Pediatric Acne Management: Optimizing Outcomes

Transcription

A CME-Certified Supplement to
Skin & Allergy News
®
Pediatric Acne Management:
Optimizing Outcomes
Faculty
Lawrence F. Eichenfield, MD, Chair
Clinical Professor of Pediatrics and Medicine (Dermatology)
Chief, Pediatric and Adolescent Dermatology
Rady Children’s Hospital
University of California, San Diego
San Diego, California
Hilary E. Baldwin, MD
Associate Professor and Vice Chair
Department of Dermatology
SUNY Downstate
Brooklyn, New York
Sheila Fallon Friedlander, MD
Clinical Professor of Pediatrics and Medicine (Dermatology)
Rady Children’s Hospital
University of California, San Diego
Anthony J. Mancini, MD
Professor of Pediatrics and Dermatology
Northwestern University Feinberg School of Medicine
Head, Division of Pediatric Dermatology
Children’s Memorial Hospital
Chicago, Illinois
Albert C. Yan, MD
Chief, Pediatric Dermatology
Children’s Hospital of Philadelphia
Associate Professor, Pediatrics and Dermatology
Perelman School of Medicine at the University of Pennsylvania
Philadelphia, Pennsylvania
Original Release Date: September 2011
Most Recent Review Date: September 2011
Expiration Date: September 3, 2012
Estimated Time to Complete Activity: 2.0 hours
Medium or Combination of Media Used:
Written Supplement
Method of Physician Participation:
Journal Supplement
A continuing medical education activity held at
Skin Disease Education Foundation’s 35th Annual
This activity is supported by
an educational grant from
Models are
for illustrative
purposes only.
Introduction
3
Acne Life Cycle: The Spectrum of Pediatric Disease
4
The Acne Continuum: An Age-Based Approach to Therapy
7
The Effects of Culture, Skin Color, and Other Nonclinical Issues on
Acne Treatment
Approach to Pediatric Acne Treatment: 15
An Update
Parents as Partners in Pediatric Acne Management
20
CME Post-Test and Evaluation 24
Jointly sponsored by
CONSUMER & PERSONAL PRODUCTS WORLDWIDE
DIVISION OF JOHNSON & JOHNSON CONSUMER COMPANIES, INC.
12
and
Method of Participation
A CME-Certified
Supplement to
Skin & Allergy News
®
Pediatric Acne
Management:
Optimizing
Outcomes
To get instant CME credits online, go to http://uofl.me/
acnemanag11. Upon successful completion of the online
test and evaluation form, you will be directed to a webpage that will allow you to receive your certificate of
credit via e-mail. Please add chse@louisville.edu to your
e-mail “safe” list.
(Type the above address into your address bar in Internet
Explorer. If you are unfamiliar with what an address bar is
or how to access yours, open Internet Explorer, then hold
down the control key and press the “O” key on your keyboard. A dialogue box will open—this is where you will
type the above address. After you have typed the address,
click OK to go to the evaluation.)
Once you have completed the evaluation, you will be
given a password. Please be sure to write it down; you
will then be able to access your certificate. Please note,
certificates will not be mailed, so be sure to print a copy
for your records. If you have any questions or difficulties,
please contact the University of Louisville School of
Medicine Continuing Health Sciences Education office at
(502) 852-5329.
Joint Sponsorship
Reprinted from
Seminars in Cutaneous
Medicine and Surgery
The manuscript was originally published
as a supplement to Seminars in Cutaneous
Medicine and Surgery, Supplement 1,
Vol. 30, No. 3S, September 2011. It has
been reviewed and approved by the
faculty as well as the Editors of Seminars
in Cutaneous Medicine and Surgery.
This continuing medical education
(CME) supplement was developed from
a clinical roundtable held during
Skin Disease Education Foundation’s
35th Hawaii Dermatology Seminar,
a CME conference, convened in Maui,
Hawaii, March 13-18, 2011.
Neither the editors of Skin & Allergy
News nor the Editorial Advisory Board
nor the reporting staff contributed to
its content. The opinions expressed in this
supplement are those of the faculty and
do not necessarily reflect the views of
the supporter nor of the Publisher.
The faculty acknowledge the editorial
assistance of Global Academy for Medical
Education, LLC, an Elsevier business, and
Joanne Still, Medical Writer, in the
development of this supplement.
Copyright © 2011 by Elsevier Inc. and its Licensors.
All rights reserved. No part of this publication may
be reproduced or transmitted in any form, by any
means, without prior written permission of the
Publisher. Elsevier Inc. will not assume responsibility
for damages, loss, or claims of any kind arising
from or related to the information contained in this
publication, including any claims related to the
products, drugs, or services mentioned herein.
2
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the
Accreditation Council for Continuing Medical Education
(ACCME) through the joint sponsorship of the University of
Louisville School of Medicine Continuing Health Sciences
Education (CHSE) and Skin Disease Education Foundation,
an Elsevier business. CHSE is accredited by the ACCME to
provide continuing education for physicians.
Designation Statement
CHSE designates this educational journal for a maximum
of 2.0 AMA PRA Category 1 Credit(s)™. Physicians
should only claim credit commensurate with the extent
of their participation in the activity.
Target Audience
The target audience for this educational supplement are
dermatologists, pediatricians, and other health care professionals involved in the treatment of pediatric patients
with acne.
Statement of Professional Practice
Gap(s)
Although acne vulgaris is most commonly seen in adolescents and young adults (85% of individuals between
12 and 24 years of age develop acne), it may be seen at
any age. The disease frequently is seen in preadolescents, and its occurrence in children as young as 7 years
of age is not rare.
Untreated acne can leave permanent scars and, as
such, create psychosocial issues for preadolescent,
adolescent, young adult, and adult patients. Emerging
therapies and regimens offer dermatologists a broader
range of options to improve tolerability, sustain positive
clinical outcomes, and effectively treat a diverse patient
population. Treatment of acne depends on the type,
extent, and severity of the condition. The current guidelines for acne management recommend the use of
combination regimens in order to address multiple
aspects of acne pathogenesis. For best outcomes,
patient care should be individualized.
To achieve this goal of personalized therapy for patients
of any age with acne, clinicians must stay informed
about the proper use of existing therapies and the
impending availability and anticipated appropriate use
of emerging options. Furthermore, although randomized, controlled clinical trials of new and existing
medications more frequently are including patients less
than 12 years of age in study populations, to date all but
a few prescription medications used to treat acne are
approved by the FDA for use in patients as young as 12
years of age. It is important for clinicians to have the
benefit of the opinions of experts to ensure that these
medications are used appropriately and safely in
younger pediatric patients.
This supplement addresses these needs and also provides an educational handout for the parents of younger
pediatric patients to help families appropriately manage
acne at home.
Learning Objectives
Upon completion of this activity, participants should be
better able to:
• Assess and classify acne vulgaris in pediatric patients,
including preteen/preadolescent patients.
• Describe the topical and systemic medications available and suitable for use in pediatric patients with
acne and note specifically which medications are
indicated and contraindicated in pediatric patients
less than 12 years of age.
• Discuss the evidence supporting how early treatment
of acne changes the course of the disease in pediatric patients.
• Select the type of medication and route of delivery
appropriate for individual patients, based on age,
severity of disease, and other factors.
• Advise patients and their parents regarding the nature
and management of the disease and on implementing strategies for coping with acne.
Disclosure
As a sponsor accredited by the ACCME, CHSE must
ensure balance, independence, objectivity, and scientific
rigor in all its sponsored educational activities. All faculty
participating in this CME activity were asked to disclose
the following:
1. Names of proprietary entities producing health care
goods or services—with the exemption of nonprofit
or government organizations and non–healthrelated companies—with which they or their
spouse/partner have, or have had, a relevant financial relationship within the past 12 months. For this
purpose, we consider the relevant financial relationships of a spouse/partner of which they are aware
to be their financial relationships.
2. Describe what they or their spouse/partner received
(eg, salary, honorarium).
3. Describe their role.
4. No relevant financial relationships.
CHSE planning committee, has no relevant financial
relationships with any commercial interests.
CME Reviewer: Timothy E. Brown, MD, Professor,
Division of Dermatology, University of Louisville, School
of Medicine, has no relevant financial relationships with
any commercial interests.
Hilary E. Baldwin, MD, has served as a consultant
and speaker for Allergan, Galderma, Medicis, and Onset.
She has also been a speaker for GlaxoS mithKline and
Ortho Dermatologics.
Lawrence F. Eichenfield, MD, has served as an investigator for Galderma, GlaxoSmithKlein, Johnson &
Johnson, Neutrogena, and Stiefel. He has also been a
consultant and/or served on the advisory board for
Coria, Galderma, GlaxoSmithKline, Intendis, Medicis,
Ortho Dermatologics, Stiefel, and Valeant.
Sheila Fallon Friedlander, MD, has served on an
advisory board for Galderma and Onset.
Anthony J. Mancini, MD, FAAP, has served as a consultant for Galderma, Medicis, and Stiefel. He has also
been a speaker for Galderma.
Albert C. Yan, MD, has no relevant financial relationships with any commercial interests.
Sylvia Reitman, MBA, has no relevant financial relationships with any commercial interests.
Joanne Still has no relevant financial relationships with
any commercial interests.
globalacademycme.com/sdef • Pediatric Acne Management: Optimizing Outcomes
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Reference
Reference
younger patients (8-11 y/o)
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Practice
Selected
Sample
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Will
consider
psychological
impact
of acne
The
Need
forChanges:
Attention
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age medications to
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confidence
in at
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panel that met durTreatconsider
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of
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anddeveloped
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● into
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likely to plan
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supplement
titled therapy
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Challenge of acne
Acne Vulgaris in PediStart acne
retinoid
less severe
●● Start
at ainyounger
age
1therapy
In
that
supplement,
the
panel
(Sheila Fallon Friedatric
Patients.”
Be more
in treating
●● Use
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them earlier
lander,
Josephpatients
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Jr,
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Fried,
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acne
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group
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younger
more
aggressively
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Levy,
MD,
and
Guy
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Webster,
MD,
in
addition
to
this
author)
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More Participant
likely to use
systemic
therapyfrom
earlier
outcomes
evaluations
Eichenfield LF1.
focused
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of
acne
pathophysiology,
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diagnosis
● Start retinoid therapy in less severe acne
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The Need for Attention
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discussion.
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Participant outcomes evaluations from Eichenfield LF1.
One reason for the focus on preadolescent acne, in particular, in
the recent panel discussion and current articles was the response of
impact
of acne,
patients“After
in the participation
spectrum of
clinicians
to theincluding
programpreadolescent
evaluation question,
doi:10.1016/j.sder.2011.08.005
discussion.
in this activity, have you decided to change one or more aspects in
reason of
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treatment
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Lawrence
F.
Eichenfield,
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more detailed attention
to acne in the
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patient.
Lawrence
Eichenfield,
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Clinical
Professor
of
Pediatrics
and
Medicine
(Dermatology)
It is hoped that these papers combine the latest medical
evidence
Guest
Editor
Chief, Pediatric and Adolescent Dermatology
with expert opinion
in a useful
and clinically
way.San Diego
Rady Children’s
Hospital,
Universitypractical
of California,
Rady Children’s
San Diego, Hospital
California
Lawrence
F. Eichenfield,
MD
University
of California
Editor
San Diego SchoolGuest
of Medicine
Rady
Children’s Hospital
• Use more topical retinoids; use them earlier
E-mail:
leichenfield@ucsd.edu
University of California
• Treat younger patients more aggressively
• More
likely to use systemic therapy earlierSan Diego School of Medicine
Reference
• Start
retinoid
therapy
in less JS,
severe
SanSF,
Diego,
California
1. Eichenfield
LF, Fowler
Friedacne
RG, Friedlander
Levy ML,
Webster
GF:proactive
Facing the
challengeacne
of acne vulgaris
pediatric patients. Semin
• Be more
in treating
E-mail:inleichenfield@ucsd.edu
Cutan Med
Surg
29:1-16,
2010 (2age
suppl
1)
• I will address
early
acne
in the younger
group
Reference
1. Eichenfield LF, Fowler JS, Fried RG, Friedlander SF, Levy ML, Webster
GF: Facing the challenge of acne vulgaris in pediatric patients. Semin
Cutan Med Surg 29:1-16, 2010 (2 suppl 1)
doi:10.1016/j.sder.2011.08.005
1. Eichenfield LF, Fowler JS, Fried RG, Friedlander SF, Levy ML, Webster
GF: Facing the challenge of acne vulgaris in pediatric patients. Semin
Cutan Med Surg 29:1-16, 2010 (2 suppl 1)
doi:10.1016/j.sder.2011.08.005
S1
S1
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Pediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdef
3
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1.
Acne
Acne Life
Life Cycle:
Cycle: The
The Spectrum
Spectrum of
of Pediatric
Pediatric Disease
Disease
Acne
Life
Cycle:
The
Spectrum
of
Pediatric
Disease
Anthony J. Mancini, MD,* Hilary E. Baldwin, MD, Lawrence F. Eichenfield, MD,
Anthony J. Mancini, MD,* Hilary E. Baldwin, MD, Lawrence F. Eichenfield, MD,
Sheila Fallon Friedlander, MD, and Albert C. Yan, MD
Sheila Fallon
Friedlander,
MD,The
and Albert
C. Yan, MD of Pediatric Disease
Acne
Life
Cycle:
Spectrum
Acne Life Cycle: The Spectrum of Pediatric Disease
§
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Anthony
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‡ on
Anthony
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atric
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ate
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versity
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1
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ate
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many years. In the
19th century, the average age of
Although
The
Demographics
The
Changing
Demographics
of neonatal
infantile
up toThe
16
logic
data, it
it and
is seen
seen
more acne)
rarely and
thanoccasionally
is neonatal
neonatal acne.
acne.
The
onset of puberty was 17 years. By the 1940s, the average age
logic
data,
is
more
rarely
than
is
of
Puberty
Onset
months
age.
The is
of infantile
typically
involve
usual
age
onset
between
3
months
of
but
of
Puberty
and
Acne
Onset
of puberty
onset wasand
about Acne
13 years, which
remained relausual
ageofof
of
onset
islesions
between
3 and
and 6
6acne
months
of age,
age,
but
the
face,
usually
the
cheeks.
Unlike
neonatal
acne,
infantile
infantile
acne
may
occur
anywhere
from
0
to
12
months
of
tivelytiming
unchanged
for the
next 3 tohas
4 decades.
Since
that time,
infantile acne may occur anywhere from 0 to 12 months of
The
of
of
followed
aa downward
The
timing
of onset
onset
of puberty
puberty
has
followed
downward
acne(hence,
is usually
more inflammatory
and patients
age
the
for
in
the
downward
trend
in
age
of
onset
of
puberty
has
resumed,
age
(hence,
thea potential
potential
for overlap
overlapprocess,
in the
the presentation
presentation
trend
for
many
years.
In
the
19th
century,
the
average
age
trend for many years. In the 19th century, the average
age of
of
may
presentand
withinfantile
comedones,
and pustules,
and
of
neonatal
acne)
and
up
to
16
particularly
with
regard
to
breast
development
and
menarche
of
neonatal
and
infantile
acne) papules,
and occasionally
occasionally
up
to
16
onset
of
puberty
was
17
years.
By
the
1940s,
the
average
age
onset
of
puberty
was
17
years.
By
the
1940s,
the
average
age
6
also withof
nodules
cysts.acne
months
age.
of
infantile
in puberty
girls. onset
months
ofoccasional
age. The
The lesions
lesions
of and
infantile
acne typically
typically involve
involve
of
of
puberty
onset was
was about
about 13
13 years,
years, which
which remained
remained relarelathe face,
face, usually
usually the
the cheeks.
cheeks. Unlike
Unlike neonatal
neonatal acne,
acne, infantile
infantile
Studies
from
the
midto
late
20th
century
indicate
that
the
tively unchanged
unchanged for
for the
the next
next 3
3 to
to 4
4 decades.
decades. Since
Since
that time,
time,
tively
that
Mid-Childhood
Acne
acne
is usually
usually aa more
more
inflammatory process,
process, and
and patients
patients
breast
and
pubic
hair
development
in
American
girls—
espeacne
is
inflammatory
the downward
downward trend
trend in
in age
age of
of onset
onset of
of puberty
puberty has
has resumed,
resumed,
the
8 As a
may
present
with
comedones,
papules,
and
and
In general,
is very
rare in children
to 6 years
of
cially
African
Americans—is
occurring
at
younger
ages.
may
presentacne
with
comedones,
papules,from
and 1pustules,
pustules,
and
particularly
with
regard
to
breast
development
and
menarche
particularly with regard to breast development and menarche
6
6
also
with
occasional
nodules
and
cysts.
age.
When
it
does
occur,
the
term
used
to
describe
the
conresult,
also with occasional nodules and cysts.
in
girls.
in
girls.regional definitions of precocious puberty have been
dition is mid-childhood acne. The reason for the relatively rare
revised.
is considered
be precocious
if it occurs
Studies
from
midcentury
that
StudiesPuberty
from the
the
mid- to
to late
lateto20th
20th
century indicate
indicate
that
Mid-Childhood
Acne
Mid-Childhood
Acne
occurrence of mid-childhood
before
6
years
of
age
in
African
American
girls,
before
7
years
Mid-Childhood
Acne acne is that, normally, adrenal
breast
and
pubic
hair
development
in
American
girls—
espebreast and pubic hair development in American girls— espesecretion
ceases
the firstfrom
year1
of 6
until
8 Asof
In
general,
acne
rare
in
years
of
of ageAfrican
in whiteAmericans—is
girls in the United
States,at
beforeages.
8 years
8
cially
occurring
younger
In
general,virtually
acne is
is very
very
rareafter
in children
children
from
1 to
to
6life
years
of
cially
African
Americans—is
occurring
atand
younger
ages.
As aa
9
around
7
years
of
age,
when
an
increase
occurs
in
adrenal
age.
When
it
does
occur,
the
term
used
to
describe
the
conage
in
European
girls.
result, regional
regional definitions
definitions of
of precocious
precocious puberty
puberty have
have been
been
age. When it does occur, the term used to describe the conresult,
androgen
production. acne.
Thus,The
in areason
child for
with
dition
is
the
relatively
A similar
trendis
not beento
in boys.if
expert
revised.
Puberty
ishas
considered
toapparent
be precocious
precocious
ifAn
it occurs
occurs
dition
is mid-childhood
mid-childhood
acne.
The
reason
for
themid-childhood
relatively rare
rare
revised.
Puberty
considered
be
it
acne, hyperandrogenism
should
beis
and ruled
out.
occurrence
of
acne
that,
adrenal
panel, 6
to analyze
puberty
timing
databefore
from 1940
to
before
years
in
American
girls,
7
occurrence
of mid-childhood
mid-childhood
acne
issuspected
that, normally,
normally,
adrenal
before
6convened
years of
of age
age
in African
African
American
girls,
before
7 years
years
10 evaluated the data for a secular trend (defined as a
The
potential
underlying
causes
include
premature
adresecretion
virtually
ceases
after
the
first
year
of
life
until
1994,
of
secretion virtually ceases after the first year of life until
of age
age in
in white
white girls
girls in
in the
the United
United States,
States, and
and before
before 8
8 years
years of
of
narche, 7
Cushing’s
adrenal
9
around
7
years of
of syndrome,
age, when
when congenital
an increase
increase
occurshyperplasia,
in adrenal
adrenal
change
in
the
distribution
of
an
outcome
in
a
population
9
age
in
European
girls.
around
years
age,
an
occurs
in
age in European girls.
gonadal orproduction.
adrenal tumors,
precocious
puberty.
androgen
production.
Thus, and
in aa frank
child with
with
mid-childhood
during
a specified
timenot
frame).
majority
of these
A
trend
been
apparent
in
An
expert
androgen
Thus,
in
child
mid-childhood
A similar
similar
trend has
has
not
been The
apparent
in boys.
boys.
Anexperts
expert
Referral
to
a
pediatric
endocrinologist
should
be
considered.
acne,
hyperandrogenism
should
be
suspected
and
ruled
out.
agreed
that
sufficient
data
exist
on
earlier
breast
development
panel,
convened
to
analyze
puberty
timing
data
from
1940
acne, hyperandrogenism should be suspected and ruled out.
panel, convened to analyze puberty timing data from 1940 to
to
10 evaluated
The
and onset
of menarche
in for
girlsaa to
support
a secular
10
1994,
the
secular
trend
(defined
as
The potential
potential underlying
underlying causes
causes include
include premature
premature adreadre1994,
evaluated
the data
data
for
secular
trend
(definedtrend.
as aa
Preadolescent
Acne congenital
narche,
Cushing’s
However,
determined that
there
were not
data
change
in they
the distribution
distribution
of an
an
outcome
in sufficient
population
narche,
Cushing’s syndrome,
syndrome,
congenital adrenal
adrenal hyperplasia,
hyperplasia,
change
in
the
of
outcome
in
aa population
gonadal
or
adrenal
tumors,
and
frank
precocious
puberty.
Acne
in
a
child
between
7
11
years
of
age
is
termed
to
suggest
a
secular
trend
for
an
alteration
of
puberty
timing
during aa specified
specified time
time frame).
frame). The
The majority
majority of
of these
these experts
experts
gonadal or adrenal tumors, and frank precocious puberty.
during
Referral
to
endocrinologist
should
preadolescent
(or prepubertal)
acne, referring
age groupin
boys.
The
cutoff
age
for
the
consideration
of
precocious
agreed
that
sufficient
data
exist
on
earlier
breast
development
Referral
to aa pediatric
pediatric
endocrinologist
shouldtobe
beanconsidered.
considered.
agreed that sufficient data exist on earlier breast development
ing rather than to a maturational stage. During these years,
puberty
in of
boys
remainsin
at girls
9 years.
and
onset
menarche
to
and
onset
of
menarche
in
girls
to support
support aa secular
secular trend.
trend.
Preadolescent
Acne
acne can appear asAcne
the
first sign of impending pubertal matNumerous
hypotheses
exist
to
explain
the
reasons
fordata
earHowever,
they
determined
that
there
were
not
Preadolescent
Acne
Preadolescent
However, they determined that there were not sufficient
sufficient
data
uration,
before
pubic
hair
or
areolar
development
in
girls
and
lier
puberty
onset.
The
factors
that
are
perhaps
most
freAcne
in
a
child
between
7
and
11
years
of
age
is
termed
to
suggest
a
secular
trend
for
an
alteration
of
puberty
timing
Acne in a child between 7 and 11 years of age is termed
to suggest a secular trend for an alteration of puberty timing
before
pubic
hair
or
testicular
enlargement
in
boys.
Most
quently
proposed
include
improved
nutrition,
obesity,
and
S3
preadolescent
(or
prepubertal)
acne,
referring
to
an
age
groupin
boys.
The
cutoff
age
for
the
consideration
of
precocious
preadolescent (or prepubertal) acne, referring to an age groupin boys. The cutoff age for the consideration of precocious
S3
authors
consider
a normal
variant,
so-calledin
which have been susing
rather
than to
toitsaa appearance
maturationalasstage.
stage.
During
thesewithout
years,
puberty
inendocrine-disrupting
boys remains
remains at
at 9
9 chemicals,
years.
ing
rather
than
maturational
During
these
years,
puberty
boys
years.
concerns
for
an
underlying
endocrinopathy.
The
typical
prepected
as
culprits
in
both
early
and
delayed
puberty.
The
acne can
can appear
appear as
as the
the first
first sign
sign of
of impending
impending pubertal
pubertal matmatNumerous hypotheses
hypotheses exist
exist to
to explain
explain the
the reasons
reasons
for earearacne
Numerous
for
sentation
is
comedonal
lesions
in
the
T
zone
of
the
face
chemicals
implicated
include
polychlorinated
biphenyls,
uration,
lier
most
uration, before
before pubic
pubic hair
hair or
or areolar
areolar development
development in
in girls
girls and
and
lier puberty
puberty onset.
onset. The
The factors
factors that
that are
are perhaps
perhaps
most frefre11
(across
the
forehead,
on
and
near
the
nose,
and
on
the
chin),
polybrominated
biphenyls,
and
phthalates.
before
pubic
hair
or
testicular
enlargement
in
boys.
Most
quently
proposed
include
improved
nutrition,
obesity,
before pubic hair or testicular enlargement in boys. Most
quently
proposed include improved nutrition, obesity, and
and
S4
althoughconsider
inflammatory
lesions also
appear.
The trend
toward earlier onset
of acne
hashave
mirrored
the
authors
its
as
normal
variant,
so-called
endocrine-disrupting
chemicals,
which
been
authors
consider
its appearance
appearance
as aa may
normal
variant, without
without
so-called
chemicals,
which
have
been sussusAs
is
well
known,
sebum
production
correlates
with
levels
downward
trend
in
puberty
timing,
demonstrated
by
two
concerns
for
an
underlying
endocrinopathy.
The
typical
prepected
as
culprits
in
both
early
and
delayed
puberty.
The
concerns for an underlying endocrinopathy. The typical prepected as culprits in both early and delayed
puberty. The
12,13 that were pubseminal studies
by Lucky
and colleagues
sentation
is
comedonal
lesions
in
the
T
zone
of
the
face
chemicals
implicated
include
polychlorinated
biphenyls,
sentation
is
comedonal
lesions
in
the
T
zone
of
the
face
chemicals
implicated
include
polychlorinated
biphenyls,
Vulgaris in
in Children
Children and
and Adolescents.
Adolescents.
11
lished in the early
1990s. The
first
of these11
was the study of
Vulgaris
(across
the
forehead,
on
and
near
the
nose,
and
on
the
chin),
polybrominated
biphenyls,
and
phthalates.
(across the forehead, on and near the nose, and on the chin),
polybrominated biphenyls, and phthalates. 12
acne
adolescent
boys
9 to onset
15 years
of age.has These
investialthough inflammatory
inflammatory lesions
lesions also
also may
may appear.
appear.
Theintrend
trend
toward
earlier
of acne
acne
mirrored
the
although
The
toward
earlier
onset of
has mirrored
the
gators
found
that
the
severity
of
acne
correlated
with
pubertal
As
is
well
known,
sebum
production
correlates
with
levels
downward
trend
in
puberty
timing,
demonstrated
by
two
downward trend in puberty timing, demonstrated by two
As is well known, sebum production correlates with levels
maturation, and almost 50% of 10- and 11-year-old boys had
as
of dehydroepiandrosterone
dehydroepiandrosterone sulfate
sulfate (DHEA-S)
(DHEA-S) in
in preadolespreadolesof
as
more than 10 comedones (grade 2 or 3 comedonal acne) even
cent girls
girls and
and boys,
boys, indicating
indicating that
that adrenal
adrenal androgens
androgens are
are aa
cent
aa
before either testicular enlargement occurred or pubic hair
es.
major determinant
determinant of
of acne
acne during
during this
this phase.
phase.
major
es.
developed. Mean acne scores correlated better with Tanner
lis
lis
stage in pubic hair than with age. Inflammatory lesions were
nnAdolescentAcne
Acne
Adolescent
markedly less common during early pubertal development
Adolescent
Acne
ppAcne vulgaris
vulgaris is
is one
one of
of the
the most
most common
common skin
skin problems
problems in
in
than were comedonal lesions. African American boys in this
Acne
ho
ho
the
United
States,
affecting
an
estimated
15%
of
individuals
cohort who were in early stages of pubertal development had
the United States, affecting an estimated 15% of individuals
he
he
7
7
of
all
ages
and
85%
of
adolescents.
more comedones than did Caucasian boys.
of all ages and 85% of adolescents.
In 1997, this group published a study of pubertal maturals.
5
s.
tion
and sex steroid hormones in relationship to acne in
ooThe Changing Demographics
prepubertal girls.13 The age range of the study population
The Changing Demographics
Ta
●
●
bof
tital
ad
en
air
er
re
nt
his
ad
ain
on
at
ad
atly
he
is
his
up
an6
of
ato
en
he
in
en
ost
che
ach
of
or
In
anal
.
morecomedonal
comedones
did
Caucasian
boys.
only
Acne
increased
with
advancing macohort
who
werelesions.
inthan
early
stages
of pubertal
development
had
more on
comedones
than
did
Caucasian
boys.were
turity
examination,
and
DHEA-S
levels
significantly
In
1997,
this
group
published
a
study
of
pubertal
maturaturity
on
examination,
and
DHEA-S
levels
were
significantly
more
comedones
than
did
Caucasian
boys.
In 1997,
this
group published
a study
of pubertal maturahigher
in the
prepubertal
girls with
acne.
tion
and
sex
steroid
relationship
to maturaacne in
higher
in the
prepubertal
girls with
acne.
In 1997,
this
group hormones
published
ain
study
of pubertal
tion
and
sex
steroid
hormones
in
relationship
to acne
in
No
similar
epidemiologic
data
have
been
published
in the
13 The age range of the study
prepubertal
girls.
population
No
similar
epidemiologic
data
have
been
published
in the
13 The
tion
and
sexgirls.
steroid
hormones
in of
relationship
to acne
in
prepubertal
age range
the study
population
United
States
since
these
studies
from
Lucky’s
group,
so
it
is
was 8.5
to 12.2
Lucky
andof colleagues
found
United
States
since13years.
these
studies
from
Lucky’s
group,
so itthat
is
prepubertal
The age
range
the
study
population
wasknown
8.5 toifgirls.
12.2
years.
Lucky
and
colleagues
found
that
not
the
epidemiology
of
acne
has
changed
in this
77.8%
of
the
girls
had
some
acne,
of
whom
nearly
half
had
not
known
if
the
epidemiology
of
acne
has
changed
in
this
was
8.5of
12.2
years.
Lucky
and
found
that
77.8%
girls
had some
acne,
of colleagues
whom
half
had
country
intothe
the
intervening
years.
However,
innearly
2008,
a group
only comedonal
lesions.
Acne
increased
with
advancing
macountry
inthe
thegirls
intervening
years.
However,
innearly
2008, half
a group
77.8%
of
had
some
acne,
of
whom
had
14
only
comedonal
lesions.
Acne
increased
with
advancing
maof
investigators
from Taiwan
published
data
on the preva14 published
turity
on examination,
and
DHEA-S
levels
were
of
investigators
from
Taiwan
data
onsignificantly
the prevaonly
lesions.
Acne
increased
with
advancing
maturitycomedonal
onskin
examination,
and
DHEA-S
levels
were
significantly
lence
of
diseases
in
a
cohort
of
3,200
children
between
6
higher
in
the
prepubertal
girls
with
acne.
lence
of
skin
diseases
in
a
cohort
of
3,200
children
between 6
turity
on
examination,
and
DHEA-S
levels
were
significantly
higher
in
the
prepubertal
girls
with
acne.
andNo
11similar
years of
age.
