A CME-Certified Supplement to Skin & Allergy News®

Pediatric Management: Optimizing Outcomes

Faculty Lawrence F. Eichenfield, MD, Chair Clinical Professor of Pediatrics and Medicine () Chief, Pediatric and Adolescent Dermatology Rady Children’s Hospital University of California, San Diego San Diego, California Hilary E. Baldwin, MD Associate Professor and Vice Chair Department of Dermatology SUNY Downstate Brooklyn, New York Sheila Fallon Friedlander, MD Clinical Professor of Pediatrics and Medicine (Dermatology) Rady Children’s Hospital University of California, San Diego Models are for illustrative San Diego, California purposes only. Anthony J. Mancini, MD Professor of Pediatrics and Dermatology Introduction 3 Northwestern University Feinberg School of Medicine Head, Division of Pediatric Dermatology Children’s Memorial Hospital Acne Life Cycle: The Spectrum 4 Chicago, Illinois of Pediatric Disease Albert C. Yan, MD Chief, Pediatric Dermatology Children’s Hospital of Philadelphia The Acne Continuum: An Age-Based 7 Associate Professor, Pediatrics and Dermatology Approach to Therapy Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania The Effects of Culture, Skin Color, 12 Original Release Date: September 2011 and Other Nonclinical Issues on Most Recent Review Date: September 2011 Expiration Date: September 3, 2012 Acne Treatment Estimated Time to Complete Activity: 2.0 hours Medium or Combination of Media Used: Approach to Pediatric Acne Treatment: 15 Written Supplement Method of Physician Participation: An Update Journal Supplement Parents as Partners in Pediatric 20 A continuing medical education activity held at Acne Management Skin Disease Education Foundation’s 35th Annual CME Post-Test and Evaluation 24

This activity is supported by Jointly sponsored by an educational grant from and

CONSUMER & PERSONAL PRODUCTS WORLDWIDE DIVISION OF JOHNSON & JOHNSON CONSUMER COMPANIES, INC. A CME-Certified Method of Participation benefit of the opinions of experts to ensure that these Supplement to To get instant CME credits online, go to http://uofl.me/ medications are used appropriately and safely in acnemanag11. Upon successful completion of the online younger pediatric patients. ® test and evaluation form, you will be directed to a web- This supplement addresses these needs and also pro- Skin & Allergy News page that will allow you to receive your certificate of vides an educational handout for the parents of younger credit via e-mail. Please add [email protected] to your pediatric patients to help families appropriately manage e-mail “safe” list. acne at home. (Type the above address into your address bar in Internet Learning Objectives Explorer. If you are unfamiliar with what an address bar is Upon completion of this activity, participants should be or how to access yours, open Internet Explorer, then hold better able to: down the control key and press the “O” key on your key- board. A dialogue box will open—this is where you will • Assess and classify acne vulgaris in pediatric patients, type the above address. After you have typed the address, including preteen/preadolescent patients. Pediatric Acne click OK to go to the evaluation.) • Describe the topical and systemic medications avail- Once you have completed the evaluation, you will be able and suitable for use in pediatric patients with Management: given a password. Please be sure to write it down; you acne and note specifically which medications are will then be able to access your certificate. Please note, indicated and contraindicated in pediatric patients Optimizing certificates will not be mailed, so be sure to print a copy less than 12 years of age. for your records. If you have any questions or difficulties, • Discuss the evidence supporting how early treatment Outcomes please contact the University of Louisville School of of acne changes the course of the disease in pediat- Medicine Continuing Health Sciences Education office at ric patients. (502) 852-5329. • Select the type of medication and route of delivery Joint Sponsorship appropriate for individual patients, based on age, This activity has been planned and implemented in accor- severity of disease, and other factors. dance with the Essential Areas and Policies of the • Advise patients and their parents regarding the nature Reprinted from Accreditation Council for Continuing Medical Education and management of the disease and on implement- Seminars in Cutaneous (ACCME) through the joint sponsorship of the University of ing strategies for coping with acne. Medicine and Surgery Louisville School of Medicine Continuing Health Sciences Disclosure The manuscript was originally published Education (CHSE) and Skin Disease Education Foundation, As a sponsor accredited by the ACCME, CHSE must as a supplement to Seminars in Cutaneous an Elsevier business. CHSE is accredited by the ACCME to ensure balance, independence, objectivity, and scientific Medicine and Surgery, Supplement 1, provide continuing education for physicians. rigor in all its sponsored educational activities. All faculty Vol. 30, No. 3S, September 2011. It has participating