Welcome back, DERM Community.
You've seen this visit. A patient sits down, touches their jawline or the side of their cheek, and says, "It's this one again."
They've tried the spot treatment. It worked for a week. Then the bump came back in the exact place it left.
The usual move is to add or switch a topical and book a follow-up. Sometimes that's right. But a lesion that keeps returning to one location usually has a driver the patient lives with every day, and no cream fixes a phone pressed to the same cheek eight hours a week.
This issue gives you two one-page tools to find that driver fast. Both are free to download and hand to patients.
By the time you sit down, you have a pattern and a list of triggers to work from.
Four patterns behind a recurring spot
The diagnostic checklist scores each pattern out of 5. The highest score is the likely root cause. Two or more high scores means mixed pattern acne, which is common.
The fourth pattern deserves the most attention. A lesion that returns to one pore over and over is sometimes a ruptured follicle that never fully healed, and sometimes something other than acne.
Using the checklist in a short visit
The checklist takes a patient about three minutes. It works best as an intake step, handed over at check-in or sent through the portal before the appointment.
Have the patient score it before you see them. Yes/no answers, five per pattern, one total per section.
Start with the top score. Ask one follow-up about the highest-scoring section. For hormonal, ask about cycle regularity and new hair growth. For friction, ask which side they sleep on and how they hold their phone.
Match the plan to the pattern. A friction-dominant patient needs a contact change before a new prescription. A hormonal-dominant patient may need a different conversation entirely.
Treat mixed scores as normal. Two high sections usually means two things to change. Pick the easier one first so the patient sees progress.
Keep the sheet. Rescoring at follow-up shows whether the pattern shifted, which tells you more than "is it better?"
The habit audit: triggers patients don't think to mention
Patients rarely volunteer that they rest their chin on their hand through every meeting or reuse a face towel for a week. They don't connect those habits to their skin, so they don't bring them up.
The habit audit asks directly. Patients check anything that applied in the last 2 to 4 weeks across five areas:
Hygiene and handling: face touching, chin resting, pillowcases, towels, makeup brushes, sweat left to dry
Tech and accessories: phone on the cheek, phone held between ear and shoulder, over-ear headphones, dirty glasses, hats and headbands
Skincare habits: heavy hair products, layered occlusives, harsh scrubs more than twice a week, switching products too often
Lifestyle and environment: stress, under 6 hours of sleep, high-glycemic or dairy-heavy diet, travel, tight clothing or backpacks, heat and steam
Products and makeup: expired products, sleeping in makeup, heavy foundations, sunscreen left on, body lotion migrating up, styling gels at the hairline
The total tells you how much of the problem is external:
The low score is the useful surprise. A patient with persistent breakouts and almost nothing checked has told you to stop looking at their routine and start looking at their hormones.
When the spot isn't acne, or needs more than you
The checklists sort acne patterns. They don't rule out a lesion that only looks like acne. Before you treat a recurring single spot as a pimple, consider:
Epidermoid cyst: a firm nodule with a central punctum that refills after it drains
Recurrent herpes simplex: tingling or burning before it appears, same location each time, often around the lips
Fixed drug eruption: returns in one place each time the patient takes a particular medication
Folliculitis: pityrosporum or gram-negative, especially when acne treatment made things worse
Basal cell carcinoma: a "pimple" that bleeds, crusts, or never fully heals in an older or sun-damaged patient. Biopsy it.
Consider escalating or referring when:
Hormonal scores are high and the patient has irregular periods, hirsutism, or sudden adult onset (evaluate for androgen excess, including PCOS)
Nodulocystic lesions are scarring or haven't responded to adequate topical and oral therapy
The diagnosis is uncertain after one treatment cycle
Interested in reaching our 8,000+ subscribers?
Click here to learn more!
Some Jobs We Think You’re Gonna Love:
Want to Go Deeper?
👋🏻 Thank you for being here, DERM community!
Recurrent acne is one of those complaints that's easy to treat on autopilot. A new cream, a follow-up in six weeks, and the same patient pointing at the same spot. We hope these two handouts give you a faster way to get to the cause and a better conversation with the person in front of you.
Thank you for reading Beneath the Surface, and for the care you bring to every skin complaint that walks through your door.
Many of our topics start with questions from readers, so if there's a presentation you keep seeing in clinic and want us to cover, reply to this email and tell us!
DERM Community | Derm for Primary Care Team