In
that
study,
the
overall
prevalence
of
epidemiologic
data
have
been
published
in the
and
11 in
years
age. In that
study,
the
overall
prevalence
of
higher
the of
prepubertal
girls
with
acne.
Nowas
similar
epidemiologic
data
have
been
published
in the
acne
17%,
and these
comedones
were
the
earliest
manifestaUnited
States
since
studies
from
Lucky’s
group,
so
it
is
acne
was
17%,
and
comedones
were
the
earliest
manifestaNoExtrapolating
similar
data
haveitbeen
published
in itthe
United
States epidemiologic
since from
these this
studies
from
Lucky’s
group,
so
tion.
study,
seems
reasonable
tois
A.J.
Mancini
et
al
not
known
if
the
epidemiology
of
acne
has
changed
in
this
tion.
Extrapolating
from
this
study,
it
seems
reasonable
to
United
States
these
studies
from
Lucky’s
group,
so
is
not known
ifasince
the
epidemiology
of
acne
has
changed
in itthis
suspect
that
similar
trend
in younger
American
children
country
in
the
intervening
years.
However,
in
2008,
a
group
suspect
thatifa the
similar
trend in younger
American
children
not
known
epidemiology
of
acne has
this
country
the intervening
However,
inchanged
2008,
ain
group
might
beinoccurring
asTaiwan
well.years.
The
available
data
highlight
the
14 published
15-17
of
investigators
from
data
on
the
prevamight
be
occurring
as
well.
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available
highlight
the
Table
Summary
of
Current
Concepts
in
Acne
Etiology
14
country
inoccurrence
the intervening
years.
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in 2008,
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from of
Taiwan
published
data
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common
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lence
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in acne,
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children
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common
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14primarily
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from of
Taiwan
published
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prevalence
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● investigators
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athat
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Current
Perspectives
–
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Current
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15-17
–
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etiology
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Table.
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in Acne
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Interleukin
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hyperkeratinization
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ing the
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ing––the
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innate
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glands
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example,
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the pathogenesis
acne. For example, sebocytes have been
found
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ing
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acetylcholine
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found
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the
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example,
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IL-10 in patients
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found
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by
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well
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and
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in acne
and
suggests
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and
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been
shown
that
sebaceous
glands
system
in acne
suggests
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etio14.
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presence
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role
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18 the
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in
presence
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Further,
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acetylcholine
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in thedifferentiation,
presence of P. sebum
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Hyperkeratosis
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paracrine
or mayThis
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Hyperkeratosis
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neurotransmitter
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Hyperkeratosis
or hyperkeratinization
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retenby
nicotine,
which
might
suggest
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role
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cholinergic
Hyperkeratosis
or
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retenparacrine
manner
or
may
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stimulated
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exogenous
fashion
by nicotine,
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suggest
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fordevelopment
the cholinergic
Acne
life in
cycle
tion
hyperkeratosis)
is a crucial
event
in the
of
system
acne
and might
suggests
thatevent
smoking
may
an etiotion
hyperkeratosis)
is a crucial
in the
development
of
by
nicotine,
which
suggest
a role
for
theplay
cholinergic
system
in
acne
and
suggests
that
smoking
may
play
anSome
etioAcne
life
cycle
acne
lesions,
but
the
pathogenesis
remains
unclear.
logiclife
role
in
acne
as
well
as other
disorders,
such
as
acne
but
the
pathogenesis
remains
unclear.
Some
system
incycle
acne
and
suggests
that follicular
smoking
may
play an
etioAcne
logic lesions,
role
in
acne
as
well
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follicular
disorders,
such
as
18 other
recent
research
has
shown
that interleukin
(IL)-1
� induces
hidradenitis
suppurativa.
creased
levels
of
dihydrotestosterone
also
may
stimulate
its
recent
research
has
that interleukin
(IL)-1� induces
logic
role
in acne
as shown
well as18other
follicular disorders,
such as
hidradenitis
suppurativa.
hyperkeratinization,
both in vitro and in vivo,
and that increased
levelssuppurativa.
of dihydrotestosterone
may stimulate
its
production.
both18in vitro andalso
in vivo,
and that inhidradenitis
creased
levels
of
dihydrotestosterone
also
may
stimulate
its
production.
Hyperkeratosis
Hyperkeratosis
production.
Microbial
Flora
Hyperkeratosis
or hyperkeratinization (also known as retenHyperkeratosis
Hyperkeratosis
or hyperkeratinization (also known as retenMicrobial
Flora
Microbial
Flora
tion
hyperkeratosis)
a crucial
event
in
theknown
development
of
The
significance
ofhyperkeratinization
P.is
is still
somewhat
controversial,
Hyperkeratosis
or
(also
as retention
hyperkeratosis)
isacnes
a crucial
event
in
the development
of
Microbial
Flora
The
significance
of
P.
acnes
is
still
somewhat
controversial,
acne
lesions,
but
the
pathogenesis
remains
unclear.
Some
with
some
arguing
against
its
role
in
pathogenesis
because
tion
hyperkeratosis)
is
a
crucial
event
in
the
development
of
acnesignificance
lesions, butofthe
pathogenesis
remains unclear.
Some
The
P.shown
is role
still
somewhat
controversial,
with
some
arguing
against
its
inmicroflora.
pathogenesis
recent
research
hasthe
that
interleukin
(IL)-1
� because
induces
the
organism
isbut
part
ofacnes
the resident
However,
it
acne
lesions,
pathogenesis
remains
unclear.
Some
�
induces
recent
research
has
shown
that
interleukin
(IL)-1
with
someshown
arguing
against
itscan
roleinduce
inmicroflora.
pathogenesis
because
the
organism
is part
of
the
resident
However,
it
both
in
vitro
and
inexpression
vivo,
and
that
inhas
been
that
P.
acnes
of
antirecent
research
has
shown
that
interleukin
(IL)-1
�
induces
both
in
vitro and
in vivo, However,
and that inthe
organism
is
part
of
the
resident
microflora.
it
has
been
shown
that
P.
acnes
can
induce
expression
of
antimicrobial
peptides and
proinflammatory
both
in vitro and in cytokines
vivo, and and
thathas
inhas
been
shown
that
P.
acnes
can
induce
expression
of
antimicrobial
proinflammatory
cytokinessynthesis
and has
an
effect onpeptides
toll-like and
receptor
2, leading to increased
microbial
proinflammatory
cytokinessynthesis
and has
an cytokines.
effect onpeptides
toll-like and
receptor
2, leading to increased
of
an
effect
on
toll-like
receptor
2,
leading
to
increased
synthesis
of cytokines.
of
cytokines.
Immunoinflammatory
Mechanisms
limited
to the
production
sebum. Androgens
have long
It
was once
thought
that theof
gland’s function
was
limited
to the
production
ofsebaceous
sebum. Androgens
have long
been
implicated
in
the
pathogenesis
of
acne
and
probably
limited to the production of sebum. Androgens have
long
exert an effect primarily on the sebaceous glands by increasing the production of sebum.
However, more recent evidence demonstrates that these
glands may have immunologic functions that play a role in
Immunoinflammatory Mechanisms
the pathogenesis of acne. For example, sebocytes have been
Immunoinflammatory
Mechanisms
A great deal of research has focused
on immunoinflammatory
Immunoinflammatory
Mechanisms
found to express functional receptors for neuropeptides, as
A great deal
research
has focused
pathways
ofofacne
pathogenesis,
including
demonstration of
A
great
deal
research
has focused
well as toll-like receptors 2 and 4, and CD markers 1d and
pathways
ofofacne
pathogenesis,
including
the
upregulation
of
multiple
cytokines
indemonstration
the presence of
pathways
of acne
pathogenesis,
including
14. Histamine-1 receptor has been demonstrated in these
the upregulation
of
multiple
cytokines
indemonstration
the
presence of
of
both
P. acnes,
as previously
mentioned,
and
lipopolysacchathe
upregulation
of
multiple
cytokines
in
the
presence
of
cells, and it has been shown that sebaceous glands produce
both
P.
acnes,
as
previously
mentioned,
and
lipopolysaccharides. Here again, toll-like receptors have been innately
both
as
previously
and
lipopolysacchainflammatory cytokines in the presence of P. acnes. Further,
rides.
toll-likementioned,
receptors
have
been
linkedP.Here
toacnes,
acneagain,
inflammation.
In addition,
it has
beeninnately
shown
rides.
Here
again,
toll-like
receptors
have
been
acetylcholine may modulate differentiation, sebum produclinked
to
acne
inflammation.
In
addition,
it
has
beeninnately
shown
that patients with acne tend to have reduced expression
of
linked
to
acne
inflammation.
In
addition,
it
has
been
shown
tion, and composition. This neurotransmitter may act in a
that patients with acne
tend to
have
reduced expression
of
anti-inflammatory
cytokines,
such
as IL-10.
that
patients with acne
tend to
have
reduced
expression
paracrine manner or may be stimulated in exogenous fashion
continued
on page of
23
anti-inflammatory
cytokines,
such
as IL-10.
anti-inflammatory cytokines, such as IL-10.
by nicotine, which might suggest a role for the cholinergic
6
Conclusion
system in acne and suggests that smoking may play an etioConclusion
logic role in acne as well as other follicular disorders, such as
2
2
2
3
3
3
4
4
4
5
5
5
6
6
6
7
7
7
8
8
8
9
9
9
10
10
10
11
11
11
12
12
12
13
The Acne Continuum:
An Age-Based Approach to Therapy
The Acne Continuum:
Sheila Fallon Friedlander, MD,* Hilary E. Baldwin, MD, Anthony J. Mancini, MD,
An
Age-Based
to MD
Therapy
The
Acne
Albert
C. Yan,Continuum:
MD, andApproach
Lawrence F. Eichenfield,
The
Acne
Continuum:
Sheila Fallon Friedlander, MD,* Hilary E. Baldwin, MD, Anthony J. Mancini, MD,
An
Age-Based
Approach
to
AlbertAge-Based
C.
Yan, MD,
and Lawrence
F. Eichenfield,
MD
The
Acne
Continuum:
An
Approach
to Therapy
Therapy
†
§
‡
¶
†
§
‡
¶
Sheila Fallon Friedlander, MD,* Hilary E. Baldwin, MD,†† Anthony J. Mancini, MD,‡‡
Sheila
Fallon
Friedlander,
MD,* Hilary E. Baldwin, MD,¶ Anthony
J. Mancini, MD,
§
vulgaris
is classically considered a disease of adolescence.
Although it most commonly
Albert C.
Yan,Acne
MD,
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Albert C. Yan,occurs
MD,and
and
Lawrence
F.
Eichenfield,
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has been best studied in that age group, it can develop
at any time during childhood. It ‡
†
Sheila Fallon isFriedlander,
MD,*
Hilary
E. Baldwin,
MD,
Anthony
J. Mancini,
important that health
care
practitioners
recognize the
manifestations
of neonatal,
infantile MD,
and
Acne vulgaris
is classically considered a disease of adolescence.
Although it most commonly
§
¶
acne,
as
well as the
differential
diagnosis
and
best therapeutic
approach
in the
younger
Albert C. Yan,childhood
MD,
and
Lawrence
F.
Eichenfield,
MD
Acne
vulgaris
is
classically
considered
a
disease
of
adolescence.
Although
it
most
commonly
occurs and has been best studied in that age group, it can develop at any time during childhood. It
An Age-Based Approach to Therapy
child. Acneiform
eruptions
in infants
and age
toddlers
can
occasionally
beany
associated
withchildhood.
scarring or
occurs
and has
best
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group,
itthe
can
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during
It
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care
practitioners
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oftime
neonatal,
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with
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theneonatal,
authors draw
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is
important
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care
practitioners
the
manifestations
infantile
and
childhood
acne,isas
well as the
differentialadiagnosis
andadolescence.
best therapeutic
approach
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Acne
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classically
considered
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Although
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own
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asthe
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as the available
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30:S6-S11
© 2011
Published by Elsevier
Inc. the authors draw on their
with
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California, San Diego, Rady Childrens Hospital, San Diego, CA
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lesions
may
ure
1), and
a distribution
may include
theItface,
scalp, chest,
appear
increase inthat
severity
with time.
is suggested
that
GlaxoSmithKline
andMD,
Ortho
Dermatologics.
Lawrence
F. Eichenfield,
hasIntendis,
served
asMedicis,
an investigator
for Galderma,
Galderma,
GlaxoSmithKline,
Ortho
Dermatologics,
Hilary
E. Baldwin,
MD, has
served
as a consultant
and
speaker
for Allerdiscussed
under
that
heading,
in
the
next
section.
More
comappear
and
increase
in
severity
with
Itor
iscondition,
suggested
that
and
back,
and
a course
lasting
up
to time.
a year
more.
In some
Lawrence
F.
Eichenfield,
MD,
has
served
as
an
investigator
for
Galderma,
GlaxoSmithKline,
Johnson
&
Johnson,
Neutrogena,
and
Stiefel.
He
has
the
term
infantile
acne
be
used
to
describe
this
as
it
Stiefel,
and Valeant.
gan,
Galderma,
Medicis, and Onset. She has also been a speaker for
monly
seen
in
the
neonatal
period
is
a
condition
that
has
been
the
term
infantile
acne
be
used
to
describe
this
condition,
as
it
GlaxoSmithKline,
Johnson
&
Johnson,
Neutrogena,
and
Stiefel.
He
has
patients,
inflammatory
and
even
nodulocystic
lesions
may
also
been
consultant
and/or
served
on
the
advisory
board
for
Coria
and
is not limited to the neonatal period; accordingly, it will be
Sheila
F. Friedlander, and
MD,Ortho
has served
on an advisory board for Galderma
GlaxoSmithKline
Dermatologics.
also
been consultant
and/or served
on the advisory
boardDermatologics,
for Coria and
Galderma,
GlaxoSmithKline,
Ortho
called
neonatal
cephalic
pustulosis
(NCP).
Inflammatory,
often
is
not
limited
to
the
neonatal
period;
accordingly,
it
will
be
appear
and
increase
in
severity
with
time.
It
is
suggested
that
and
Onset.
Lawrence
F. Eichenfield,
MD, hasIntendis,
served asMedicis,
an investigator
for Galderma,
discussed under that heading, in the next section. More comGalderma,
GlaxoSmithKline,
Intendis,
Medicis,
Ortho Dermatologics,
Stiefel,
Valeant.
pustular
lesions
early
tend
resolve
Anthony
J. and
Mancini,
MD,
FAAP,
servedNeutrogena,
as a consultant
for Galderma,
discussed
under
that
heading,
in describe
the
section.
More
comthe
term
infantile
acne
bevery
used
to
thistocondition,
as it
GlaxoSmithKline,
Johnson
& has
Johnson,
and Stiefel.
He has
monly
seen
in theappear
neonatal
period
isand
anext
condition
that
hassponbeen
Stiefel,
and
Valeant.
Sheila
Friedlander,
MD,
has
on athe
an
advisory
for
Galderma
Medicis,
and
Stiefel.
He
has served
also been
speaker
for board
Galderma.
alsoF.been
consultant
and/or
served
on
advisory
board
for Coria
and
taneously
within
first
4
to
8
weeks
of
life.
Male
infants
are
monly
seen
in
the
neonatal
period
is
a
condition
that
has
been
is
not
limited
to
the
neonatal
period;
accordingly,
it
will
be
called neonatal cephalic pustulosis (NCP). Inflammatory, often
Sheila
F.Onset.
Friedlander,
has served
on an
advisory board
for
andC.
Albert
Yan,
MD,
has MD,
no relevant
financial
relationships
with
anyGalderma
commerGalderma,
GlaxoSmithKline,
Intendis,
Medicis, Ortho
Dermatologics,
affected
five
times
more
often
than
female
infants
and
the
called
neonatal
cephalic
pustulosis
(NCP).
Inflammatory,
often
discussed
under
that
heading,
in
the
next
section.
More
comand
Onset.
Anthony
J. and
Mancini,
MD, FAAP, has served as a consultant for Galderma,
pustular lesions appear very early and tend to resolve sponcial interests.
Stiefel,
Valeant.
lesions
are
characteristically
the
face
(Figure
2).
It
pustular
lesions
early
to
resolve
Anthony
J. Mancini,
MD,
FAAP,
hasbeen
served
as
a consultant
for Galderma,
monly
seen
in theappear
neonatal
isand
atocondition
that
hassponbeen
Medicis,
and
Stiefel.
He
has
also
a
speaker
for
Galderma.
taneously
within
the
firstvery
4 period
tolimited
8 weeks
oftend
life.
Male
infants
are
Corresponding
author:
Sheila
Fallon
Friedlander,
MD,
Clinical
Professor
of
PediatSheila F. Friedlander, MD, has served on an advisory board for Galderma
Medicis,
and
Stiefel.
He
has
also
been
a
speaker
for
Galderma.
Albert
C.
Yan,
MD,
has
no
relevant
financial
relationships
with
any
commerhas
been
estimated
that
up
to
20%
of
newborns
experience
taneously
within
the
first
4
to
8
weeks
of
life.
Male
infants
are
called
neonatal
cephalic
pustulosis
(NCP).
Inflammatory,
rics and
Medicine (Dermatology), University of California San Diego. Rady Chiland
Onset.
affected
five times
more
often than
female
infants andoften
the
Albert
C.interests.
Yan,
MD,San
hasDiego,
no relevant
financial
relationships with any commer2
cial
this
form
of
neonatal
acne.
dren’s
CA. E-mail:
sfriedlander@chsd.org
affected
five
times
more
often
than
female
infants
and
pustular
lesions
appear
very
early
and
tend
to
resolve
sponAnthony
J.Hospital,
Mancini,
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has served
as a consultant for Galderma,
lesions are characteristically limited to the face (Figure 2).the
It
cial interests.
Corresponding
author:
Sheila
Friedlander,
MD, Clinical
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Stiefel.
HeFallon
has also
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lesions
areestimated
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2).are
It
taneously
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Male
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Corresponding
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Sheila Fallon Friedlander,
MD,
Clinical
Professor
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and
Medicine
University
of
California
San
Diego.
Rady
ChilAlbert C. Yan, MD, has no relevant financial relationships with any commerhas
been
estimated
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to
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affected
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and
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Rady
ChilHospital, San Diego, CA. E-mail: sfriedlander@chsd.org
this form of neonatal acne.
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interests.
S6 dren’s
front matter © 2011 Published by Elsevier Inc.
this form
neonatal acne.2 limited to the face (Figure 2). It
dren’s Hospital, San Diego, CA. E-mail: sfriedlander@chsd.org
lesions
areofcharacteristically
Corresponding
author:
Sheila
Fallon
Friedlander,
MD,
Clinical
Professor
of
Pediatdoi:10.1016/j.sder.2011.07.002
has been estimated that up to 20% of newborns experience
rics and
Medicine
(Dermatology),
University
of California San Diego. Rady ChilPediatric
Acne
Management:
Optimizing
Outcomes • globalacademycme.com/sdef
7
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1085-5629/11/$-see
mattersfriedlander@chsd.org
© 2011 Published by Elsevier Inc.
this form of neonatal acne.2
Hospital, San Diego, front
CA. E-mail:
S6
1085-5629/11/$-see
front
matter
©
2011
Published
by
Elsevier
Inc.
doi:10.1016/j.sder.2011.07.002
Neonatal Acne
Neonatal Acne
Neonatal
Acne
Neonatal Acne
Neonatal Acne
es
nd
er,
CP
ne
s3
13
ast
ed
S8
Table 1 Differential Diagnosis of Pediatric Acne in Patients <12 Yea
Condition
Angiofibromas (adenoma sebaceum)
S7
Figure
Figure 11 Infantile
Infantile acne.
acne. (A)
(A) Infantile
Infantile acne
acne with
with erythematous
erythematous papules
papules
and
comedones
present.
(B)
Infantile
acne
with
and
Figure
1
Infantile
acne.
(A)
Infantile
acne
with
erythematous
papules
and comedones present. (B) Infantile acne with comedones
comedones
and
inflammatory
papules.
Photos
Sheila
Fallon
Friedlander,
and
comedones
present.
(B) courtesy
Infantile
acne
with
comedones
and
inflammatory
papules.
Photos
courtesy of
of
Sheila
Fallon
Friedlander,
Figure 1. Infantile
MD.
inflammatory
papules.Acne
Photos courtesy of Sheila Fallon Friedlander,
MD.
A. With Erythematous Papules and Comedones Present
MD.
B. With Comedones and Inflammatory Papules
Photos courtesy of Sheila Fallon Friedlander, MD.
Associated with tub
Mid-facial clustering
Typically initially pin
Check for hypopigm
examination may be
● Query regarding fam
hypopigmented spot
● Signs other than hyp
Figure
demFigure 33 Adrenal
Adrenal Gland
Gland Enlargement.
Enlargement. This
This photomicrograph
photomicrograph
demchildhood
onstrates
enlargement—suggesting
hyperactivity—
of
reFigure
3 Adrenal
Gland Enlargement.
This photomicrograph
demonstrates
enlargement—suggesting
hyperactivity—
of the
the zona
zona
reAseptic of
facial
granuloma in a newborn.
●ofUsually
ticularis
the
(elsevier.com)
onstrates
hyperactivity—
the zonaanre-isolated,
ticularis ofenlargement—suggesting
the adrenal
adrenal gland
gland in a newborn.
(elsevier.com)
Figure
Adrenal
Gland
Drug
exposure
● Phenytoin and other
ticularis
of3.the
adrenal
glandEnlargement
in a newborn. (elsevier.com)
This photomicrograph demonstrates enlargement—
● Lithium
suggesting hyperactivity—of the zona reticularis ●of Isoniazid
the adrenal
gland
in
a
newborn.
(elsevier.com)
● Corticosteroids
(ora
with topical ketoconazole 2% cream twice daily
and the lewith
topical
ketoconazole
2% cream twice daily
and the
le- comm
sions
resolved
rapidly.folliculitis
Eosinophilic
pustular
● Scalp
lesions
sions
resolved
rapidly.
However,
subsequent
studies of the possible
correlation
Erythema
toxicum
neonatorum
● Seen
commonly in n
However,
subsequent
studies
of
the
possible
correlation
between M. furfur and pustular lesions in neonates
● Can be have
pustular
● Usually
disappears
w
between
M. furfur and
pustular
in neonates
yielded conflicting
results.
Some lesions
have shown
that nothave
all
yielded
results.
Some
have cultures,
shown
that
all
● Uncommon
Hormonalconflicting
pathology:
adrenal
disease
patients
with
pustulosis
have
positive
andnot
some
● Must
be
ruled
(particularly
patients
with congenital
pustulosis
have
positive
cultures,
and
some
who
are
cultureadrenal
positive
do not
have
any
skin
le- out w
patients
6any
years
age)
hyperplasia),
adrenal
tumors,
true findings
patients
who
are
culture
positive
do not have
skinof
lesions.
One
explanation
for
these
is that
such
outprecocious
puberty, premature
sions.
One
for these findings
is thattosuch
outbreaks
may explanation
represent
a hypersensitivity
reaction
the presadrenarche,
gonadal tumors,
breaks
represent
reaction
presence
ofmay
M. furfur
rathera hypersensitivity
than aearly
disease caused
by to
an the
absolute
onset of polycystic ovarian syndrome 4-6
4-6
ence
of M.
rather than
a disease caused by an absolute
increase
in furfur
the number
of organisms.
Infections
● Staphylococcal
4-6
increase
in theproposed
number that
of organisms.
It has been
some cases
of comedonal disease
● Pityrosporum follicu
has beenmay,
proposed
of comedonal
disease
in It
neonates
in fact,that
be some
a lesscases
inflammatory
response
to
● Herpes simplex
in
may, inthis
fact,would
be a less
response
to
M.neonates
furfur, although
not inflammatory
explain the●clinical
obserAtypical mycobacter
M.
furfur,
thisdisease
wouldtends
not explain
thelonger
observation
thatalthough
comedonal
to persist
than
the
●clinical
Candida
species
vation
that
comedonal
disease
tends
to
persist
longer
than
the
pustular
Until further research clarifies
this issue,hyperke
Keratosiscondition.
pilaris
● Gray-white,
pustular
condition. to
Until
further
clarifies
thisoverlap
issue,
it seems reasonable
assume
thatresearch
there may
be● some
Most
commonly
occ
it
reasonable
assume
that there
be some
overlap
ofseems
conditions
(NCPtoand
infantile
acne) may
in some
patients,
in
and
cheeks
of
conditions
(NCP and
infantile
in some
patients,
in occasi
● Papules
whom
the conditions
may
occur acne)
simultaneously.
Oncemay
atwhom
the
conditions
may
occur
simultaneously.
Once
attributed
to
maternal
placental
androgens,
the
more
recently
Milia
● Characteristically sm
tributed
maternal placental
androgens,
more
recently
Extremely
common i
acceptedtohypothesis
for true neonatal
acnethe
is ●an
increase
in
accepted
hypothesis
for
true
neonatal
acne
is
an
increase
in
(DHEA) production
causes by
en-sweat re
Miliaria
● Caused
(DHEA)
production
causes
enCommon
in first few
largement and, in some cases,
hyperactivity
of●the
fetal adreFine
vesicles,
largement
and, in some
hyperactivity
of●the
fetal
adre- papule
nal gland (Figure
3). Ancases,
association
with severe
adolescent
Molluscum
contagiosum
● Often
looks like acn
nal
gland
(Figure
3).been
An association
withthesevere
adolescent
acne
later in
life has
suggested, but
data
supporting
22
● Insupporting
most patients, pre
acne
lifenot
hasrobust.
been suggested,
but the data
such later
a linkinare
Periorificial
dermatitis
● Noncomedonal
such
a link are
not robust.2
● Classic distribution
Diagnosis
Acne
Diagnosisand
andTreatment
TreatmentofofNeonatal
Neonatal
Acne
● Does
not respond to
Diagnosis
and
Treatment
of
Neonatal
Acne
● is
May
represent
The first goal in a neonate with pustular lesions
to rule
out a juv
The
first goal
neonate
with pustular
lesions
todiagnosis
rule
out
bacterial,
viral,inora fungal
infections.
The differential
Pomade
acne
● is
Form
of occlusion
fo
bacterial,
viral, or fungal
infections.
The differential
diagnosis
Question
patient
an
includes erythema
toxicum
neonatorum
(seen●commonly
in
cosmetic
o
includes
neonatorum
commonly
in
neonates,erythema
it usuallytoxicum
disappears
within the (seen
first week
or twoproducts
of
Verrucae
planae
(flat
warts)
●
Koebner
phenomeno
neonates,
it
usually
disappears
within
the
first
week
or
two
of
life), milia, miliaria, sebaceous gland hyperplasia, and drug
present,
is a useful
life),
milia,
sebaceous
gland hyperplasia,
andordrug
reaction
(to miliaria,
either maternal
medications
or to topical
sys●
Typically
noninflamm
reaction
(to either
maternaltomedications
topical
systemic drugs
administered
the baby). or
In to
almost
allorcases,
●
Common
warts may
temic drugs administered to the baby). In almost all cases,
●
●
●
●
Some evidence suggests that in a subset of patients, NCP
Some
evidence suggests
that in furfur
a subset
of patients,InNCP
may
be associated
with Malassezia
colonization.
one
Figure 3 Adrenal Gland Enlargement. This photomicrograph dem-3
may
bepublished
associatedinwith
Malassezia
furfur
colonization.
In one3
study
1996,
a
group
of
French
investigators
onstrates enlargement—suggesting hyperactivity— of the zona re-3
study
published
in 1996,
a group
investigators
sampled
smears
from of
theFrench
faces
and
necks of 13
ticularis ofand
theexamined
adrenal gland
in a newborn.
(elsevier.com)
sampled
smearsneutrophils
from the faces
13
neonates.and
In 8examined
of the samples,
andand
M. necks
furfur of
yeast
neonates.
In 8 ofThe
the infants
samples,
neutrophils
and M.were
furfur
yeast
were identified.
with
positive smears
treated
were identified. The infants with positive smears were treated
with topical ketoconazole 2% cream twice daily and the lesions resolved rapidly.
However, subsequent studies of the possible correlation
between M. furfur and pustular lesions in neonates have
yielded conflicting results. Some have shown that not all
patients with pustulosis have positive cultures, and some
patients who are culture positive do not have any skin lesions. One explanation for these findings is that such outbreaks may represent a hypersensitivity reaction to the presence of M. furfur rather than a disease caused by an absolute
increase in the number of organisms.4-6
It has been proposed that some cases of comedonal disease
in neonates may, in fact, be a less inflammatory response to
M. furfur, although this would not explain the clinical obserthese other conditions can be ruled out based on the age of
vation that comedonal disease tends to persist longer than the
these
other conditions
can beand
ruled
out basedofonthe
thelesions,
age of
the patient,
the distribution
morphology
pustular
condition.
furtherpustules
researchof
issue,
Figure
with
superficial
neonatal
cephalic
Figure 22 Infant
Infant
with Until
superficial
pustules
ofclarifies
neonatalthis
cephalic
the
patient,
the
distribution
and
morphology
of
the
lesions,
pustulosis.
and results of laboratory evaluations. (Differential diagnosis
Figure
2 Infant with tosuperficial
pustules
of neonatal
it
seems
assume that
there may
be some cephalic
overlap
pustulosis.
Figure reasonable
2. Infant With Superficial
Pustules
of Neonatal
pustulosis.
and
resultsinofTables
laboratory
(Differential
is shown
1 andevaluations.
2; features of
neonatal vsdiagnosis
those of
ofCephalic
conditions
(NCP
and
infantile
acne)
in
some
patients,
in
Pustulosis
infantile acne are listed in Table 3.)
whom the conditions may occur simultaneously. Once atSignificant hormonal abnormalities may rarely be a cause
tributed to maternal placental androgens, the more recently
8
of lesions in this age group; a laboratory workup is not indiaccepted hypothesis for true neonatal acne is an increase in
dehydroepiandrosterone (DHEA) production causes en-
ca
ar
w
hypopigmented spots
itially pink,
nitially
pink,then
thenwhite
white
●
hypopigmented
hypopigmentedmacules
macules(ash-leaf
(ash-leafspots);
spots);Wood’s
Wood’slamp
lampSigns other than hypopigmented macules are usually not present in early
childhood
nnmay
maybe
behelpful
helpfulto
todemonstrate
demonstratethese
thesemacules
macules
Table
1.
