Are you sure that you have acne? Case#2

(updated 10/18/2020)

Numerous red bumps and pus-bumps (pustules) on Bob’s forehead

“Dr. T, I have tried everything to get rid of my adult acne, and nothing has ever worked.” – a man in his late 20s told me; let’s call him Bob. “The last year was just terrible – my acne is all over my face, it’s like a plague, and the funny thing is that it was not nearly as bad during my puberty! What the heck is going on now with my skin doc???” he continued. OK, we will figure it out, Bob, but first, tell me what you have tried thus far? “The better question, doc, would be what I haven’t yet! OK, I tried every over-the-counter acne medicine, then I went to my doctor, who gave me some antibiotics, which worked to some degree but never cleared it. So that’s where I’m now.” I see, let me examine you. I see small pustules (pus bumps) and inflamed papules (red bumps) on your face, but I don’t see any blackheads. Since you do not have blackheads, then you probably don’t have acne, but something else.

Let me gently scrape some of your pimples with a blade, and I will look at pus smear on the microscope. “Fine doc, just go ahead.” I looked at the smear immediately in my clinic. Lo and behold, on the microscopic exam, there were numerous carrot-shaped Demodex folliculorum mites (see photo). Bob, you don’t have acne – you have Demodex folliculitis! “What the heck is that doc?” It is just an infestation of your hair follicles with a quite common skin mite called Demodex folliculorum. But, for some reason, it is quite severe in your case.

Five carrot-shaped Demodex mites under the microscope

After 2 months of treatment with antiparasitic cream and face wash, Bob’s “acne” cleared.

Bob’s case is another example where standard anti-acne medications were not helpful for a skin rash that looked like acne.  The bottom line is the same as in our previous case: not everything that looks like acne is acne. Even physicians can misdiagnose them. A good rule of thumb is: “No acne without blackheads.” In general, all over-the-counter acne medicines containing salicylic acid, benzoyl peroxide, or adapalene will clear or at least somewhat improve acne after 6-8 weeks of use. If there is no improvement whatsoever, then you should see your healthcare provider or even a dermatologist for a correct diagnosis.

Please do not hesitate to send me any comments or questions in the comment section below.

Thank you, and take care in these challenging times for everyone.

Dr. T

Viseslav Tonkovic-Capin, MD, FAAD

Dermatologist & Dermatopathologist

Diplomate of American Board of Dermatology

Fellow of the American Academy of Dermatology

Fellow of the American Acne and Rosacea Society

Fellow of the American Society for Dermatologic Surgery

Dermatology Foundation Leaders Society Member

Instagram: Dr. T (@acnedoc)

Dr. T practices in the greater Kansas City metro area and has authored more than twenty articles and book chapters on various skin diseases, including acne, in the top scientific national and international journals. He was also interviewed by multiple national media outlets, including NBC, HuffPost, Men’s Health, and Cosmopolitan, on different topics, including skincare and acne.

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