in this CME activity were asked to disclose been reviewed and approved by the Designation Statement the following: faculty as well as the Editors of Seminars CHSE designates this educational journal for a maximum in Cutaneous Medicine and Surgery. of 2.0 AMA PRA Category 1 Credit(s)™. Physicians 1. Names of proprietary entities producing health care should only claim credit commensurate with the extent goods or services—with the exemption of nonprofit of their participation in the activity. or government organizations and non–health- related companies—with which they or their Target Audience spouse/partner have, or have had, a relevant finan- This continuing medical education The target audience for this educational supplement are cial relationship within the past 12 months. For this (CME) supplement was developed from dermatologists, pediatricians, and other health care pro- purpose, we consider the relevant financial relation- a clinical roundtable held during fessionals involved in the treatment of pediatric patients ships of a spouse/partner of which they are aware Skin Disease Education Foundation’s with acne. to be their financial relationships. 35th Hawaii Dermatology Seminar, a CME conference, convened in Maui, Statement of Professional Practice 2. Describe what they or their spouse/partner received Hawaii, March 13-18, 2011. Gap(s) (eg, salary, honorarium). 3. Describe their role. Neither the editors of Skin & Allergy Although acne vulgaris is most commonly seen in ado- News nor the Editorial Advisory Board lescents and young adults (85% of individuals between 4. No relevant financial relationships. nor the reporting staff contributed to 12 and 24 years of age develop acne), it may be seen at CHSE planning committee, has no relevant financial its content. The opinions expressed in this any age. The disease frequently is seen in preadoles- relationships with any commercial interests. supplement are those of the faculty and cents, and its occurrence in children as young as 7 years CME Reviewer: Timothy E. Brown, MD, Professor, do not necessarily reflect the views of of age is not rare. the supporter nor of the Publisher. Division of Dermatology, University of Louisville, School Untreated acne can leave permanent scars and, as of Medicine, has no relevant financial relationships with The faculty acknowledge the editorial such, create psychosocial issues for preadolescent, any commercial interests. assistance of Global Academy for Medical adolescent, young adult, and adult patients. Emerging Hilary E. Baldwin, MD, has served as a consultant Education, LLC, an Elsevier business, and therapies and regimens offer dermatologists a broader and speaker for Allergan, Galderma, Medicis, and Onset. Joanne Still, Medical Writer, in the range of options to improve tolerability, sustain positive She has also been a speaker for GlaxoS mithKline and development of this supplement. clinical outcomes, and effectively treat a diverse patient Ortho Dermatologics. population. Treatment of acne depends on the type, Lawrence F. Eichenfield, MD, has served as an inves- extent, and severity of the condition. The current guide- tigator for Galderma, GlaxoSmithKlein, Johnson & lines for acne management recommend the use of Johnson, Neutrogena, and Stiefel. He has also been a Copyright © 2011 by Elsevier Inc. and its Licensors. combination regimens in order to address multiple consultant and/or served on the advisory board for All rights reserved. No part of this publication may aspects of acne pathogenesis. For best outcomes, Coria, Galderma, GlaxoSmithKline, Intendis, Medicis, be reproduced or transmitted in any form, by any Ortho Dermatologics, Stiefel, and Valeant. means, without prior written permission of the patient care should be individualized. Publisher. Elsevier Inc. will not assume responsibility To achieve this goal of personalized therapy for patients Sheila Fallon Friedlander, MD, has served on an for damages, loss, or claims of any kind arising advisory board for Galderma and Onset. from or related to the information contained in this of any age with acne, clinicians must stay informed publication, including any claims related to the about the proper use of existing therapies and the Anthony J. Mancini, MD, FAAP, has served as a con- products, drugs, or services mentioned herein. impending availability and anticipated appropriate use sultant for Galderma, Medicis, and Stiefel. He has also of emerging options. Furthermore, although random- been a speaker for Galderma. ized, controlled clinical trials of new and existing Albert C. Yan, MD, has no relevant financial relation- medications more frequently are including patients less ships with any commercial interests. than 12 years of age in study populations, to date all but Sylvia Reitman, MBA, has no relevant financial rela- a few prescription medications used to treat acne are tionships with any commercial interests. approved by the FDA for use in patients as young as 12 Joanne Still has no relevant financial relationships with years of age. It is important for clinicians to have the any commercial interests.

