BOSTON – Pediatricians treat preadolescent acne nearly as often as dermatologists but appear to be less comfortable with the use of topical retinoids, according to the results of a study of almost 55 million pediatric acne visits.
"This study identifies a significant knowledge gap among pediatricians, in terms of treatment of acne based on age of the patient. This is especially important in the preadolescent age group, since pediatricians treat acne in this population nearly as much as dermatologists," Dr. Laura F. Sandoval wrote in a poster presented at the American Academy of Dermatology’s Summer Academy Meeting.
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Slightly more than two-thirds of adolescent acne is managed by dermatologists, data shows.
Treatment by physicians in different specialties differed markedly. The younger the child, the more likely a pediatrician treated the acne; most (75.6%) neonatal or infantile acne was managed by a pediatrician. However, the older the child, the more likely a dermatologist treated the acne; slightly more than two-thirds (67.1%) of adolescent acne was managed by a dermatologist. Dermatologists and pediatricians almost equally managed preadolescent acne – 38.4% and 34.2%, respectively.
NAMCS (National Ambulatory Medical Care Survey) data were collected for outpatient visits of children receiving a diagnosis of acne vulgaris during 1993-2009. Patient visits were stratified by age groups: younger than 1 year (neonatal or infantile acne), 1-6 years (mid-childhood acne), 7-11 years (preadolescent acne), and 12-18 years (adolescent acne). Medications prescribed for each age group were compared across physician specialties.
There were almost 55 million estimated visits for patients aged 18 years and younger with a diagnosis of acne. Adolescent acne accounted for most of these visits (91.4%), followed by preadolescent visits (4.8%), mid-childhood visits (0.9%) and neonatal or infantile acne visits (3.0%).
Treatment of preadolescent and adolescent acne differed substantially between dermatologists and pediatricians/primary care physicians (PCPs), with prescribing differences being most pronounced in the preadolescent population. Topical retinoids were prescribed mainly by dermatologists in this age group, while oral antibiotics were preferred by pediatricians/PCPs.
"Comedonal acne is the most common type of acne in preadolescents and thus warrants the use of topical retinoids. Most PCPs have minimal dermatologic education and may be unaware of the benefits of retinoids," wrote Dr. Sandoval of the Center for Dermatology Research at Wake Forest University in Winston-Salem, N.C., and her coauthors.
The most common treatment for preadolescent acne across all specialties was adapalene (14.4%), followed by benzoyl peroxide [BPO] (12.8%), tretinoin (12.5%), minocycline (10.4%), and a combination of BPO/erythromycin (8.1%). The most common treatment for adolescent acne was tretinoin (19.5%), followed by isotretinoin (18.1%), minocycline (16.9%), BPO (16.1%) and adapalene (14.1%).
Isotretinoin was the only medication commonly prescribed in adolescents but not in preadolescents, by both dermatologists and pediatricians/PCPs.
This could be because severe acne is typically rare in young children, according to Dr. Sandoval and her colleagues. And, severity is not recorded by the NAMCS, making it difficult to determine whether preadolescent children had severe enough acne to warrant the use of isotretinoin.
However, when topicals, BPO, and antibiotics fail, isotretinoin should be considered, the researchers noted. Also, isotretinoin should be considered in preadolescents when scarring is a concern.
While dermatologists prescribed isotretinoin and topical retinoids more frequently for adolescent acne than did pediatricians/PCPs, "Hesitancy to prescribe isotretinoin by PCPs may be due to strict requirements of federal monitoring programs, the need for monitoring blood work, and/or safety concerns," the authors noted.
Although tetracycline is the only Food and Drug Administration–approved drug for use in children aged 8 years and older, the data showed it was prescribed to an estimated 120,000 patients younger than 8 years, including children as young as 3 years. This practice was seen among both dermatologists and pediatricians. In all cases, it was used in conjunction with tretinoin, BPO, and/or topical clindamycin.
Minocycline is only FDA approved for use in patients 12 years and older. However, it was prescribed more often in younger patients than are doxycycline and tetracycline by both dermatologists and pediatricians/PCPs.
"All specialties recognize that off-label prescribing is necessary given the very limited range of treatment that is currently FDA-approved for preadolescent patients," the researchers wrote. "PCPs may have outdated concerns in regards to the efficacy and tolerability of retinoids, which is not supported by newer retinoid formulations."
The Center for Dermatology Research at Wake Forest is supported by an educational grant from Galderma. Principal investigator, Dr. Steven R. Feldman, reported significant financial relationships with several pharmaceutical companies, including Galderma. Dr. Sandoval and her other coauthors reported no conflicts of interest.