Patient Age, Severity Should Guide Acne Tx

SEATTLE — The treatment of acne in adolescents should be tailored to the type and severity of lesions and the adolescent's age, according to Dr. Annette Wagner.

Fully 80% of teenagers develop acne, noted Dr. Wagner, a pediatric dermatologist at Northwestern University in Chicago. "But the age of onset is really young now that puberty is starting earlier," she commented. "I see comedones on many 8-year-olds in my clinic."

Myths abound when it comes to the cause of acne, she said at a meeting sponsored by the American Academy of Pediatrics. Chocolate, fatty foods, poor eating habits, and lack of cleanliness have all been wrongly accused. The real culprit is an inherited genetic predisposition to form comedones, or pores plugged by keratin behind which oil and bacteria can accumulate.

"This is familial," she stressed. "That's the No. 1 big thing, and I tell that to every adolescent in the room in front of the parent, because parents can make their kids feel responsible for their acne," nagging them about diet, not washing their face, and such.

Myths are equally common when it comes to treating acne. Removing oil is ineffective because oil itself is not to blame, she said. And although most teenagers believe otherwise, sunlight does not improve acne; in fact, because it stimulates T cells in the skin, sun exposure causes the condition to flare.

As long as cosmetics are labeled noncomedogenic or nonacneogenic—and most today are—they neither cause nor worsen acne, according to Dr. Wagner. Facials promote desquamation of the skin, but this process is not impaired in adolescence, and facials can do more harm than good. "Don't let cosmetologists manipulate the faces of your adolescents," she recommended. "That's not an appropriate treatment for acne."

Perhaps the most important myth of all is that acne is harmless, she commented. "Not only does it cause scarring, it does so much to make adolescents feel bad about themselves," she observed. "If you can offer treatment that will help, you are doing the right thing."

Moreover, "acne should be treated at any age—don't wait for these children to be adolescents or high school students," Dr. Wagner commented, offering some rules of thumb as to when treatment is appropriate. "I always treat it when any patient requests it, even if it's minor acne," she said, and all adolescents with lesions should be offered treatment. Systemic treatment is also warranted if acne is visible from across the examination room or if it has caused any scarring.

As far as skin care basics, Dr. Wagner recommended that young people with acne be advised to wash their skin gently. "Tell them, use your hands—not washcloths, not buff puffs, not exfoliants. Those make acne worse." They should also use a mild soap, preferably a liquid one, and apply sunscreen daily.

Excessive washing, application of petroleum jelly, and manipulation should be avoided. "I tell kids, if you squeeze a zit, you are going to be looking at it for about a month; if you don't squeeze it, it will dry up in about 10 days," she said.

Topical steroids used to treat seborrheic dermatitis also will worsen acne, she noted, so other agents should be selected for managing scale around the nose and scalp, or in the skin creases. Friction and sweating under clothing, as occur especially in young athletes, and exposure to aerosolized fat, as occurs in teenagers who work over deep fryers, also are exacerbating factors.

"But probably the thing that worsens acne more than anything else is working too hard to get rid of it," Dr. Wagner commented. "So less is better in this particular case."

Adolescents with relatively mild acne should be started on benzoyl peroxide, Dr. Wagner advised. "I like to put it in a wash form," she noted. "I tell them, wash your face with it in the morning and at night. That prevents them from using cleansers that aren't right."

In addition, they also should be prescribed a topical retinoid and, if they have inflammatory lesions, a topical antibiotic. Because retinoids can cause peeling, they should initially be used every other day and applied in a very small amount—a quarter of the size of a pea—only to the area affected by comedones, with a gradual increase in frequency and amount.

Importantly, Dr. Wagner noted, adolescents should be counseled about a realistic time frame for seeing improvement. "It takes 3 months to get a comedone out of your skin with appropriate treatment, and it sometimes takes a month and half to even be able to use the retinoid every night," she said. "So this is not going to happen for this weekend's dance, and you have got to tell them that because that is their expectation."