2 globalacademycme.com/sdef • Pediatric Acne Management: Optimizing Outcomes Volume 30, Number 3S September 2011 Introduction

cne vulgaris is among the most common skin diseases, affect- Table Intended Practice Changes: Selected Sample Aing almost all individuals by the time they reach adulthood. ● Will not hesitate to treat younger patients [with acne] Acne is most commonly seen in patients between 12 and 17 years of ● More confidence in prescribing acne medications to age, but it may occur at any age, from birth through late adulthood. younger patients (8-11 y/o) The articles in this supplement resulted from the meeting of a panel ● Will consider psychological impact of acne and factor of experts convened during the Skin Disease Education Founda- into treatment plan tion’s 35th Annual Hawaii Dermatology Seminar in March 2011. It ● Start acne therapy at a younger age was our goal to review the latest evidence and current expert opin- ● Use more topical ; use them earlier ● Treat younger patients more aggressively ions on the diagnosis and treatment of acne. ● More likely to use systemic therapy earlier The authors involved in the development and writing of the ● Start therapy in less severe acne following articles utilized the terminology proposed by the Ameri- ● Be more proactive in treating acne can Acne and Society and the Acne Alliance of North ● I will address early acne in the younger age group American Pediatric Acne Guidelines Panel, not yet published, cat- Source: Participant outcomes evaluations from Eichenfield LF1. egorizing pediatric acne into four groups: (0-4 weeks of age), (1 through 12 months of age), mid-childhood acne (�1 through 6 years of age), and preadolescent acne (�7 impact of acne, including preadolescent patients in the spectrum of through 11 years of age). The presentation and differential diagnosis discussion. of each group is distinct, and these papers emphasize the spectrum One reason for the focus on preadolescent acne, in particular, in of acne across the ages, the appropriate workup and management, the recent panel discussion and current articles was the response of Volume 30, Number 3S and—with the limited database of therapy underSeptember age 12—the 2011 need clinicians to the program evaluation question, “After participation to extrapolate from findings involving children 12 years of age and in this activity, have you decided to change one or more aspects in older. the treatment of your patients?” A total of 407 out of 700 respon- IntroductionWhile the term pediatric acne can be used variably, the expert dents (64.4%) answered in the affirmative. The verbatim state- Volume 30, Number 3S panel emphasized acne and its differential diagnosisSeptember and treatment 2011 ments regarding intended practice changes (a selected sample is from birth up until adolescence. It is increasingly recognized that shown in the Table) indicated that clinicians might benefit from significant numbers of preadolescents have significant acne, and it more detailed attention to acne in the younger pediatric patient. It is hoped that these papers combine the latest medical evidence Volume 30, Number 3S cne vulgaris is among the most commonSeptember skin diseases, 2011 affect- isTable importantIntended to understand Practice Changes: the epidemiology Selected and Sample presentations of Introduction with expert opinion in a useful and clinically practical way. Aing almost all individuals by the time they reach adulthood. ●acneiformWill not conditions hesitate toin the treat different younger pediatric patients age [withgroups. acne] Acne is most commonly seen in patients between 12 andIntroduction 17 years of ● More confidence in prescribing acne medications to age, but it may occur at any age, from birth through late adulthood. younger patients (8-11 y/o) Lawrence F. Eichenfield, MD IntroductionThecne articles vulgaris in this is supplement among the most resulted common from the skin meeting diseases, of a affect- panel Table●TheWillIntended considerNeed Need Practice psychologicalfor for Changes:Attention Attention impact Selected of acne Sampleto and factor Guest Editor ing almost all individuals by the time they reach adulthood. Aof experts convened during the Skin Disease Education Founda- ●PreadolescentsWillinto not treatment hesitate plan to treat younger patients [with acne] Acnetion’s is 35th most Annual commonly Hawaii seen Dermatology in patients between Seminar 12 in and March 17 years2011. of It ●●toMoreStart Preadolescents acneconfidence therapy in at prescribing a younger acne age medications to Rady Children’s Hospital ● Use more topical retinoids; use them earlier University of California age,Tablewas but ourIntended it goal may to occurreview Practice at anythe Changes: latest age, from evidence birth Selected and through current