Case Report: 23-Year-Old Female with Chronic Acne Managed at Village Dermatology in Katy & Houston, Texas
Introduction
Acne is one of the most common dermatological conditions seen in young adults, particularly affecting the face. At Village Dermatology, serving patients in Katy, Texas and Houston, Texas, we frequently evaluate patients who have struggled for years with breakouts and are looking for safe and effective solutions. This case highlights the management of a 23-year-old female with a chronic facial rash consistent with acne that had been present for two years.
Patient Presentation
The patient, a 23-year-old female, presented with a chief complaint of a bumpy rash on the face. The rash was moderate in severity and persistent for the past two years. She had not previously received structured treatment and was concerned about both the cosmetic and long-term impact of her acne.
Examination Findings
A focused skin examination of the face revealed:
Comedonal papules
Inflammatory papules and pustules
Distribution across the central and lateral face
The patient appeared well-developed, alert, and in no acute distress. A dermatoscope was used during the exam to aid in evaluation.
Diagnosis
Based on clinical findings, the patient was diagnosed with acne vulgaris (L70.0), consisting of both comedonal and inflammatory lesions.
Management Plan
The patient and her care team reviewed several treatment options, including topical therapy, oral antibiotics, and isotretinoin (Accutane). Since the patient currently relies on condoms as her sole method of birth control and is not interested in starting oral contraceptive pills or an IUD, isotretinoin was not recommended at this time due to safety guidelines.
Instead, a comprehensive acne treatment plan was initiated:
Morning Routine (AM)
Wash with a gentle cleanser
Apply clindamycin 1% gel to the entire face
Apply a moisturizer with broad-spectrum SPF 30+ sunscreen
Evening Routine (PM)
Wash with a gentle cleanser
Apply a pea-sized amount of tretinoin 0.025% cream (gradual introduction)
Apply a moisturizing cream (brands such as CeraVe, Cetaphil, Vanicream, or La Roche-Posay recommended)
Oral Medication
Doxycycline 100 mg, one capsule twice daily with food and water.
Counseling & Education
The patient was counseled that improvement may take 2–3 months, with an expected 60–80% reduction in acne lesions. She was advised to contact the office if acne worsened, scars developed, or cysts appeared. Detailed instructions were provided on medication safety, skin care routines, and expectations.
Follow-Up
The patient will return in 31 days for reevaluation. If topical and oral therapies do not provide sufficient improvement, isotretinoin may be reconsidered under appropriate contraceptive conditions.
Conclusion
This case illustrates a thoughtful, stepwise approach to acne management at Village Dermatology in Katy and Houston, Texas. With patient education, prescription therapy, and consistent follow-up, most patients can achieve significant improvement in both the appearance and impact of acne.