New combination topical products offer some advantages, she observed. For example, benzoyl peroxide or a retinoid promotes desquamation, so combining these with a topical antibiotic helps an antibiotic better penetrate the skin. And zinc helps overcome antibiotic resistance. Furthermore, adolescents—especially boys, who dislike putting anything on their skin—may have better compliance when given a combination product.

Noting that skin care may be a low priority in this age group generally, she recommended telling adolescents to just apply their medication at night even if they are too tired to wash their face. "It's not a problem of dirt or not removing oil," she said. "It's a problem of not doing the treatment."

Resorting to oral antibiotic therapy should be based on several factors, but age is not one of them, she said. Instead, this therapy should be initiated whenever a child has inflammatory lesions and topical therapy has failed, or when the acne can be seen from across the room, is cystic, or involves the trunk. In addition, "I go much more quickly to oral treatment in boys with inflammatory acne because they will take pills much more willingly than they will put products on their skin."

"You should treat with oral antibiotics for a minimum of 6 months," she said. "And it's typical to treat for several years because it's not a short period of time that acne is a problem."

Birth control pills should be considered for acne treatment in older girls.

Finally, if adolescents wish to treat acne scars, they must be free of any new lesions for at least a year, said Dr. Wagner.

She reported having no conflicts of interest relevant to her presentation.

'Probably the thing that worsens acne more than anything else is working too hard to get rid of it.'

Source DR. WAGNER

Adolescents—especially boys, who dislike putting anything on their skin—may do best with a combination product.

Source ©Stephen Strathdee/iStockphoto.com

SEATTLE — The treatment of acne in adolescents should be tailored to the type and severity of lesions and the adolescent's age, according to Dr. Annette Wagner.

Fully 80% of teenagers develop acne, noted Dr. Wagner, a pediatric dermatologist at Northwestern University in Chicago. "But the age of onset is really young now that puberty is starting earlier," she commented. "I see comedones on many 8-year-olds in my clinic."

Myths abound when it comes to the cause of acne, she said at a meeting sponsored by the American Academy of Pediatrics. Chocolate, fatty foods, poor eating habits, and lack of cleanliness have all been wrongly accused. The real culprit is an inherited genetic predisposition to form comedones, or pores plugged by keratin behind which oil and bacteria can accumulate.

"This is familial," she stressed. "That's the No. 1 big thing, and I tell that to every adolescent in the room in front of the parent, because parents can make their kids feel responsible for their acne," nagging them about diet, not washing their face, and such.

Myths are equally common when it comes to treating acne. Removing oil is ineffective because oil itself is not to blame, she said. And although most teenagers believe otherwise, sunlight does not improve acne; in fact, because it stimulates T cells in the skin, sun exposure causes the condition to flare.

As long as cosmetics are labeled noncomedogenic or nonacneogenic—and most today are—they neither cause nor worsen acne, according to Dr. Wagner. Facials promote desquamation of the skin, but this process is not impaired in adolescence, and facials can do more harm than good. "Don't let cosmetologists manipulate the faces of your adolescents," she recommended. "That's not an appropriate treatment for acne."

Perhaps the most important myth of all is that acne is harmless, she commented. "Not only does it cause scarring, it does so much to make adolescents feel bad about themselves," she observed. "If you can offer treatment that will help, you are doing the right thing."

Moreover, "acne should be treated at any age—don't wait for these children to be adolescents or high school students," Dr. Wagner commented, offering some rules of thumb as to when treatment is appropriate. "I always treat it when any patient requests it, even if it's minor acne," she said, and all adolescents with lesions should be offered treatment. Systemic treatment is also warranted if acne is visible from across the examination room or if it has caused any scarring.

As far as skin care basics, Dr. Wagner recommended that young people with acne be advised to wash their skin gently. "Tell them, use your hands—not washcloths, not buff puffs, not exfoliants. Those make acne worse." They should also use a mild soap, preferably a liquid one, and apply sunscreen daily.

Excessive washing, application of petroleum jelly, and manipulation should be avoided. "I tell kids, if you squeeze a zit, you are going to be looking at it for about a month; if you don't squeeze it, it will dry up in about 10 days," she said.