Differential
Diagnosis
of
Pediatric
Acne
in
Patientsan≤12
Years ofpainless
Age1 nodule on the cheek
Aseptic
facial
isolated,
rding family
history
of
angiofibromas,
arding
family
history
ofgranuloma
angiofibromas,seizures,
seizures,and
and ● Usually
nted spots
ented
spots
Drug
exposure
●Comment
Phenytoin and other anticonvulsants
Condition
in
rthan
thanhypopigmented
hypopigmentedmacules
maculesare
areusually
usuallynot
notpresent
present
inearly
early
●
Angiofibromas (adenoma sebaceum)
• Lithium
Associated with tuberous sclerosis
●• Isoniazid
Mid-facial clustering of lesions, often in the alar creases
●• Corticosteroids
(oral,
inhaled)
Typically initially pink,
then topical,
white
isolated,
isolated,painless
painlessnodule
noduleon
onthe
thecheek
cheek
Check for
hypopigmented
macules (ash-leaf spots); Wood’s lamp examination may be
Eosinophilic
pustular folliculitis
●• Scalp
lesions
common
and
anticonvulsants
andother
other
anticonvulsants
helpful to demonstrate these macules
Erythema toxicum neonatorum
●• Seen
commonly
in history
neonates
Query regarding
family
of angiofibromas, seizures, and hypopigmented spots
●• Can
be
pustular
Signs other than hypopigmented macules are usually not present in earlychildhood
oids (oral,
roids
(oral,topical,
topical,inhaled)
inhaled)
●• Usually
disappears within the first week of life
Aseptic facial granuloma
Usually an isolated, painless nodule on the cheek
ns common
ons
common
● Uncommon
Hormonal pathology: adrenal disease
Drug exposure
• Phenytoin and other anticonvulsants
●• Must
(particularly congenital adrenal
monly
monlyin
inneonates
neonates
Lithiumbe ruled out when acneiform lesions occur in mid-childhood (1 through
6
years of age)
hyperplasia),
adrenal
tumors,
true
stular
stular
• Isoniazid
precocious
puberty,
premature
•
Corticosteroids
(oral, topical, inhaled)
appears
within
the
first
week
of
life
sappears within the first week of life
adrenarche,
gonadal
tumors,
early
Eosinophilic pustular folliculitis
• Scalp lesions common
n
onset
of polycystic
ovarian
syndrome
led out
acneiform
lesions
occur
in
mid-childhood
(1
uled
outwhen
when
acneiform
lesions
occur
in
mid-childhood
(1through
through
Erythema toxicum neonatorum
• Seen
commonly in neonates
●• Staphylococcal
age)
age) Infections
Can be pustular
●• Pityrosporum
folliculitis
Usually disappears
within the first week of life
●
Herpes
simplex
• Uncommon
Hormonal pathology: adrenal disease (particularly
mycobacteria
Must be ruled
out when acneiform lesions occur in mid-childhood (1 through 6 years of age)
congenital adrenal hyperplasia), adrenal tumors, true ●• Atypical
●
Candida
species
precocious
puberty,
premature
adrenarche,
gonadal
ccal
occal
tumors, early
onset of polycystic ovarian syndrome
Keratosis
pilaris
● Gray-white, hyperkeratotic, follicular papules
m folliculitis
um
folliculitis
●• Most
commonly occur on the extensor surfaces of the upper arms, thighs,
Infections
Staphylococcal
plex
mplex
• and
Pityrosporum
cheeksfolliculitis
ycobacteria
ycobacteria
Herpes simplex
●• Papules
may occasionally be inflammatory
ecies
pecies
• Atypical mycobacteria
Milia
●
Characteristically
small (1 to 2 mm), white, globoid, noninflammatory papules
e,hyperkeratotic,
hyperkeratotic,follicular
follicularpapules
papules
• Candida species
● Extremely
common in newborns but may be seen in older children and adults
monly
on
the
extensor
surfaces
of
the
upper
arms,
thighs,
monlyoccur
occur
on
the
extensor
surfaces
of
the
upper
arms,
thighs,
Keratosis pilaris
• Gray-white, hyperkeratotic, follicular papules
s
Miliaria
●• Caused
by sweat
often
occurs
in upper
covered
Most commonly
occur retention;
on the extensor
surfaces
of the
arms,areas
thighs, and cheeks
ay
ayoccasionally
occasionallybe
beinflammatory
inflammatory
●• Common
first few weeks
of life
Papules mayinoccasionally
be inflammatory
●• Fine
vesicles, papules,
papulovesicles
stically
papules
sticallysmall
small
(1to
to22mm),
mm),white,
white,globoid,
globoid,noninflammatory
noninflammatory
papules
Milia (1
Characteristically
small (1 to 2ormm),
white, globoid, noninflammatory papules
common
in
newborns
but
may
be
seen
in
older
children
and
adults
commonMolluscum
in newborns
but may be seen in older children
and adults
contagiosum
●• Often
looks
like inacne
whenbutinflamed
Extremely
common
newborns
may be seen in older children and adults
●• In
mostbypatients,
presents
umbilicated,
pearly papules
sweat
sweatretention;
retention;
oftenoccurs
occursin
incovered
coveredareas
areas
Miliaria often
Caused
sweat retention;
often with
occursclassic
in covered
areas
Common in first few weeks of life
nnfirst
weeks
firstfew
few
weeksof
oflife
life
Periorificial
dermatitis
●• Noncomedonal
Fine vesicles,
papules, oraround
papulovesicles
es,
es,papules,
papules,or
orpapulovesicles
papulovesicles
●• Classic
distribution
mouth, eyes, and nose
●• Does
not like
respond
to standard
Molluscum
contagiosum
Often looks
acne when
inflamed acne therapy
sslike
when
likeacne
acne
wheninflamed
inflamed
In most
patients, presents
with classic
umbilicated,
pearly papules
●• May
represent
a juvenile
form of
acne rosacea
ients, presents
tients,
presentswith
withclassic
classicumbilicated,
umbilicated,pearly
pearlypapules
papules
Pomade
acne
●• Form
of occlusion folliculitis
Periorificial
dermatitis
Noncomedonal
onal
donal
The
acne continuum
S9
Classic distribution
mouth,
eyes, and
nosethe use of hair styling or other
●• Question
patientaround
and/or
parents
about
tribution around
stribution
aroundmouth,
mouth,eyes,
eyes,and
andnose
nose
• cosmetic
Does not respond
to standard
products
on oracne
neartherapy
the face
espond
espondto
tostandard
standardacne
acnetherapy
therapy
acne rosaceaWhen Hyperandrogenism Is Suspected1
•1May represent a juvenile
form4 ofEvaluation
Table
Table
2
Differential
Diagnosis
of
Neonatal
Acne
ent aajuvenile
form
of
sent
juvenile
form
ofacne
acne
rosacea
Verrucae
planae
(flatrosacea
warts)
● Koebner phenomenon (appearance of lesions along a site of trauma), when
Pomadecommon:
acne
• present,
Form of occlusion
folliculitis
is a useful
More
● distinguishing
Family & drug feature
exposure history
clusion folliculitis
cclusion
folliculitis
• Question patient and/or parents about the use of hair styling or other cosmetic products
●other
Typically
noninflammatory
● Drugparents
reaction
(to maternal
medications
topical
or
●
Search
for
axillary,
genital odor/hair
atient and/or
about
the
patient
and/or
parents
about
theuse
useof
ofhair
hairstyling
stylingoror
orto
other
on or near the face
be present
elsewhere
systemic
drugs
administered to the baby) ● Common warts may
● Assess
breast
& testicular development
roducts on
or
products
on
ornear
nearthe
theface
face
planae (flat warts)
• Koebner phenomenon (appearance of lesions along a site of trauma), when present,
● Verrucae
Erythema
toxicum
neonatorum
● Laboratory considerations:
henomenon
(appearance
of
along
when
henomenon
(appearance
oflesions
lesions
alongaasite
siteof
oftrauma),
trauma),
whendistinguishing
is a useful
feature
Milia
aauseful
feature
• Typically noninflammatory–Testosterone (free and total)
useful●distinguishing
distinguishing
feature
● Miliaria
–Dehydroepiandrosterone
sulfate (DHEA-S)
• Common warts may be present
elsewhere
oninflammatory
oninflammatory
is Sebaceous
shown in Tables
1hyperplasia
and 2; features of neonatal vs those of
cated
unless height,
weight, or maturational abnormalities
●
gland
–Luteinizing
hormone
arts may
warts
maybe
bepresent
presentelsewhere
elsewhere
infantile acne are listed in Table 3.)
are–Follicle-stimulating
noted (this does not
include neonatal gynecomastia,
hormone
Significant
hormonal abnormalities may rarely be a cause
which
is a normal variant).
–Prolactin
Less
common:
Table 2. Differential Diagnosis of Neonatal Acne1
lesions
in this age
group;
a laboratory workup is not indiBecause NCP is self-limited and transient, treatment is not
–17-Hydroxyprogesterone
●ofViral,
bacterial,
fungal
infection
–Bone
age
●cated
Endocrinopathy
of
cated
unless
of
unless height,
height, weight,
weight, or
or maturational
maturational abnormalities
abnormalities
More
Common:
• Drug reaction (to maternal medications or to topical or
are
are noted
noted (this
(this does
does not
not include
include neonatal
neonatal gynecomastia,
gynecomastia,
systemic drugs administered to the baby)
which
e
se
whichisisaanormal
normalvariant).
variant).
• Erythema toxicum neonatorum
iBecause
diBecause NCP
NCP isis self-limited
self-limited and
and transient,
transient, treatment
treatment isis not
not
Diagnosis
and Treatment of Infantile Acne
• Milia
necessary. However, when parents are concerned and a discus• Miliaria
The
more common conditions that should be considered in
sion about the condition fails to reassure them, some providers
• Sebaceous
gland
hyperplasia
the
differential
diagnosis
are listed in Table 1. The physical
prescribe topical ketoconazole 2% cream twice daily for 1 week.
examination
should always include assessment of growth
Less Common:
No clinical trials support such use of ketoconazole; however, its
and
charting
of the
infant’s
height and weight. Blood pressure
• Viral,
bacterial,
fungal
infection
use is based on the clinical experience of the authors, which has
also
should be measured and monitored to rule out cortico• Endocrinopathy
shown that this therapy may sometimes be helpful.
steroid or androgen-secreting disorders. Accelerated growth
If the lesions are still present after 4 weeks of age or if
Pediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdefof hands and feet suggests the need for further workup. In9
comedonal lesions are prominent, the patient may have
addition, the clinician should be alert for androgen effects,
infantile acne and may require more aggressive therapy
srs
k.
ts
as
if
ve
py
he
a
ao-
on
xeis
be
in
est
en
shown that this therapy may sometimes be helpful.
use is based on the clinical experience of the authors, which has
shown
this therapy may sometimes be helpful.
The acnethat
continuum
comedonal
lesions are prominent, the patient may have
infantile acne and may require more aggressive therapy
comedonal lesions are prominent, the patient may have
1
over
In cases in whichofcomedones
persist
and the
Table 2time.
Differential
Acne
infantile
acne andDiagnosis
may requireNeonatal
more aggressive
therapy
family desires treatment, topical benzoyl peroxide or a
over
In cases in which comedones persist and the
Moretime.
common:
topical retinoid is appropriate. For persistent inflamma● Drug desires
reactiontreatment,
(to maternaltopical
medications
or peroxide
to topical or
family
benzoyl
or a
tory
disease,drugs
a topical antibiotic
(clindamycin
or erythrosystemic
the persistent
baby)
topical
retinoid isadministered
appropriate.toFor
inflammamycin)
should be added.
● Erythema
neonatorum
tory
disease,toxicum
a topical
antibiotic (clindamycin or erythro●
Milia
mycin) should be added.
also should be measured and monitored to rule out corticoof hands and feet suggests the need for further workup. In
S9
addition, the clinician should be alert for androgen effects,
1
ofTable
hands
and
feet
suggests
the
need
for
further
workup.
In
Evaluation
When
Hyperandrogenism
Suspected
such as4.odor,
changes
in areolae
and testes, Is
and
the presence
addition,
the
clinician
should
be
alert
for
androgen
effects,
1
Table
4
Evaluation
When
Hyperandrogenism
Is
Suspected
of
axillary
and/or
genital
hair.
Children
in
whom
these signs
•
Family
&
drug
exposure
history
such as odor, changes in areolae and testes, and the presence
are
noted&forshould
have
complete laboratory workup, as
Search
axillary,
genital aodor/hair
● •Family
drug
exposure
history
of
axillary
and/or
genital development
hair.
Children in whom these signs
•
Assess
breast
&
testicular
listed
in
Table
4.
● Search
for
axillary,
genital
odor/hair
are
noted
should
have
a
complete
laboratory workup, as
Laboratory
considerations:
Children
whose
examination
is within normal lim● •Assess
breast
& clinical
testicular
development
listed
in Table 4.(free and total)
– Testosterone
● Laboratory
considerations:
its
generally
do
not
require
further
workup
and may be
– Dehydroepiandrosterone
sulfate
(DHEA-S) is within normal limChildren
whose(free
clinical
examination
–Testosterone
andregimens
total)
treated
with
the
standard
shown
in
Table
5. How–
Luteinizing
hormone
S10–Dehydroepiandrosterone
its
generally do not require sulfate
further(DHEA-S)
workup and may be
● Miliaria
ever,
high index of suspicion
pathology must
– aFollicle-stimulating
hormone for underlying
treated
with thehormone
standard regimens shown in Table 5. HowInfantile
Acne
● Sebaceous gland
hyperplasia
Infantile
Acne
– Prolactin for
be–Luteinizing
maintained
acne that presents after the first year of life
ever,
high
index of suspicion
for underlying
pathology must
–Follicle-stimulating
Table
5a17-Hydroxyprogesterone
General
for and
Treating
–before
Infantile
Acne
and
6 to 7Approach
years ofhormone
age,
moreAcne
aggressive evaluation
Infantile
acne, which—like
neonatal acne—is more common
be–Prolactin
maintained
Less common:
– Bone age for acne that presents after the first year of life
is
required
in that age
group (see the following
section on
in male infants, may be seen in children from birth to approx● Mild
(comedonal
or mixed
and inflammatory
● Viral, bacterial,
fungal infection
and
before
6 to 7 years
of age, comedonal
and more aggressive
evaluation
Infantile
acne, which—like
neonatal acne—is more common
lesions)
“Mid-Childhood
Acne”).
Careful
follow-up
is
mandatory
and
imately
12
months
of
age.
However,
it
more
commonly
pre–Bone
age
● Endocrinopathy
isTable
required
in
that
age
group
(see
the
following
section
on
in
male infants, may be seen in children from birth to approx5.
General
Approach
for
Treating
Acne
–
Topical
benzoyl
peroxide
or
topical
retinoid
OR
should include continued monitoring and charting of matusents after the neonatal period. The classic presentation is
“Mid-Childhood
Acne”).
Careful
follow-up
is
mandatory
and
imately 12 months of age. However, it more commonly pre– Topical
combination
therapy (benzoyl
peroxide
rational
milestones
observation
forinflammatory
features
of plus
virilizapredominantly comedonal, but inflammatory lesions may be
• Mild include
(comedonal
orand
mixed
comedonal and
lesions)
should
continued
monitoring
and charting
of
matusents after the neonatal period. The classic presentation is
retinoid,
benzoyl
peroxide
plus
topical
antibiotic,
or or
tion.–IfTopical
the condition
proves
refractory
to OR
standard therapy
present (either inflammatory comedones or—particularly in
benzoyl
peroxide
or
topical
retinoid
rational
milestones
and
observation
for
features
of
virilizapredominantly comedonal, but inflammatory lesions may be
Diagnosis
and
Treatment
of
Infantile
Acne
benzoyl
peroxide
plus
both
topical
antibiotic
and
any –evidence
of virilization
occurs,peroxide
a complete
laboratory
young
infants—
concomitant
pustular
neonatal
lecombination
therapy (benzoyl
plus retinoid,
necessary.
However,
when parents
are concerned
and acne
a discustion.
IfTopical
the common
condition
proves
refractory
to standard
therapy or
present
(either
inflammatory
comedones
or—particularly
in
OR plus
The retinoid)
more
conditions
thatareshould
be peroxide
considered
benzoyl
peroxide
topical antibiotic,
or
benzoyl
plus in
workup
and
bone
age
assessment
appropriate.
sions).
Infantile
acne
also
may
be
nodular.
The
lesions
most
sion about
the condition
fails to reassure
some providers
any
evidence
of
virilization
occurs,
a
complete
laboratory
young
infants—
concomitant
pustularthem,
neonatal
acne le– differential
Topical
sulfacetamide
S9
the
diagnosis
are
listed
in
Table
1.
The
physical
both topical
antibioticisand
Topical
treatment
theretinoid)
initialORtherapy for significant,
commonly
appear
on the face, but
lesions
may
seen
prescribe
topical
ketoconazole
twicealso
daily
for be
1 week.
– –Topical
dapsone
workup
andsulfacetamide
bone
agealways
assessment
are appropriate.
sions).
Infantile
acne also may2%
becream
nodular.
The
lesions
most
Topical
examination
should
include
assessment
of growth
comedonal
infantile
acne,
including
benzoyl
peroxide
and
on
the
neck,
back,
and
chest.
Although
infantile
acne
usually
If response
is inadequate
, consider
adding
afor
retinoid
No clinical trials
support
such
usebut
of ketoconazole;
however,
its
Topical
treatment
is
the
initial
therapy
significant,
commonly
appear
on the
face,
lesions also may
be seen
–
Topical
dapsone
and
charting
of
the
infant’s
height
and
weight.
Blood
pressure
1
tretinoin
as monotherapy
or
combination
therapy.
If inflamresolves
by 1 year
age, Hyperandrogenism
the
condition
canauthors,
persist
for
several
Table
Evaluation
When
Is Suspected
product
to
a regimen
that
does not
already
include
it,
usethe
is4based
the of
clinical
experience
of the
which
has
comedonal
acne,
including
peroxide
on
neck,on
back,
and7chest.
Although
infantile acne
usually
If response
isinfantile
inadequate,
consider
adding
a benzoyl
retinoid
product
tocorticoa and
also
should
be
measured
and
monitored
to rule
outbe
matory
lesions
are
present,
topical
antibiotics
may
added
months
or
even
years.
changing
the
concentration
and/or
type
of
vehicle
in
regimen that
does not already or
include
it, changing therapy.
the concentration
●
Family
& this
drug
exposure
history
shown
that
therapy
sometimes
tretinoin
asandrogen-secreting
monotherapy
combination
If inflamresolves
by
1 year
of age,may
the
condition be
canhelpful.
persist for several
steroid
or
disorders.
Accelerated
growth
thetype
retinoid
product,
or changing
to
a combination
and/or
of vehicle
in the retinoid
product,
or changing
to be
a added
7
●
Search
for
axillary,
genital
odor/hair
If
the
lesions
are
still
present
after
4
weeks
of
age
or
if
matory
lesions
are
present,
topical
antibiotics
may
months
or
even
years.
ofcombination
hands
and
feet
suggests
the
need
for
further
workup.
In
Table 3. Neonatal vs Infantile Acne1
product product
that has
tried.
thatnot
hasbeen
not been
tried.
●comedonal
Assess breast
& testicular
development
lesions
are prominent,
the patient may have
addition,
the
clinician
should
be
alert
for
androgen
effects,
●infantile
Laboratory
considerations:
Neonatal
Infantile
• Moderate (combined comedonal and inflammatory)
acne
and
may require
Table 3 Neonatal
vs Infantile
Acne1more aggressive therapy
such
as odor,(combined
changes incomedonal
areolae andand
testes,
and the presence
●
Moderate
inflammatory)
Onset
Often 2 to(free
3 weeks
oftotal)
age
Often 3 to 6 months of age
–Testosterone
and
– Add oral antibiotic (erythromycin, macrolide derivatives such
over time. In cases in which comedones
persist
and
the
–
Add
oral
antibiotic
(erythromycin,
macrolide
derivatives
of
axillary
and/or
genital
hair.
Children
in
whom
these signs
1 (DHEA-S)
Neonatal
Lesions
Pustules;vs
less
likely, comedones
Comedones, pustules,
cysts
–Dehydroepiandrosterone
sulfate
Table
3 Neonatal
Infantile
Acne
as clarithromycin; in patients >8 yearsInfantile
of age, doxycycline
family
desires
treatment,
topical
benzoyl
peroxide
or
a
such
as
clarithromycin;
in
patients
>8
years
of age, as
are noted
should haveOften
a complete
laboratory
workup,
Possible
Malassezia
speciesOften
colonization
play
or minocycline)*
–Luteinizing
hormone
Onset
2 toFor
3Androgens
weeks
ofmay
age
3 to 6 months
of age
Neonatal
Infantile
topical
retinoid
is
appropriate.
persistent
inflammadoxycycline
or
minocycline)*
etiology
(neonatal
cephalic
pustulosis)
a
role
listed
in Tablestrength
4. of topical retinoid
– Increase
–Follicle-stimulating hormone
Lesions
Pustules;
less
likely,
pustules,
tory
disease,
a topical
antibiotic
or
erythroIncrease
strength
ofComedones,
topical
retinoid
Course
Spontaneous
resolution,
persistofcomedones
forage
months
Onset
Often 2 to(clindamycin
3Can
weeks
Often
to
6treatment,
months
of cysts
age
–Prolactin
In–Children
older
girls who
do not
respond
to 3other
consider
hormonal
whose
clinical
examination
is within
normal
limusually by
about
1 month of age to years
In
older
girls
who
do
not
respond
to
other
treatment,
mycin)
should
be
added.
therapy
with
a
combination
oral
contraceptive
Malassezia
species
colonization
(neonatalitscephalic
Androgens
may
play a role
Possible
etiology
generally
do
not
require
further
workup
and
may
be
Lesions
Pustules;
less
likely,
comedones
Comedones,
pustules,
cysts
Sequelae None
Scarring possible with
consider hormonal therapy with a combination oral
pustulosis)inflammatory disease;
–Bone age
treated
with
the
standard
regimens
shown
in
Table
5.
HowSevere
Malassezia species colonization (neonatal •
cephalic
Androgens may play a role
Possible etiology
contraceptive
possible
association
with by aboutever,
– aCombination
therapy
with
benzoyl
peroxide
high
of suspicion
forretinoid
underlying
pathology
must
Course
Spontaneous
resolution,
usually
1 month
ofindex
agetopical
Can persist
for and/or
months
to years
pustulosis)
Infantile Acne
severe acne in adolescence
and/or antibiotic
AND that presents after the first year of life
be
maintained
for
acne
Sequelae
None
Scarring
possible
with inflammatory
Course
Spontaneous resolution, usually by about●1Severe
month
of age
Can persist
for months
to years
–before
Oral antibiotic
Diagnosis
and
Treatment
Infantile
Acne
Diagnosis
Treatment
ofofInfantile
Acne
and
6 to 7 years
of age,
and with
more
aggressive
evaluation
Infantile acne,and
which—like
neonatal
acne—is
more
common
– Combination
topical
therapy
retinoid
and/or
disease;
possible
association
If
no
response,
switch
to
a
different
oral
antibiotic
and/or
increase
Sequelae
None
Scarring
possible
with
inflammatory
istopical
required
that
age
group
(see
the
following
section
on
in male
infants,
mayconditions
be seen
in children
frombebirth
to approxbenzoylin
peroxide
and/or
antibiotic
AND
with
severe
acne
in
adolescence
The
more
common
that should
considered
in
consider
product strengths or combinations
If no response,
disease;follow-up
possible
association
–
Oral
antibiotic
“Mid-Childhood
Acne”).
Careful
is
mandatory
and
imately
12 months
of age.are
However,
more 1.
commonly
prethe
differential
diagnosis
listed initTable
The physical
oral isotretinoin.
severeoral
acne
in adolescence
If
no response,
switch to with
amonitoring
different
and/or
should
include
andantibiotic
charting
of matusents after theshould
neonatal
period.
The assessment
classic presentation
is
examination
always
include
of growth
*Experience
with othercontinued
oral antibiotics has
been reported, including
trimethoprimincrease
topical
product
strengths
or
combinations
sulfamethoxazole
and
cephalexin.
(Fenner
JA,
Wiss
K,
Levin
NA.
Oral
cephalexin
for
acne
rational
milestones
and
observation
for
features
of
virilizapredominantly
comedonal,
but
inflammatory
lesions
may
be
and charting of the infant’s height and weight. Blood pressure
vulgaris: Clinical experience with 93 patients. Pediatr Dermatol. 2008;25:179-183.)
If
no
response,
consider
oral
isotretinoin
tion. If the condition proves refractory to standard therapy or
present
(either
inflammatory
or—particularly
in
also
should
be measured
and comedones
monitored to
rule out cortico*Experience
withofother
oral antibiotics
hasabeen
reported,
including
any evidence
virilization
occurs,
complete
laboratory
young
infants—
concomitant
pustular
neonatal
acne
lesteroid or androgen-secreting disorders. Accelerated growth
trimethoprim-sulfamethoxazole
and
cephalexin.
(Fenner JA,
workup
and
bone
age
assessment
are
appropriate.
sions).
Infantile
acne
also
may
be
nodular.
The
lesions
most
of hands and feet suggests the need for further workup. In
Wiss K, Levin NA. Oral cephalexin for acne vulgaris: Clinical
Topical
treatment is the initial therapy for significant,
commonlythe
appear
on the
face,be
butalert
lesions
also may be
seen
addition,
clinician
should
for androgen
effects,
experience with 93 patients. Pediatr Dermatol. 2008;25:179comedonal
infantile acne, including benzoyl peroxide and
on the
andinchest.
Although
infantile
acne
usually
such
asneck,
odor,back,
changes
areolae
and testes,
and the
presence
183.)
tretinoin as monotherapy or combination therapy. If inflamresolves
1 yeargenital
of age, hair.
the condition
persistthese
for several
of
axillarybyand/or
Childrencan
in whom
signs
7
matory lesions are present, topical antibiotics may be added
months
or should
even years.
are
noted
have
a complete laboratory workup, as
to
the therapeutic regimen. If necessary, systemic antibiotics
listed in Table 4.
can be added as well. Drugs in the tetracycline class should
Children whose clinical examination is within normal limnot be administered to children less than 8 years of age.
its
generally
do
not
require
further
workup
and
may
be
1
Table 3 Neonatal vs Infantile Acne
In severe, refractory cases involving large, nodular lesions,
treated with the standard regimens shown in Table 5. HowNeonatal
Infantile
scarring is a potential long-term risk. In
such cases, clinicians
ever, a high index of suspicion for underlying pathology
must
Onset
Often
2 to 3after
weeks
age
3 to 6 months
of age
have used intralesional Often
corticosteroids
as well
as low-dose
be
maintained for acne that
presents
the of
first
year of life
systemic
isotretinoin
with
good
effect.
A
suggested
dosage for
and
before
6
to
7
years
of
age,
and
more
aggressive
evaluation
Lesions
Pustules; less likely, comedones
Comedones, pustules, cysts
isotretinoin
is
0.2
to
1
mg/kg/day
for
4
to
14
months.
If
is required in that age group (see the following section on
Malassezia species colonization (neonatal cephalic
Androgens may play a role
Possible etiology
isotretinoin is considered, the patient’s family should be cau“Mid-Childhood Acne”). Careful
follow-up is mandatory and
pustulosis)
tioned about possible adverse effects. Intralesional injection
should include continued monitoring and charting of matuCourse
Spontaneous resolution, usually by aboutof1 amonth
of age (1 toCan
for months to years
corticosteroid
2.5 persist
mg/kg triamcinolone)
is a nonrational
milestones and observation
for features of virilizaSequelae
None
Scarringnodules.
possible with inflammatory
systemic alternative to manage
tion.
If the condition proves
refractory to standard therapy or
disease; possible association
any evidence of virilization occurs, a complete laboratory
10
globalacademycme.com/sdef • Pediatric
Acnesevere
Management:
Outcomes
with
acne Optimizing
in adolescence
workup and bone age assessment are appropriate.
Mid-Childhood
Acne
Topical treatment is the initial therapy for significant,
(s
te
co
ab
ch
T
(p
m
na
dr
co
ti
sh
as
m
w
ti
P
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st
w
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si
ca
so
le
dr
to
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ce
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se
th
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in
ti
th
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en
es
es
es
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9al
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ld
s,
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ns
se
se
or
or
If
If
uuon
on
nn-
e.
e.
al
systemic alternative to manage nodules.
Mid-Childhood Acne
Mid-Childhood
Acne
Mid-Childhood Acne
The age range for mid-childhood acne is 1 to 7 years of age.
The
range
for mid-childhood
is 1 in
to the
7 years
of age.
The age
most
common
conditions to acne
consider
differential
The
most common
conditions
to consider
in thepilaris,
differential
diagnosis
(Table 1) are
angiofibromas,
keratosis
milia,
diagnosis
(Table
1) are
angiofibromas,
keratosispityrosporum
pilaris, milia,
miliaria, flat
warts,
molluscum
contagiosum,
miliaria,
flatand
warts,
molluscum
contagiosum,
pityrosporum
folliculitis,
periorificial
dermatitis.
Also,
medicaS.F. certain
Friedlander
et al
folliculitis,
and
periorificial
dermatitis.
Also,
certain
medications to which children in this age group may
exposed
may
S.F. be
Friedlander
et
al
tions
to an
which
children
in this age
group
may be
exposed may
induce
acneiform
eruption.
These
include
anticonvulsants
(such
and isoniazid,
as well anticonvulsants
as topical, sysinduceasanphenytoin)
acneiform eruption.
These include
(such
and isoniazid, as well as topical, systemic, as
andphenytoin)
inhaled corticosteroids.
temic,
and inhaled
corticosteroids.
Although
underlying
hormonal pathology occurs less
Althoughthan
underlying
pathology
less
commonly
do the hormonal
dermatologic
diseases occurs
mentioned
commonly
than
do
the
dermatologic
diseases
mentioned
above, such pathology should be seriously considered when
above,
pathology
should
be seriously
considered
when
childrensuch
in this
age group
present
with acneiform
lesions.
children
in this
age group
present include
with acneiform
The possible
hormonal
conditions
adrenal lesions.
disease
The
possible congenital
hormonal conditions
include adrenal
disease
(particularly
adrenal hyperplasia),
adrenal
tu(particularly
congenitalpuberty,
adrenalpremature
hyperplasia),
adrenal gotumors, true precocious
adrenarche,
mors,
true precocious
puberty,
adrenarche,
gonadal tumors,
and early
onset premature
of polycystic
ovarian syntumors,
onset
of polycystic
ovarian
syndrome.
nadal
tumors,and
andearly
early
onset
of polycystic
ovarian
syndrome.
drome.
The clinician should ask about a family history of partial
The clinician
should
ask about
familyreview
historyofofmedicapartial
congenital
adrenal
hyperplasia.
