Case Report: 30-Year-Old Female with Recurrent Acne After Multiple Isotretinoin Courses

At Reena Jogi MD, Village Dermatology in Katy and Houston, Texas, we frequently evaluate adult patients who struggle with persistent or recurrent acne—sometimes even after multiple rounds of isotretinoin. This case features a 30-year-old female presenting with moderate acne affecting the nose, face, and trunk, despite extensive prior treatments.

Patient Background

The patient reported experiencing acne since her teenage years, including:

• Blackheads and whiteheads

• Inflammatory papules and pustules

• Cysts and nodules

• Post-inflammatory hyperpigmentation (PIH)

She has previously completed five courses of isotretinoin, with the most recent one in 2020, each lasting approximately 5½ months.
Despite this, breakouts continued to recur. She is currently using tretinoin 0.025% and had been on spironolactone 50 mg twice daily, but she ran out of spironolactone in September.

Clinical Examination

A focused examination of the areas of concern was completed.
Findings included:

• Comedonal lesions

• Inflammatory papules and pustules

• Acne lesions on the face and trunk

• Evidence of pigmentary changes from prior breakouts

The patient was alert, well-nourished, and in no distress.

Assessment and Plan

1. Acne Vulgaris (L70.0)

This patient has a long history of acne unresponsive to multiple treatment modalities. Given her history and current goals, a comprehensive discussion was held regarding all viable treatment pathways.

Treatment Options Reviewed:

• Oral antibiotics (not recommended long-term due to microbiome impact)

• Hormonal treatments (spironolactone, oral contraceptives)

• Topical agents

• AviClear laser therapy

• Red light therapy with or without Ameluz

• Repeat Accutane (patient declined)

The patient reported previously tolerating spironolactone well without side effects and expressed interest in resuming it. She also noted persistent hyperpigmentation after each breakout.

Final Treatment Plan:

Restart Spironolactone

• Dose: 50 mg twice daily

• Reviewed:

  • Possible side effects (menstrual irregularity, breast tenderness, dizziness, low blood pressure)

  • Long-term safety profile

  • Need to discontinue 1 month prior to family planning

Increase Tretinoin Strength

• Strength increased from 0.025% to 0.05%

• Reviewed correct application and tolerability

Add Azelaic Acid for Hyperpigmentation

• Azelaic acid 15–20% recommended to improve:

  • PIH

  • Texture

  • Mild acne flares

Other Recommendations

• Benzoyl peroxide wash for antibacterial control

• Non-comedogenic skincare routine

• Daily SPF 30+ sunscreen to prevent darkening of pigment

Patient was given written handouts and pricing comparisons for AviClear vs. red light therapy for future consideration.

She elected to:

• Restart spironolactone

• Increase tretinoin strength

• Begin azelaic acid

• Follow up annually, unless flares occur sooner

Patient Counseling

Skin Care Recommendations

Cleansers:

• Cetaphil Oil Control

• CeraVe Foaming

• SkinMedica AHA/BHA Cleanser

• Neutrogena Oil-Free Acne Wash

Moisturizers:

• CeraVe PM

• Cetaphil Oil Control

• EltaMD UV Clear

Expectations

• Acne is a chronic condition that may recur throughout adulthood

• Improvement may take 2–3 months

• Scarring and PIH risks increase with untreated inflammation

• Patient should report:

  • Worsening acne

  • New cysts or scarring

  • Allergic reactions

  • Mood changes

  • Side effects from spironolactone

Discussion

This case illustrates the challenges of recurrent adult acne, even after multiple isotretinoin cycles. Many patients require a multi-modal approach that includes:

• Hormonal regulation

• Topical retinoids

• Pigment management

• Lifestyle and skincare guidance

• Consideration of light and laser therapies

At Reena Jogi MD, Village Dermatology, we create personalized, evidence-based treatment plans for acne patients throughout Katy and Houston, Texas, focusing on both long-term results and skin health.