Topical steroids used to treat seborrheic dermatitis also will worsen acne, she noted, so other agents should be selected for managing scale around the nose and scalp, or in the skin creases. Friction and sweating under clothing, as occur especially in young athletes, and exposure to aerosolized fat, as occurs in teenagers who work over deep fryers, also are exacerbating factors.

"But probably the thing that worsens acne more than anything else is working too hard to get rid of it," Dr. Wagner commented. "So less is better in this particular case."

Adolescents with relatively mild acne should be started on benzoyl peroxide, Dr. Wagner advised. "I like to put it in a wash form," she noted. "I tell them, wash your face with it in the morning and at night. That prevents them from using cleansers that aren't right."

In addition, they also should be prescribed a topical retinoid and, if they have inflammatory lesions, a topical antibiotic. Because retinoids can cause peeling, they should initially be used every other day and applied in a very small amount—a quarter of the size of a pea—only to the area affected by comedones, with a gradual increase in frequency and amount.

Importantly, Dr. Wagner noted, adolescents should be counseled about a realistic time frame for seeing improvement. "It takes 3 months to get a comedone out of your skin with appropriate treatment, and it sometimes takes a month and half to even be able to use the retinoid every night," she said. "So this is not going to happen for this weekend's dance, and you have got to tell them that because that is their expectation."

New combination topical products offer some advantages, she observed. For example, benzoyl peroxide or a retinoid promotes desquamation, so combining these with a topical antibiotic helps an antibiotic better penetrate the skin. And zinc helps overcome antibiotic resistance. Furthermore, adolescents—especially boys, who dislike putting anything on their skin—may have better compliance when given a combination product.

Noting that skin care may be a low priority in this age group generally, she recommended telling adolescents to just apply their medication at night even if they are too tired to wash their face. "It's not a problem of dirt or not removing oil," she said. "It's a problem of not doing the treatment."

Resorting to oral antibiotic therapy should be based on several factors, but age is not one of them, she said. Instead, this therapy should be initiated whenever a child has inflammatory lesions and topical therapy has failed, or when the acne can be seen from across the room, is cystic, or involves the trunk. In addition, "I go much more quickly to oral treatment in boys with inflammatory acne because they will take pills much more willingly than they will put products on their skin."

"You should treat with oral antibiotics for a minimum of 6 months," she said. "And it's typical to treat for several years because it's not a short period of time that acne is a problem."

Birth control pills should be considered for acne treatment in older girls.

Finally, if adolescents wish to treat acne scars, they must be free of any new lesions for at least a year, said Dr. Wagner.

She reported having no conflicts of interest relevant to her presentation.

'Probably the thing that worsens acne more than anything else is working too hard to get rid of it.'

Source DR. WAGNER

Adolescents—especially boys, who dislike putting anything on their skin—may do best with a combination product.

Source ©Stephen Strathdee/iStockphoto.com

SEATTLE — The treatment of acne in adolescents should be tailored to the type and severity of lesions and the adolescent's age, according to Dr. Annette Wagner.

Fully 80% of teenagers develop acne, noted Dr. Wagner, a pediatric dermatologist at Northwestern University in Chicago. "But the age of onset is really young now that puberty is starting earlier," she commented. "I see comedones on many 8-year-olds in my clinic."

Myths abound when it comes to the cause of acne, she said at a meeting sponsored by the American Academy of Pediatrics. Chocolate, fatty foods, poor eating habits, and lack of cleanliness have all been wrongly accused. The real culprit is an inherited genetic predisposition to form comedones, or pores plugged by keratin behind which oil and bacteria can accumulate.

"This is familial," she stressed. "That's the No. 1 big thing, and I tell that to every adolescent in the room in front of the parent, because parents can make their kids feel responsible for their acne," nagging them about diet, not washing their face, and such.

Myths are equally common when it comes to treating acne. Removing oil is ineffective because oil itself is not to blame, she said. And although most teenagers believe otherwise, sunlight does not improve acne; in fact, because it stimulates T cells in the skin, sun exposure causes the condition to flare.