A acareful
congenital
adrenal
hyperplasia.InA addition,
careful review
medications should
be performed.
bloodof pressure
tions
be performed.
In addition,
blood
pressure
shouldshould
be measured.
Unless medication
reaction
is identified
should
be measured.
Unless
medication
reactionforis abnormal
identified
as the cause,
the patient
should
be assessed
as
the cause,asthe
patient above.
shouldAbe
for laboratory
abnormal
maturation,
described
fullassessed
hormonal
maturation,
described
above. A are
full indicated
hormonalfor
laboratory
workup andasbone
age assessment
any paworkup
bone age assessment
tient withand
mid-childhood
acne. are indicated for any patient with mid-childhood acne.
Preadolescent
Acne
Preadolescent Acne
Preadolescent
Acne
Many children between 7 and 11 years of age are in various
thorough
physical
examination
and family
history
arediffersufficient to rule
out other
dermatologic
conditions
in the
cient
to
rule
out
other
dermatologic
conditions
in
the
differential and establish the diagnosis of preadolescent acne.
ential
and establish
diagnosis
acne.
Physical
findingsthe
that
suggestofanpreadolescent
underlying hormonal
Physical
findings
that
suggest
an
underlying
hormonal
pathologic process as the cause of acneiform lesions in prepathologic
the cause
of acneiform
lesions
in preadolescent process
patientsasinclude
recalcitrant
disease,
significant
adolescent
patients
includeofrecalcitrant
disease,lesions,
significant
and/or rapid
development
pustular nodular
and
and/or
development
pustular
nodular
and
lack of rapid
response
to standardofacne
therapy.
Signs lesions,
of abnormal
lack
of response
to standard
acne therapy.
Signs
of abnormal
hormonal
stimulation
also include
signs of
sexual
developThe
acne
continuum
hormonal
stimulation
also
include
signs
of
sexual
develop-is
10,11
ment
or
virilization.
In
such
cases,
further
workup
The acne continuum 10,11
ment
or virilization.
such include
cases, further
workup
is
indicated;
laboratory testsInshould
those listed
in Taindicated;
laboratory
tests
should
include
those
listed
in
Table 4. Bone age should also be evaluated. In addition, if Cushble 4.syndrome
Bone age should
also be evaluated.
In addition,hormone
if Cushing’s
is suspected,
adrenocorticotropic
ing’s
syndrome
is
suspected,
adrenocorticotropic
hormone
stimulation testing can be considered.
stimulation
testingrecommend
can be considered.
Some clinicians
initial therapy with a benzoyl
Some
clinicians
recommend
with a benzoyl
peroxide wash for patients withinitial
very therapy
mild comedonal
acne,
peroxide
wash
for
patients
with
very
mild
comedonal
acne,
but all of the topical medications that are used for acne
in
but
all
of
the
topical
medications
that
are
used
for
acne
in
patients 12 years of age or older also are appropriate for use in
patients
12
years
of
age
or
older
also
are
appropriate
for
use
in
preadolescents. The efficacy and safety data on these younger
preadolescents.
The
efficacy
and
safety
data
on
these
younger
patients are limited: tretinoin has been tested in children as
patientsasare
limited:
tretinoin
been tested
in children as
11 and has
young
8 years
of age,
a benzoyl
peroxide/adapalene
11 and a benzoyl peroxide/adapalene
young
as
8
years
of
age,
combination topical agent has been tested in children as
combination
topical
agent
has on
been
in children
as
young
as 10 years
of age.
Based
the tested
large body
of efficacy
young
as 10
years
of age.
on the
large body
of efficacy
and
safety
data
from
olderBased
pediatric
patients
(ie, those
from
and
safety
data
from
older
pediatric
patients
(ie,
those
from
12 through 17 years of age)—and, as extensive clinical expe12
through
17
years
of
age)—and,
as
extensive
clinical
experience has shown—it is reasonable to presume similar effirienceand
hassafety
shown—it
is reasonable
presumebecause
similar preefficacy
in younger
children.toHowever,
cacy
and
safety
in
younger
children.
However,
because
preadolescent patients tend to produce less sebum than do older
adolescenttheir
patients
lesssensitive.
sebum than
do older
patients,
skin tend
tendstotoproduce
be more
To improve
patients,
their
skin
tends
to
be
more
sensitive.
To
improve
tolerance, it is often helpful to initiate therapy with decreased
tolerance, itofisapplication
often helpful
initiate therapy
with decreased
frequency
(fortoexample,
twice weekly
or every
frequency
of
application
(for
example,
twice
weekly
ormedievery
other day), and application of smaller amounts of the
other
day),
and
application
of
smaller
amounts
of
the
medication. In addition, the daily application of a noncomedocation.moisturizer
In addition,
thebedaily
application of a noncomedogenic
may
useful.
genic
moisturizer
may
be
useful.
When necessary for the treatment of severe, nodulocystic
When
necessary for patients,
the treatment
of severe,
nodulocystic
acne
in preadolescent
systemic
agents—including
acne
in
preadolescent
patients,
systemic
agents—including
oral isotretinoin—should be considered.
Many children between 7 and 11 years of age are in various
Many
between
and preadolescent
11 years of age
are in
various
stages children
of puberty,
so the7term
is now
preferred
stages
of puberty, so
theinterm
preadolescent
is now
preferred
when considering
acne
children
who are in
this age
range.
when
considering
in children
are in
this age range.
The appearance
ofacne
comedonal,
onlywho
mildly
inflammatory
leThe
appearance
of
comedonal,
only
mildly
inflammatory
sions in children in this age group represents what might lebe
sions
children
in this age
represents
be
calledin
adrenal
awakening
andgroup
is generally
not awhat
sign might
of worriSummary
called
adrenal awakening and is generally not a sign of worrisome pathology.
Summary
Summar
y
some
Thepathology.
seminal studies on this topic by Lucky and colAcne
can occur at any time in life; cause for concern differs
8,9
The 8,9
seminal
on this topic
by Lucky
colAcne can occur
at of
anypresentation.
time in life; Neonatal
cause for disease
concernisdiffers
leagues
showedstudies
that comedonal
acne may
be seenand
in childepending
on age
often
leagues
showed
comedonal
childepending
on
age
of
presentation.
Neonatal
disease
is often
dren
as8,9
young
as 7that
years
of age andacne
that may
girls be
areseen
moreinlikely
transient and may be related to pityrosporum disease.
Acne
dren
youngthan
as 7 years
of age
andpreadolescent
that girls are more
likely
transient
and in
may
related to pityrosporum
disease.
Acne
to be as
affected
are boys
in the
age group.
that
presents
thebe
postneonatal
period but before
1 year
of
to
affected than
are boys inacne
the preadolescent
age group.
that
presents
in
the
postneonatal
period
but
before
1
year
of
Thebeprevalence
of comedonal
among all children
in the
age is usually defined as infantile disease and generally is not
The
prevalence
of
comedonal
acne
among
all
children
in
the
age is usually
defined
as infantile
diseaseIn
andcontrast,
generallydisease
is not
United States 11 years of age or younger is 47.3%. Comeassociated
with
underlying
pathology.
United
States
11 most
years common
of age orform
younger
Comeassociated
with
underlying
pathology.
In
contrast,
disease
donal acne
is the
seen isin47.3%.
the preadolesthat presents between 1 and 7 years of life is of more concern,
donal
acne
is thewith
mosta common
form seen
in the preadolesthat presents
between for
1 and
7 yearsunderlying
of life is of more
concern,
cent age
group,
typical mid-face
distribution.
Other
and
a full evaluation
possible
hormonal
paThe acne
continuum
S11
cent
age
group,
a typical
distribution.
Other
and
a
full
evaluation
for
possible
underlying
hormonal
pasites,
such
as thewith
conchal
bowlmid-face
of the ears,
also may be
inthology is warranted. Children as young as 7 years of age can
sites,
such
as the conchal
bowl ofisthe
ears,
be inthology is warranted. Children as young as 7 years of age can
volved.
Typically,
the condition
mild
in also
this may
age group.
volved.
Typically,
the
condition
ishas
mild
this
ageifgroup.
Severe
comedonal
disease
in
been
associated
with
ble 4. Bone
age should
also
be girls
evaluated.
Ininaddition,
Cushpresent with mild, usually comedonal disease, which most
Severe
comedonal
disease
in
girls
has
been
associated
with
severe
acne
in
adolescence.
ing’s syndrome is suspected, adrenocorticotropic hormone
often is a normal physiologic occurrence.
severe
in
adolescence.
The acne
dermatologic
conditions
and possible drug reactions
stimulation
testing
can
be considered.
Treatment at any age depends on the type and severity of
The
dermatologic
conditions
and possible
drug
that
should
be considered
in theinitial
differential
diagnosis
are the
Some
clinicians
recommend
therapy
with areactions
benzoyl
involvement. Comedonal disease responds best to topical
that
should
be
considered
the differential
diagnosis
areacne,
the
same
as for
patients
with in
mid-childhood
(particularly
peroxide
wash
for patients
with
very mildacne
comedonal
benzoyl peroxide and topical retinoid products; inflammasame
patients
mid-childhood
including
angiofibromas,
keratosis
pilaris,
perioral
but allasoffor
the
topicalwith
medications
that
areacne
used(particularly
fordermatiacne in
tory disease usually benefits from the addition of topical or
including
keratosis
perioral for
dermatitis,
and pityrosporum
patients
12angiofibromas,
years of agefolliculitis).
or older
also pilaris,
are appropriate
use in
systemic antibiotics. Severe disease may warrant treatment
tis,
folliculitis).
Inand
thepityrosporum
absenceThe
of findings
suggesting
hyperandrogenism,
a
preadolescents.
efficacy
and safety data
on these younger
with systemic isotretinoin, regardless of age. Families should
In
the
absence
of
findings
suggesting
hyperandrogenism,
a
thorough
physical
examination
and
family
history
are
suffipatients are limited: tretinoin has been tested in children as
always be counseled regarding the risks and benefits of any
11 and a and
thorough
family
history
arediffersufficient
out other
dermatologic
conditions
in the
youngtoasrule
8physical
years
ofexamination
age,
therapeutic option.
benzoyl
peroxide/adapalene
cient
to
rule
out
other
dermatologic
conditions
the
differential
and
establish
theagent
diagnosis
of preadolescent
acne.
combination
topical
has been
tested ininchildren
as
references on page 20
ential
and
establish
diagnosis
preadolescent
acne.
Physical
findings
that
suggest
underlying
References
young
as 10
years ofthe
age.
Based
onofan
the
large body hormonal
of
efficacy
11
Physical
findings
suggest
underlying
hormonal
pathologic
process
asthat
the cause
of an
acneiform
lesions
in from
pre1. Tom WL, Friedlander SF: Acne through the ages: Case-based observaand
safety data
from
older
pediatric
patients
(ie,
those
tions through childhood and adolescence. Clin Pediatr (Phila) 47:639pathologic
cause
of as
acneiform
lesions
inexpepreadolescent
patients
recalcitrant
disease,
significant
12 throughprocess
17 yearsasinclude
ofthe
age)—and,
extensive
clinical
p
p
of
o
in
bin
b
to
to
sy
sy
w
w
al
al
th
th
R
R1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
Hilary E. Baldwin, MD,* Sheila Fallon Friedlander, MD,†† Lawrence F. Eichenfield, MD,‡‡
Hilary E. Baldwin, MD,* Sheila
Fallon Friedlander,¶MD, Lawrence F. Eichenfield, MD,
§
Anthony
J. Mancini,
MD,
Albert C. Yan,
MDColor,
§ and
The
Effects
of
Culture,
Skin
and
Anthony
J. Mancini,
MD,
and
Albert C. Yan,
MD¶
kin The
Color,
Other
Nonclinical
Issues
onColor,
Acne
Treatment
Effects
ofand
Culture,
The effective
safe treatment of Skin
acne vulgaris
often is affected by individual patient
The
effective
and
safe
treatment
of
acne
vulgaris
often
is
affected
bycolor
individual
patient
characteristics, including skin color and cultural background. Skin of
is especially
suesand
onOther
Acne
Treatment
characteristics,
including
skin
color
and
cultural
background.
Skin
of
color
is
especially
prone toNonclinical
hyperpigmentation, both from
lesions and from
therapy.Treatment
Clinicians also
Issues
onirritating
Acne
prone to hyperpigmentation, both from lesions and from irritating therapy. Clinicians also
should be aware of cultural attitudes and folk remedies
that may adversely affect derma†
‡
‡ Friedlander,
E.should
Baldwin,
MD,*ofsuch
Sheila
Fallon
MD, Lawrence
F. Eichenfield,
MD,
be
aware
cultural
attitudes
and folk remedies
affect derma†that may adversely
‡
lander,Hilary
MD,†Hilary
Eichenfield,
tologicF.
conditions
asMD,
acne.
E.Lawrence
Baldwin,
MD,*
Sheila
Fallon
Friedlander,
§such
¶ MD, Lawrence F. Eichenfield, MD,
tologic
conditions
as
acne.
Anthony
J.
Mancini,
MD,
and
Albert
C.
Yan,
MD
¶
Semin Cutan Med
Inc. All rights reserved.
§ Surg 30:S12-S15 © 2011 Elsevier
¶
n, MDAnthony J. Mancini,
MD,
C. Yan,
Semin Cutan
Medand
SurgAlbert
30:S12-S15
© 2011MD
Elsevier Inc. All rights reserved.
The Effects of Culture, Skin Color,
and Other
Nonclinical
Issues on Acne Treatment
ne vulgaris often is affected
individual
Thebyeffective
andpatient
safe treatment of acne vulgaris often is affected by individual patient
C
C
linicians who treat patients with acne vulgaris must con-
d cultural background. Skin
of color is especially
linicians
who
treat
patients
acne
vulgaris
characteristics,
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Medicis, and Stiefel. He has also been a speaker for Galderma.
in light-skinned
According
to the
sugManipulation
of individuals.
lesions is associated
with
an authors,
increasethis
in PIH,
Albert C. Yan, MD, has no relevant financial relationships with any commergests that acnethevulgaris
in African
Americans
is clinically
underscoring
importance
of early
and effective
therapyand
to
reserved. S12cial 1085-5629/11/$-see
interests.
front matter © 2011 Elsevier Inc. All rights reserved.
histopathologically
different
from
the
disease
found
in
Caucaeliminate
acne
lesions.
The
tendency
to
develop
PIH
appears
Corresponding
author: Hilary E. Baldwin, MD, Associate Professor and Vice
doi:10.1016/j.sder.2011.07.005
sians,
which maydetermined.
explain whyIthyperpigmentation
and lesions,
scarring
to
be genetically
is not limited to cystic
Chair, Department of Dermatology, SUNY Downstate, Brooklyn, NY.
3
but
is seen
with lesions
of all types.persons.
E-mail: hilary.baldwin@downstate.edu
is more
common
in darker-skinned
No acne treatments have been identified as causal for PIH.
12
However, the irritation associated with topical therapy can inS12 1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. crease the risk of PIH in skin of color. To minimize irritation,
versity of California, San Diego School of Medicine, San Diego, CA
clinical
picture
in patients
with
acneofvulgaris
theDiego,
needCA
to be
versity
of
San Dermatology,
Diego
School
Medicine,isSan
§Professor
of California,
Pediatrics and
Northwestern
University’s
Feinaware
of
variations
in
skin
color,
culture,
and
attitudes
of
§Professor
of
Pediatrics
and
Dermatology,
Northwestern
University’s
berg School of Medicine, Head, Division of Pediatric Dermatology, FeinChilberg
School
of
Medicine,
Head,
Division
of
Pediatric
Dermatology,
Chilboth
patients
and
their
parents.
dren’s Memorial
IL
*Associate
Professor Hospital,
and Vice Chicago,
Chair, Department
of Dermatology, SUNY
C
A
A
c
ti
is
le
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ra
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tr
P
C
nd
eggs
eut
se
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H.
is
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darker-skinned
iswhy
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in darker-skinned
persons.
sians,
which
may in
explain
hyperpigmentation
and scarring
scarring
sians,
which
may
explain
why hyperpigmentation
and
Perceptions,
Perceptions,
No
acne
treatments
have
No
been
acne
identified
treatments
as
causal
have
been
for
PIH.
identified
as causal for PIH.
is more common in darker-skinned persons.
is
more common
in darker-skinned
persons.
However,
the
irritation
associated
However,
with
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irritation
topical
therapy
associated
can
with
intopical
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inPerceptions,
No acne treatments have been identified as causal for PIH.
Customs,
Habits,
Customs,
and Fads
Habits, and Fa
Perceptions,
No acne
treatments
have
identified
as causal
for
PIH. To minimize
Perceptions,
Customs,
crease
the the
risk
of PIH in
crease
skinbeen
ofthe
color.
risk To
of PIH
minimize
in skin
irritation,
of
irritation,
However,
irritation
associated
with
topical
therapy
cancolor.
inCustoms,
Habits,
and
Fads
However,
thepatients
irritation
associated
with
topical
therapy
in- should
Some
and/or
their
Some
parents
patients
hold
and/or
the perception
their parents
andhold the
Customs,
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and
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treatment
of
with
treatment
skin ofcolor.
color
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shouldwith
be approached
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of color
be patients
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Habits,
and
Fads
crease
crease the
the risk
risk of
of PIH
PIH in
in skin
skin of
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To minimize
minimize irritation,
irritation,
belief
that
“natural”
agents
belief
are
that
superior
“natural”
to
agents
“drugs”
are
in
superior
the
to
and/or their parents hold the perception and
with this inofmind.
Specifically,
with this
acute
in irritation
mind. Specifically,
from approached
topical
acute
benirritationSome
from patients
topical bentreatment
Some
patients
and/or of
their
parents
hold
theacne
perception
and
treatment of patients
patients with
with skin
skin of
of color
color should
should be
be approached
treatment
of
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variety
treatment
diseases,
including
of
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variety
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diseases,
vulgaris.
including
In
a
beliefbethat
“natural”
zoyl peroxide
and retinoid
zoylpreparations
peroxide
and
should
retinoid
be avoided,
preparations
if should
avoided,
if agents are superior to “drugs” in the
with
belief
that
“natural”
agents
are
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toproduct
“drugs”
inwhich
the there a
with this
this in
in mind.
mind. Specifically,
Specifically, acute
acute irritation
irritation from
from topical
topical benbenfact,
the
only
such
product
fact,
on
the
which
only
such
there
are
even
on
meager
treatment
of aconvariety of diseases, including acne vulgaris. In
possible.
Whenand
initiating
possible.
topical
retinoid
When should
initiating
therapy,
lower
conretinoid
therapy,
lower
zoyl peroxide
retinoid
preparations
betopical
avoided,
if
treatment
of a variety
of
diseases,
including
vulgaris.
In
zoyl
peroxide
and
retinoid
preparations
should
becream
avoided,
if
data
regarding
benefit
indata
acne
regarding
iswhich
tea-tree
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which
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tea-tree
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fact,
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centrations
can
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centrations
cream
formulations
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formulations
gels
rather
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gels
possible. When initiating topical retinoid therapy, lower confact,
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product
on
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minor
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macotherapy
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usemore
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and applications
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perceive as
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beaincreased
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in aa stepwise
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but
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information
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Sometimes
individuals attempt to be well informed,
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When
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but
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information
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deficient—for
example,
knowledge
that
acne
lesions
themselves
are
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source
of
PIH.
resulting
in
the
dissemination
resulting
of
in
incorrect
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dissemination
notions
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ofthe
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and blogs that are opinion-rich and fact-poor,
sary
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necesInternet
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When
acne
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prompt
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lesions
is
necesperpetuation
of myths. Parental
perpetuation
fears of
arising
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from
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resulting
the
approach
to topical
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approach
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advisable
may
mononot be advisable
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atherapy
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notions and
and the
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sary
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such
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mation
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interfere
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of
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perpetuation
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it as
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with
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lescents
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Countering
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earlier
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mation
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oral
erroneous
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erroneous
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lescents
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ismight
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and openof
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lescents
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tience,
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of erroneous
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overly
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PIH.
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In long-lasting
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openofcomedones,
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patients
of
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patients
anecdotal
with
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color,
shows
anecdotal
that
1
experience
shows
that
1
overly aggressive extraction can cause long-lasting PIH. In
tience, discussion, and education.
overly
aggressive
extraction
canofretinoids
cause
long-lasting
PIH.surIn
Tanning
Tanning
month
treatment
month
topical
treatment
prior
withshows
totopical
acne
retinoids
prior to acne surpatientsofwith
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color,
anecdotal
experience
that
1
patients
with skin Comedones
of color,
anecdotal
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shows are
that
1 easily extracted with
gery
is
beneficial.
gery
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are
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more
easily
Comedones
extracted
with
more
Artificial and natural sunlight
Artificial
mayand
improve
natural
the
sunlight
appearance
may improve
of
th
Tanning
month
Tanning
month of
of treatment
treatment with
with topical
topical retinoids
retinoids prior
prior to
to acne
acne sursurTanning
less pigment-producing
less
trauma.
pigment-producing
trauma.with
acne
temporarily.
Tan
skin
acne
provides
temporarily.
some
Tan
camouflage
skin
provides
for
the
some
cam
gery
is
beneficial.
Comedones
are
more
easily
extracted
Artificial and natural sunlight may improve the appearance of
gery is beneficial. Comedones are more easily extracted with
Artificial
natural
sunlight
may
appearance
of as it is
Hyperpigmentation often
Hyperpigmentation
is more of a problem
often
for is
patients
more of a problem
forofand
patients
redness
acne
lesions.
redness
In provides
addition,
ofimprove
acne
as itlesions.
isthe
a crude
In addition,
form
of
less
acne temporarily.
Tan skin
some
camouflage
for the
less pigment-producing
pigment-producing trauma.
trauma.
acne
temporarily.
Tan
skin
provides
some
camouflage
for
the
than
is acne itself. Treatment
thanisis
options
acne of
itself.
for
PIH
Treatment
include
options
hydro- for PIH
include
hydrolight
therapy,
sun
exposure
light
may
therapy,
also as
result
sun
exposure
in
an short-term
may
Hyperpigmentation
often
more
a problem
for patients
redness
of acne
lesions.
In addition,
it is
a crude
formalso
of result i
Hyperpigmentation
often
is more
of a problem
for
patients
redness
of
acne
lesions.
In
addition,
as
it
is
a
crude
form
of
quinones,
topical
retinoids,
quinones,
and
multiple
topical
types
retinoids,
of
cosmeceuand
multiple
types
of
cosmeceuimprovement
in
lesions,
improvement
and
the
observation
in
lesions,
that
and
sunlight
the
observatio
than is acne itself. Treatment options for PIH include hydrolight
therapy,
sun
exposure
may
also
result
in
an
short-term
light
therapy,
sun
exposure
may
also
result
in
an
short-term
than
is
acne
itself.
Treatment
options
for
PIH
include
hydro5-7
8
5-7
8
9
9
Chemical
peels
and
laser
Chemical
and
light
peels
therapy
and
laser
and
light
therapy
tical
products.
tical
products.
improves acneinislesions,
not lost
improves
on patients.
acne isInnot
colder
lost climates,
on patients. In
quinones, topical retinoids, and multiple types of cosmeceuimprovement
improvement
in lesions, and
and the
the observation
observation that
that sunlight
sunlight
quinones,
topical
retinoids,
and
multiplebut
types
of cosmeceu5-7
88 and laser
99
5-7but
can be
effective
must
can
be
be
approached
effective
cautiously
must
be
to
approached
avoid
cautiously
to
avoid
some
patients
prolong
their
some
suntans
patients
by
prolong
using
tanning
their
suntans
beds. by usin
Chemical
peels
and
light
therapy
tical
products.
5-7
8
9
improves
acne
is
not
lost
on
patients.
In
colder
climates,
5-7 Chemical peels8 and laser and light therapy9
improves
acne
is
not
lost
on
patients.
In
colder
climates,
tical
products.
further
hyperpigmentation
further
and
hyperpigmentation
the possibility
of scarring.
and
the possibility
ofpatients
scarring.prolong
Unfortunately,
the
temporary
Unfortunately,
improvement
the
temporary
in
appearance
improvemen
can
be
effective
but
must
be
approached
cautiously
to
avoid
some
their
suntans
by
using
tanning
can be effective but must be approached cautiously to avoid
some patients prolong their suntans by using tanning beds.
beds.
makes
it
difficult
for
clinicians
makes
it
to
difficult
convince
for
patients
clinicians
of
to
theconvince
further
hyperpigmentation
and
the
possibility
of
scarring.
Unfortunately, the temporary improvement in appearance
further hyperpigmentation and the possibility of scarring.
Unfortunately,
the
temporary
improvement
in associated
appearance
long-term
skin
damage
long-term
associated
skin
with
damage
ultraviolet
light
ex-with ultr
makes it difficult for clinicians to convince patients of the
Preadolescent Patients
Preadolescent Patients
makes
it difficult for clinicians
to convince patients of the
posure.
posure.
long-term
skinpadamage associated with ultraviolet light exPreadolescent
It
is common for Patients
preadolescents
It is common
and for
early
preadolescents
adolescent paand early
adolescent
Preadolescent
Patients
long-term
skin damage associated with ultraviolet light exPreadolescent
Patients
posure.
tients—particularly
girls—to
seek treatment
for
“blemishes”
seekpatreatment
for “blemishes”
posure.
It is common for preadolescents
and earlygirls—to
adolescent
It
is common
for itself.
preadolescents
and
early
adolescent
pa-noncompliant
Culture,
Culture, Doctors,
rather
than
acne
rather
Many
than
are
noncompliant
acne
itself.
Many
with
are
acne
withDoctors,
acne
tients—particularly girls—to seek treatment for “blemishes”
girls—to
seek
treatment
for
“blemishes”
Culture,
Doctors,
and
and
Medication
Adherence
andMedication
MedicationAdherence
Adherence
Culture,
Doctors,
treatment
regimens
because
treatment
they are
regimens
more concerned
because they
with
are moreCulture,
concernedDoctors,
with
rather
rather than
than acne
acne itself.
itself. Many
Many are
are noncompliant
noncompliant with
with acne
acne
the appearance
of PIH. the
It isappearance
important
to
of stress
PIH. Ittoisthese
important
pa- to stress
to these
paIn a recent
meta-analysis
In aofrecent
adherence
meta-analysis
of peopleofofadherence
color
of
and
Adherence
treatment
treatment regimens
regimens because
because they
they are
are more
more concerned
concerned with
with
and Medication
Medication
Adherence
tients
that control
of acne,
tients
using
thatthe
control
prescribed
of acne,
therapeutic
using pathe prescribed
therapeutic
and
language
diversities
and
to
medications
language
diversities
in
general,
to
medications
Manias
in
g
the
appearance
of
PIH.
It
is
important
to
stress
to
these
In a recent meta-analysis of adherence of people of color
the appearance of PIH. It is important to stress to these paIn
athe
recent
meta-analysis
ofWilliams
adherence
of people
of color
10
10
regimens,
will
decrease
the
regimens,
amount
will
of
PIH
decrease
in
the
the
future
amount
as
it
of
PIH
in
future
as
it
and
Williams
and
failed
to
identify
any
factors
failed
that
to
identify
would
be
any
factor
tients that control of acne, using the prescribed therapeutic
and language diversities to medications in general, Manias
tients
that control
offormation.
acne,
usingMeanwhile,
the
prescribed
therapeutic
and
diversities
to medications
in general,
Maniasto medic
10
10
decreases
decreases
new
formation.
offer
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thelanguage
offer
treathelpful
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helpful
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improving
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adherence
regimens
regimens, new
will lesion
decrease
the
amount
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PIH inthe
the
future
as it
and
Williams
to
identifyinany
factors that
would
be
10
10 failed
regimens,
will
decrease
the
amount
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PIH
in
the
future
as
it
and
Williams
failed
to
identify
any
factors
that
would
ment
of PIH
often
helps
ment
promote
of Meanwhile,
PIH
adherence
often helps
to acne
promote
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adherence
to acnethese
among
populations.
among
Thus,
these
ittoispopulations.
up to the clinician’s
Thus,be
it is up to
decreases
new
lesion
formation.
the
offer
of treathelpful
intherapy.
improving
adherence
medication
regimens
decreases
new
lesion
formation.
Meanwhile,
the
offer
of treathelpful
in
improving
adherence
to
medication
regimens
The
data
are
sparse
on
specific
The
data
treatments
are
sparse
for
on
acne
specific
in
younger
treatments
for
acne
in
younger
awareness
and sensitivity
awareness
to workitand
withup
sensitivity
individual
topatients
work with ind
ment of PIH often helps promote adherence to acne therapy.
among
among these
these populations.
populations. Thus,
Thus, it is
is up to
to the
the clinician’s
clinician’s
ment
of PIH
often
helps
promote
adherence
acne
therapy.
patients
with
skin
of
color,
patients
but treatments
itwith
is reasonable
skin for
of to
color,
to extrapolate
but
it is reasonable
extrapolate
and to
their
families.
andtotheir
families.
The
data
are
sparse
on
specific
acne
in
younger
awareness
and
sensitivity
work
with
individual
patients
The data are sparse on specific treatments for acne in younger
awareness
and sensitivity to work with individual patients
S14
from efficacy
and safety
studies
from efficacy
thatisincluded
and safety
patients
studies
between
that includedand
patients
betweendistrust authority,
Some patients
Some patients
in general;
distrust
others
authority,
have ain genera
patients
patients with
with skin
skin of
of color,
color, but
but it
it is reasonable
reasonable to
to extrapolate
extrapolate
and their
their families.
families.
particular
bias
against
doctors
particular
whose
bias
cultural
against
or
doctors
racial
whose
back-a cultura
12
and
17
years
of
age
with
12
similar
and
17
skin
years
colors.
of
age
with
similar
skin
colors.
from efficacy
efficacy and
and safety
safety studies
studies that
that included
included patients
patients between
between
Some patients
patients distrust
distrust authority,
authority, in
in general;
general; others
others have
have
from
Some
a
ph
grounds
are
dissimilar
to
their
own.
It
is
likely
that
dermaparticular
bias
against
doctors
whose
cultural
or
racial
back12 and 17 years of age with similar skin colors.
S13
particular
biasthis
against
whose cultural
or racial
back12 and 17 years of age with similar skin colors.
m
tologists see
moredoctors
than clinicians
in other
specialties
because racial differences are readily apparent. It often beAcne-Related
Acne-RelatedScarring
Scarring
vi
hooves the clinician to address possible concerns in an open
es
and direct manner at the initial visit.
Acne can also be associated with keloidal scars in skin of
w
At the other end of the spectrum are patients who embrace
color, with acne lesions often transforming almost impercepsc
authority literally without question. In some cultures, asking
tibly into keloids. In some cases, the only indication that acne
al
questions of an authority figure, such as a physician, is conis the underlying cause of keloids is the distribution of the
w
sidered
to
be
an
insult.
