Case Report: 38-Year-Old Female with Acne and Benign Skin Lesions
At Reena Jogi MD, Village Dermatology in Katy and Houston, Texas, we provide comprehensive dermatologic care for both medical skin conditions and cosmetic concerns. This case features a 38-year-old female who presented for evaluation of acne and multiple benign skin lesions distributed throughout the body.
Patient Background
The patient is a new patient who presented with two primary concerns:
Persistent acne on the face, present for several years.
Brown skin lesions on the body, present for years and unchanged.
Her acne was described as moderate, consisting of comedonal and inflammatory papules and pustules on the face and scalp. She was currently using Altreno (tretinoin 0.05% lotion) and clindamycin 1% solution, reporting that her skin was overall stable with this regimen.
Clinical Examination
A full-body skin examination was performed, including the scalp, face, neck, chest, abdomen, back, extremities, buttocks, and nails.
The patient appeared well-developed, well-nourished, and in no acute distress, with a normal mood and affect.
A dermatoscope was used to closely evaluate pigmented lesions. Findings were largely benign, with the following notable conditions identified:
1. Acne Vulgaris (L70.0)
Findings:
Comedonal papules and inflammatory lesions on the face and scalp.
Plan and Counseling:
The patient was advised to continue Altreno 0.05% lotion nightly and clindamycin phosphate 1% solution daily.
We discussed long-term acne management, including potential escalation to spironolactone or isotretinoin (Accutane) in the future if topicals lose effectiveness.
Skin Care Recommendations:
Use non-comedogenic cleansers such as Cetaphil Oil Control, CeraVe Foaming Cleanser, or Neutrogena Oil-Free Acne Wash.
Use oil-free moisturizers like CeraVe PM or EltaMD UV Clear.
Apply broad-spectrum sunscreen SPF 30+ daily.
The patient was reminded that acne is a chronic skin condition that can take 2–3 months to show improvement and that consistency is key for long-term results.
Prescriptions:
Altreno 0.05% lotion: Apply pea-sized amount nightly (45 g, 5 refills)
Clindamycin phosphate 1% solution: Apply to affected areas daily (60 mL, 5 refills)
2. Benign Nevi (D22.5)
Findings:
Regular, symmetrical, evenly pigmented macules and papules scattered across the body.
Plan:
The patient was reassured that these moles are benign and do not require removal.
She was educated on monthly self-skin checks and advised to schedule annual full-body skin exams.
Patient Counseling:
Contact the office if any mole changes in size, shape, or color, or itches or bleeds.
Continue to use broad-spectrum sunscreen SPF 30+ daily.
3. Lentigines (L81.4)
Findings:
Light tan, reticulated macules in sun-exposed areas.
Plan and Counseling:
The patient was informed that lentigines (sun spots) are benign but may be treated for cosmetic reasons with:
Bleaching creams
Topical retinoids
Chemical peels
Laser therapy
She was advised on sun protection and sun avoidance to prevent further darkening.
4. Sebaceous Hyperplasia (L73.8)
Findings:
Small, orange-yellow papules with visible blood vessels on the face.
Plan:
The patient was counseled that sebaceous hyperplasia is benign and can be treated with laser therapy or electrodesiccation if desired for cosmetic reasons.
5. Cherry Angiomas (D18.01)
Findings:
Bright red papules on the trunk, consistent with cherry angiomas.
Plan:
The patient was reassured these are benign vascular growths.
Treatment is not necessary, though they may be removed using laser or electrodesiccation for cosmetic purposes.
Follow-Up
The patient was advised to return annually for a skin check and sooner if she notices any new or changing lesions. Her acne regimen will be reassessed at her next visit to determine if additional therapies are warranted.
Discussion
This case highlights the value of a comprehensive dermatologic evaluation that addresses both medical and aesthetic concerns.
At Reena Jogi MD, Village Dermatology, we combine advanced acne treatments with thorough skin cancer screening and cosmetic dermatology services for patients in Katy and Houston, Texas.
By maintaining healthy skin habits, using evidence-based topical treatments, and scheduling regular exams, patients can achieve clear, healthy, and radiant skin.