Sample late expert adulthood. opin- Inyounger 2010, this patients author served (8-11 on y/o) a similar expert panel that met dur- cne vulgaris is among the most common skin diseases, affect- ● Treat younger patients more aggressively San Diego School of Medicine ing almost all individuals by the time they reach adulthood. Theions articles on the in diagnosis this supplement and treatment resulted offrom acne. the meeting of a panel ●ingWill the 34thconsider Annual psychological Hawaii Dermatology impact Seminar of acne and and developed factor a A ● Will not hesitate to treat younger patients [with acne] ● intoMore treatment likely to plan use systemic therapy earlier San Diego, California Acne is most commonly seen in patients between 12 and 17 years of of expertsThe authors convened involved during in the the Skin development Disease Education and writing Founda- of the supplement titled “Facing the Challenge of Acne Vulgaris in Pedi- ● More confidence in prescribing acne medications to ●● StartStart acne retinoid therapy therapy at a in younger less severe age acne E-mail: leichenfi[email protected] tion’sfollowing 35th articles Annual utilized Hawaii the Dermatology terminology Seminar proposed in March by the 2011. Ameri- It atric Patients.”1 In that supplement, the panel (Sheila Fallon Fried- age, but it may occur at any age, from birth through late adulthood. younger patients (8-11 y/o) ●● UseBe more more proactive topical retinoids; in treating use acne them earlier wascan our Acne goal and to review Rosacea the Society latest evidence and the and Acne current Alliance expert of Northopin- lander, MD, Joseph F. Fowler, Jr, MD, Richard G. Fried, MD, Moise The articles in this supplement resulted from the meeting of a panel ● Will consider psychological impact of acne and factor ●● TreatI willyounger address patientsearly acne more in the aggressively younger age group Reference ionsinto on treatment the diagnosis plan and treatment of acne. of experts convened during the Skin Disease Education Founda- American Pediatric Acne Guidelines Panel, not yet published, cat- ●Source:L.More Levy, ParticipantMD, likely and to Guyuse outcomes F.systemic Webster, evaluations therapy MD, in from earlieraddition Eichenfield to this LFauthor)1. The authors involved in the development and writing of the 1. Eichenfield LF, Fowler JS, Fried RG, Friedlander SF, Levy ML, Webster tion’s 35th Annual Hawaii Dermatology Seminar in March 2011. It ●egorizingStart acne pediatric therapy acne at into a younger four groups: ageneonatal acne (0-4 weeks ●focusedStart retinoid on current therapy views inof acneless severepathophysiology, acne the diagnosis GF: Facing the challenge of acne vulgaris in pediatric patients. Semin was our goal to review the latest evidence and current expert opin- ●followingofUse age), moreinfantile articles topical acne utilized(1 retinoids; through the terminology 12use months them proposed earlier of age), bymid-childhood the Ameri- ●andBe evaluation more proactive of the condition, in treating and acne the medical and psychosocial Cutan Med Surg 29:1-16, 2010 (2 suppl 1) ● Treat younger patients more aggressively ions on the diagnosis and treatment of acne. canacne Acne(�1 and through Rosacea 6 years Society of age), and the and Acnepreadolescent Alliance acneof North(�7 ●impactI will of address acne, including early acne preadolescent in the younger patients age in the group spectrum of ● More likely to use systemic therapy earlier Americanthrough 11 Pediatric years ofAcne age). The Guidelines presentation Panel, and not differential yet published, diagnosis cat- discussion. 1 The authors involved in the development and writing of the ● Start retinoid therapy in less severe acne Source: Participant outcomes evaluations from Eichenfield LF . following articles utilized the terminology proposed by the Ameri- egorizingof each group pediatric is distinct, acne into and four these groups: papersneonatal emphasize acne the(0-4 spectrum weeks One reason for the focus on preadolescent acne, in particular, in ●ofBe age), moreinfantile proactive acne (1 in through treating 12 acne months of age), mid-childhood the recent panel discussion and current articles was the response of can Acne and Rosacea Society and the Acne Alliance of North ●ofI acne will across address the early ages, the acne appropriate in the younger workup age and group management, 1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. S1 � � impactclinicians of acne, to the including program preadolescent evaluation question, patients “After in the participation spectrum of American Pediatric Acne Guidelines Panel, not yet published, cat- acneand—with( 1 through the limited 6 years database of age),of therapy and underpreadolescent age 12—the acne need( 7 doi:10.1016/j.sder.2011.08.005 