedonal papules concentrated on the cheeks and chin
No evidence of cystic or nodular lesions
Overall appearance consistent with hormonal acne
The patient appeared well-nourished and in no acute distress. A dermatoscope was used to closely assess the lesions and confirm the diagnosis.
Diagnosis
Clinical findings were consistent with adult female acne (L70.0) — a chronic inflammatory condition commonly associated with hormonal fluctuations, particularly around the menstrual cycle or after stopping birth control.
Treatment Plan
After reviewing her history and prior therapies, Dr. Reena Jogi recommended a comprehensive, multi-step acne regimen designed to reduce inflammation, prevent new breakouts, and improve long-term skin texture and tone.
Morning Routine
Clindamycin 1% lotion: Apply to affected areas every morning to decrease acne-causing bacteria and reduce redness.
Non-comedogenic moisturizer: Recommended brands include CeraVe Oil Control or EltaMD UV Clear SPF 46, which also provide sun protection for sensitive skin.
Evening Routine
Tretinoin 0.05% cream: Apply a pea-sized amount to the entire face at bedtime, two to three times per week initially. Gradually increase to nightly use as tolerated.
Counseling: Wait 30 minutes after washing your face before applying tretinoin. Dry skin completely to reduce irritation.
Moisturizer: Apply a gentle, oil-free moisturizer afterward if dryness occurs.
Oral Therapy
Spironolactone 50 mg: Take one tablet twice daily to address hormonal causes of acne.
Side effects discussed: Breast tenderness, menstrual irregularities, fatigue, dizziness, and mild diuretic effect.
Precautions: Not for use during pregnancy; blood work may be required to monitor potassium levels in certain patients.
Patient Counseling
Dr. Jogi provided detailed counseling about acne management expectations:
Acne is a chronic condition that may require consistent treatment for months to maintain control.
Results take time: Most patients see a 60–80% improvement after 2–3 months of regular use.
Lifestyle habits: Use gentle, non-comedogenic products and avoid picking or squeezing lesions to prevent scarring.
Follow-up care: Patients should contact the clinic if acne worsens, new cysts or scarring develop, or side effects occur.
Discussion
This case highlights a common scenario of adult hormonal acne recurrence after stopping oral contraceptives, successfully managed with a combination of topical and oral therapies.
At Reena Jogi MD Dermatology in Katy and Houston, Texas, treatment plans are tailored to the individual’s skin type, history, and goals. The integration of retinoids, antibiotics, and hormonal therapy helps restore clear skin while minimizing long-term scarring and emotional distress.
Outcome
The patient began her regimen of tretinoin, clindamycin, and spironolactone with excellent adherence and understanding of potential side effects. A follow-up visit was scheduled in one year, with the option to return sooner for acne reassessment or treatment optimization.