When
dealing
with
such
patients,
it
is
lesions over the chest, back, upper arms, and jaw. In such
ev
incumbent
on
the
physician
to
draw
out
questions
during
a
cases, aggressive therapy with isotretinoin might be warPr
clinical encounter, or the patient may leave with inadequate
ranted, even in younger adolescents. New acne/keloid lesion
rin
information or understanding of his or her condition or the
formation will stop and the keloids can subsequently be
co
prescribed treatment regimen.
treated.
tr
Perceptions,
Folk Remedies
13
R
aes
een
ce
ng
nis
a
te
he
re
prescribed
prescribed treatment
treatment regimen.
regimen.
14,15aggressive
constitutesto areduce
cutaneous
emergency
merits
treatment
the risk
of furtherand
scarring.
14,15
14,15
treatment
treatment to
to reduce
reduce the
the risk
risk of
of further
further scarring.
scarring.14,15
Folk
Remedies
Folk
Remedies
Folk Remedies
Remedies
Recent Evidence
ononMental Health
Recent
Evidence
Recent
Evidence
on
Recent
Evidence
onSuicide
and
Suicide
Mental
Health
and
Mental
Health
and
Suicide
Suicide
AMental
recently Health
publishedand
study
by Halvorsen and colleagues1616
A recently published study by Halvorsen and colleagues16
Folk remedies for dermatologic and other conditions are
Folk
for dermatologic
and
conditions
are
Folk remedies
remedies
dermatologic
and other
other
conditions
are
commonly
used,for
particularly
by patients
of Hispanic,
Asian,
commonly
used,
particularly
by
patients
of
Hispanic,
Asian,
commonly
used,
particularly
by
patients
of
Hispanic,
Asian,
and Caribbean descent. As many as 50% of inner-city paand
descent.
As
as 50%
of
paand Caribbean
Caribbean
descent.on
Asamany
many
50% either
of inner-city
inner-city
patients
use folk remedies
regularasbasis,
as replacetients
use
folk
remedies
on
a
regular
basis,
either
as
replacetients
use
folk
remedies
on
a
regular
basis,
either
as
replacements for or adjuncts to prescribed medications. These pracments
for
or
to
medications. These
pracmentsare
foroften
or adjuncts
adjuncts
to prescribed
prescribed
These
tices
not mentioned
andmedications.
may interfere
withpracthe
tices
often
mentioned
and may
with
the
tices are
are treatment
often not
not plan.
mentioned
may interfere
interfere
with
the
intended
The folkand
remedies
may cause
irritaintended
treatment
plan.
The
folk
remedies
may
cause
irritaintended
plan. the
Therisk
folk for
remedies
may cause irritation
and, treatment
thus, increase
hyperpigmentation
in
tion
and,
thus,
increase
the
risk
for
hyperpigmentation
in
tion
and,
thus,
increase
the
risk
for
hyperpigmentation
in
patients of color, as well as decreasing the acceptance and use
patients
of
color,
as
well
as
decreasing
the
acceptance
and
use
patients
of
color,
as
well
as
decreasing
the
acceptance
and
use
of topical medications that would otherwise be effective.
of
of topical
topical medications
medications that
that would
would otherwise
otherwise be
be effective.
effective.
Consequences
of
Consequences
of
Consequences
ofIneffective/
Consequences
of
Ineffective/Delayed
Treatment
Ineffective/Delayed
Ineffective/Delayed
Treatment
Delayed Treatment Treatment
Numerous articles have been published regarding the negaNumerous
articles
have
published
regarding
the negaNumerous
articlesimpact
have been
been
published
regarding
tive
psychological
of acne
vulgaris.
Layton the
andnegacoltive
psychological
impact
of
acne
vulgaris.
Layton
and
col11 showed that
tive psychological
impact
of
acne
vulgaris.
Layton
and
colleagues
emotional
scarring
often
persists
into
11
11
leagues
showed
that
emotional
scarring
often
persists
into
11
leagues
showed
that
emotional
scarring
often
persists
into
adulthood, long after acne has resolved, even in the absence
adulthood,
long
adulthood,
long after
after acne
acne has
has resolved,
resolved, even
even in
in the
the absence
absence
of
physical scarring.
of
physical
scarring.
of In
physical
scarring.
addition to their medical benefits, interventions to imIn
to
medical
interventions to
imIn addition
addition
to their
their
medical benefits,
benefits,
improve
appearance
are important
to patientinterventions
comfort andto
qualprove
appearance
are important
to patient
comfort
and
qual12 showedtothat
prove
appearance
patient
comfort
and
quality
of life.
Dalgard are
et alimportant
the
appearance
of
the
12
12
ity
Dalgard
al
that
appearance of
ity of
ofislife.
life.
Dalgardinet
etsocial
al12 showed
showed
that the
the
of the
the
skin
important
interactions,
asappearance
well as having
a
skin
is
important
in
social
interactions,
as
well
as
having
a
skin
is
important
in
social
interactions,
as
well
as
having
crucial impact on self-image and self-worth. In current Amer-a
crucial
impact
on
self-image
and
self-worth.
In
current
Amercrucial
impactwith
on self-image
and self-worth.
In current
American
culture,
society’s ongoing
emphasis
on beauty
(if
ican
culture,
with
society’s
ongoing
emphasis
on
beauty
(if
ican
culture,
with
society’s
ongoing
emphasis
on
beauty
(if
not outright physical perfection), teenagers and even preadnot
outright
physical
perfection),
teenagers
and
even
preadnot outright
physical
teenagers
and even preadolescent
patients
mayperfection),
interpret acne
as life-altering
if not
olescent
olescent patients
patients may
may interpret
interpret acne
acne as
as life-altering
life-altering ifif not
not
life-ending.
life-ending.
life-ending.
It has been well documented that acne is associated with
It
been
that
is
with
It has
has
been well
well documented
documenteddecreased
that acne
acne dating,
is associated
associated
with
social
dysfunction—including
participasocial
decreased
dating,
participasocial
decreased
dating,
participation in sports, and social interactions with peers—as well as
tion
sports,
and
social
interactions
with
well as
13 well as
tion in
in an
sports,
andeffect
socialon
interactions
with peers—as
peers—as
having
adverse
academic performance.
13
13
having
an
adverse
effect
on
academic
performance.
having
effect
academic performance.
Thereanisadverse
evidence
thatonpsychological
problems13caused
There
is
evidence
that
psychological
problems caused
is evidence
psychological
by There
acne decrease
withthat
treatment
and that problems
identifyingcaused
early
by
acne
decrease
with
treatment
and
that
identifying
early
14 Several studby acne
treatment
andofthat
early
acne
anddecrease
treating with
it improve
quality
life.identifying
14
14
acne
and
treating
it
improve
quality
of
life.
Several
stud14
acne
and
treating
it
improve
quality
of
life.
Several
studies have shown that rapid improvement with treatment is
ies
that
improvement
with
is
ies have
have shown
shown
that rapid
rapid
improvement
with treatment
treatment
particularly
important
in the
pediatric population.
Thera-is
particularly
important
in
the
pediatric
population.
Theraparticularly
important
in the
pediatric
population.
Therapeutic
strategies
that result
in rapid
improvement
have
the
peutic
strategies
that
result
in
rapid
improvement
have
peutic strategies
result
in rapid
improvement
have the
the
greatest
beneficialthat
effect
on the
psychological
well-being
of
greatest
effect on
well-being
of
greatest beneficial
beneficial
on the
the psychological
psychological
well-being
of
patients
with acne.effect
For example,
acne surgery
and injecH.E.
Baldwin
et
al
patients
with
acne.
For
example,
acne
surgery
and
injecpatients
with acne.
For can
example,
acne surgery
injections
of existing
lesions
be helpful
adjunctsand
to initial
tions
of
existing
lesions
can
be
helpful
adjuncts
to
initial
tions of existing lesions can be helpful adjuncts to initial
pharmacologic treatment, because they have a more immediate effect on appearance.
Physical scarring is a tendency that is unique to the individual. Furthermore, the severity of the lesions does not necessarily correlate with the risk for scarring. Some patients
with very small papules and comedones develop “icepick”
scars, whereas some others with nodulocystic acne eventually clear with no visible sequelae. It is not possible to predict
which patients or which lesions will develop acne scars; however, the more lesions occur, the greater the risk for scarring.
Prompt, effective treatment is the best way to prevent scarring. The development of scarring in a patient with acne
constitutes a cutaneous emergency and merits aggressive
treatment to reduce the risk of further scarring.14,15
14
Recent Evidence on
A
published
study
Halvorsen
and
colleagues
A recently
recently
published
study by
bythe
Halvorsen
andthat
colleagues
provides
evidence
supporting
observation
suicidal16
provides
evidence
supporting
the
observation
that
suicidal
providesand
evidence
the observation
that in
suicidal
ideation
mentalsupporting
health problems
are increased
teenideation
and
mental
health
problems
are
increased
in
teenideation
and
mental
health
problems
are
increased
in
agers with acne. Of almost 5,000 adolescents enrolled inteenthat
agers
with
acne.
Of
almost
5,000
adolescents
enrolled
in
that
agers with
Of almost 5,000
adolescents
enrolled
that
study,
14%acne.
self-identified
as having
substantial
acnein(destudy,
14%
self-identified
as
having
substantial
acne
(destudy,
14%
self-identified
as
having
substantial
acne
(described by study participants as “a lot” or “very much acne”).
scribed
study
as “a
or
acne”).
scribed by
by
study participants
participants
“a lot”
lot”
or “very
“very much
much
acne”).
Suicidal
ideation
was
reportedasmore
than
twice
as
frequently
Suicidal
ideation
was
reported
more
than
twice
as
frequently
Suicidal
ideation
more
twice as
by
girls and
more was
thanreported
three times
as than
frequently
in frequently
boys with
by
more
than
three times
frequently
in boys
with
by girls
girls and
andacne
more
than
times as
aswho
frequently
boys
with
substantial
than
bythree
the patients
reportedinno
or little
substantial
acne
than
by
the
patients
who
reported
no
or
substantial
acne than
by the patients awho
reported
no or little
little
acne.
The study
also demonstrated
strong
association
beacne.
demonstrated aa strong
association
beacne. The
The study
study also
also
strong
association
between
substantial
acnedemonstrated
and an increase in
mental
health probtween
substantial
acne
and
an
increase
in
mental
health
probtween
substantial
acne
and
an
increase
in
mental
health
problems, such as poor social interactions, lack of thriving in
lems,
as
interactions,
lems, such
such
as poor
poor social
social
interactions, lack
lack of
of thriving
thriving in
in
school,
and increased
bullying.
school,
and
increased
bullying.
school,
and
increased
bullying.
This study supports a long history of experience with adThis
supports aa long
of experience
with
This study
study
long history
history
experience
with adadolescents
withsupports
acne and indicates
that of
it would
be appropriolescents
with acne
indicates
that itit would
appropriolescents
acne and
andconsider
indicates
would be
be impact
appropriate
for all with
clinicians
to
thethat
psychological
of
ate
for
to
consider
the
impact of
ate disease.
for all
all clinicians
clinicians
to least,
consider
the psychological
psychological
of
the
At the very
clinicians
should have impact
a heightthe
At
very
least,
clinicians
should have
aa heightthe disease.
disease.
At the
the
veryand
least,
clinicians
have
heightened
awareness
about
establish
an should
informal
assessment
ened
awareness about
and
establish
an informal
assessment
ened
about
and of
establish
informal
assessment
of
the awareness
psychosocial
impact
acne onaneach
patient.
Patients
of
the
psychosocial
impact
of
acne
on
each
patient.
Patients
of
the
psychosocial
impact
of
acne
on
each
patient.
Patients
with severe acne (or any patients with acne, regardless
of
with
severe
acne
(or
any
patients
with
acne,
regardless
of
with
severe
acne
(or
any
patients
with
acne,
regardless
of
severity) who have any indication of mental health problems
severity)
who
have
any
indication
of
mental
health
problems
severity)
who
have
any
indication
of
mental
health
problems
may benefit from a more formal evaluation and possible
may
may benefit
benefit from
from aa more
more formal
formal evaluation
evaluation and
and possible
possible
counseling.
counseling.
counseling.
For many years, drugs like isotretinoin were implicated in
For
years, drugs
like
were
in
For many
many
like isotretinoin
isotretinoin
were implicated
implicated
in
increasing
theyears,
risk drugs
of depression
and suicidal
ideations in
increasing
the
risk
of
depression
and
suicidal
ideations
in
increasingwith
the acne.
risk ofThe
depression
and Halvorsen
suicidal ideations
in
patients
study by
and colpatients
with
acne.
The
study
by
and
colpatients16,17
with
acne. the
Theview
study
by Halvorsen
Halvorsen
and such
colleagues
supports
of many
clinicians that
16,17
16,17
leagues
supports
the
view
of
many
clinicians
that
such
16,17 supports the view of many clinicians that such
leagues
problems in patients with acne exist exclusive of any theraproblems
in
with
acne exist
of
problems
in patients
patientsAs
with
existofexclusive
exclusive
of any
any theratherapeutic
intervention.
theacne
authors
this study
conclude:
peutic
intervention.
As
the
authors
of
this
study
conclude:
peutic intervention.
As thesuicidal
authorsideation
of this study
conclude:
“Adverse
events including
and depression
“Adverse
events
including
suicidal
ideation
and
depression
“Adverse
events
includingwith
suicidal
ideation
and may
depression
that
have been
associated
therapies
for acne
reflect
that
have
associated
with
therapies
for acne
may
reflect
thatburden
have been
been
associatedacne
withrather
therapies
may
the
of substantial
thanfor
theacne
effects
ofreflect
medthe
burden
of
substantial
acne
rather
than
the
effects
of
the burden
ofevidence
substantial
acne rather
than the effects
of medmedication.”
This
should
be communicated
to patients
ication.”
This
evidence
should
be
communicated
to
patients
ication.”
This
evidence
should
be
communicated
to
patients
and their parents when oral therapy—including isotretiand
parents
when
oral
isotretiand their
theirindicated
parents as
when
oral therapy—including
therapy—including
isotretinoin—is
a treatment
of choice.
noin—is
indicated
as
a
treatment
of
choice.
noin—is indicated as a treatment of choice.
Conclusion
Conclusion
Conclusion
Conclusion
Acne
isofcommonly
withtreatment
postinflammatory hyperEffects
nonclinical associated
issues on acne
Acne
associated
with
postinflammatory
hyperAcne is
is commonly
commonly
associated
withwhich
postinflammatory
pigmentation
in patients
of color,
often can behypermore
pigmentation
in
patients
of
color,
which
often
can
be
pigmentation in patients of color, which often can be more
more
bothersome to patients than are the acne lesions that caused
the dyschromia. In skin of color, PIH can occur secondary to
any acne lesion, even comedonal lesions with no clinical
appearance of inflammation.
Early and effective therapy, tailored not only to the acne
severity but also to the level of psychological distress, is extremely important.
In determining treatment regimens, clinicians must take
into consideration the widely varying differences that exist
among patients of different ages and of different ethnic and
cultural backgrounds.
6
7
8
9
10
11
12
References
page 23
1. Perkins A, Cheng C, Hillebrand G, Miyamoto K,continued
Kimball A:onComparison of the epidemiology of acne vulgaris among Caucasian, Asian,
Continental Indian, and African American women. J Eur Acad Dermatol Venereol November 25, 2010 [Epub ahead of print]
13
14
Albert C. Yan, MD,* Hilary E. Baldwin, MD,† Lawrence F. Eichenfield, MD,‡
Sheila Fallon Friedlander, MD,§ and Anthony J. Mancini, MD¶
Approach
to Pediatric
Acne
Treatment:
An
Update
By late adolescence,
almost all individuals
have experienced
some degree
of acne.
A broad
range of acne treatments has been shown to be safe and effective in adults. While still
sparse, emerging data now also document similar safety and efficacy of these agents for
children >12 years of age. For younger children with preadolescent acne, where data are
more limited or unavailable, it seems reasonable
to extrapolate from the findings
of studies
‡
Albert
C.involving
Yan, MD,*
Hilary
E. Baldwin, MD,†† Lawrence
F. Eichenfield, MD,‡
,† Lawrence
F.
Eichenfield,
MD,
older
children >12 years of age.
This article reviews the latest evidence
Albert Sheila
C. Yan,
MD,*
Hilary E.MD,
Baldwin,
MD, J.Lawrence
F. ¶Eichenfield, MD,‡ and
§ and Anthony
¶ current
Fallon
Friedlander,
Mancini,
MD
expert opinions
on
acne
therapies
in
the
pediatric
age group.
ny J. Mancini,
MD
§
¶
Sheila Fallon Semin
Friedlander,
MD,
and Anthony
J.Elsevier
Mancini,
MD
Cutan Med
Surg 30:S16-S21
© 2011
Inc. All
rights reserved.
cne Approach
Treatment:toAn
Update Acne Treatment: An Update
Pediatric
Approach to Pediatric Acne Treatment: An Update
†
‡
Albert C. some
Yan,degree
MD,*ofHilary
E. Baldwin, MD, Lawrence F. Eichenfield, MD,
ls have experienced
acne. A broad
§
¶ degree of acne. A broad
By late adolescence, almost
all individuals have experienced some
Sheila
Fallon
Friedlander,
MD,
own to be
safe and
effective
in adults. While
still and Anthony J. Mancini, MD
range of acne treatments has been shown to be safe and effective in adults. While still
cne is a nearly universal phenomenon typically affecting
ent similar safety and efficacy of these agents for
sparse, emerging data now also document similar safety and efficacy of these agents for
children with preadolescent
acne,
where
data
are
American
children
between
ages
of 12 and 17 years
By
late adolescence,
all individuals
have experienced
some
degree
acne.the
A broad
children
>12 years ofalmost
age. For
younger children
with preadolescent
acne,ofwhere
data
are
1 Given this high prevalence, it is not surprising then
sonable to extrapolate from
the
findings
of
studies
of
age.
rangelimited
of acne
been shown
to betosafe
and effective
in findings
adults. While
still
more
ortreatments
unavailable,has
it seems
reasonable
extrapolate
from the
of studies
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sparse,
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es in the pediatric age group.
total
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where with
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are treatment of acne
current
opinions
on acne
therapies
in thethat
pediatric
age group.
2011 Elsevier Inc. All rights
reserved.
more
limited
or
unavailable,
it seemsAssocireasonable
to extrapolate
from the
findings
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vulgaris
therights
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involving
older children
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article
reviews
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and
ate Professor, Pediatrics
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of Medicine
substantial
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expert
opinions PA
on acne therapies in thetion
pediatric
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reserved.
cne isProfessor
a nearlyand
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cne is a nearly universal phenomenon typically affecting
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topical
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children
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of California,
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§Clinical
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and Medicine,
University
of
that
total
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associated
with Dermatology,
the treatment
of acne
American
children
between
ages
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and 17
tioners,
and
dermatologists,
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interesting
to note
that
difthat
total
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theoftreatment
of years
acne
vulgaris
in the United States exceeded $2.2 billion, including
of
age.
ciferences
in
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have
been
described
vulgaris in the United States exceeded $2.2 billion, including
¶Professor
of Pediatrics
and Dermatology,
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University’s
Fein*Chief,
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theate
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berg
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the
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that
total
direct
costs
associated
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ofofacne
Memorial of
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Chicago,
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representative
data
regarding
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pethe University
Pennsylvania,
Philadelphia,
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1
tion products.
NY
2
Publication
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jointly
sponsored
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the
University
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LouAcne
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of
†Associate
Professor
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Vice
Chair,
Department
of
Dermatology,
SUNY
vulgaris
in
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United
States
exceeded
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billion,
including
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and
dermatologists,
Yentzer
et
al
found
that
der*Chief, Pediatric Dermatology, Children’s Hospital of Philadelphia, AssociAcne vulgaris is traditionally managed with a variety of
isville
Continuing
Health
Sciences
Education
and1),
SkinSchool
Downstate,
Brooklyn,
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ate
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and
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Perelman
of Education
Medicine
topical
and
systemic
medications
(Table
asDisease
well
as acne
the
substantial
costs of
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over-the-counter
matologists
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most,
byacne
topditopical
and prescribe
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Foundation
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ennition
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ical
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son Consumer
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surgery techniques. Although the disease is commonly enatric
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countered
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peroxide
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ofmanaged
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rely
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JohnsonofConsumer
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versity
California,
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primary
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of
tioners,
and
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diftopical
and
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medications
(Table
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as
well
as
acne
Albert
C.
Yan,
MD,
has
no
relevant
financial
relationships
with
any
commerBP
most,
followed
by
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topical
tretinoin,
§Clinical
Professor
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and
Medicine,
Dermatology,
University
of
‡Clinical Professor of Pediatrics and Medicine (Dermatology), Chief, Peditioners, and dermatologists, it is interesting to note that difcial interests.
California,
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Diego,
CA
ferences
practices
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Although
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San described
Diego,
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erythromycin
(Table
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appears
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in prescribing
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have
described
Hilary
E. Baldwin,
MD,
hasDermatology,
servedSchool
as aIn
consultant
andSan
speaker
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Aller¶Professor
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and
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Diego
of
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Diego,
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between
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nationally
countered
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ofcare
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gan, School
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and
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speaker
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berg
of Medicine,
Head,
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of Pediatric
Chil§Clinical
Professor
ofMedicis,
Pediatrics
and
Medicine,
Dermatology,
of
representative
data
regarding
the
prescribing
patterns
of
petioners,
and
dermatologists,
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interesting
to
note
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ical
clindamycin,
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well
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prodGlaxoSmithKline
andRady
Ortho
Dermatologics.
dren’s
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IL Hospital, San
representative data regarding the prescribing patterns of difpeCalifornia,
San Diego,
Childrens
Diego, CA
2 found
udiatricians
and
dermatologists,
Yentzer
et
al
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derferences
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ucts such in
asand
BP
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and
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Lawrence
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Publication
of Pediatrics
this CME article
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and
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diatricians
dermatologists,
Yentzer
al
found
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deron
matologists
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has
between
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analysis
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isville
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Health
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Education
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berg
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matologists
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been
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Coria
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clindamycin,
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ical
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Galderma,
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son
Consumer
& Personal
Products
of Johnson
&
Publication
of
this
CME
article
was
jointly
sponsored
byDivision
the University
of Louperoxide
(BP)
for
the
treatment
ofWorldwide
acne.
Pediatricians
rely
on
diatricians
and
dermatologists,
al2 found that
and 17% (BP)
for
pediatricians.
peroxide
for
the treatment Yentzer
of acne.et
Pediatricians
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and
Valeant.
Johnson
Consumer
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isville
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erBP
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matologists
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followed
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Sheila
F. Yan,
Friedlander,
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on an
advisory
board
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Albert
C.
MD,
no relevant
relationships
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commerBP However,
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topicaldistinct
clindamycin,
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Foundation
andhas
supported
byserved
anfinancial
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oral
erythromycin
(Table 2). There appears to be considical
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oral(Table
minocycline,
and
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patterns.
Although retinoids
have
demonstrated
good
efficacy
and
Onset.
interests.
son
Consumer
& Personal Products Worldwide Division of Johnson &
and
oral
erythromycin
2). There
appears
to
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considerAnthony
J.
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FAAP,
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as aof
consultant
for Galderma,
erable
inMD,
terms
of employment
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topHilary
E.overlap
Baldwin,
has
served
asserved
a consultant
and
speaker
for Allerperoxide
(BP)
for
the
treatment
of
acne.
Pediatricians
rely
on
for
comedonal
as
well
as
mildly
inflammatory
acne
and
repreJohnson
Consumer
Companies,
Inc.
or
erable overlap in terms of employment of retinoids, BP,
topMedicis,
has
also
been combination
a relationships
speaker
for Galderma.
Medicis,
and
Onset.
She
has also
been
aany
speaker
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icalgan,
clindamycin,
as
well
as
fixed
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prodAlbert
C.Galderma,
Yan,and
MD,Stiefel.
has
noHe
relevant
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with
commerBP
most,
followed
by
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clindamycin,
topical
tretinoin,
sent
about
46%
of
prescribed
acne
products
among
dermatoloical clindamycin, as well as fixed combination topical prodCorresponding
author:and
Albert
C. Dermatologics.
Yan, MD, Chief, Pediatric Dermatology,
GlaxoSmithKline
Ortho
cial
interests.
ucts
such
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� clindamycin
and BP � erythromycin. Both
and
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There
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about
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such
BP represent
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erythromycin.
Both
Children’s
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Associate
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and
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erable
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gan, Galderma, Medicis, and Onset. She has also been a speaker for
nd
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ical
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vania,
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yana@email.chop.edu
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ucts
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Lawrence
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underutilized
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However, there are some distinct differences in prescribing
Sheila
Friedlander,
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on©
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matter
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rightsand
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been
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and/or
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patterns.
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patterns. Although retinoids have demonstrated good efficacy
and doi:10.1016/j.sder.2011.07.004
Onset. GlaxoSmithKline, Intendis, Medicis, Ortho Dermatologics,
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as MD,
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have
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adAnthony
Mancini,
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for
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as welltoasa mildly
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sent
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products
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are
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verse
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sent about 46% of prescribed acne products among dermatology,
Corresponding
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C. Yan,
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Pediatric
Dermatology,
gists,
represent
about
12% of
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addition
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the selection
of
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patterns.
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demonstrated
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andretinoids
Onset. author:
nd
gists,
represent
onlyhave
about
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of pediatrician-pre2 Given
Children’s
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of FAAP,
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Associate
Professor,
Pediatrics
and
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J.
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scribed
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that
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likely
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well
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scribed
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vania, Philadelphia,
E-mail:
yana@email.chop.edu
Corresponding
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Albert
C. Yan,
MD, Chief, Pediatric Dermatology,
with treatment
regimens.only
Ointments,
creams,
gels, and solugists,
retinoids represent
about 12%
of pediatrician-preChildren’s Hospital of Philadelphia, Associate Professor, Pediatrics and
2 Given
tions
have
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most
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employed;
scribed
agents.
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pediatricians
likely
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Dermatology Perelman School of Medicine at the University of Pennsylreserved.
however,
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formulations
as inflammatory
well as novel
of patients
with vehicle
comedonal
and mildly
Philadelphia, PA. E-mail:
yana@email.chop.edu
S16vania,
1085-5629/11/$-see
front matter
© 2011 Elsevier Inc. All rights reserved. cohort
doi:10.1016/j.sder.2011.07.004
delivery options have been introduced and should be considPediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdef
15
S16
ered among the therapeutic options to individualize treat1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. ment and, thereby, optimize treatment outcomes.
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however, several new vehicle formulations
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and should be considered among the therapeutic options to individualize treatered
among
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therapeutic
options
to Fleischer
individualize treatSource:
Adapted
Yentzer BA,
Irby CE,
ment
and,
thereby,
optimize
treatment
outcomes.AB Jr, Feldman
SR. thereby,
Pediatr Dermatol
ment
and,
optimize25:635-639,
treatment2008.
outcomes.
A number of new topical products for acne treatment have
A number of new topical products for acne treatment have
been developed and introduced recently. These include
been developed and introduced recently. These include
products formulated with foam and hydrogel vehicles, novel
fixed combinations of components, and a recently introTable 1 Acne Medications Currently Available
duced
gel formulation
of theAvailable
sulfone antibiotic/antiTable 1 topical
Acne Medications
Currently
Topical
agents,
by
class
inflammatory dapsone.
Topical
agents,
by class
● Retinoid
agents
Foam and
hydrogel vehicles have the advantage of easy
● Retinoid
agents
– Adapalene
spreadability
with little residue. These vehicle formulations may
–– Adapalene
Tazarotene
be especially
suited
to treatment of hair-bearing areas (such as in
–– Tazarotene
Tretinoin
male–patients)
or applied more easily over larger body surface
Tretinoin
● Benzoyl peroxide formulations (numerous over-theareas
such asperoxide
onprescription
the chest
andproducts)
back.(numerous
Clindamycin
is available in
●
Benzoyl
formulations
over-thecounter and
counter
and
prescription
products)
a● hydroethanolic
foam,
and
a
new
tretinoin
0.025%
� clindaAntibiotics
●
Antibiotics
mycin
fixed combination product is available in a hydro– 1.2%
Clindamycin
–– Clindamycin
gel formulation.
Other novel fixed combinations include those
Erythromycin
–– Erythromycin
containing
antibiotic
� BP, antibiotic � retinoid, and BP �
Sodium
sulfacetamide
–– Sodium
Sulfur
retinoid
(Tablesulfacetamide
3). Although use of the component agents
– Sulfur products
●
Combination
separately
may
be moreCurrently
economical,
fixed-combination
1. Acne
Medications
Available
● Table
Combination
products peroxide
– Antibiotic-benzoyl
fixed
combinations
products
guarantee
the
stability
of
the
components
–– Antibiotic-benzoyl
peroxide
fixed combinationswithin
Antibiotic-retinoid
fixed
combinations
Topical
Agents, by class
these
formulations
and
improve
adherence
–– Antibiotic-retinoid
fixed combinations to therapy beBenzoyl
• Retinoid
agentsperoxide-retinoid fixed combinations
cause– fewer
applications
are needed during
the day.
Benzoyl
peroxide-retinoid
– Adapalene
● Keratolytic
agents
(eg, salicylicfixed
acid)combinations
Systemic
antibiotic
therapy
has
been
a
mainstay
of treat●
Keratolytic
agents
(eg,
salicylic
acid)
– Tazarotene
● Anti-inflammatory
agents (eg, dapsone)
ment
for
acne.
These
agents
include
primarily
tetracycline
●
Anti-inflammatory
agents
(eg,
dapsone)
– Tretinoin
derivatives
in patients
years of age and older; the age re• Benzoyl peroxide
formulations
Systemic
agents,
by8class
Systemic
agents,
by
class
striction
reflects
concerns
about
dentalproducts)
enamel staining in
(numerous
over-the-counter
and
prescription
● Oral antibiotics
●
antibiotics
•Oral
Antibiotics
individuals
younger
than
8
years
of
age.
Data
on prescribing
– Tetracycline derivatives
Tetracycline
derivatives
––Clindamycin
patterns
that dermatologists
tend to favor doxycycline
X show
Doxycycline
X
Erythromycin
X Doxycycline
Minocycline
and–minocycline,
whereas pediatricians frequently use tetraX
Minocycline
– Sodium
sulfacetamide
2
X
Tetracycline
cycline.
