What Would Your Next Step Be?

A woman in her 50s presented for evaluation of her acne that had just started appearing a few months prior with intermittent lesions in the chin area. She takes Adderall (amphetamine/ dextroamphetamine mixed salts) for attention deficit hyperactivity disorder and admits to having more stress than usual in the last few months. She says she has been without menses the last 2 years and is considered menopausal.  

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What would your next step be?

A.    Blood testing to confirm menopause
B.    Hormonal testing to evaluate for hyperandrogenic state
C.    Treat with oral doxycycline and topical metronidazole
D.    Add a selective serotonin reuptake inhibitor (SSRI) to help reduce stress levels
E.    Consider hormone replacement therapy if no contraindications
F.    Other

Answer on next page.

Answer: Acne excoriée

This patient was diagnosed with acne excoriée—a condition characterized by the impulse or compulsion to pick at mild acne. The chin area is a common area for stress hormonal breakouts, however, the degree of injury is exacerbated by the picking. Unfortunately, amphetamines increase the compulsion to pick and can increase anxiety. 

Given the circumstances in this case, it was decided to decrease the dosage of her amphetamines with placing her on oral doxycycline. If not better at her follow-up visit, low-dose spironolactone would be considered. If the impulse to pick had not abated, other strategies involving a therapist would also be considered.