Pediatric Acne

Lawrence Eichenfield, MD

Lots of new studies have been conducted with regards to pediatric acne along with some updates to The American Acne and Rosacea Society’s Pediatric Guidelines, which have also been recently endorsed by The American Academy of Pediatrics.

For dermatologists, mid-childhood (age 1 – 7) acne is most worrisome. It can be associated with premature adrenarche, Cushings Syndrome, CAH, gonadal/adrenal tumors, and precocious puberty. The evaluation for mid-childhood acne includes testicular size (males), hirsutism, clitoromegaly, androgenetic alopecia, increased muscle mass, and deepening of the voice (males).  If the acne is persistent, severe, or virilizing, tests/examinations include a growth chart, evaluation including bone age, tanner stage, Total/Free testosterone, DHEAS, androstenedione, LH, FSH, prolactin, and 17OH-progesterone. Dermatologists should also consider a referral to an endocrinologist.

Pre-adolescent (7 ≤ 12 years) acne is common and may precede other signs of pubertal maturation. A complete work-up beyond history and physical is generally unnecessary unless there are signs of androgen excess, polycystic ovarian syndrome, or other systemic abnormalities

How should we manage preadolescent acne?

It’s important to remember that comedones are often early common on the forehead and mid-face and the truncal area is much less common. This may precede other signs of puberty. For the most part, it correlates with sebum output and sebaceous follicle numbers. P. acnes colonization is a key thing to keep in mind. **The prevalence of severity of acne of acne correlates with advanced pubertal maturation.

Acne Guidelines: Recommendations and Highlights

Acne Categorization by Age

  • Acne in neonates- 0-6 wk
  • Infantile – 0-1
  • mid-childhood 1-7
  • preadolescent 7-12
  • adolescent 12-19

 

Initial Therapy: recommendations regarding initial therapy

OTC products such as benzoyl peroxide as a single agent, topical retinoids, or combinations of topical retinoids, antibiotics, and benzoyl peroxide as individual agents or fixed-dose combinations

Topical retinoids (tretinoin, adapalene, tazarotene) may be used as monotherapy or in combination products and in regimens of care for all types and severities of acne in children and adolescents of all age

Topical Antibiotics

  • Topical antibiotics (clindamycin, erythromycin) are not recommended as monotherapy
  • If topical antibiotic treatment is to be prolonged for more than a few weeks, topical benzoyl peroxide should be added, or utilized in combination products

Oral Antibiotics

  • Oral antibiotics are appropriate for moderate to severe inflammatory acne at any age
  • Second generation tetracyclines (doxycycline, minocycline) are sometimes preferred to tetracycline because of ease of use, fewer problems with absorption, and less frequent dosing

Fixed Dose Combination Treatment

  • May be useful in regimens of care for all types and severities of acne

Hormonal Therapy

  • Second-line therapy in regimens of care in pubertal females with moderate to severe acne. Tobacco use and family history of thrombotic events should be assessed.
  • Due to concerns about growth and bone density, many experts recommend withholding OCs for acne unassociated with endocrinologic pathology until one year after onset of menstruation

Isotretinoin


  • Isotretinoin is recommended for severe, scarring, and/or refractory acne in adolescents and may be utilized in younger patients
  • Extensive counseling particularly regarding the avoidance of pregnancy, as well as careful monitoring of potential side effects and toxicities, is recommended

What about off-label treatment?

Below is a summary of some recent studies that look at off-label therapy for pediatric acne.

Tretinoin 0.04% micro-gel

  •  8-12 mild to moderate acne
  • Mean 59 lesions (9 inflammatory)
  • 12 weeks: 48% lesion count decrease
  • Tretinoin 0.04% vehicle controlled 8-11 yrs
  • Ada 0.1/BP2.5% vehicle-controlled 9-11 yrs

Retinoids

111 pt 9-11 yr olds, Retin A 0.04% micro db, vehicle controlled study, 12 wks

  • 66% prepubertal; 65 lesions (9.5 inflammatory)
  • 44% Non-inflam lesion count (vs 30%)

285 pt 9-11 yr olds, Ada .1-BP 2.5, db vc 12wks

  • 54 lesions (15 inflammatory)
  • 47% clear/almost clear (vs 15%)
  • App 50% Total lesion count decrease (vs<10%)

Oral Antibiotics

Short-term combination therapy and long-term relapse prevention in the treatment of severe acne vulgaris.

Doxycycline (DCN) and (Adapalene 0.1% – benzoyl peroxide 2.5%) = (A/BPO) or vehicle qd x 12 weeks, then A/BPO vs vehicle

  • 76% lesion count decrease

What about Isotretinoin-induced flares?

  • Appears to be a dose-related phenomenon, so start at a low dose to avoid this problem

What about prevention?

  • Systemic cyclines for anti-inflammatory effects (e.g. Mino or Doxy q day x 2 weeks)
  • Patient monitoring