Conference Coverage
WAIKOLOA, HAWAII – A major impetus behind the first-ever evidence-based guidelines on the management of pediatric acne was to close significant practice gaps identified between what the acne experts recommend and what many clinicians do, according to the lead author of the guidelines.
"One of the points we wanted both dermatologists and primary care physicians to be aware of is that when you see acne in a 7- to 10-year-old, it’s predictive of much worse acne years later. That has been underappreciated," Dr. Lawrence F. Eichenfield said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation (SDEF).
"It used to be said that you didn’t need to start worrying about acne until age 12, but the data shows that acne is now incredibly common in 8-, 9-, and 10-year-olds. There is clear evidence that puberty is occurring earlier, and acne is, too. Acne can be the first sign of normal puberty, starting as young as 7 years of age," he observed.
Frontline Medical News
Bruce Jancin interviews Dr. Larry Eichenfield
Another point the guidelines panel sought to publicize: While the traditional view has been that scarring acne comes from deep nodular and nodulocystic lesions, new data suggest that’s not the case. Plenty of patients with acne scars never had nodulocystic acne, nor did they pick at their lesions, Dr. Eichenfield said. Serial imaging studies demonstrate that acne scars don’t necessarily even come from inflammatory acne lesions. Instead, many such scars arise from erythematous red spots, simple papules, or even closed comedones. And scarring isn’t always an adult process; it can occur in pediatric patients.
"If you see evidence of scarring, that may move you to be much more aggressive in your acne therapy. It’s still easier for us to prevent acne scarring than it is to fix it. Prevention is clearly the way to go," observed Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children’s Hospital and professor of clinical pediatrics and medicine at the University of California, San Diego.
He noted that one significant practice gap in acne therapy highlighted in a recent national study involves underutilization of topical retinoids. Investigators analyzed data from the National Ambulatory Medical Care Survey for 2005-2010 and determined that a topical retinoid was prescribed in 41% of acne-related physician visits. Moreover, patients who saw a pediatrician or family physician were 77% less likely to get a prescription for a topical retinoid than those who visited a dermatologist. Older age, male gender, and being on Medicaid were other factors associated with a significantly lower likelihood of receiving a prescription for a topical retinoid (J. Dermatol. Treat. 2014; 25:110-4).
That 41% rate for topical retinoids is much too low, according to Dr. Eichenfield. The recent guidelines emphasize that topical retinoids are useful as monotherapy or in fixed-combination products in treating acne of all types and severities in children and adolescents of all ages.
Another recent study that focused on national treatment patterns for acne in 7- to 12-year-olds, found striking differences according to physician specialty. The top three medications prescribed by dermatologists in these preadolescent patients were the topical retinoid adapalene in 35.9%, benzoyl peroxide in 16.9%, and the topical retinoid tretinoin in 16.1%. In contrast, the top three prescribed by pediatricians and family physicians were minocycline in 13.4%, oral clindamycin in 10.5%, and tretinoin in 10.5% (Pediatr. Dermatol. 2013;30:689-94). The fairly common use of oral clindamycin for acne documented in this study is disturbing; acne experts almost never use that drug because there are other oral antibiotic options with much better safety profiles, Dr. Eichenfield said.
The guidelines (Pediatrics 2013;131:S163-86), which were developed by the American Acne and Rosacea Society and endorsed by the American Academy of Pediatrics, contain detailed acne treatment algorithms. Among the key points:
• Topical antibiotics are not recommended as monotherapy for acne for longer than a few weeks because of the risk of inducing bacterial resistance. Beyond several weeks, topical benzoyl peroxide should be added, because it has a potent antimicrobial effect across a broad range of organisms and it does not promote bacterial resistance.
• The guidelines recommend oral antibiotics as appropriate for moderate to severe acne at any age, but not as monotherapy because of the growing threat posed by global antibiotic resistance. Instead, oral antibiotics should always be used with topical retinoids and usually in conjunction with benzoyl peroxide. The patient should be using the retinoid when starting the oral antibiotic so that when the oral antibiotic is discontinued, usually after a few months, the topical agent can assume a key role in maintaining remission.