1
Section 1 Adolescent health Case 1 Erin Campbell
Instructions for the doctor Th is is a short case.
Please take a history from Erin, examine her face only, then outline the most likely diagnosis and negotiate a management plan with her.
Scenario
Erin Campbell is a 14-year-old girl who presents to you with moderate facial acne. Her mum has come with her to the surgery but lets Erin see you on her own.
Th e following information is on her summary sheet:
Past medical history Nil signifi cant
Medication Nil
Allergies Nil
Immunisations Up to date
Social history Lives with parents.
SECTION 1 ADOLESCENT HEALTH
2
Instructions for the patient Erin Campbell You are 14 years old and attend the local high school. Your zits dominate your life. Each morning your mum shouts at you to get dressed and ready for school while you stare at your zits in the mirror. You are convinced that you will never have a boyfriend like all your other friends. You used to take comfort in eating chocolate and cheese but have stopped since a friend said that was causing your zits.
You are embarrassed to be going to see the GP and hope the doctor will be kind.
Th e following information is on your summary sheet:
Past medical history Nil signifi cant
Medication Nil
Allergies Nil
Immunisations Up to date
Social history Lives with Mum.
ERIN CAMPBELL CASE 1
3
Suggested approach to the case Establish rapport with Erin
Open-ended questions to explore Erin’s concerns and expectations about her acne.
Specifi c questions Duration of acne
Location of acne
Impact of acne on social life and relationships
What has she tried so far as treatment?
What does she think causes the acne?
General health, e.g. are her periods regular?
Request permission to examine.
Examination Examine the face —confi rm acne —describe signs: comedones, pustules, erythema or scarring.
Management Explain medical understanding of cause of acne without using jargon
Reassure that diet is not proven to change acne
Reassure that acne can be controlled, should not stop her socialising
Advise against picking or squeezing
Off er treatment depending on what Erin has already tried
Advise regular washing with soap
Avoid oily or greasy skin preparations
Treatment takes 4–8 weeks to be eff ective, can combine topical and oral treatments
Reduce excess cells (hyperkeratinisation ) 1 Topical retinoids, azelaic acid
SECTION 1 ADOLESCENT HEALTH
4
Reduce bacteria (propioniobacterium acnes) Benzoyl peroxide, strength according to skin type Topical antibiotics (combine with Benzoyl peroxide to reduce antibiotic
resistance) 2 Oral antibiotics—tetracyclines not recommended until bone and teeth
development complete
Rebalance hormones (reduce androgen excess) Oral contraceptives containing an anti-androgen, such as cyproterone with
ethinyloestradiol
Reduce sebum hypersecretion Oral isotretinoin—high risk of teratogenicity
Arrange follow-up.
Case commentary
Adolescent acne is a common problem and can lead to physical and psychological scarring. 3 Refer to Figure 1, centre insert page A. 4 Myths about its cause abound but the doctor can reassure Erin that the acne is not her fault and is not related to junk food. However, there are other good reasons to encourage a healthy diet.
Typically many treatments will have been tried at home prior to consulting a GP. It is important to fi nd out what Erin has tried so you are off ering something new rather than a treatment that has already been tried and failed.
For some teenagers, the hidden agenda of an acne presentation is a request for contraception. Th is requires sensitive exploration. A phrase that I fi nd useful is: ‘Some people who come to see me know that the contraceptive pill helps with their skin; is this the case with you?’ Th e question about Erin’s periods is to assess the likelihood of polycystic ovarian syndrome.
Common pitfalls
Teenagers determine the severity and impact of their acne, not doctors. Th is case tests the doctor’s ability to practise in a patient-centred framework. Low marks will be given to doctors who dismiss Erin as having a few pimples which are insignifi cant and which she should learn to live with.
ERIN CAMPBELL CASE 1
5
References 1. Goodman, G 2006, ‘Managing acne vulgaris eff ectively’ , Australian Family
Physician , vol. 35, no. 9, pp. 705–8. 2. Laubscher, T, Regier, L & Jin, M et al. 2009, ‘Taking the stress out of acne
management’ , Canadian Family Physician , vol. 55, no. 3, pp. 266–9. 3. Goodman, G 2006, ‘Acne and acne scarring: the case for active and early
intervention’ , Australian Family Physician , vol. 35, no. 7, pp. 503–4. 4. Usatine, RP, Smith, MA & Mayeavz Jr, EJ 2009. Th e Color Atlas of Family
Medicine , McGraw-Hill, New York, NY, p. 439.
Top Related