Source: Participant outcomes evaluations from Eichenfield LF1. discussion. egorizing pediatric acne into four groups: neonatal acne (0-4 weeks throughto extrapolate 11 years from of age). findings The presentationinvolving children and differential 12 years of diagnosis age and in this activity, have you decided to change one or more aspects in theOne treatment reason offor your the focus patients?” on preadolescent A total of 407 acne, out in of particular, 700 respon- in of age), infantile acne (1 through 12 months of age), mid-childhood ofolder. each group is distinct, and these papers emphasize the spectrum thedents recent (64.4%) panel discussionanswered in and the current affirmative. articles The was the verbatim response state- of acne (�1 through 6 years of age), and preadolescent acne (�7 impactof acneWhile of across acne, the term the including ages, pediatric the preadolescent appropriate acne can be workup patients used variably, andin the management, spectrum the expert of clinicians to the program evaluation question, “After participation discussion.and—withpanel emphasized the limited acne database and its differentialof therapy under diagnosis age 12—the and treatment need ments regarding intended practice changes (a selected sample is through 11 years of age). The presentation and differential diagnosis in this activity, have you decided to change one or more aspects in tofrom extrapolateOne birth reason up from for until the findings adolescence. focus on involving preadolescent It is children increasingly acne, 12 yearsin recognized particular, of age and that in shown in the Table) indicated that clinicians might benefit from of each group is distinct, and these papers emphasize the spectrum the treatment of your patients?” A total of 407 out of 700 respon- theolder.significant recent panel numbers discussion of preadolescents and current have articles significant was the response acne, and of it more detailed attention to acne in the younger pediatric patient. of acne across the ages, the appropriate workup and management, dentsIt is (64.4%) hoped that answered these papers in the combine affirmative. the latest The medical verbatim evidence state- cliniciansis importantWhile the to the toterm understand program pediatric evaluation the acne epidemiology can question, be used and variably, “After presentations participation the expert of and—with the limited database of therapy under age 12—the need mentswith expert regarding opinion intended in a useful practice and changesclinically (a practical selected way. sample is inpanelacneiform this emphasized activity, conditions have acne you in and decidedthe its different differential to change pediatric diagnosis one age or more groups. and aspectstreatment in to extrapolate from findings involving children 12 years of age and shown in the Table) indicated that clinicians might benefit from thefrom treatment birth up of until your adolescence. patients?” A It total is increasingly of 407 out recognized of 700 respon- that older. more detailed attentionLawrence to acne in theF. Eichenfield, younger pediatric MD, patient. Chair dentssignificant (64.4%) numbers answered of preadolescents in the affirmative. have significant The verbatim acne, and state- it Lawrence F. Eichenfield, MD While the term pediatric acne can be used variably, the expert It is hoped thatClinical these Professor papers combineof Pediatrics the and latest Medicine medicalGuest (Dermatology) evidence Editor panel emphasized acne and its differential diagnosis and treatment mentsisThe important regarding Need to understand intended for practice the Attention epidemiology changes (a and selected to presentations sample of is Chief, Pediatric and Adolescent Dermatology with expert opinionRady Children’s in a useful Hospital, and clinically University practical of California, way. San Diego from birth up until adolescence. It is increasingly recognized that shownacneiform in theconditions Table) indicatedin the different that clinicians pediatric age might groups. benefit from morePreadolescents detailed attention to acne in the younger pediatric patient. Rady Children’sSan Diego, HospitalCalifornia significant numbers of preadolescents have significant acne, and it LawrenceUniversity F. Eichenfield, of California MD InIt 2010, is hoped this that author these served papers on combine a similar the expert latest panel medical that evidence met dur- is important to understand the epidemiology and presentations of Table. Intended Practice Changes: Selected Sample San Diego SchoolGuest of Medicine Editor withTheing the expert 34th Need opinion Annual infor Hawaii a useful Attention Dermatology and clinically Seminar practical to and way. developed a acneiform conditions in the different pediatric age groups. San Diego, California