Tetracycline generally is less costly than the other
– Sulfur
Tetracycline
– X
Macrolide
derivatives
derivatives,
but
the
longer half-lives of doxycycline and mi• Combination
products
– Macrolide
derivatives
X
Azithromycin
nocycline
permit
onceor fixed
twice-daily
dosing compared to
– Antibiotic-benzoyl
peroxide
combinations
X
X Azithromycin
Erythromycin
the –four-times-daily
dosing
typically
required
with tetracyAntibiotic-retinoid
fixed
combinations
Erythromycin
– X
Cephalosporins
––Benzoyl
peroxide-retinoid
combinations
cline.
Less
frequent
dosing fixed
of any
medication is more likely to
Cephalosporins
X Cephalexin
• Keratolytic
agents (eg, salicylic acid)
Cephalexin
– X
Penicillins
• Anti-inflammatory
agents (eg, dapsone)
– Penicillins
X
Amoxicillin
Table
3
Novel
Therapeutic
Amoxicillin
Systemic
Agents,
by class Options
– X
Trimethoprim-sulfamethoxazole
– Trimethoprim-sulfamethoxazole
Oral
antibiotics
●•Combination
Novel
agent oral contraceptives
●
––Tetracycline
derivatives
● Combination
oral contraceptives
Dapsone
– Drospirenone
Doxycycline
–– Drospirenone
● Novel
combinations
of components
Drospirenone/levomefolate
Minocycline
–– Drospirenone/levomefolate
Antibiotic/benzoyl
peroxide fixed combinations
Ethinyl estradiol/norethindrone
Tetracycline
–– Ethinyl
estradiol/norethindrone
Antibiotic/retinoid
fixed
combinations
Ethinyl derivatives
estradiol/norgestimate
––Macrolide
Ethinyl
estradiol/norgestimate
Benzoyl
peroxide/retinoid fixed combinations
● Hormonal
agents
Azithromycin
● Hormonal
agents
– Spironolactone
Erythromycin
–
Spironolactone
● Systemic
retinoids
– Cephalosporins
● Systemic
retinoids
– Isotretinoin
Cephalexin
– Isotretinoin
– Penicillins
Amoxicillin
– Trimethoprim-sulfamethoxazole
• Combination oral contraceptives
– Drospirenone
– Drospirenone/levomefolate
– Ethinyl estradiol/norethindrone
– Ethinyl estradiol/norgestimate
• Hormonal agents
– Spironolactone
• Systemic retinoids
– Isotretinoin
16
peroxide 5% topical gel
peroxide 5% topical gel
Adapalene
Adapalene
Erythromycin 3%/benzoyl
Erythromycin
peroxide 5%3%/benzoyl
topical gel
peroxide 5%
topical gel
Table 2. Most Frequently Prescribed Tetracycline
Medications
by Specialty
Doxycyline
Doxycyline
Tetracycline
Tetracycline
Clindamycin 1%/benzoyl
Pediatricians
Dermatologists
Tetracycline
Clindamycin
1%/benzoyl
peroxide 5%
topical gel
peroxide
5%
Benzoyl peroxide
Adapalene
Minocycline
Erythromycin topical gel
Minocycline
Erythromycin
Clindamycin
Source:
Adapted from Yentzer BA,Tretinoin
Irby CE, Fleischer AB Jr, FeldSource:
Adapted
Yentzer
BA, Irby CE,
Fleischer AB Jr, Feldman SR.
Pediatrfrom
Dermatol
25:635-639,
2008.
Tretinoin
Clindamycin
man SR. Pediatr Dermatol 25:635-639,
2008.
Erythromycin
Minocycline
products
formulated
with foam Benzoyl
and hydrogel
Clindamycin
1%/
peroxide vehicles, novel
products
formulated
with foam and hydrogel
vehicles, novel
fixed
combinations
of gel
components, and a recently introbenzoyl
peroxide 5% topical
fixed combinations of components, and a recently introduced
topical3%/
gel formulation of the sulfone antibiotic/antiErythromycin
duced
topical gel formulation ofDoxycycline
the sulfone antibiotic/antiinflammatory
benzoyl peroxidedapsone.
5% topical gel
inflammatory dapsone.
Foam and hydrogel vehicles Erythromycin
have the advantage
of easy
Adapalene
3%/
Foam and hydrogel vehicles have the advantage
of easy
spreadability with little residue. These
vehicle
formulations
benzoyl
peroxide
5% topical gelmay
spreadability with little residue. These
vehicle
formulations
may
be especially suited to treatment of hair-bearing areas (such as in
beDoxycyline
especially suited to treatment ofTetracycline
hair-bearing areas (such as in
male patients) or applied more easily over larger body surface
male
patients) or applied more easily
over larger
body surface
Tetracycline
Clindamycin
1%/ is
areas
such as on the chest and back.
Clindamycin
available in
areas such as on the chest and back.
Clindamycin
available
benzoyl
peroxide 5%istopical
gel in
a hydroethanolic foam, and a new tretinoin 0.025% � clindaa Minocycline
hydroethanolic foam, and a new
tretinoin 0.025% � clindaErythromycin
mycin
1.2% fixed combination product
is available in a hydromycin
1.2%
fixed
combination
product
is available inDermatol.
a hydroAdapted from Yentzer
Irby CE, fixed
Fleischercombinations
AB Jr, Feldman SR. Pediatr
gelSource:
formulation.
OtherBA,novel
include those
2008.
gel25:635-639,
formulation.
Other novel fixed combinations include those
containing antibiotic � BP, antibiotic � retinoid, and BP �
containing antibiotic � BP, antibiotic � retinoid, and BP �
retinoid (Table 3). Although use of the component agents
retinoid (Table 3). Although use of the component agents
separately may be more economical, fixed-combination
separately may be more economical, fixed-combination
products guarantee the stability of the components within
products guarantee the stability of the components within
these formulations and improve adherence to therapy bethese formulations and improve adherence to therapy because fewer applications are needed during the day.
cause fewer applications are needed during the day.
Systemic antibiotic therapy has been a mainstay of treatSystemic antibiotic therapy has been a mainstay of treatment for acne. These agents include primarily tetracycline
ment for acne. These agents include primarily tetracycline
derivatives in patients 8 years of age and older; the age rederivatives in patients 8 years of age and older; the age restriction reflects concerns about dental enamel staining in
striction reflects concerns about dental enamel staining in
individuals younger than 8 years of age. Data on prescribing
individuals younger than 8 years of age. Data on prescribing
patterns show that dermatologists tend to favor doxycycline
patterns show that dermatologists tend to favor doxycycline
and minocycline, whereas pediatricians frequently use tetraand minocycline,
whereas pediatricians frequently use tetracycline.22 Tetracycline generally is less costly than the other
cycline. Tetracycline generally is less costly than the other
derivatives, but the longer half-lives of doxycycline and miderivatives, but the longer half-lives of doxycycline and minocycline permit once- or twice-daily dosing compared to
nocycline permit once- or twice-daily dosing compared to
the
dosing typically required with tetracyS18 four-times-daily
the
four-times-daily dosing typically required with tetracycline. Less frequent dosing of any medication is more likely to
cline. Less frequent dosing of any medication is more likely to
result in better treatment adherence. Moreover, data on anTable 3 Novel
Therapeutic
tibiotic
resistance
patterns Options
of Propionibacterium acnes indicate
Table 3 Novel Therapeutic Options
that
the
proportion
of
organisms
resistant to doxycycline and
● Novel agent
●
Novel
agent
minocycline
are
lower
than
with
either erythromycin or tet– Dapsone
– Dapsone
racycline.
Finally, photosensitivity
and gastrointestinal side
●
Novel
combinations
of components
● Novel
combinations of peroxide
components
– Antibiotic/benzoyl
fixeddoxycycline
combinations
effects
tend
to be somewhat
lower with
and mi–– Antibiotic/benzoyl
peroxide
fixed combinations
Antibiotic/retinoid
fixed
combinations
nocycline compared to tetracycline.
–– Antibiotic/retinoid
fixed combinations
Benzoyl peroxide/retinoid
fixedwhen
combinations
Alternative
have been used
traditional tetra– Benzoylagents
peroxide/retinoid
fixed combinations
cycline derivative agents have proved insufficiently effective
or in cases in which side effects preclude the use of antibiotics
in the tetracycline class. Although randomized clinical trial
data
are3.not
available
for these
alternative agents, case series
Table
Novel
Therapeutic
Options
have documented the efficacy and apparent tolerability of
Novel Agent 3 cephalexin,4 trimethoprim and trimethoprimamoxicillin,
• Dapsone
5 and azithromycin6 for patients with acne
sulfamethoxazole,
Novel
Combinations
of Components
who were either unable
to take or had previously failed ther• Antibiotic/benzoyl peroxide fixed combinations
apy with more conventional therapeutic agents.
• Antibiotic/retinoid fixed combinations
published
data on
amoxicillin
•The
Benzoyl
peroxide/retinoid
fixed
combinationsare scant and involve
assessments from retrospective chart reviews.3 One large case
4 reviewed the responses of
series by Fenner and colleagues
globalacademycme.com/sdef • Pediatric
Acne Management:
Optimizing Outcomes
93 acne patients who received 98 courses of cephalexin.
th
ag
an
w
am
an
co
no
id
P
D
ol
nu
m
ic
ac
8
ve
nate
nd
etde
mi-
ave
cs
ial
es
of
Table
4microbial
FDA Approvals
for resMedication
not demonstrating
a significant
impactAge
on Indications
altering native
20 and Pediatric
cycline
derivative
have preclude
proved insufficiently
effective
ident
flora.
or
in whichagents
side effects
the use ofclinical
antibiotics
in in
thecases
tetracycline
class.
Although
randomized
trial
20
ident
microbial
flora.
or the
in cases
in whichclass.
side effects
preclude
the use of
antibiotics
in
randomized
trial
data
aretetracycline
not available
for Although
these alternative
agents,clinical
case series
in
the
tetracycline
class.
Although
randomized
clinical
trial
PreadolescentAcne
Acne
data
not available
these alternative
agents,
case series
Preadolescent
have are
documented
thefor
efficacy
and apparent
tolerability
of
Drug
Category
Active
Drug
Common Brand Nam
Preadolescent
Acne
data
are
not
available
for
these
alternative
agents,
case
series
3 cephalexin,
4 trimethoprim
have
documented
the efficacy
and apparent
tolerability of
and trimethoprimamoxicillin,
Data
are limited on the use of
acne medications in the preadPreadolescent
Acne
have
documented
the
efficacy
and
apparent
tolerability
of
3
4
Topical
Tretinoin
Retin-A
0.025%,
0.05%, 0
5 and azithromycin
6 forand
trimethoprim
trimethoprimamoxicillin, cephalexin,
Data
areretinoid
limited
on the
of acne�7
medications
in the
preadsulfamethoxazole,
patients
with acne
olescent
population
(ie,use
patients
to 11 years
of age).
A
3 cephalexin,4 trimethoprim and trimethoprimAvita
0.025%
amoxicillin,
Data
are
limited
on
the
use
of
acne
medications
in
the
preadsulfamethoxazole,
olescent
population
patientsthe
�7heterogeneous
to 11 years ofgroup
age).S19
A
Approach
pediatric
acnetotreatment
who weretoeither
unable
take or had previously failed thernumber of
case series(ie,
highlight
of
0.05%
sulfamethoxazole,
olescent of
population
(ie,
patients
�7
to 11Atralin
years
of
age).
A
who
weremore
eitherconventional
unable
to take
or had previously
number
case
highlight
the
heterogeneous
group
of
apy with
therapeutic
agents. failed thermedications
usedseries
forAdapalene
children
with
infantile
acne.
Two
clinDifferin 0.1%,
0.3%
who
were
either
unable
to
take
or
had
previously
failed
thernumber
of
case
series
highlight
the
heterogeneous
group
of
apy
with
more
conventional
therapeutic
medications
forTazarotene
children
with
infantileTazorac
acne.
Two
clin-0.1%
The
published
data and
on amoxicillin
areagents.
scant and involve
ical trials
haveused
evaluated
the
of tretinoin
for
preadolescent
Table
4 FDA
Approvals
Pediatric
Age
Indications
for Medications
Commonly
Employed
foruse
Acne
0.05%,
apy
with
more
conventional
therapeutic
agents.
medications
used
for
children
with
infantile
acne.
Two
clin3
The
published
data
on
amoxicillin
are
scant
and
involve
ical
trials
have
evaluated
the
use
of
tretinoin
for
preadolescent
assessments from retrospective chart reviews. One large case
acne. In one open-label study involving 40 patients between
Date
of
The
published
data
on
amoxicillin
are
scant
and
involve
3
ical
trials
have
evaluated
the
use
of
tretinoin
for
preadolescent
4 reviewed
large case
assessments
from and
retrospective
chart
reviews.theOne
acne.
one
open-label
study involving
40aAkne-Mycin,
patients
between
8Topical
andIn
12antibiotic
years
of age,
tretinoin
0.04% in
microsphere
gel Emg
series by Fenner
colleagues
responses
of
Erythromycin
Erygel,
3 One large case
Earliest
FDA
assessments
fromand
retrospective
chart
reviews.the
acne.
In
one
open-label
study
involving
40
patients
between
4 reviewed
8
and
12
years
of
age,
tretinoin
0.04%
in
a
microsphere
gel
series
by
Fenner
colleagues
responses
of
vehicle
demonstrated
good
efficacy
and
safety,
with
patients
93
acne
patients
who
received
98
courses
of
cephalexin.
4 reviewed the
Drug by
Category
Active Drug
Common
Brand
Names
Approval
AgeinIndication
8
and
12
years
of
age,
tretinoin
0.04%
a
microsphere
gel
series
Fenner
and
colleagues
responses
of
vehicle
demonstrated
good
efficacy
and
safety,
with
patients
93
acneinvestigators
patients who
receivedthat
98 only
courses
of cephalexin.
Clindamycin
T
showing both tolerability
and also moderateCleocin
improvement
on
These
reported
22%
of patients
vehicle
demonstrated
good
efficacy
and
safety,
with
patients
Topical
retinoid
Tretinoin
Retin-A
0.025%,
0.05%,
0.1%
October
1971
>12
years
93
acne
patients
who
received
98
courses
of
cephalexin.
21
Evoclin
showing
both tolerability
and also
moderate
improvement
on
These
reported
thatwith
only
22% whereas
of patients
the Evaluator’s
Global Severity
Score.
The
U.S. Food and
showedinvestigators
no response or
worsened
therapy,
the
Avita
January
1997Severity
>12
years
showing
both
tolerability
and an
also
moderate
on
21 Theimprovement
These investigators
reported
that
only
22% 0.025%
of patients
the
Evaluator’s
Global
Score.
U.S.
Food
and
showed
nopatients
responsewere
or
worsened
with
therapy,
whereas
the
Drug
Administration
granted
age
indication
of
10
years
or
remaining
either somewhat
improved
(29%),
21 The U.S. Food and
Atralinwhereas
0.05% the
July 2007
>10
years
the
Evaluator’s
Global
Severity
Score.
showed
no
response
or
worsened
with
therapy,
Topical
antiDapsone
Aczone
Drug
Administration
granted
an
age
indication
of
10
years
or
remaining
patients
were
either
somewhat
improved
(29%),
older
for
tretinoin
0.05%
gel,
based
on
the
trial
data
submitmuch improved (45%),
or cleared (4%). Trimethoprim
and
Adapalene
Differin
0.1%,
0.3%
May 1996 granted >12
years
inflammatory
Drug
Administration
an
age
indication
of
10
years
or
remaining
patients
were
either
somewhat
improved
(29%),
older
for
tretinoin
0.05%
gel,
based
on
the
trial
data
submitmuch
improved
(45%),
or
cleared
(4%).
Trimethoprim
and
most acne medications
are indicated for use
considerable
pe-0.1% ted. Otherwise,
Tazarotene have seen Tazorac
0.05%,
June 1997
>12
years
older
for
tretinoin
0.05%
gel,
based
on
the
trial
data
submitmuch improved (45%), or cleared
(4%).
Trimethoprim
and
ted.
Otherwise,12most
medications
are indicated
for use
have
seen
considerable
pein
individuals
yearsacne
of age
or older (Table
4).
diatric usage for treatment of a variety
of
both
cutaneous and
Fixed
ted.
Otherwise,
most
acne
medications
are
indicated
for
use
have
seen
considerable
pein
individuals
12
years
of
age
or
older
(Table
4).
diatric
usage
forinfections,
treatment
of a the
variety
cutaneous
and Emgel
DespiteJanuary
the limited
data available
for the
of these
medTopical
antibiotic
Erythromycin
Akne-Mycin,
Erygel,
1985
Indicated
for use
pediatric
use;
no
extracutaneous
but
use of
of both
these
agents in acne
combination
in Despite
individuals
12 years
of age
or older
(Table
4).
diatric usage forinfections,
treatment but
of a variety
of these
both cutaneous
and
the
limited
data
available
for
the
use
of
these
med5,7 in acne
extracutaneous
use of
agents
ications
in
infants
and
preadolescent
patients,
clinical
judgspecific
age
restrictions
generally has been
regarded asthe
a third-line
option.
product:
Despite
the
limited
datato
available
forpatients,
the use clinical
of
these judgmedextracutaneous
infections,
but
use of these
agents
acne
5,7
ications
infants
and
Clindamycin
Cleocin
T in
July
1980
>12 years
ment
be
exercised
select
appropriate
therapies
for
generally
has been
regarded
as the
a third-line
option.
BP should
� in
Abx
BPpreadolescent
� erythromycin
Benzamycin
More extensive
data
are available
regarding
the use
of
azi5,7
ications
in
infants
and
preadolescent
patients,
clinical
judggenerally
has
been
regarded
as
a
third-line
option.
ment
should
be
exercised
to
select
appropriate
therapies
for
Evoclin
October
2004
>12
years
children
with
acne.
Topical
BP,
topical
retinoids,
and
topical
More
extensive
data
are
available
regarding
the
use
of
aziBP
�
clindamycin
Benzaclin
thromycin for acne. A review of the available literature reveals
ment should
be
exercised
toBP,
select
appropriate
therapies
for
More extensive
data
are available
regarding
the usereveals
of azichildren
with
acne.
Topical
topical
retinoids,
and
topical
8-10
Duac
antibiotics
have
been
used
with
some
success
in
younger
thromycin
for
acne.
A
review
of
the
available
literature
and one nonrandomthree randomized controlled trials
children
with
acne.
Topical
BP,
topical
retinoids,
and
topical
Topical
antiDapsone
Aczone
July
2005
>12
years
22 For
thromycin
for acne.controlled
A review oftrials
the 8-10
available
literature
reveals
antibiotics
have
been
used
withwith
some
success
younger
Acanya
children with
acne.
those
more
severeinacne,
sysand one
nonrandomthree
randomized
noninferiority
of
ized
controlled
trial11 that demonstrated
8-10 and one nonrandomantibiotics
have
been
used
with
some
success
in
younger
22
inflammatory
three
randomized
controlled
trials
BP
�
retinoid
BP
�
tretinoin
Epiduo
11
children
with
acne.
For
those
with
more
severe
acne,
temic antibiotic therapy
has included erythromycin andsysits
that demonstrated
of
ized
controlled
azithromycin
to trial
doxycycline;
azithromycinnoninferiority
also was not in22 For those with more severe acne, sys11 that demonstrated noninferiority of
children
with
acne.
Retinoid
�
Abx
Tretinoin
� cephalexin;
Ziana
ized
controlled
trial
temic
antibiotic
therapy
hasand
included
erythromycin
and
its
derivatives,
trimethoprim,
these
have
been
12
azithromycin
to
doxycycline;
azithromycin
also
was
not
inferior to minocycline in one open-label study. In addition,
Fixed
temic
antibiotic
therapy
has
included
erythromycin
and
its
clindamycin
Veltin
derivatives,
trimethoprim,
and
cephalexin;
these
have
been
azithromycin
to
doxycycline;
azithromycin
also
was
not
in12
used with success in cases in which tetracycline and its de13-16 and
ferior
to minocycline
in one
open-label
study.
In addition,
four
open,
noncontrolled
studies
one12retrospective
combination
Oral
antibiotic
Erythromycin
EES,
Eryped,
Ery-tab
derivatives,
trimethoprim,
and
cephalexin;
these
have
been
used
withare
success
in cases in
which
deferior
to minocycline
in one
open-label
study.
In addition,
13-16 and
rivatives
less desirable,
given
theirtetracycline
propensityand
for its
dental
17 indicated
four
open,
studies
one
retrospective
product:
chart
reviewnoncontrolled
that
azithromycin
improved
acne.
used with
success
in cases given
in and
which
tetracycline
and
its de13-16 and one retrospective
rivatives
are
less
desirable,
their
propensity
for
dental
four
open,
noncontrolled
studies
17
enamel
staining.
Tetracycline
doxycycline
are
generally
chart
review
indicated
azithromycin
improved
acne.
BP �
Abx
BP �that
erythromycin
October 1984
>12 years Sumycin and others
However,
there
is heterogeneity
in study Benzamycin
design
as well
as
Tetracycline
rivativesstaining.
are
lessforTetracycline
desirable,
given
their
for
dental
17
enamel
and
doxycycline
generally
chart review
that
azithromycin
improved
acne.
recommended
children
years
ofpropensity
ageVibramycin,
andareolder
with and A
BP
clindamycin
December
2000 8>12
years
However,
thereindicated
isofheterogeneity
in study
design
as well
as
Doxycycline
Doryx
dosage regimens
the �
azithromycin
and Benzaclin
the
control
drug.
enamel
staining.
Tetracycline
and
doxycycline
are
generally
recommended
for
children
8
years
of
age
and
older
with and ot
However,
there
is
heterogeneity
in
study
design
as
well
as
severe
acne;
minocycline
carries
a
recommendation
for
chilDuac
August
2002
>12
years
dosage
of the
azithromycinthe
and
thehalf-life
controlofdrug.
Minocycline
Dynacin,
Minocin,
Most ofregimens
these studies
acknowledged
long
azirecommended
for
children
8
years
of
age
and
older
with
severe
acne;
minocycline
carries
a
recommendation
for
chilAcanya
October
2008
>12
years
dosage
regimens
of
the
azithromycin
and
the
control
drug.
dren 12 years of age and older with moderate-to-severe
acne.
Solodyn
Most
of these
acknowledged
long as
half-life
of four
azithromycin
andstudies
typically
gave the drugthe
as often
three to
severe
acne;
minocycline
carries
a
recommendation
for
children
12 years
of age
older>12
withyears
moderate-to-severe
acne.
BP of
� these
retinoid
BPacknowledged
� tretinoin the long
Epiduo
December
2008
Most
studies
half-life
offour
aziCombination
oraland
contraceptives
may beBactrim,
helpful for
postTrimethoprimSeptra
thromycin
andor
typically
gave
drug
as often
as
three to
times
a week
as seldom
asthe
three
times
per
month.
dren
12
years
of
age
and
older
with
moderate-to-severe
acne.
Retinoid
�
Abx
Tretinoin
�
Ziana
November
2006
>12
years
Combination
oral
contraceptives
may
be
helpful
for
postthromycin
and
typically
gave
the
drug
as
often
as
three
to
four
sulfamethoxazole
menarchal
adolescents
and
adults.
However,
because
of
contimes
a week or asanseldom
as three times
per month.
Erythromycin,
older
macrolide
derivative,
is used less
Combination
oral
contraceptives
may
be
helpful
for
postclindamycin
Veltin
July
2010
>12
years
menarchal
adolescents
and
adults.
However,
because
of
conAmoxicillin
Amoxil
times
a
week
or
as
seldom
as
three
times
per
month.
cerns
about
premature
epiphyseal
closure,
their
use
in
preErythromycin,
anErythromycin
is used Ery-tab
less
often
now because
ofolder
the macrolide
emergencederivative,
and EES,
establishment
of
menarchal
adolescents
and
adults.
However,
because
of
Oral
antibiotic
Eryped,
April
1965
Indicated
for
pediatric
use;
no
cerns
about patients
prematuregenerally
epiphyseal
closure,
their use
in conpremenarchal
is
not
advised
except
in
Erythromycin,
an
older
macrolide
derivative,
is
used
less
often
nowresistance
because of
the emergence
and establishment
of
antibiotic
among
P. acnes organisms.
There is evispecific
age
restrictions
cerns
about
premature
epiphyseal
closure,
their
use
in
preCephalexin
Keflex
menarchal
patients
generally is notSpironolactone
advised except
in
consultation
with
an
endocrinologist.
and
its
often
now
because
of
the
emergence
and
establishment
of
antibiotic
resistance Tetracycline
among P. resistance
acnes organisms.
There
is and
eviSumycin
and
others
September
1954
>8 isyears
dence for significant
antibiotic
among
P. acnes,
menarchal
patients
generally
not
advised
except
in
consultation
with an endocrinologist.
Spironolactone
and its
analog,
drospirenone,
are
sometimes
used
in
the
treatment
of
antibiotic
resistance
among
P.
acnes
organisms.
There
is
evidence
for significant
antibiotichas
resistance
among
P. acnes,Doryx
and
Doxycycline
Vibramycin,
Adoxa
December
1967
>8 yearsSpironolactone
it is clear
that erythromycin
been largely
abandoned
by and analog,
Azithromycin
Zithromax
consultation
with
an
endocrinologist.
and
its
drospirenone,
are sometimes
usedagents
in the treatment
of
and
some 1982
adolescents,
but years
these
do not curdence
for significant
antibiotic
resistance
among
P. acnes,
2 and
Minocycline
Dynacin,
Minocin,
others
August
>12
it
is clear
that erythromycin
largely
abandoned
by and adults
exboth
dermatologists
(2.8%) has
andbeen
pediatricians
(7.2%),
analog,
drospirenone,
are
sometimes
used
in
the
treatment
of
adults
and
some
adolescents,
but
these
agents
do
not
currently
playMay
a significant
role in>12
preadolescent
acne.
it is clear
that erythromycin
has
largely
abandoned
by
2 exSolodyn
2006 Isotretinoin
years Accutane
both
dermatologists
and been
pediatricians
(7.2%),
Systemic
retinoid
cept
perhaps
for use(2.8%)
in prepubertal
children
or pregnant
adults
and
some
adolescents,
but
these
agents
do
not
currently playJuly
a significant
role in2 preadolescent
acne.
2 exTrimethoprimBactrim,
Septra
1973
months
both perhaps
dermatologists
(2.8%)
and pediatricians
(7.2%),
Amnesteem
cept
for alternative
use
in prepubertal
children
or pregnant
females
in whom
agents may
be less appropriate.
rently play a significant role in preadolescent
acne.
cept perhaps
for alternative
use sulfamethoxazole
in prepubertal
children
or pregnant
Sotret
females
in have
whom
agents may
be less
appropriate.
Clinicians
become
increasingly
aware
of
the
impact
of
Improving
Amoxicillin
November 1979
Indicated for Claravis
pediatric use; no
females in have
whombecome
alternative
agents may
beAmoxil
less
appropriate.
Clinicians
increasingly
aware
of18the
impact of
acne therapy
on causing “ecological
mischief.”
Widespread
Improving
Improving
Adherence
specific
age
restrictions
Clinicians
have
increasinglymischief.”
aware of18the
impact of
Adherence
Pediatric
Patients
Abx
� antibiotics; BP �in
benzoyl
peroxide.
Improving
acne
therapy
on become
causing
“ecological
Widespread
use of
antibiotics
for
acne
has been presumed
to be one
Cephalexin
Keflex
January
1971
Indicated
for
pediatric
use; no
18
Adherence
in
Pediatric
Patients
in
Pediatric
Patients
acneoftherapy
on causing
“ecological
mischief.”
Widespread
Source:
Drugs@FDA (http://www.accessdata.fda.gov/scripts/cder/drugsat
use
antibiotics
for for
acne
been
presumed
to be one
possible
driving force
thehas
selection
of antibiotic-resistant
A
recent literature search
using
the
key terms
adherence, comspecific
age Patients
restrictions
Adherence
in
Pediatric
use of antibiotics
for
acne
been of
presumed
to be one
possible
driving force
for
thehas
selection
antibiotic-resistant
A
recentor
literature
search
using>6
the
keyofterms
comAzithromycin
Zithromax
November
1991
P. acnes species.
Studies
looking
at P. acnes
antibiotic resispliance,
concordance
yielded
a months
list
moreadherence,
than 168,000
possible
driving
force
for
the
selection
of
antibiotic-resistant
A
recent
literature
search
using
the
key
terms
adherence,
comP.
acnes
species.
Studies
looking
at
P.
acnes
antibiotic
resispliance,
or
concordance
yielded
a
list
of
more
than
168,000
tance profiles have indicated increasing rates of antibiotic
articles. Although this is a highly heterogeneous group
of
P.
acnes
species.
Studies
looking
at
P.
acnes
antibiotic
resispliance,
or
concordance
yielded
a
list
of
more
than
168,000
19
>12 years
Maykey
1982
Systemic
retinoid
Accutane
tance
profiles
indicated
increasing rates
ofA.C.antibiotic
articles.
Although
this is are
a highly
heterogeneous
group of
resistance
overhave
time.Isotretinoin
articles, some
themes
highlighted
in these references.
Yan
et
al
tance profiles
indicated increasing rates
of antibiotic
articles. some
Although
this
is are
a highly
heterogeneous
group of
>12 years
November
2002
Amnesteem
resistance
over have
time.19
articles,
key themes
highlighted
in these references.
resistance over time.19
articles, some
key themes
highlighted
years in these references.
December
2002 are >12
Sotret
>12
years
2003 regimens.
Claravis
Simplify April
treatment
Successful
adherence is inw
This provides a rationale for incorporation
of BP into acne
versely related to the number of agents that must be taken or
al
therapeutic
regimens
where peroxide.
possible, either as a separate
Abx
� antibiotics;
BP � benzoyl
Source:
applied and the number of times each day that they must be
agent orDrugs@FDA
as part of (http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm).
a fixed combination, particularly when
C
taken or used. For patients who have difficulty with adequate
antibiotics are employed, as the use of BP has been associated
on
compliance, fixed-combination products may improve adwith a reduction in development of antibiotic resistance
le
herence to the prescribed regimen. Interestingly, however,
among P. acnes. Likewise, use of subantimicrobial doses of
ea
one multistep, multicomponent, over-the-counter acne
antibiotics has shown some limited benefit for patients with
product has generated a reported $830 million in sales
pa
comedonal and inflammatory lesions, while at the same time
Simplify
treatmenta regimens.
