A 17-year-old boy presents to his primary care physician with a chief concern of "bad" skin that has not improved despite home remedies. The patient has had lesions on his face that have persisted since he was 13 years of age. He has a diet high in refined carbohydrates and has gained 20 pounds since starting high school. Physical exam is notable for the findings in Figure A. The patient is started on benzoyl peroxide and topical retinoids. He returns 1 month later stating that his symptoms are roughly the same. Which of the following is the most appropriate next step in management?
Continue current therapy for 1 more month
Dietary intervention
Isoretinoin
Topical antibiotics
Topical antibiotics
This patient is presenting with persistent acne vulgaris that is refractory to topical benzoyl peroxide and retinoids. The next step in management is topical antibiotics.

Acne vulgaris is caused by blockage or outlet obstruction of the pilosebaceous unit. It presents with erythema, pustules, and comedones typically in young men going through puberty. Risk factors include stress, excessive sweating, greasy skin care products, and steroid use. The management of acne vulgaris, in order, is to start with topical benzoyl peroxide and topical retinoids, topical antibiotics, oral antibiotics, and isoretinoin. It is important to try a therapy for a proper duration before switching to a more invasive therapy.

Eichenfield et al. review the evidence regarding the treatment of patients with acne vulgaris. They discuss how this disease can be treated with benzoyl peroxide. They recommend using antibiotics or isotretinoin for refractory cases.

Figure/Illustration A is a clinical photograph demonstrating diffuse comedones over the forehead (red circle). These findings are classically seen in patients with acne vulgaris.

Incorrect Answers:
Answer A: Continuing current therapy for 1 more month is unnecessary as this patient's symptoms have not improved at all with 1 month of therapy. Continuing current therapy would be appropriate if the patient had only tried therapy for a few days.

Answer B: Dietary interventions have not been shown to improve outcomes in acne vulgaris. Stopping illicit substances such as performance enhancing steroids can be effective in reducing acne symptoms but there is no evidence this patient has been using steroids.

Answer C: Isoretinoin is the last-line therapy for acne vulgaris. It should not be given to pregnant women as it is teratogenic. Women taking isoretinoin should be on reliable birth control. Topical and oral antibiotics should be used first.

Answer D: Oral antibiotics would be indicated after topical antibiotics fail. Topical antibiotics should be tried first as these do not have systemic side effects.

Bullet Summary:
The management of acne vulgaris is to start with topical benzoyl peroxide and topical retinoids, followed by topical antibiotics, oral antibiotics, and isoretinoin in increasing order of severity.