cystic acne - Nursing Case Study

Pathophysiology

• Primary mechanism: The process begins with the overproduction of sebum in the sebaceous glands due to hormone fluctuations. As sebum production increases, it combines with dead skin cells to form a plug in the hair follicle, causing the formation of a comedone.

• Secondary mechanism: Propionibacterium acnes (P. acnes), a bacteria that lives on the skin, proliferates within the plugged follicle. This leads to inflammation, redness, and the formation of pus-filled cysts or nodules – the characteristic features of cystic acne.

• Key complication: Persistent inflammation can lead to damage of the skin tissue. This often results in severe scarring, which might need medical interventions for correction. Furthermore, the emotional distress caused by the appearance of cystic acne can lead to mental health issues, like depression and anxiety.

Patient Profile

Demographics:

24-year-old female, university student

History:

• Key past medical history: Mild persistent acne since adolescence

• Current medications: Over-the-counter acne creams and washes

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Painful, cystic nodules on face, back, and chest with some resulting scars

• Key symptoms: Persistent breakout of inflamed and pus-filled cysts, redness and swelling, pain around cysts, occasional fever

• Vital signs: Blood pressure 135/90 mm Hg, pulse rate 95 bpm, temperature 99.8°F, respiratory rate 18 breaths per minute

Section 1

Change in Patient Status:

Over the next few weeks, the patient’s condition appears to be deteriorating, despite her strict adherence to the prescribed treatments. The frequency and severity of her acne breakouts have increased, with more inflamed, pus-filled cysts appearing on her face, back, and chest. She reports of increased pain around these cysts, making it difficult for her to sleep comfortably at night. The patient also reports feeling generally unwell with malaise and intermittent fevers. Her vital signs are now as follows: Blood pressure 140/95 mm Hg, pulse rate 100 bpm, temperature 100.6°F, respiratory rate 20 breaths per minute.

The elevated blood pressure and heart rate could indicate an increased stress level due to her current condition. The rise in temperature suggests a possible systemic infection. The increase in respiratory rate may be a compensatory mechanism for the fever, or it could be related to her increased stress level. These changes in her physiological status could be indicative of a potential underlying issue such as a hormonal imbalance or an immune system disorder. It also raises the question of antibiotic resistance in the context of Propionibacterium acnes, which may require further investigation.

Section 2

New Diagnostic Results:

Upon discussing her worsening condition with the dermatologist, further diagnostic tests were ordered. The patient's bloodwork reveals an elevated white blood cell count at 15,000 cells per microliter, indicative of an ongoing infection. Her C-reactive protein (CRP) is also elevated at 18 mg/L, suggesting systemic inflammation. Hormonal panel shows a higher-than-normal level of androgens, which might be contributing to the excessive sebum production and subsequent acne.

The presence of these abnormal results necessitates a reevaluation of her current treatment plan and the consideration of other underlying conditions. For instance, the hormonal imbalance could suggest a condition such as Polycystic Ovary Syndrome (PCOS), which is associated with acne. The elevated CRP and WBC could also suggest that her body is fighting a systemic infection, possibly related to her severe acne or another hidden condition. These findings present a complex clinical picture that requires a multidisciplinary approach, involving her primary care physician, an endocrinologist, and her dermatologist.

Section 3

Change in Patient Status:

In the following weeks, the patient's condition deteriorated. She reported increased fatigue, weight gain, and irregular menstrual periods. Her acne worsened, with more inflamed, painful cysts appearing on her face, chest, and back. She also experienced increased hirsutism, with excess hair growth on her chin and upper lip.

On physical examination, her weight was noted to have increased by 5kg since her last visit. Skin examination revealed an increased number of inflamed, pus-filled cystic acne on her face, chest, and back. Further, a pelvic examination revealed an enlarged, polycystic ovary. These new findings, coupled with her elevated androgen levels and irregular periods, strongly suggested the presence of Polycystic Ovary Syndrome. This diagnosis could explain her worsening acne, as PCOS often leads to an overproduction of androgens, which can stimulate excessive sebum production and exacerbate acne. The diagnosis of PCOS also added a new dimension to her treatment plan, necessitating the adjustment of her current acne medication regimen and the introduction of hormonal therapy.

Section 4

New Diagnostic Results:

The patient underwent further diagnostic testing, which included an ultrasound of the pelvis and hormonal blood tests. The ultrasound confirmed multiple small cysts on both ovaries, further supporting the suspected diagnosis of PCOS. Blood tests revealed elevated levels of luteinizing hormone (LH) at 14 IU/L (normal range: 2-12 IU/L), which is a common finding in PCOS. Her total testosterone was also elevated at 80 ng/dL (normal range: 15-70 ng/dL).

These findings confirmed the diagnosis of PCOS and the need for a multidimensional treatment approach. The elevated LH and testosterone levels, along with the clinical symptoms of hirsutism and acne, indicated that the patient's PCOS was causing hyperandrogenism. This hormonal imbalance was leading to increased sebum production, which in turn exacerbated her cystic acne. The healthcare team would have to balance the management of her acne with the hormonal treatment for PCOS, without aggravating one while treating the other. The challenge of this case required careful clinical reasoning to ensure effective symptom control and long-term management of her PCOS.

Section 5

Change in Patient Status:

Over the next few days, the patient's condition started to worsen. The cystic acne became increasingly painful and inflamed, with erythema and induration noted on physical examination. The acne was also spreading to previously unaffected areas, indicating a worsening inflammatory response. In addition to this, the patient started to experience episodes of irregular heavy menstrual bleeding, further indicating a worsening hormonal imbalance.

These changes in the patient's status indicated a need for re-evaluation of the current treatment plan. Her worsening acne and the onset of irregular menses suggested that her hyperandrogenism was not adequately controlled. This would require careful consideration of the current medication regimen and possibly the introduction of more potent anti-androgen therapies. Further hormonal blood tests were ordered to evaluate the efficacy of current hormonal treatments, and a dermatology consult was sought for expert opinion on managing her worsening cystic acne. The nursing team had to provide supportive care, ensuring effective analgesia for her painful acne and emotional support for the distress caused by her deteriorating condition. This case continues to challenge the healthcare team's clinical reasoning, emphasizing the importance of regular re-evaluation and adaptation in the face of changing patient status.