This patient has recalcitrant nodulocystic acne, and the most appropriate next step in therapy is to discontinue his current medications and start oral isotretinoin. Acne is a chronic inflammatory skin condition characterized by open and closed comedones (blackheads and whiteheads, respectively) and inflammatory lesions, including papules, pustules, or nodules. Patients with severe acne can develop large, painful cysts; nodules; and interconnecting sinus tracts on the face, neck, and trunk. It is important to treat this disease aggressively as it can cause permanent scarring that can be disfiguring. Isotretinoin is an oral retinoid that is extremely effective in treating severe nodular acne. However, it is associated with significant side effects, including teratogenicity, mucocutaneous effects (cheilitis, pruritus, photosensitivity, or desquamation), skin thinning, myalgia, liver toxicity, and hyperlipidemia. Because of this, its use is limited to patients with recalcitrant disease. When used in women of childbearing age, prescribers and patients must participate in an FDA-mandated risk management program to minimize the risk of possible fetal exposure to isotretinoin. This patient has severe nodular acne that has been recalcitrant to oral antibiotic treatment; therefore, isotretinoin is an appropriate next step in treatment. In some patients, isotretinoin may be used as first-line treatment for severe, nodulocystic acne, and may also be appropriate for treatment of less severe inflammatory acne that is recalcitrant to multimodality therapy with topical retinoids and oral antibiotics.

Topical metronidazole is first-line therapy for rosacea; however severe nodular acne is usually treated initially with systemic antibiotics. It is important to educate patients that antibiotic treatments often take 6 to 8 weeks to demonstrate an effect. This patient has been on an oral antibiotic for 6 months and continues to have severe acne on his face and neck.

A change to an alternative topical retinoid (such as tazarotene) or another oral antibiotic (such as minocycline) is not expected to dramatically improve his acne. In addition, guidelines recommend that the duration of oral antibiotic therapy be limited; specifically, oral antibiotics should be used for 3 months and the patient reassessed for response. For patients who respond, antibiotics are discontinued.