As long as cosmetics are labeled noncomedogenic or nonacneogenic—and most today are—they neither cause nor worsen acne, according to Dr. Wagner. Facials promote desquamation of the skin, but this process is not impaired in adolescence, and facials can do more harm than good. "Don't let cosmetologists manipulate the faces of your adolescents," she recommended. "That's not an appropriate treatment for acne."

Perhaps the most important myth of all is that acne is harmless, she commented. "Not only does it cause scarring, it does so much to make adolescents feel bad about themselves," she observed. "If you can offer treatment that will help, you are doing the right thing."

Moreover, "acne should be treated at any age—don't wait for these children to be adolescents or high school students," Dr. Wagner commented, offering some rules of thumb as to when treatment is appropriate. "I always treat it when any patient requests it, even if it's minor acne," she said, and all adolescents with lesions should be offered treatment. Systemic treatment is also warranted if acne is visible from across the examination room or if it has caused any scarring.

As far as skin care basics, Dr. Wagner recommended that young people with acne be advised to wash their skin gently. "Tell them, use your hands—not washcloths, not buff puffs, not exfoliants. Those make acne worse." They should also use a mild soap, preferably a liquid one, and apply sunscreen daily.

Excessive washing, application of petroleum jelly, and manipulation should be avoided. "I tell kids, if you squeeze a zit, you are going to be looking at it for about a month; if you don't squeeze it, it will dry up in about 10 days," she said.

Topical steroids used to treat seborrheic dermatitis also will worsen acne, she noted, so other agents should be selected for managing scale around the nose and scalp, or in the skin creases. Friction and sweating under clothing, as occur especially in young athletes, and exposure to aerosolized fat, as occurs in teenagers who work over deep fryers, also are exacerbating factors.

"But probably the thing that worsens acne more than anything else is working too hard to get rid of it," Dr. Wagner commented. "So less is better in this particular case."

Adolescents with relatively mild acne should be started on benzoyl peroxide, Dr. Wagner advised. "I like to put it in a wash form," she noted. "I tell them, wash your face with it in the morning and at night. That prevents them from using cleansers that aren't right."

In addition, they also should be prescribed a topical retinoid and, if they have inflammatory lesions, a topical antibiotic. Because retinoids can cause peeling, they should initially be used every other day and applied in a very small amount—a quarter of the size of a pea—only to the area affected by comedones, with a gradual increase in frequency and amount.

Importantly, Dr. Wagner noted, adolescents should be counseled about a realistic time frame for seeing improvement. "It takes 3 months to get a comedone out of your skin with appropriate treatment, and it sometimes takes a month and half to even be able to use the retinoid every night," she said. "So this is not going to happen for this weekend's dance, and you have got to tell them that because that is their expectation."

New combination topical products offer some advantages, she observed. For example, benzoyl peroxide or a retinoid promotes desquamation, so combining these with a topical antibiotic helps an antibiotic better penetrate the skin. And zinc helps overcome antibiotic resistance. Furthermore, adolescents—especially boys, who dislike putting anything on their skin—may have better compliance when given a combination product.

Noting that skin care may be a low priority in this age group generally, she recommended telling adolescents to just apply their medication at night even if they are too tired to wash their face. "It's not a problem of dirt or not removing oil," she said. "It's a problem of not doing the treatment."

Resorting to oral antibiotic therapy should be based on several factors, but age is not one of them, she said. Instead, this therapy should be initiated whenever a child has inflammatory lesions and topical therapy has failed, or when the acne can be seen from across the room, is cystic, or involves the trunk. In addition, "I go much more quickly to oral treatment in boys with inflammatory acne because they will take pills much more willingly than they will put products on their skin."

"You should treat with oral antibiotics for a minimum of 6 months," she said. "And it's typical to treat for several years because it's not a short period of time that acne is a problem."

Birth control pills should be considered for acne treatment in older girls.

Finally, if adolescents wish to treat acne scars, they must be free of any new lesions for at least a year, said Dr. Wagner.

She reported having no conflicts of interest relevant to her presentation.

'Probably the thing that worsens acne more than anything else is working too hard to get rid of it.'

Source DR. WAGNER

Adolescents—especially boys, who dislike putting anything on their skin—may do best with a combination product.

Source ©Stephen Strathdee/iStockphoto.com