Successful
adherence
is resinworldwide,23 attesting to the popularity of therapeutic ritunot demonstrating
significant impact
on altering
native
20
versely
related toflora.
the number
of agents that must be taken or
ident microbial
als, particularly among adolescents.
applied and the number of times each day that they must be
17
Consider vehicle appropriateness. Adherence also depends
taken or used. For patients who have difficulty with adequate
Preadolescent
Acne
on identifying patient preferences and matching vehicle secompliance,
fixed-combination
products may improve ad-
ygel, Emgel
January 1985
Indicated for pediatric use; no
specific age restrictions
July 1980
>12 years
Table 4. FDA Approvals and Pediatric Age Indications for Medications Commonly Employed for Acne
October 2004
>12 years
Drug Category
Active Drug
Common Brand Names
Date of Earliest FDA Approval
July 2005
>12 years
Topical retinoid
Tretinoin
Retin-A 0.025%, 0.05%, 0.1%
October 1971
Avita 0.025%
January 1997
Atralin 0.05%
July 2007
Adapalene
Differin 0.1%, 0.3%
May 1996
Age Indication
≥12 years
≥12 years
≥10 years
≥12 years
Tazarotene
Tazorac 0.05%, 0.1%
June 1997
≥12 years
October
1984
>12
years
Topical antibiotic
Erythromycin
Akne-Mycin, Erygel, Emgel
January 1985
Indicated for pediatric use;
December 2000
>12 years
no specific age restrictions
August 2002
>12
years
Clindamycin
Cleocin T
July 1980
≥12 years
October 2008
>12 years
Evoclin
October 2004
≥12 years
December 2008
>12 years
Topical antiinflammatory
Aczone
July 2005
≥12 years
November 2006 Dapsone
>12 years
Fixed combination
product
July 2010
>12 years
y-tab
Indicated for pediatric
use; no
BP+Abx April 1965
BP+erythromycin
Benzamycin
October 1984
≥12 years
BP+clindamycin
Benzaclin
December 2000
≥12 years
hers
September 1954 >8 years
Duac
August 2002
≥12 years
ryx and Adoxa December 1967
>8 years
Acanya
October 2008
≥12 years
cin, and others August 1982
>12 years
BP+retinoidMay 2006
BP+tretinoin
Epiduo
December 2008
≥12 years
>12 years
July 1973
2 months
Retinoid+Abx
Tretinoin+
Ziana
November 2006
≥12 years
clindamycin
Veltin
July 2010
≥12 years
November 1979 Erythromycin
Indicated for pediatric
use;
no
Oral antibiotic
EES, Eryped,
Ery-tab
April 1965
January 1971
Indicated for pediatric use; no
Tetracycline
Sumycin and others
September 1954
≥8 years
Vibramycin, Doryx and Adoxa
December 1967
≥8 years
November 1991 Doxycycline
>6 months
Minocycline
Dynacin, Minocin, and others
August 1982
≥12 years
S20
S20
Solodyn
May 2006
≥12 years
>12 years
May 1982
>12 years
November 2002 TrimethoprimBactrim, Septra
July 1973
2 months
ointment.
>12 years
December 2002 sulfamethoxazole
ointment. Patients
Patients with
with oily
oily skin
skin may
may tolerate
tolerate gels
gels or
or solusolu>12
years
April 2003
tions,
whereas
those
with
dry
or
combination
skin
may
prefer
tions, whereas
those
mayuse;
prefer
Amoxicillin
Amoxil
November
1979with dry or combination
Indicated forskin
pediatric
lotions
lotions or
or creams.
creams.
er/drugsatfda/index.cfm).
nor
be
te
der,
ne
es
Cephalexin
Keflex
January 1971
Adjust
effects
may
arise
no specific
restrictions
Adjust regimens
regimens for
for tolerability.
tolerability. Side
Side
effectsage
may
arise with
with
use
of
topical
acne
medications,
particularly
at
the
start of a
use of topical
acne
medications, particularly
Azithromycin
Zithromax
November
1991
≥6 months at the start of a
new
It is possible to mitigate these
new treatment.
treatment.
these side
side effects
effects by
by
Systemic retinoid
Isotretinoin
Accutane
May 1982It is possible to mitigate
≥12 years
matching
the
vehicle
to
the
patient’s
skin
type,
as
mentioned
matching
the vehicle
skin
type, as mentioned
Amnesteem
November
2002 to the patient’s≥12
years
above.
patients
more
sensitive
Sotret
December
2002 who
years
above. Some
Some
patients
who may
may have
have≥12
more
sensitive skin
skin may
may
23
have
concerns
about
tolerating
topical
retinoid
therapy;
Claravis
April
2003
≥12
years
worldwide, attesting to the popularity of therapeutic rituhave concerns about tolerating topical retinoid therapy; these
these
individuals
Abx=antibiotics;
BP=benzoyl
peroxide.
Source: Drugs@FDA (http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm).
als,
particularly
among
adolescents.
individuals may
may benefit
benefit from
from gradual
gradual escalation
escalation of
of the
the retiretinoid,
initially
applying
the
medication
every
other
night
for
noid, initially applying the medication every other night for 1
1
Consider vehicle appropriateness. Adherence also depends
to
to 2
2 weeks
weeks before
before advancing
advancing to
to every-night
every-night therapy.
therapy. AlternaAlternaon identifying patient preferences and matching vehicle setively,
tively, some
some patients
patients prefer
prefer using
using medication
medication every
every night
night by
by
S20
A.C.
Yan
et al
lections
to those preferences. For example, gels and foams are
using
short-contact
applications
for
30
to
60
minutes
during
using
short-contact
applications
for
30
to
60
minutes
during
S20 to spread on hairy areas such as the male chest. Other
A.C. Yan et al
easier
the first
first 1
1 to
to 2
2 weeks
weeks before
before advancing
advancing to
to overnight
overnight therapy.
therapy.
the
patients
may
prefer
the
tactile
sensation
of
a
cream
over
an
Starting
with
lower-potency
retinoids
and
advancing
to
ointment. Patients with oily skin may tolerate gels or soluStarting
with lower-potency retinoids and advancing to higherhigherConclusion
ointment.
Patients
with
oily
skin
may
tolerate
gels
or
solupotency
retinoids
Conclusion
tions, whereas those with dry or combination skin may prefer
potency
retinoids at
at follow-up
follow-up visits
visits may
may also
also improve
improve effieffitions,
those with dry or combination skin may prefer
A wide
range
of acne therapies
are available for pediatric use.
cacy
while
minimizing
irritancy.
lotionswhereas
or creams.
cacy
while
minimizing
irritancy.
A
wide range
ofof
acne
therapies
are available
pediatric�use.
lotions or creams.
Although
most
these
are indicated
for usefor
in patients
12
Although
most
of
these
are
indicated
for
use
in
patients
�
12
Provide
written
action
plans,
videos,
text-messaging
reyears
of
age,
judicious
use
of
these
medications
in
an
off-label
Adjust regimens for tolerability. Side effects may arise with
Provide written action plans, videos, text-messaging reyears
of age,
judicious
useplans,
ofpreadolescent
these
medications
in
off-label
Adjust
regimens
formedications,
tolerability. particularly
Side effectsatmay
minders.
Written
action
educational
videos,
and
textfashion
for
children
with
acne
is an
reasonable
use of topical
acne
thearise
startwith
of a
minders.
Written
action
plans,
educational
videos,
and
textfashion
for
children
with
preadolescent
acne
is
reasonable
use
of
topical
acne
medications,
particularly
at
the
start
of
a
messaging
reminders
about
using
prescribed
medications
are
until morereminders
research isabout
available
usemedications
of these agents
new treatment. It is possible to mitigate these side effects by
messaging
usingregarding
prescribed
are
until
more
research
is
available
regarding
use
of
these
agents
new
treatment.
It
is
possible
to
mitigate
these
side
effects
by
among
the
various
techniques
advocated
to
reinforce
treatin the preadolescent
population.
matching the vehicle to the patient’s skin type, as mentioned
among
the various techniques
advocated to reinforce treatin Most
therecommendations
preadolescent
matching
thepatients
vehicle to
themay
patient’s
skin type,
as mentioned
ment
and
“Cheerleadchildren withpopulation.
mild
acne willadherence.
tolerate topical
agents
above. Some
who
have more
sensitive
skin may
ment
recommendations
and improve
improve
adherence.
“CheerleadMost
children
with
mild
acne
will
tolerate
topicaleither
agents
above.
Some
patients
who
may
have
more
sensitive
skin
may
ing”
by
the
clinician
and
staff
who
see
signs
of
improvement
such
as
BP,
topical
retinoids,
and
topical
antibiotics,
as
have concerns about tolerating topical retinoid therapy; these
ing” by the clinician and staff who see signs of improvement
such
as
BP,
topical
retinoids,
and
topical
antibiotics,
either
as
have
concerns
about
tolerating
topical
retinoid
therapy;
these
can
encourage
patients
to
continue
with
their
prescribed
regsingle
agents
or
in
fixed
combinations,
especially
if
the
dosing
individuals may benefit from gradual escalation of the retican encourage patients to continue with their prescribed regsingle
agents
or
in
fixed
combinations,
especially
if
the
dosing
individuals
may
benefitthe
from
gradual every
escalation
the for
retiimens.
of these agents is escalated gradually, using some of the technoid, initially
applying
medication
otherof
night
1
imens.
of
thesediscussed.
agents is escalated
gradually,
using some ofacne
the technoid,
initially
applying
the
medication
every
other
night
for
1
niques
Those with
moderate-to-severe
may
to 2 weeks before advancing to every-night therapy. Alterna-globalacademycme.com/sdef • Pediatric
Manage
expectations.
It
is
important
to
anticipate
side
ef18
Acne
Management:
Optimizing
Outcomes
niques
discussed.
Those
with
moderate-to-severe
acne
may
to
2
weeks
before
advancing
to
every-night
therapy.
AlternaManage
expectations.
It
is
important
to
anticipate
side
efrequire
systemic
therapy.
Children
8
years
of
age
and
older
tively, some patients prefer using medication every night by
require
systemic
therapy.
Children
8
years
of
age
and
older
fects
and
educate
patients
in
advance
that
most
side
effects
do
tively,
some
patients
prefer
using
medication
every
night
by
fects
and
educate
patients
in
advance
that
most
side
effects
do
should
be
able
to
tolerate
tetracycline
derivatives,
including
using short-contact applications for 30 to 60 minutes during
C
C
A
A
Al
Al
ye
ye
fas
fas
un
un
in
in
su
su
sin
sin
of
of
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do
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to
to
log
log
cr
cr
bi
bi
wi
wi
do
do
ap
ap
ab
ab
th
th
R
R
1
1
uer
th
a
by
ed
ay
se
ti1
aby
ng
y.
rfi-
extre
atdnt
g-
efdo
imens.
imens.
imens.
Manage
expectations.
It
is
important
to
anticipate
side
efManage
expectations.
It
is
important
to
anticipate
side
efManage
expectations.
It
is
important
to
anticipate
side
Manage
expectations.
It in
is advance
important
tomost
anticipate
side efeffects
and
educate
patients
that
side
effects
do
fects
and
educate
patients
in
advance
that
most
side
effects
do
fects
and
educate
patients
in
advance
that
most
side
effects
do
fects
and
educate
patients
in
advance
that
most
side
effects
do
not
require
stopping
a
medication
but
can
be
managed
sucnot
require
stopping
a
medication
but
can
be
managed
sucnot
require
stopping
a
medication
but
can
be
managed
sucnot
require
stopping
aadjustments
medication in
butthe
canregimen.
be managed
successfully
with
minor
Pediatric
cessfully
with
minor
adjustments
in
the
regimen.
Pediatric
cessfully
with
minor
adjustments
in
the
regimen.
Pediatric
cessfully
with
minor
adjustments
in
the
regimen.
Pediatric
and
especially
adolescent
patients
also benefit
from
underand
especially
adolescent
patients
benefit
from
underand
especially
adolescent
patients also
also
benefit
from
underand
especially
adolescent
alsotime
benefit
from
understanding
the
definition
of
aa patients
“reasonable
frame”
for
seeing
standing
the
definition
of
“reasonable
time
frame”
for
seeing
standing
the
definition
of
a
“reasonable
time
frame”
for
seeing
standing
the
definition
of
a
“reasonable
time
frame”
for
seeing
signs
of
improvement.
These
patients
often
have
unrealistic
signs
of
improvement.
These
patients
often
have
unrealistic
signs of
of improvement.
improvement. These
These patients
patients often
often have
have unrealistic
unrealistic
signs
expectations
of
seeing
improvement
in
hours
to
days
(often
expectations
of
seeing
improvement
in
hours
to
days
(often
expectations
of
seeing
improvement
in
hours
to
days
(often
expectations
of
seeing
improvement
in
hours
to
days
(often
reinforced
by
what
they
see
in
advertisements
for
over-thereinforced
by
what
they
see
in
advertisements
for
over-thereinforced
by
what
they
see
in
advertisements
for
over-thereinforced
by
what
they
see
in
advertisements
for
over-thecounter
products
that
promise
overnight
results),
whereas
counter
products
that
promise
overnight
results),
whereas
counter
products
that
promise
overnight
results),
whereas
counter
products
that
promise
overnight
results),
whereas
the
typical
improvement
is
measured
in
weeks
to
months.
the
typical
improvement
is
measured
in
weeks
to
months.
the typical
typical improvement
improvement is
is measured
measured in
in weeks
weeks to
to months.
months.
the
Monitor
for
psychological
comorbidities.
The
psychological
Monitor
for
psychological
comorbidities.
The
psychological
Monitor
for
psychological
comorbidities.
The
psychological
24
Monitor
for
psychological
comorbidities.
The
psychological
24
affirmed
that
impact
of
acne
can
be
considerable.
One
study
affirmed
that
impact
of
acne
can
be
considerable.
One
study
24
affirmed
that
impact
of
acne
can
be
considerable.
One
study
24
affirmed
that
impact
of
acne
can
be
considerable.
One
study
adolescent
patients
often
have
psychological
and
especially
adolescent
patients
often
have
psychological
and
especially
adolescent
patients
often
have
psychological
and
especially
adolescent
patients
often
have
psychological
and
especially
mood
issues related
to their
acne in
a severity-dependent
mood
mood issues
issues related
related to
to their
their acne
acne in
in aaa severity-dependent
severity-dependent
mood
issues
related
to
their
acne
in
severity-dependent
fashion.
The
more
severe
the
acne,
the
more
severe
and
more
fashion.
The
more
severe
the
acne,
the
more
severe
and
more
fashion.
The
more
severe
the
acne,
the
more
severe
and
more
fashion.
The
more
severe
the
acne,
the
more
severe
and
more
prevalent
were
the
mood
disturbances
that
were
noted.
Cliprevalent
were
the
mood
disturbances
that
were
noted.
Cliprevalent
were
the
mood
disturbances
that
were
noted.
Cliprevalent
were
the
mood
disturbances
that
were
noted.
Clinicians
who
care
for
patients
with
acne
should
remain
alert
nicians
who
care
for
patients
with
acne
should
remain
alert
nicians
who
care
for
patients
with
acne
should
remain
alert
nicians
who
care
for
patients
with
acne
should
remain
alert
for
the
presence
of
depression
or
other
emotional
or
social
for
the
presence
of
depression
or
other
emotional
or
social
for
the
presence
of
depression
or
other
emotional
or
social
for
the
presence
of
depression
or
other
emotional
or
social
issues,
and
may
provide
encouragement
for
the
patient
and
issues,
and
may
provide
encouragement
for
the
patient
and
issues,
and
may
provide
encouragement
for
the
patient
and
issues,
and
may
provide
encouragement
for
the
patient
and
family
to
seek
counseling
or
other
therapy,
as
appropriate.
family
to
seek
counseling
or
other
therapy,
as
appropriate.
family
to
seek
counseling
or
other
therapy,
as
appropriate.
family to seek counseling or other therapy, as appropriate.
Consider
cost
issues.
Medication
can
have
Consider
cost
issues.
Medication costs
costs
can
have aaa substansubstanConsider
cost
issues.
costs
can
Consider
cost
issues. Medication
Medication
costs
can have
have
a substansubstantial
impact
on
whether
aa prescription
is
filled
and
on
whether
tial
impact
on
whether
prescription
is
filled
and
on
whether
tial
impact
on
whether
aa prescription
is
filled
and
on
whether
tial
impact
on
whether
prescription
is
filled
and
on
whether
aa patient
who
begins
using
a
medication
remains
adherent
patient
who
begins
using
a
medication
remains
adherent
aa patient
who
begins
using
a
medication
remains
adherent
patient
who begins using
a medication
remains
adherent
with
the
recommended
regimen
in
the
long
term.
Cost
conwith
the
recommended
regimen
in
the
long
term.
Cost
conwith
the
recommended
regimen
in
the
long
term.
Cost
conwith
the
recommended
regimen
in
the
long
term.
Cost
considerations
should
be
taken
into
account
when
selecting
apsiderations
should
be
taken
into
account
when
selecting
apsiderations
should
be
taken
into
account
when
selecting
apsiderations
should
be
taken
into
account
when
selecting
appropriate
medications.
propriate
medications.
A.C. Yan et al
propriate
medications.
propriate medications.
Conclusion
Conclusion
A wide range of acne therapies are available for pediatric use.
Although most of these are indicated for use in patients � 12
years of age, judicious use of these medications in an off-label
fashion for children with preadolescent acne is reasonable
until more research is available regarding use of these agents
in the preadolescent population.
Most children with mild acne will tolerate topical agents
such as BP, topical retinoids, and topical antibiotics, either as
single agents or in fixed combinations, especially if the dosing
Approach
to pediatric
acne treatment
of these agents
is escalated
gradually, using some of the techniques discussed. Those with moderate-to-severe acne may
require
Children 8 years
of age 10:469-473,
and older
acne systemic
comedonicatherapy.
and papulo-pustulosa.
J Chemother
1998be able to tolerate tetracycline derivatives, including
should
13.
Antonio JR,and
Pegasminocycline,
JR, Cestari TF,which
DoNascimento
LV: Azithromycin
doxycycline
have more
favorable
pulses in the treatment of inflammatory and pustular acne: Efficacy,
antibiotic-resistance
profiles
and
dosing
schedules
than
tolerability, and safety. J Dermatolog Treat 19:210-215, 2008 does
tetracycline.
When
possible,
BP A,
should
be Potenza
incorporated
into
14.
Innocenzi D,
Skroza
N, Ruggiero
Concetta
M, Proietti
I:
Moderate
acne vulgaris:
Efficacy,
azitopical
regimens
in an effort
totolerance
reduce and
the compliance
potential of
fororal
“ecothromycin
thriceand
weekly.
Croat 16:13-18,
logical
mischief”
theActa
riskDermatovenerol
of altering native
resident2008
mi15. Kapadia N, Talib A: Acne treated successfully with azithromycin. Int J
crobial
flora.
When
effective,
subantimicrobial
doses
of
antiDermatol 43:766-767, 2004
biotics
areF,preferable
to higher
doses,
although
many
patients
16.
Gruber
Grubisic-Greblo
H, Kastelan
M, Brajac
I, Lenkovic
M, Zamolo
G:
withAzithromycin
moderate-to-severe
mayinrequire
antimicrobial
compared with acne
minocycline
the treatment
of acne comedonica
and papulo-pustulosa.
J Chemother 10:469-473, 1998
doses
to control
their disease.
17. Ultimately,
Fernandez-Obregon
AC:
Azithromycin
for thenot
treatment
of acne. IntofJ
optimal outcomes require
only selection
Dermatol 39:45-50, 2000
appropriate
also an
understanding
18.
Leyden JJ, pharmacotherapy,
Del Rosso JQ, Webster but
GF: Clinical
considerations
in the
about
factorsofthat
affect
with recommended
treatment
acnemay
vulgaris
andcompliance
other inflammatory
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Dermatol Clin 27:1-15, 2009
therapeutic
regimens.
therapeutic
therapeutic regimens.
regimens.
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MK,
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BC,
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RK:
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of
oral
azithromycin
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MK,
Ghiya
BC,
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RK:
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of
oral
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with
daily
doxycycline
in
the
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of
acne
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pulse
with
daily
doxycycline
in
the
treatment
of
acne
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pulse with
with daily
daily doxycycline
doxycycline in
in the
the treatment
treatment of
of acne
acne vulgaris.
vulgaris. Indian
Indian JJ
pulse
Indian
Dermatol
Venereol Leprol
Leprol
69:274-276, 2003
2003
Dermatol
Venereol
69:274-276,
Approach
to
pediatric
acne
treatment
Dermatol
Venereol
Leprol
69:274-276,
2003
Dermatol
Venereol
Leprol
69:274-276,
2003
12.
Gruber
F,
Grubisić-Greblo
H,
Kastelan
M,
Brajac
I,
Lenković
M, Za12.
Gruber
F,
H,
Kastelan M,
Brajac I,
Lenković
Za12.
Gruber
F, Grubisić-Greblo
Grubisić-Greblo
H,
M,
Lenković M,
M,
12. molo
Gruber
Grubisić-Greblo
H, Kastelan
Kastelan
M, Brajac
Brajac I,
I,in
M, ZaZamolo
G:F,
Azithromycin
compared
with minocycline
minocycline
inLenković
the treatment
treatment
of
G:
Azithromycin
compared
with
the
of
molo
G:
Azithromycin
compared
with
minocycline
in
the
treatment
molo
Azithromycin
with minocycline
in the 10:469-473,
treatment of
of
acne G:
comedonica
andcompared
papulo-pustulosa.
J Chemother
1998
13. Antonio JR, Pegas JR, Cestari TF, DoNascimento LV: Azithromycin
pulses in the treatment of inflammatory and pustular acne: Efficacy,
tolerability, and safety. J Dermatolog Treat 19:210-215, 2008
14. Innocenzi D, Skroza N, Ruggiero A, Concetta Potenza M, Proietti I:
Moderate acne vulgaris: Efficacy, tolerance and compliance of oral azithromycin thrice weekly. Acta Dermatovenerol Croat 16:13-18, 2008
15. Kapadia N, Talib A: Acne treated successfully with azithromycin. Int J
Dermatol 43:766-767, 2004
16. Gruber F, Grubisic-Greblo H, Kastelan M, Brajac I, Lenkovic M, Zamolo G:
Azithromycin compared with minocycline in the treatment of acne comedonica and papulo-pustulosa. J Chemother 10:469-473, 1998
17. Fernandez-Obregon AC: Azithromycin for the treatment of acne. Int J
Dermatol 39:45-50, 2000
18. Leyden JJ, Del Rosso JQ, Webster GF: Clinical considerations inS21
the
treatment of acne vulgaris and other inflammatory skin disorders: A
status report. Dermatol Clin 27:1-15, 2009
19. Eady AE, Cove JH, Layton AM: Is antibiotic resistance in cutaneous
propionibacteria clinically relevant? Implications of resistance for acne
patients and prescribers. Am J Clin Dermatol 4:813-831, 2003
20. Skidmore R, Kovach R, Walker C, et al: Effects of subantimicrobialdose doxycycline in the treatment of moderate acne. Arch Dermatol
139:459-464, 2003
21. Eichenfield L, Matiz C, Funk A, Dill SW: Study of the efficacy and
tolerability of 0.04% tretinoin microsphere gel for preadolescent acne.
Pediatrics 125:1316-1323, 2010
22. Cunliffe WJ, Baron SE, Coulson IH: A clinical and therapeutic study of
29 patients with infantile acne. Br J Dermatol 145:463-466, 2001
23. Katz S: Online exclusive: Proactive reformulates packaging. Available at:
http://www.beautypackaging.com/articles/2010/01/online-exclusiveproactiv-reformulates-packaging. Accessed July 19, 2011.
24. Dalgard F, Gieler U, Holm JO, Bjertness E, Hauser S: Self-esteem and
body satisfaction among late adolescdents with acne: Results from a
population survey. J Am Acad Dermatol 59:46-51, 2008
References
19
19
20
21
22
23
24
hne
yl
e,
in
in
er
as
ne
as
cy
m
efieer
ve
ed
ry
dio-
ic
ng
Parents as Partners in Pediatric Acne Management
Volume 30, Number 3S
September 2011
Parents As Partners in Pediatric Acne Management
C
ooperation and communication between parents or
other caregivers and a child’s clinicians are essential to
providing the highest quality of medical treatment, regardless
of the health issue at hand. The provision of written materials
has
long continuum
been recognized as a valuable means of enhancing
The acne
the parents’ knowledge about the child’s condition, diagnostic tests, therapeutic procedures, and medications. Written
ble 4. Bone
agecan
should
also be evaluated.
In addition,informaif Cushmaterials
also
be effective
tools for reinforcing
ing’s and
syndrome
is suspected,
hormone
tion
instructions
providedadrenocorticotropic
directly to the patient
and
stimulation
testing
can
be
considered.
parents in clinical encounters.
Some clinicians recommend initial therapy with a benzoyl
The treatment of acne in preadolescent patients is someperoxide wash for patients with very mild comedonal acne,
times a challenge for clinicians, for two main reasons. First,
but all of the topical medications that are used for acne in
when a child between 7 and 11 years of age presents with
patients 12 years of age or older also are appropriate for use in
facial acne lesions, parents usually require reassurance about
preadolescents. The efficacy and safety data on these younger
the accuracy of the diagnosis and the fact that acne is normal
patients are limited: tretinoin has been tested in children as
in children in this age group.
Acne generally is thought of as
young as 8 years of age,11 and a benzoyl peroxide/adapalene
a “teenager’s disease” and is usually associated with the onset
combination topical agent has been tested in children as
of puberty. The appearance of lesions in a child who may not
young as 10 years of age. Based on the large body of efficacy
have
any external
puberty patients
may cause
parents
to
S11
and safety
data fromsigns
olderofpediatric
(ie, those
from
worry
that
the
child
has
some
underlying
disease,
such
as
12 through 17 years of age)—and, as extensive clinical expehormonal
imbalance.
rience has
shown—it
is reasonable
to presume
similarmost
effipresent
with
mild, usually
comedonal
disease, which
Second,
once in
theyounger
parents children.
are comfortable
withbecause
the diagnocacy
and
safety
However,
preoften is a normal physiologic occurrence.
sis,
the issue
of treatment
must sebum
be addressed.
adolescent
patients
tooptions
produce
than
do With
older
Treatment
at anytend
age depends
onless
the type and
severity
of
few
exceptions,
standard
acne
therapy
is
approved
by the
patients, theirComedonal
skin tends to
be more
sensitive.
involvement.
disease
responds
bestTotoimprove
topical
U.S.
Food itand
Drughelpful
Administration
(FDA) for
as
tolerance,
is often
to initiate
withpatients
decreased
benzoyl
peroxide
and topical
retinoidtherapy
products;
inflammayoung
as
12
years
of
age.
The
recommendations
for
use
of
frequency
application
(for from
example,
twice weekly
or every
tory
diseaseofusually
benefits
the addition
of topical
or
other day),
and application
smallermay
amounts
of treatment
the medisystemic
antibiotics.
Severe of
disease
warrant
cation.
In
addition,
the
daily
application
of
a
noncomedowith systemic isotretinoin, regardless of age. Families should
genic moisturizer
mayregarding
be useful.the risks and benefits of any
always
be counseled
When
necessary
for
the treatment of severe, nodulocystic
therapeutic option.
The
Acne
Continuum:
Ansystemic
Age-Based
Approach
acne in preadolescent patients,
agents—including
References
References
over-the-counter (OTC) topical products for mild acne (such
as those containing benzoyl peroxide) are unlikely to cause
parental concerns; however, a child with moderate-to-severe
acne may require more aggressive therapy with prescription
products that are FDA-indicated for pages 12 years of age and
S11
older. The authors have experienced resistance from some
parents who hesitate to allow their children to be treated with
presentmedications.
with mild, usually
disease,
which
most
“adult”
This is acomedonal
particular issue
when
oral medoften is is
a normal
physiologic
occurrence.
ication
an appropriate
option—
even including, in rare
Treatment
at any age depends on the type and severity of
cases,
isotretinoin.
involvement.
disease
responds
best toover
topical
The averageComedonal
age of onset of
puberty
has decreased
the
benzoyl
peroxide
topical retinoid
products; inflammapast
50 years,
and and
the presentation
of preadolescent
acne is
no
either
unusual
or a from
causethe
foraddition
concern.ofMany
clinitorylonger
disease
usually
benefits
topical
or
cians
whoantibiotics.
treat children
now disease
are aware
of this
phenomenon,
systemic
Severe
may
warrant
treatment
as
well
as its implications,
most
parents
are not.
with
systemic
isotretinoin, whereas
regardless
of age.
Families
should
The authors
collaborated
in developing
a parent
education
always
be counseled
regarding
the risks and
benefits
of any
handout
that
is
designed
to
help
bridge
this
information
gap.
therapeutic option.
It includes background information on acne, reinforces the
message
regarding the normalcy of preadolescent acne, disReferences
cusses
skin
and addresses
acne treatment
1. Tomappropriate
WL, Friedlander
SF:care,
Acne through
the ages: Case-based
observaoptions
their
appropriate
use.
tionsand
through
childhood
and adolescence.
Clin Pediatr (Phila) 47:639651, 2008
2. Antoniou C, Dessinioti C, Stratigos
AJ, Katsambas
AD: ClinicalMD
and
Lawrence
F. Eichenfield,
therapeutic approach to childhood acne: An update. Pediatr Dermatol
Anthony J. Mancini, MD
26:373-380, 2009
Albert
C. A:
Yan,
MD
3. Rapelanoro R, Mortureux P, Couprie B, Maleville
J, Taieb
Neonatal
Sheila
Fallon
Friedlander,
Malassezia furfur pustulosis. Arch
Dermatol
132:190-193,
1996 MD
4. Niamba P, Weill FX, Sarlangue J, Labrèze
C, Couprie
B, Taïeh MD
A: Is
Hilary
E. Baldwin,
common neonatal cephalic pustulosis (neonatal acne) triggered by
Malassezia sympodialis? Arch Dermatol 134:995-998, 1998
5. Bernier V, Weill FX, Hirigoyen V, et al. Skin colonization by Malassezia
species in neonates: A prospective study and relationship with neonatal
cephalic pustulosis. Arch Dermatol 138:215-218, 2002
6. Ayhan M, Sancak B, Karaduman A, Arikan
S, Sahin S:from
Colonization
to Therapy
continued
page 11of
neonate skin by Malassezia species: Relationship with neonatal cephalic
pustulosis. J Am Acad Dermatol 57:1012-1018, 2007
7. Chew EW, Bingham A, Burrows D: Incidence of acne vulgaris in patients with infantile acne. Clin Exp Dermatol 15:376-377, 1990
8. Lucky AW, Biro FM, Huster GA, Morrison JA, Elder N: Acne vulgaris in
early adolescent boys. Correlations with pubertal maturation and age.
