As a pediatrician, you are on the front line of acne treatment for neonates, children, and adolescents. Acne is a very common condition that will affect 80% of your patients at some point in their lives. It can be easy to diagnose, but acne is often difficult to evaluate and manage. Presentations vary from mild to severe, and you’re likely to see a wide range of acne severity as you treat babies, children, and adolescents through office consultations and regular wellness checks.
Minimal intervention is reasonable for children with mild, comedonal acne. Most are unaware and unconcerned about their acne. It is important to stress they should avoid aggressive facial scrubbing and "popping zits." A discussion of acne physiology that dispels common myths – for example, that junk foods and poor hygiene cause acne in children and adolescents – also is useful.
By Dr. Brooke Sikora
Early intervention is essential to successful management. Prompt initiation of acne therapy can prevent sequelae that, if left untreated, can include significant scarring and emotional distress for your patients.
Refer your patient to a dermatologic surgeon early if the child’s acne is recalcitrant to treatment or shows early signs of scarring. Dermatologic surgeons understand the science behind healthy skin and can help your patients with the special needs of skin through every stage of life.
The differential diagnosis for acneiform eruptions varies by age. Neonatal acne (or neonatal cephalic pustulosis, as it is sometimes called) can affect about one in five babies. It is usually self-limited and requires no treatment, although topical ketoconazole can be prescribed if the parents are concerned or the presentation is extensive.
Infantile acne is less common. This occurs between the ages of 6 months and 1 year. Typical lesions include comedones or more inflammatory lesions. Benzoyl peroxide products and/or topical retinoids can be used to treat infantile acne if it is comedonal.
Acne that appears at age 1-7 years is very rare. Toddlers and children with this early childhood acne also should be evaluated further and/or referred to a specialist. A careful history and physical examination are warranted. Measure height and weight, and plot them on the growth chart. Also look for signs of virilization or precocious sexual development.
An abnormal blood pressure can point to congenital adrenal hyperplasia in the neonatal period. Rule out hyperandrogenism, particularly with severe or persistent infantile acne or sudden onset childhood acne. Refer patients to an endocrinologist if you are uncertain, or if any of the following screening tests are abnormal: bone age, serum DHEA (dehydroepiandrosterone), and free testosterone levels. (Total testosterone can be checked if the free testosterone test is unavailable.) Also consider serologic measures of follicle stimulating hormone, luteinizing hormone, prolactin, and 17 alpha-hydroxyprogesterone.
Performance of an exhaustive search for hyperandrogenism in your office is unnecessary in the majority of neonates, infants, children, and adolescents. It is important to know when these screening tests should be ordered and when to refer to a specialist for further evaluation and/or management.
Prepubertal or adolescent acne can occur earlier than parents might expect (at around 8 years of age), and can be the first sign of pubertal maturation. Distinguish comedonal from inflammatory acne to determine appropriate therapy.
Treatment with topical retinoids is the best for comedonal acne. Take the time to educate parents and the child on proper application of a topical retinoid. Instruct them to apply a pea-sized amount to dry skin every other night (or even every third night) for the first 2-4 weeks. This initial small dose can be titrated up gradually over time to minimize adverse effects. Improper use can lead to significant irritation and dryness, and contribute to the lack of treatment compliance.
As with any disease process, patient education is extremely important and can have a great impact on outcomes. Extensively counsel patients and parents on therapy options, and stress the importance of compliance with your recommended treatment regimen.
If the child has inflammatory acne lesions, a combination of benzoyl peroxide and topical antibiotic therapy (erythromycin or clindamycin) is more effective than either agent alone. With more severe acne, oral antibiotics may be warranted. Keep in mind that the tetracycline family of antibiotics can interfere with bone and teeth development, and is contraindicated in children younger than 8 years. Treatment with erythromycin or with Mutual Pharmaceutical’s Bactrim (a combination of sulfamethoxazole and trimethoprim) is appropriate for this age group. For older children with fully developed teeth, oral tetracycline, minocycline, and doxycycline are often the antibiotics of choice.