CASE WRITE UP

DERMATOLOGY POSTING
NAME : SANGARI A/P SARKUNA SINGAM
STUDENT ID : 1001439079
Year 4, Group 1
Date : 21/1/2015
HISTORY TAKING

Patient's Information
Name : Mr X.
Age : 31 years old
Gender: Male
Race: Malay
Religion : Islam
Marital Status : Married
Address: Kuala Terengganu.
Occupation : Works at TNB.
Date of clerking: 21/2/2016

Chief Complaint

Patient came in for follow up and continuation of treatment for the papular and pustular skin
lesions of his face, trunk and back.

History of presenting illness

Patient's skin condition started when he was in late teens, he noticed that his face became oily
very fast and he would frequently get comedones both white and black (>10) with papules
and pustules ( >5) on his face, around the neck and his back but at that time it was minimal
and he did not seek for treatment until last year when his skin condition worsened especially
his back and trunk with the number of comedones ( >50 )and papulopustular( >50) whereas
his face had a number of comedones ( >20) and papulopustular( > 20). His face skin became
red and looked inflamed. Patient then started to get worried about his appearance which then
prompt him to seek for treatment at HSNZ dermatology clinic last year. He was assessed and
given a topical agent( retinoid) and oral antibiotic ( doxycycline) which he has been on for 2
months now. His skin condition has markedly improved with his face only having a few
remaining skin lesions which is barely visible and this is same with the skin on his trunk.
There are however scarring marks seen over the face and trunk. The lesions on his back is
still numerous in number but has improved compared to before. The other parts of the body
were no affected.

Systemic Review : ( Unremarkable)

Cardiovascular system : No exertional dyspnea, paroxysmal nocturnal dyspnoea, orthopnea

and ankle edema, chest pain, palpitation
Respiratory system : No shortness of breath , cough, sputum production, hemoptysis or
coryzal symptoms.
Gastrointestinal system : No abdominal pain, vomiting or change in bowel movement.
Urinary system : No dysuria, urinary frequency or hesitancy.
Nervous system: No headache, fainting attacks, seizure, weakness or numbness of extremities
Musculoskeletal system : No joint, bone or muscular pain.

Past history of skin and related disorders

Patient has similar problem when he was in his teens but it was milder and affected his face
and back mostly otherwise he did not have any skin conditions or atopic diseases like
eczema, asthma or hay fever previously.

Past medical History

Patient has no known chronic medical illness like diabetes,hypertension, tuberculosis and
HIV.

Drug History

Patient has been on topical agent ( retinoids) and oral doxycyclin for two months. He has no
known drug allergy.

Family History

None of his family members have skin problem like him and there is no family history of
skin diseases like psoriasis or history of atopic diseases like asthma or eczema.
Social and Occupational History

The patient works at tenaga nasional berhad ( TNB) as a technician and there is no history of
exposure to oils, tars, hydrocarbons or any chemicals. He is smoker but does not take alcohol
or any recreational drugs. He has a normal balanced diet although he does frequently take
food high in sugar content and fat.

Effect of the disease on the patient.

Patient's self esteem and confidence has reduced due to his condition although it is not severe
to the extent of affecting his daily life activities, work and marriage life.

PHYSICAL EXAMINATION

General examination

The patient is a medium built man and he appeared healthy.

Vital Signs

Blood Pressure: Was not able to take.

Pulse rate : 82 beats per minute, normal volume and regular rhythm
Respiratory rate : 18 breaths per minute
Temperature : 37◦C
Pain score : 0

General Observation:

Hands : No pallor or cyanosis and capillary refill time was 2 seconds. On the arms there were
no rashes.

Face : No conjuctival pallor and there was no central cyanosis and the oral hygiene was
good.

Neck : There were no cervical lymph node enlargement. Trachea was centrally located.

Lower limbs : There were no pitting edema

Local Skin Examination

Face : There are minimal comedones and papules seen ( hardly visible from 2.5m away from
skin) with a few scarring marks and the skin appeared greasy. Otherwise the skin does not
looked inflamed and there are no pustules, cyst or nodules seen.

Neck : There were a few comedones ( > 5) and pustules ( 2-3) seen with scarring.

Trunk : There were papules ( > 20) and a few pustules ( > 5) seen with scarring marks which
covered less than half of the affected area. No cyst or nodules seen.

