NEW YORK – In May 2013, the American Acne and Rosacea Society, with the endorsement of the American Academy of Pediatrics, published evidence-based recommendations for the diagnosis and treatment of pediatric acne that incorporated mid-childhood acne, which is a sign of hyperandrogenism that must be worked up.
The guidelines "are a great reference for you for treatment algorithms and an excellent resource for treating pediatric acne," Dr. Andrea L. Zaenglein said during a presentation at the American Academy of Dermatology’s summer meeting.
Dr. Andrea L. Zaenglein
Dr. Zaenglein provided a brief, but detailed summary of the classifications during her presentation, and offered some tips and practice pearls along the way.
Neonatal acne
This acne occurs in less than 20% of healthy infants who are between 2 weeks and 3 months old, and it presents in the form of papules and pustules. This common eruption rarely needs treatment, but clinicians can prescribe a topical antifungal, such as 2% ketoconazole cream, if pressed by the parents, Dr. Zaenglein noted.
Infantile acne
Unlike neonatal acne, this condition is true acne, said Dr. Zaenglein, professor of dermatology and pediatrics at Penn State/Hershey (Penn.) Medical Center. The acne, which usually presents as comedones, occurs between 3 and 6 months of age and lasts for about 1-2 years. This form of acne is usually caused by increased adrenal production of DHA, or dehydroepiandrosterone, and in boys, increased testicular androgens.
"It’s a temporary problem and usually fixes itself," said Dr. Zaenglein. "Take a full history and make sure they don’t have any signs of an underlying cause for hyperandrogenism."
Data from retrospective studies have shown that family history plays an important role, and babies with infantile acne may be at a higher risk of developing adolescent acne.
"It’s important to treat infantile acne, because it can cause scarring," said Dr. Zaenglein. The treatment principles are the same as adolescent acne. "However, remember that babies are not little adults," she said. Do not use benzoyl peroxide wash, because it can get into babies’ eyes. Instead, prescribe leave-on formulations in form of creams at lower strengths (2.5%-5%). Topical retinoids should also be used, but in a gentler formulation. Oral erythromycin is another option for more severe inflammatory acne (30 mg-50 mg/kg per day divided two or three times a day), although it might cause an upset stomach. In that case, try azithromycin, she said.
Mid-childhood acne
This new acne classification presents between 1 and 7 years of age, and requires a full exam to assess secondary sexual characteristics. Always rule out hyperandrogen states, such as Cushing’s syndrome, congenital adrenal hyperplasia, premature adrenarche, and precocious puberty, or a hormone-producing tumor, said Dr. Zaenglein. Early adrenarche also can be a risk factor for polycystic ovary syndrome. "Follow these patients closely throughout the teenage years," she advised.
The work-up for this mid-childhood acne is extensive, she said. In addition to various hormones, look at bone age and the growth chart. "And if you’re not sure, send them to a pediatric endocrinologist," she recommended.
To treat these children, apply the same principles as adolescent acne, but know that adherence is typically an issue. "Simplify the regimen, and encourage the parents to get involved," Dr. Zaenglein said.
Preadolescent acne
Acne in preadolescents is becoming more common as puberty begins earlier worldwide, said Dr. Zaenglein. The acne can present as a result of early onset of adrenarche in girls around 6 or 7 years or age, and boys between ages 7 and 8, or earlier, depending on body mass index and race. Comedonal acne in particular could be the first sign of pubertal maturation in girls, "so make sure you follow these kids," Dr. Zaenglein advised.
Preadolescent acne commonly occurs in the T-zone, and it may be a predictor of severe acne in later years, she added.
Of note, pseudoacne can occur in the nasal creases, in the form of milia, comedones, or inflamed papules. However, these lesions are not really acne and can be associated with atopic dermatitis or other conditions, said Dr. Zaenglein. They can be treated with topical antibiotics, benzoyl peroxide, or comedone extraction, she said.
The treatment principles for adolescent acne apply to preadolescent acne as well, with some modifications, Dr. Zaenglein said. Try to simplify the routines to once-daily to improve adherence, and warn parents about benzoyl peroxide staining. Also, ask about the presence of permanent teeth before considering a tetracycline, since the therapy can stain the teeth, she noted. To help kids take the pills, use a favorite breakfast spread, she suggested.