Pimples with scarring on ...

A 12-year-old boy was referred from the Department of Child Health with a 6-month history of reddish plaque on his face. Six months prior to admission, the patient had noticed some acne rising on his forehead and both of his cheeks. After a period of time, the condition had worsened as the acne had also started to appear on his nose, chin, and both of his temples. As the acne became filled with pus, the patient voluntarily popped the lesions, leading to development of scars. Prior to admission, the patient had already used over-the-counter skin care and consumed medications from family physicians. None provided any satisfactory lesion improvement.

No history of photosensitivity, oral ulcers, joint pain, or lesion exacerbation following sun exposure was found. The patient scarcely consumed spicy foods, although he consumed dairy products such as milk, yoghurt, and cheese on a daily basis. No history of long-term medication use and no family history of similar conditions were found. Physical examination of his forehead, glabella, and temples showed multiple erythematous plaques, along with scars, opened and closed comedones, papules, and pustules. On dermoscopy, we did not find any telangiectasia, hyperpigmentation, and poikilodermatous appearance.

Laboratory examinations were conducted, including routine hematological testing, complete urinalysis, complement 3 (C3) level, C4 level, anti-double-stranded deoxyribonucleic acid level, and antinuclear antibody level. We also performed skin biopsy and direct immunofluorescence (DIF) staining.

The patient was treated with topical alpha-hydroxy acid 10% lotion in the morning and evening, topical benzoyl peroxide and clindamycin gel on the lesion, topical retinoic acid 0.05% cream applied to the entire face at night, and glycolic acid face soap. An intralesional injection of 0.5 mL triamcinolone acetonide 10 mg/mL was also administered once a week for the management of the hypertrophic scar.

On the next follow-up, the laboratory results revealed a positive antinuclear antibody with a titer of 1:100 and a speckled pattern. The other laboratory results were within normal limits. Histopathological examination revealed mild spongiosis and neutrophil infiltrate in the epidermal layer, mixed infiltrate of lymphocytes, histiocytes, and neutrophils, a couple of foreign bodies' granuloma in the dermal layer, and fibrotic tissue at the border of incision. Immunoglobulin (IgA, IgM, and IgG), C3 and C1q, and fibrinogen deposit were negative according to DIF staining examination 

On his second visit, some improvements were observed: fewer comedones, papules, and pustules; a more diffuse erythematous base; and minimal shrinkage of the hypertrophic scars.