Arch Dermatol 127:210-216, 1991
9. Lucky AW, Biro FM, Huster GA, Leach AD, Morrison JA, Ratterman J:
Acne vulgaris in premenarchal girls: An early sign of puberty associated
with rising levels of dehydroepiandrosterone. Arch Dermatol 130:308314, 1994
10. Krakowski AC, Eichenfield LF: Pediatric acne: Clinical presentations,
evaluation, and management. J Drugs Dermatol 6:589-593, 2007
11. Eichenfield LF, Matiz C, Funk A, Dill SW: Study of the efficacy and
tolerability of 0.4% tretinoin microsphere gel for preadolescent acne.
Pediatrics 125:e1316-e1323, 2010
1. Tom WL, Friedlander SF: Acne through the ages: Case-based observations through childhood and adolescence. Clin Pediatr (Phila) 47:639651, 2008
2. Antoniou C, Dessinioti C, Stratigos AJ, Katsambas AD: Clinical and
Acne
can occur at any time in life; cause for concern differs
therapeutic approach to childhood acne: An update. Pediatr Dermatol
depending
on 2009
age of presentation. Neonatal disease is often
26:373-380,
transient
and R,
may
be related
to pityrosporum
disease.
Acne
3. Rapelanoro
Mortureux
P, Couprie
B, Maleville J, Taieb
A: Neonatal
pustulosis.
Arch Dermatol
thatMalassezia
presentsfurfur
in the
postneonatal
period132:190-193,
but before1996
1 year of
4. is
Niamba
P, Weill
FX, Sarlangue
J, Labrèze
Couprie
B, TaïehisA:
Is
age
usually
defined
as infantile
diseaseC,and
generally
not
common neonatal cephalic pustulosis (neonatal acne) triggered by
associated with underlying pathology. In contrast, disease
Malassezia sympodialis? Arch Dermatol 134:995-998, 1998
that
presents
between
1 and 7V,years
of life
is of more
5. Bernier
V, Weill
FX, Hirigoyen
et al. Skin
colonization
by concern,
Malassezia
and species
a full inevaluation
for
possible
underlying
hormonal
paneonates: A prospective study and relationship with neonatal
cephalic
pustulosis. Arch
Dermatol
thology
is warranted.
Children
as138:215-218,
young as 72002
years of age can
6. Ayhan M, Sancak
B, Karaduman
A, Arikan
S, Inc.
Sahin
Colonization
1085-5629/11/$-see
front
matter © 2011
Elsevier
AllS:rights
reserved.of
neonate skin by Malassezia species: Relationship with neonatal cephalic
doi:10.1016/j.sder.2011.08.006
pustulosis. J Am Acad Dermatol 57:1012-1018, 2007
7. Chew EW, Bingham A, Burrows D: Incidence of acne vulgaris in pa20 tients with infantile acne. Clin Exp Dermatol 15:376-377, 1990
Summary
8. Lucky AW, Biro FM, Huster GA, Morrison JA, Elder N: Acne vulgaris in
My Child Has Acne: Information and a Guide
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There are a number of conditions that can look like acne, so your
child should be examined and diagnosed by a health care practiPediatric
Management:
tioner. Acne
If a child
has mildOptimizing
acne (comedones
that are not inflamed or
too numerous) and if the condition is not bothersome to your child,
good skin care may be all that is needed at this point.
i
21
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Acne
Treatments
Acne
Treatments
Acne
Acne Treatments
Treatments
Acne
Treatments
Facials
and and
other
treatments
to remove,
squeeze,
or “clean
out”out”
pimples
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other
treatments
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remove,
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pimples
Acne
Treatments
Facials
other
treatments
to
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Acne
Treatments
Facials
and
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treatments
to remove,
remove,the
squeeze,
or this
“clean
out”
pimples
are
notand
recommended.
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skin in
way
can
make
are not recommended. Manipulating the skin in this way can make
are
not
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Manipulating
the
skin
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way
can
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are Facials
not
recommended.
Manipulating
the
skin
init this
this
way
can
make
acne
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can lead
to scarring.
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likely
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to remove,
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Facials
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also
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skin
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will
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tolerate
medications.
For
the
same
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are
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able
to
tolerate
acne
medications.
For
the
same
reason,
children
should
be
discouraged
from
picking
at
their
pimples.
worse
and
can
lead
to
scarring.
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also
makes
it
more
likely
that
the
children
should
be discouraged
from
picking
atmore
theirlikely
pimples.
acne
worse
and
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it
that
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Medications
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What
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same
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do
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for
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What
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acne
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Medications
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andformaother
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tion
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and
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children
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their
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tion
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reducing
or
removing
the
bacteria,
and
other
tionthings
of What
new (like
pimples
byskin
reducing
or
removing
the
oil,
bacteria,
and
other
things
(like
dead
skin
cells)
that that
clog
the pores.
They
can
also
decrease
do
acne
treatments
do?
Medications
for
acne
stop
the
formadead
cells)
clog
the
pores.
They
can
also
decrease
What
do
acne
treatments
do?
Medications
for
acne
stop
the
formathings
(like
dead
skin
cells)
that
clog
the of
pores.
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also decrease
things
(like
dead
skin
cells)
thatresponse
clog
pores.
They
can
decrease
the
inflammation
or irritation
the
tocan
bacteria.
It
can
tion
of new
pimples
byirritation
reducing
orthe
removing
theskin
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and
other
the
inflammation
or
response
of skin
the
toalso
bacteria.
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can
tion
of new
pimples
byirritation
reducing
or removing
the
oil,
bacteria,
andIt
other
the
inflammation
or
response
of
the
skin
to
bacteria.
can
the things
inflammation
or
irritation
response
of
the
skin
to
bacteria.
Itdecrease
can
take
from
4
to
8
weeks
before
it
is
clear
whether
the
medication
is is
(like
dead
skin
cells)
that
clog
the
pores.
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can
also
take
from
4
to
8
weeks
before
it
is
clear
whether
the
medication
things
(like4dead
skin
cells)
that clog
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pores. Theythe
canmedication
also decrease
take
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to
weeks
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is
takethe
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to 8
8your
weeks
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it response
ismedications
clear whether
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medication
effective
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child.
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or
irritation
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to
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for
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doskin
not
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child.
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medications
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condieffective
for
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child.
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improves
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itmedication
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weeks
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8toweeks
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theand
medication
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tion—the
acne
because
the
medication,
it
tion—the
acne
because
the
medication,
and
it therefore
therefore
must
be continued
in child.
order
to
prevent
return
of do
the
acne
lesions.
effective
for improves
your
These
medications
“cure”
the
condimust
be
continued
inThese
order
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prevent
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ofnot
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effective
for
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be
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in
order
prevent
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acne
lesions.
must
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continued
in
order
to
prevent
return
of the
the
acneapplied
lesions.
There
are many
types
of to
acne
treatments.
Some
are
the
tion—the
acne
improves
because
of
the
medication,
and
it to
therefore
are
many
types
of
acne
Some
are
to the
tion—the
acne
improves
because
of treatments.
the
medication,
and
itapplied
therefore
There
are
many
types
of
acne
treatments.
Some
are
applied
to
the
There
are
many
types
of
acne
treatments.
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are
applied
to
the
skin
(topical
medications)
and
some
are
taken
by
mouth
(oral
medmust
be
continued
in
order
to
prevent
return
of
the
acne
lesions.
skin
(topical
medications)
and
some
are
taken
by
mouth
(oral
medmust
be continued
in order and
to prevent
return
of by
themouth
acne lesions.
skin
(topical
medications)
some
are
taken
(oral
medskinications).
(topical
medications)
some
are
taken
by
mouth
(oral
medications).
In are
most
cases
ofand
mild
acne,
the
doctor
willare
start
with
There
types
of
treatments.
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applied
toa thea
In many
most
cases
ofacne
mild
acne,
the
doctor
will
start
with
There
are
many
types
of
acne
treatments.
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are
applied
to
the
ications).
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most
cases
of
mild
the
doctor
will
start
with
aa
ications).
Inmedication.
most
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mild
acne,
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doctor
will
start
with
topical
medication.
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isacne,
the
most
common
type
seen
in
skin
(topical
medications)
some
are
taken
by
mouth
(oral
medtopical
acne
isare
the
most
type
seen
in
skin
(topical
medications)
andand
some
taken
bycommon
mouth
(oral
medtopical
medication.
Mild
acne
is
the
most
common
type
seen
in
topical
medication.
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acne
ismore
the
most
common
type
seen
in a
preadolescent
children.
If acne
is
severe,
ifdoctor
it does
not not
respond
ications).
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most
cases
of
mild
acne,
the
will
start
with
preadolescent
children.
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acne
is
more
severe,
if
it
does
respond
ications).
In
most
cases
of
mild
acne,
the
doctor
will
start
with
a
preadolescent
children.
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acne
is
severe,
if
does
not
respond
preadolescent
children.
IfMild
acneacne
is more
more
severe,
if it
it
does
notbody
respond
adequately
to topical
medication,
oris ifthe
it ifcovers
large
body
surface
topical
medication.
most
common
seen
adequately
to topical
medication,
or
itcommon
covers
large
surface
topical
medication.
Mild
acne is the
most
typetype
seen
in in
adequately
to
topical
medication,
or
if
it
covers
large
body
surface
adequately
to
topical
medication,
or
if
it
covers
large
body
surface
areas
such
as
the
back
and
chest,
oral
antibiotics
are
usually
pre-prepreadolescent
children.
If
acne
is
more
severe,
if
it
does
not
respond
areas
such
as
the
back
and
chest,
oral
antibiotics
are
usually
preadolescent
children.
If acne
is more
severe, if it does
not respond
areas
such
as
back
and
chest,
oral
are
usually
areas
such
asInthe
the
back
and
chest,
oralorantibiotics
antibiotics
are
usually
prescribed.
In the
most
severe
cases,
isotretinoin
maymay
be
used,
butpreit
is it is
adequately
to topical
medication,
it covers
large
body
surface
scribed.
the
most
severe
cases,
be
used,
but
adequately
to topical
medication,
or ifisotretinoin
it ifcovers
large
body
surface
scribed.
In
the
most
severe
cases,
isotretinoin
may
be
used,
but
scribed.
Insuch
the
most
severe
cases,
isotretinoin
may
be used,
butItit
it is
ispreuncommon
to as
need
this
last
medication
in
preadolescents.
areas
the
back
and
chest,
oral
antibiotics
are
usually
uncommon
to
need
this
last
medication
in
preadolescents.
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areas
such astothe
back
andlast
chest,
oral antibiotics
are usually It
preuncommon
need
this
medication
in
preadolescents.
is
uncommon
tostart
need
this
last
medication
inlikely
preadolescents.
It
isit is
always
bestbest
to
with
the
agents
least
likely
to may
cause
effects,
scribed.
In
the
most
severe
isotretinoin
beside
used,
but
always
to start
with
thecases,
agents
least
to
cause
side
effects,
scribed.
In
the
most
severe
cases,
isotretinoin
may
be
used,
but
it
is
always
to
with
least
likely
to
cause side
always
best
to start
start
with the
the agents
agents
least
likely
to
side effects,
effects,It is
such
asbest
topical
medications,
in mild
disease.
uncommon
to medications,
need
in cause
preadolescents.
such
as topical
inmedication
mild
disease.
uncommon
to medications,
need
thisthis
lastinlast
medication
in preadolescents.
It is
such
as
topical
mild
disease.
such
as
topical
medications,
in
mild
disease.
Some
patients
have
awith
good
result
with
just
oneto
medication,
but
always
best
to
start
the
agents
least
likely
cause
side
effects,
Some
patients
have
a
good
result
with
just
one
medication,
but
always
best
to start
witha the
agents
least
likely
to cause
side effects,
Some
patients
have
good
result
with
just
one
medication,
but
Some
patients
result
with
just
one medication,
many
willas
need
tohave
use
agood
combination
ofdisease.
treatments:
twotwo
or more
such
topical
medications,
in mild
many
will
need
to ause
a in
combination
of treatments:
orbut
more
such
as
topical
medications,
mild
disease.
many
will
need
to
aa combination
treatments:
two
or
many
willtopical
need
to use
use
combination
ofwith
treatments:
two
or more
more but
different
agents
or
an
oral
plus
aof
topical
medication.
Some
patients
have
aorgood
result
just
one
medication,
different
topical
agents
an
oral
plus
a topical
medication.
Some
patients
have
aorgood
result
with
just
one
medication,
but
different
topical
agents
an
oral
plus
aa topical
medication.
different
topical
agents
or
an
oral
plus
topical
medication.
Other
treatments
used
for
acne
include
corticosteroid
injections,
many
will
need
to
use
a
combination
of
treatments:
two
or more
Other
treatments
used
for
acne
include
corticosteroid
injections,
many
willtreatments
need to use
a combination
of treatments:
twoinjections,
or more
Other
used
for
acne
include
corticosteroid
Other
used
for
acne
include
injections,
which
are treatments
used
to help
relieve
and
to
decrease
the size
and
encourdifferent
orpain
anpain
oral
plus
topical
medication.
which
aretopical
used
toagents
help
and
toacorticosteroid
decrease
the size
and
encourdifferent
topical
agents
orrelieve
an
oral
plus
adecrease
topical
medication.
which
are
used
to
help
relieve
pain
and
to
the
size
which
are
used
to
help
relieve
pain
and
toinclude
decrease
thedermatologists
size and
and encourencourage healing
oftreatments
large,
inflamed
acne
nodules.
Also,Also,
dermatologists
someOther
used
for
acne
corticosteroid
injections,
age
healing
of
large,
inflamed
acne
nodules.
someOther
treatments
used foracne
acne
includeAlso,
corticosteroid
injections,
age
healing
of
large,
inflamed
nodules.
dermatologists
someage which
healing
of used
large,
acne
nodules.
dermatologists
sometimes
perform
“acne
surgery,”
using
a fine
needle,
a pointed
blade,
orencouranor an
are
toinflamed
help
relieve
pain
and
toAlso,
decrease
the
size
and
times
perform
“acne
surgery,”
using
a fine
needle,
asize
pointed
blade,
which
are
used
to
help
relieve
pain
and
to
decrease
the
and
encourtimes
perform
“acne
using
aa fine
needle,
aa pointed
blade,
or
times
perform
“acne
surgery,”
usingextractor
fine
needle,
pointed
blade,
or
an
instrument
known
assurgery,”
a comedone
to mechanically
cleanclean
outan
aout a
age
healing
of
large,
inflamed
nodules.
Also,
dermatologists
someinstrument
known
as
a comedone
extractor
todermatologists
mechanically
age
healing
of
large,
inflamed
acneacne
nodules.
Also,
someinstrument
known
as
aa comedone
extractor
to
mechanically
clean
out
aa
instrument
known
as
comedone
extractor
to
mechanically
clean
out
clogged
pore.
One
must
always
balance
the
risk
for
inducing
a
scar
with
times
perform
“acne
surgery,”
using
a
fine
needle,
a
pointed
blade,
or
an
clogged
pore.
One
must
always
balance
the
risk
for
inducing
a
scar
times
perform
“acne
surgery,”
using
a fine
needle,
a inducing
pointed blade,
or
anwith
clogged
pore.
One
must
always
balance
the
risk
for
a
scar
with
clogged
pore.benefits
One
must
always
balance
the risk
for
inducing
aproviders
scar
with
the
potential
ofasany
procedure.
Many
health
carecare
providers
willout
instrument
known
a comedone
extractor
tohealth
mechanically
clean
a
the potential
benefits
of
any
procedure.
Many
will
instrument
known
as
a
comedone
extractor
to
mechanically
clean
out
a
the
benefits
of
any
procedure.
Many
health
care
providers
will
the potential
potential
benefits
ofmust
any
procedure.
Many
health
care
providers
will
start
out with
topical
or
combination
topical/oral
treatment
plans
before
clogged
pore.
One
always
balance
the
risk
for
inducing
a
scar
with
start
out
with
topical
or
combination
topical/oral
treatment
plans
before
clogged
pore.
One must
always balance
the risk for
inducingplans
a scar
with
start
out
with
topical
or
topical/oral
treatment
before
startthe
out
with
topical
or combination
combination
topical/oral
treatment
plans
before
using
more
invasive
treatments.
Some
believe
that
priorprior
treatment
withwith
potential
benefits
of any
procedure.
Many
health
care
providers
using
more
invasive
treatments.
Some
believe
that
treatment
the
potential
benefits
of any
procedure.
Many
health
caretreatment
providers
willwill
using
more
invasive
treatments.
Some
believe
that
prior
with
using
more
invasive
treatments.
Some
believe
that
prior
treatment
with
topical
retinoids
can
“loosen”
whiteheads
and and
blackheads
and and
so make
start
out
with
topical
or
combination
topical/oral
treatment
plans
before
topical
retinoids
can
“loosen”
whiteheads
blackheads
so
make
start
outretinoids
with topical
or combination
topical/oral
treatmentand
plans
before
topical
can
whiteheads
and
blackheads
so
topical
retinoids
can “loosen”
“loosen”
whiteheads
and
blackheads
and
so make
makewith
it
easier
tomore
physically
remove
suchsuch
bumps.
using
invasive
treatments.
Some
believe
that
prior
treatment
it
easier
to
physically
remove
bumps.
using
more
invasive treatments.
Some
believe that prior treatment with
it
to
remove
such
bumps.
it easier
easier
to physically
physically
remove
such
bumps.
Heat-based
devices
as
well
aswhiteheads
light
andand
laserblackheads
therapy
are
being
topical
retinoids
can
“loosen”
and
so make
Heat-based
aswhiteheads
well
as light
laser
therapy
being
topical
retinoids
candevices
“loosen”
and laser
blackheads
andare
so are
make
Heat-based
devices
as
well
as
light
and
therapy
Heat-based
devices
as
well
light
and
lasersuch
therapy
areinbeing
being
studied
to see
whether
there
is as
any
role
for such
treatments
mild
it
easier
to
physically
remove
such
bumps.
studied
to
see
whether
there
is
any
role
for
treatments
in
mild
it
easier to physically
remove
such
bumps.
studied
whether
there
is
any
role
for
such
treatments
in
mild
studied
to see
see
whether
there
iswell
anythere
role
for
such
treatments
inare
mild
to
moderate
acne.
At
this
time,
there
islight
not
enough
evidence
to
make
Heat-based
devices
as
as
and
laser
therapy
being
to
moderate
acne.
At
this
time,
is
not
enough
evidence
to
make
Heat-based
devices
astime,
well there
as light
and laser therapy
are
being
to
acne.
At
this
is
evidence
to
to moderate
moderate
acne.
At
this
time,
there
is not
not enough
enough
evidence
to make
make
recommendations
about
their
use.
studied
to
see
whether
there
is use.
any
for such
treatments
in mild
recommendations
about
their
studied
to see
whether
there
isuse.
any
rolerole
for such
treatments
in mild
recommendations
about
their
recommendations
about
their
use.
to
moderate
acne.
At
this
time,
there
is
not
enough
evidence
to
make
to moderate acne. At this time, there is not enough evidence to make
recommendations
about
recommendations
about
theirtheir
use.use.
General
Information
About
Using
Topical
General
Information
About
Using
Topical
General
Information
About
Using
Topical
General
Information
About
Using
Topical
Acne
Medications
Acne
Medications
Acne
Medications
General
Information
About
Using
Topical
General
Information
About
Using
Acne
Medications
General
Information
About
Using
Topical
● Apply
medication
to clean,
dry dry
skinskin
andand
spread
it around
the the
● Apply
medication
to clean,
spread
it around
●
Apply
medication
to
clean,
dry
skin
and
spread
it
Medications
Topical
Acne
Medications
●Acne
Apply
medication
to face
clean,
dry
and
spread
it around
around
the
entire
area
of the
affected
byskin
acne.
Avoid
the corners
of the
entire
area
of face
the
affected
by acne.
Avoid
the
corners
of the
Acne
Medications
entire area of the face affected by acne. Avoid the corners of the
●
●
●
●
●
●
●
●
●
●
●
●
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●
●
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●
●
●
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●
●
●
●
●
●
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●
●
●
●
●
●
●
●
●
●
●
●
entire
areanose,
of
the
face
byin
acne.
Avoid
the
corners
of
the
eyes,
nose,
and
lips,
asaffected
the
skin
these
areas
is
more
● Apply
medication
to
dry
skin
and
spread
itsensitive.
around
eyes,
and
lips,
asclean,
the
in
these
areas
is around
more
sensitive.
Apply
medication
to
clean,
dryskin
skin
and
spread
it
the the
eyes,
and
lips,
as
skin
in
these
areas
is
sensitive.
eyes,
nose,
andof
lips,
as
the
skin
inlayer
these
areas
is more
more
sensitive.
Less
isnose,
usually
better.
Athe
thin
layer
of
medication
isthe
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likely
to the
area
the
face
affected
by
acne.
Avoid
corners
of
● entire
Less
is
usually
better.
A
thin
of
medication
is
less
likely
to
entireisarea
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benzoyl
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bedtime
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the
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ide
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ide
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ide
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areday.
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ide
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the
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ide
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or combinations
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asthe
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or combinations
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finding
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When
starting
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acne
medications,
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only
those
agents
for
at
least
2your
weeks.
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that
time,
if desired,
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is
best
for
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agents
for
at
least
2
weeks.
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that
time,
if
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nonprethat is best
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for
at
least
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weeks.
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weeks.
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be
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scription
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antime,
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be
scription
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asAfter
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cleanser
can
be
tried.
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develops,
using
the
OTC
product.
agents
for
at
least
2
weeks.
that
time,
desired,
a
nonpretried.
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irritation
develops,
stop
using
the
product.
agents
for at least 2develops,
weeks. After
that
time,
ifOTC
desired,
a nonpretried.
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stop
using
the
product.
tried.
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irritation
develops,
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OTC or
product.
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or any
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procedures
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such
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or
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procedures
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lead
to exexcessive
irritation
should
be avoided
during
retinoid
tried.
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irritation
develops,
stop
using
the
OTC
product.
cessive
irritation
should
be
avoided
during
retinoid
therapy.
tried.
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irritation
develops,
stop
using
the OTC
product.
cessive
and
should
be
avoided
retinoid
therapy.
cessive
irritation
and
should
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avoided
during
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therapy.
Benzoyl
peroxide
fabrics
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cessive
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and
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cessive
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and
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Side
Effects
of
Oral
Acne
Medications
Side
Effects
of
Oral
Acne
Medications
Side
Effects
of
Oral
Acne
Medications
Side
Effects
of
Oral
Acne
Medications
Side
Effects
ofminocycline,
Oral
Acne
Medications
●Side
Tetracycline,
and
doxycycline
are are
in the
samesame
● Tetracycline,
minocycline,
and
doxycycline
in the
Effects
of
Oral
Acne
Medications
● Tetracycline,
minocycline,
and
doxycycline
are
in
the
same
Side
Effects
of
Oral
Acne
Medications
● class
Tetracycline,
minocycline,
and
doxycycline
areside
inside
the
same
of
drugs,
and
they
have
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possible
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in in
class of drugs, and they have
several
possible
effects
Topical
Oral
Topical
Oral
class
of
and
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in
Topical
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Medications
Medications
class
of drugs,
drugs,
they
have
several
possible
side
effects
in
common.
If you
notice
any
ofseveral
the
following,
stop
using
the
Medications
Medications
● Tetracycline,
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and
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are
in using
the
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● Tetracycline,
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and
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are
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Medications
Medications
common.
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you
notice
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the
following,
stop
using
the
Medications
Medications
common.
If
you
notice
any
of
the
following,
stop
using
the
medication
and
notify
the
health
care
provider:
headaches;
class
of
drugs,
and
they
have
several
possible
side
effects
medication
and
notify
the
health
care
provider:
headaches;
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Oral
● Benzoyl
peroxide
helps
include
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of drugs,
and
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have several
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● Benzoyl
peroxide
helps● Antibiotics
● Antibiotics
include
tetracyclinemedication
and
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care
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●
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peroxide
helps
include
and
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health
care
provider:
headaches;
Medications
Medications
blurred
vision;
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sensitivity;
heartburn
or
stomach
common.
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you
notice
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the
following,
stop
blurred
vision;
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sensitivity;
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orusing
stomach
fight
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and and ●
class
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to
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or
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to
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and
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blurred
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sensitivity;
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orgums,
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bacteria
and and
is believed
to to class
minocycline,
and(tetracycline,
doxycycline,
which
pain;
irritation
of
the
esophagus;
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of
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or or
medication
and
notify
the
health
care
provider:
headaches;
bacteria
is
believed
minocycline,
and
doxycycline,
which
pain;
irritation
of
the
esophagus;
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Benzoyl
peroxide
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and
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well
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reserved
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National
Institute
of
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and
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and
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include
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and acid,
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22
ts
al,
se
it
tias
sis
ry
of
of
aly
wn
of
of
e.
dine
e,
at
nt
ng
ed
ic
to
al
ne
gy
x-
ke
st
nd
5.
linked
to
acne
it
has
been
that P. acnes In
canaddition,
induce expression
antilinked
to shown
acne inflammation.
inflammation.
In
addition,
it has
has been
beenofshown
shown
11.
11.
that
with
tend
expression
of
microbial
peptides
and proinflammatory
cytokines
and has
that patients
patients
with acne
acne
tend to
to have
have reduced
reduced
expression
of
6.
Acne
Cycle:
The Spectrum
of Pediatric
Disease
anti-inflammatory
cytokines,
as
an
effectLife
on toll-like
receptor
2,such
leading
to increased
synthesis
anti-inflammatory
cytokines,
such
as IL-10.
IL-10.
of cytokines.
12.
12.
Conclusion
Conclusion
Immunoinflammatory
Mechanisms
The
epidemiology,
demographics,
and
pathophysiology
The
epidemiology,
demographics,
and
pathophysiology of
of
A
great
deal of research
has focused on
immunoinflammatory
acne
have
described
in
acne in
in adolescents
adolescents
have been
been well
well
describeddemonstration
in the
the literature.
literature.
pathways
of acne pathogenesis,
including
of
Fewer
studies
acne
condiFewer
studies have
have
focused
oncytokines
acne and
andinacneiform
acneiform
condithe
upregulation
of focused
multipleon
the presence
of
tions
in
pediatric
patients
less
than
12
years
of
age.
True
acne
tions
in
pediatric
patients
less
than
12
years
of
age.
True
acne
both P. acnes, as previously mentioned, and lipopolysacchais
seen
in
less
about
6
years
of
is rarely
rarelyHere
seenagain,
in patients
patients
less than
than
abouthave
6 or
or 7
7been
yearsinnately
of age,
age,
rides.
toll-like
receptors
but
it
is
important
to
note—and
to
educate
parents—that
but it is
to note—and
to educate
linked
to important
acne inflammation.
In addition,
it hasparents—that
been shown
acne
may
first
sign
of
of
in
acne patients
may be
be the
the
first
signtend
of onset
onset
of puberty
puberty
in preadolescent
preadolescent
that
with
acne
to have
reduced
expression of
children
7
years
children (ie,
(ie, those
those from
from
7 through
through
11
years of
of age).
age). Ongoing
Ongoing
anti-inflammatory
cytokines,
such 11
as IL-10.
research
continues
to
elucidate
and
expand
on
research continues to elucidate and expand on the
the etiologic
etiologic
factors
factors involved
involved in
in the
the development
development of
of acne.
acne.
Conclusion
References
References
The
epidemiology, demographics, and pathophysiology of
S5
1.
SF,
LF,
Fowler
JF
Acne
1. Friedlander
Friedlander
SF, Eichenfield
Eichenfield
LF, well
Fowler
JF Jr,
Jr, et
et al:
al: in
Acne
epidemiology
acne
in adolescents
have been
described
theepidemiology
literature.
and
pathophysiology.
Semin
Med
29:2-4, 2010
andstudies
pathophysiology.
Semin Cutan
Cutan
Med Surg
Surg
2010 condiFewer
have focused
on acne
and29:2-4,
acneiform
2. Cantatore-Francis JL, Glick SA: Childhood acne: Evaluation and mantionsagement.
in pediatric
patients less than 12 years of age. True acne
Dermatol Ther 19:202-209, 2006
is3.rarely
seen
in
patients
less than
aboutC,6Couprie
or 7 years
of age,
Niamba P, Weill FX, Sarlangue
J, Labreze
B, Tiaeh
A: Is
but common
it is important
to
note—and
to
educate
parents—that
neonatal cephalic pustolosis (neonatal acne) triggered by
sympodialis?
Dermatol
134:995-998,
1998
acneMalassezia
may be the
first signArch
of onset
of puberty
in preadolescent
Effects
of
nonclinical
issues
on
acne
treatment
4.
Sancak
B,
Ayhan
M,
Karaduman
A,
Arikan
S:
In
vitro
activity
of ketochildren (ie, those from 7 through 11 years of age). Ongoing
conazole,
itraconazole
and
terbinafine
against
Malassezia
strains
isoresearch continues to elucidate and expand on the etiologic
lated from neonates [in Turkish]. Microbiyol Bul 39:301-308, 2005
factors
involvedpatients
in the development
of and
acne.
bothersome
than
are theacne
acne
lesions
caused
5. Bergman J,toEichenfield
LF:
Neonatal
cephalicthat
pustulosis:
Is
the dyschromia.
In skin
of color,
PIH can
occur secondary
to
Malassezia the whole
story?
Arch Dermatol
138:255-257,
2002
References
6. Tom
Friedlander
Acne throughlesions
the ages: with
Case-based
observaany
acneWL,
lesion,
evenSF:comedonal
no clinical
1. Friedlander
Eichenfield
Fowler JF Jr,
et Pediatr
al: Acne(Phila)
epidemiology
tions through
childhood
andLF,
adolescence.
Clin
47:639appearance
ofSF,
inflammation.
and
pathophysiology.
Semin
Cutan
Med
Surg
29:2-4,
2010
651,
2008
Effects
nonclinical
issues
on acne
treatment
Earlyofand
effective
therapy,
tailored
not only to the acne
7. National Campaign to Control Acne: Secaucus (NJ): Thomson Professeverity
but
also
to
the
level
of
psychological
distress, is exsional Postgraduate Services. 2003
tremely
bothersome
patients
acne
lesions
that caused
8. Golubimportant.
MS,to
Collman
GW,than
Fosterare
PM,the
et al:
Public
health implications
of
determining
treatment
regimens,
must 3)take
altered
puberty In
timing.
121:S218-S230,
2008
(suppl
theIndyschromia.
skinPediatrics
of color,
PIH canclinicians
occur
secondary
to
9. Toppari
J, Juul A: even
Trends
in puberty
timing
indifferences
human
andno
environmeninto
consideration
the widely
varying
that
exist
any
acne
lesion,
comedonal
lesions
with
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23

Pediatric Acne Management: Optimizing Outcomes

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