Case Report: Treating Moderate Inflammatory Acne in a Teen Male
Expert Acne Care in Katy & Houston, Texas
Introduction
Acne is one of the most common reasons teenagers and young adults seek dermatologic care. Moderate inflammatory acne—especially when cysts and nodules are present—can be physically uncomfortable and emotionally distressing, with the potential for long-term scarring if left untreated.
At Reena Jogi, MD, we provide individualized acne treatment plans for patients in Katy and Houston, Texas, combining medical therapy, education, and long-term skin health strategies. This case highlights the initial management of moderate facial acne in a 19-year-old male using oral and topical therapies.
Patient Background
A 19-year-old male presented as a new patient with a chief complaint of acne affecting the face. The acne had been present for several months and had worsened over the prior two months, particularly after receiving a facial treatment.
The patient described:
Inflammatory pimples
Cysts and nodules
Moderate severity acne
Ongoing breakouts despite over-the-counter products
Clinical Examination
A focused dermatologic examination was performed, including evaluation of the scalp, head, and face. The patient appeared well developed, well nourished, alert, and in no acute distress. A dermatoscope was used to further assess the acne lesions.
Clinical findings included:
Inflammatory papules and pustules
Comedonal papules
Distribution limited to the face
No signs of scarring at this time
Diagnosis
The patient was diagnosed with moderate inflammatory acne vulgaris (L70.0), characterized by a combination of inflammatory and comedonal lesions.
Treatment Discussion & Plan
Treatment options were discussed in detail, including:
Topical therapies
Oral antibiotics
Isotretinoin (Accutane) as a future option if needed
After reviewing the risks, benefits, and expectations, the patient elected to proceed with a combination regimen of oral antibiotics and topical medications, with the understanding that isotretinoin could be considered if adequate improvement is not achieved.
Prescribed Acne Treatment Regimen
The following medications were prescribed and sent to the patient’s local pharmacy:
Oral Medication
Doxycycline hyclate 100 mg
Take one capsule twice daily with a full glass of water
Avoid lying down for at least 1 hour after taking
Topical Medications
Clindamycin 1% lotion – apply to the face in the morning
Differin (adapalene) 0.3% gel – apply a pea-sized amount at bedtime
Sulfacetamide sodium–sulfur 10%–5% cleanser – wash face 1–2 times daily as tolerated
Skin Care & Acne Education
Extensive counseling was provided to support treatment success and prevent irritation.
Recommended non-comedogenic products include:
Cleansers:
Cetaphil Oil Control, CeraVe Foaming Cleanser, SkinMedica AHA/BHA Cleanser, Neutrogena Oil-Free Acne WashMoisturizers & Sunscreen:
CeraVe PM, Cetaphil Oil Control, EltaMD UV Clear SPF 30+
The patient was educated that acne is a chronic condition and improvement typically takes 2–3 months, with up to 60–80% improvement expected during this time.
Medication Counseling Highlights
Doxycycline: Risk of sun sensitivity, gastrointestinal upset, and esophageal irritation; importance of sun protection and proper administration
Topical retinoids: Apply only at night, wait 30 minutes after washing, and use moisturizer if dryness occurs
Topical clindamycin: Potential irritation; reduce frequency if sensitivity develops
The patient was instructed to contact the office if acne worsens, scarring develops, or adverse reactions occur.
Follow-Up Plan
The patient will return for follow-up in 4 months to assess response to therapy. If acne does not improve adequately, isotretinoin therapy may be considered at that time.
Expert Acne Treatment in Katy & Houston, Texas
Early, effective treatment of acne is essential to prevent scarring and protect self-confidence. At Reena Jogi, MD, we offer comprehensive acne care—from topical therapies to isotretinoin—tailored to each patient’s needs.
If you or your teenager are struggling with acne, schedule a consultation with our dermatology team serving Katy and Houston, Texas.