Back : There were numerous comedones ( > 50) and papules (>50) seen with a few pustules
( > 10) and scarring marks covering more than half of the affected area. No cyst or nodules
seen.

No significant findings on other parts of the body.

Abdominal Examination

Inspection : Abdomen is not distended, no scars, moves with respiration and umbilicus is
centrally located and inverted.

Palpation: Soft and non-tender. No hepatosplenomegaly and kidneys are not ballotable.

Percussion: Was resonant and shifting dullness was negative.

Auscultation : Normal bowel sounds were heard.

Respiratory System Examination

Inspection: Chest moves symmetrically with respiration and there is no signs of laboured
breathing.

Palpation : Trachea is centrally located. Chest expansion is equal and vocal fremitus is
normal.

Percussion : Equally resonant on both sides.

Auscultation : Normal air entry on both sides and there is no added sounds like crepitations
or wheeze. Vocal resonance is normal.
Cardiovascular System

Inspection : No chest deformity or scars.

Palpation : Apex is felt at 5th intercostal space, mid-clavicular line. No heaves or thrills.

Auscultation : Normal first and second heart sound heard.

Central Nervous System

No abnormal posture or fasiculations. Tone, power and reflexes are normal on both
extremities. Higher cortical function and sensory function is intact.

Summary

Mr.X, a 31 year old man who came in to the dermatology clinic for follow up for the
papulopustular skin lesions on his face, trunk and back which started when he was in his
teens and worsened over the years. Local examination of the skin revealed that there were
minimal remaining comedones and papules on his face and trunk but extensive on his back.

Provisional Diagnosis

Moderate acne vulgaris ( Based on CASS scale)

Differential diagnosis

- Rosacea

- Systemic lupus erythematosus

- Photodermatoses

- Seborrhoeic dermatitis

Management
- Advice the patient on how to care of his skin. Use non-drying soap to wash face and do not
pick on the acnes.
- Topical agents and oral antibiotic preferably topical retinoids and oral doxycycline.( In this
case, ask patient to continue the treatment)
Discussion

Acne is a chronic inflammation of the pilosebaceous units. It can be divided into

inflammatory( papules, pustules and nodules) and non-inflammatory( open and closed
comedones). Pathogenesis is multifactorial and the most important factors involved are :

a. Increased sebum production

b.Propionibacterium acnes proliferation

c.Altered follicular keratinisation

d.Inflammation

Clinical features

Usually effects the face and often the trunk. Hallmark is the comedones :

Open comedones ( Blackheads): dilated keratin-filled follicles and closed comedones

( Whiteheads) : accumulation of sebum and keratin deeper in the pilosebaceous ducts.

Inflammatory papules, nodules and cyst occur and may arise from comedones.

Distinct clinical variants

Acne conglobata : Severe cystic acne with more involvement of the trunk than the face.
Coalescing nodules, cysts, abscesses, and ulceration; occurs also on buttocks.

Acne fulminans : Rare but severe presentation of acne, associated with fever, arthralgias and
systemic inflammation with raised neutrophil count and plasma viscocity.

Acne excoriee : Self inflicted excoriations due to compulsive picking of pre-existing or

imagined acne lesions.

Secondary acne : Comedonal acne can be caused by cosmetics or occupational exposure to

oils, tars or chlorinated aromatic hydrocarbons.
Comprehensive Acne Severity Scale( CASS)

Acne treatment

Can be pharmacological and non-pharmacological. Pharmacological treatment is divided into

2 phases : Induction ( Aim for remission) and maintenance therapy.

Induction therapy

Consist of topical and systemic treatment.

Example of tropical treatment : Benzoyl peroxide ( BPO), retinoids ( isotretinoin,

tretinoin), antibiotics ( clindamycin, erythromycin),dapsone, azelaic acid, salicylic acid,
sulfur and its combination.

Example of systemic treatment: Antibiotics ( tetracycline, doxycycline, erythromycin,

minocycline, azithromycin), hormonal therapy ( COCs) and isotretinoin.

Maintenance therapy

Mainly topical therapy. ( Eg adapalene, tazarotene, azelaic acid)

Non-pharmacological treatment includes physical therapy such as laser, phototherapy,

chemical peels and comedone extraction.