supplement titled “Facing the Challenge of Acne Vulgaris in Pedi- Preadolescents• Will not hesitate to treat younger patients [with acne] • Use more topical retinoids; use them earlierE-mail:Rady leichenfi[email protected] Children’s Hospital atric Patients.”1 In that supplement,Lawrence the panel F. (Sheila Eichenfield, Fallon Fried- MD • Treat younger patients more aggressively University of California In• 2010, More thisconfidence author in served prescribing on a similaracne medications expert panel to younger thatGuest met Editor dur- lander,patients MD, (8-11 Joseph y/o) F. Fowler, Jr, MD, Richard G. Fried, MD, Moise • More likely to use systemic therapy earlierSan Diego School of Medicine The Need for Attention to ing the 34th Annual Hawaii Dermatology Seminar and developed a Reference L.• Levy, Will consider MD, and psychological Guy F. Webster, impact MD,of acne in and addition factor into to this author) • Start retinoid therapy in less severe acne San Diego, California Preadolescents supplement titled “Facing the ChallengeRady of Acne Children’s Vulgaris Hospital in Pedi- 1. Eichenfield LF, Fowler JS, Fried RG, Friedlander SF, Levy ML, Webster focusedtreatment on current plan views of acne pathophysiology, the diagnosis • Be moreGF: proactive Facing the in treating challenge acne of acne vulgarisE-mail: in leichenfi[email protected] pediatric patients. Semin 1 University of California In 2010, this author served on a similar expert panel that met dur- atricand• StartPatients.”evaluation acne therapyIn of thatthe at condition, supplement, a younger andage the the panel medical (Sheila and Fallon psychosocial Fried- • I will addressCutan Med early Surg acne 29:1-16, in the younger 2010 (2 age suppl group 1) San Diego School of Medicine ing the 34th Annual Hawaii Dermatology Seminar and developed a lander, MD, Joseph F. Fowler, Jr, MD, Richard G. Fried, MD, Moise Reference L.Source: Levy, Participant MD, and outcomes Guy F.evaluations Webster, from Eichenfield MD, in LF additionSan1. Diego, to this California author) supplement titled “Facing the Challenge of Acne Vulgaris in Pedi- 1. Eichenfield LF, Fowler JS, Fried RG, Friedlander SF, Levy ML, Webster E-mail: leichenfi[email protected] atric Patients.”1 In that supplement, the panel (Sheila Fallon Fried- focused on current views of acne pathophysiology, the diagnosis GF: Facing the challenge of acne vulgaris in pediatric patients. Semin and evaluation of the condition, and the medical and psychosocial Cutan Med Surg 29:1-16, 2010 (2 suppl 1) lander, MD, Joseph F. Fowler, Jr, MD, Richard G. Fried, MD, Moise Reference1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. S1 L. Levy, MD, and Guy F. Webster, MD, in addition to this author) doi:10.1016/j.sder.2011.08.005 1. Eichenfield LF, Fowler JS, Fried RG, Friedlander SF, Levy ML, Webster focused on current views of acne pathophysiology, the diagnosis GF: Facing the challenge of acne vulgaris in pediatric patients. Semin and evaluation of the condition, and the medical and psychosocial Cutan Med Surg 29:1-16, 2010 (2 suppl 1) 1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. S1 doi:10.1016/j.sder.2011.08.005

1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. S1 doi:10.1016/j.sder.2011.08.005 Pediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdef 3 Acne Life Cycle: The Spectrum of Pediatric Disease † ‡ AnthonyAcne J. Mancini, Life MD,* Cycle: Hilary The E. Baldwin, Spectrum MD,† Lawrence of Pediatric F. Eichenfield, Disease MD,‡ Anthony J. Mancini, MD,* Hilary§ E. Baldwin, MD, Lawrence¶ F. Eichenfield, MD, Sheila Fallon Friedlander, MD, and Albert C. Yan, MD Sheila Fallon Friedlander, MD,§ and Albert C. Yan, MD¶ Acne Life Cycle: The Spectrum of Pediatric Disease Acne is no longer simply a diagnosis based on the† appearance of characteristic lesions on the ‡ Anthony J. Mancini,Acne is no MD,* longer simply Hilary a diagnosis E. Baldwin, based on MD, the† appearanceLawrence of characteristic F. Eichenfield, lesions‡ on MD, the Anthonyskin J. Mancini, of adolescents. MD,* TheHilary presentation E. 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The goal of this article is Semin Cutan Med Surg 30:S2-S5 © 2011 Elsevierdiscussion Inc.acne All has rights beenof the reserved. the disease lack of by consensus age groups. on how Accumulating to organize and the generallyadolescents,to12 provide years of considered an age teenagers, overview are not as ofsopostadolescents, individuals acne clear-cut. on the between The pediatric andgoal 12 young of age and this spectrum, adults— 18article years is I to provide an overview of acne on the pediatric age spectrum, recentdiscussion*Professor evidence of ofPediatrics the has disease and led Dermatology,by to agegrowing groups. Northwestern consensus Accumulating University’s about Fein-and age ofgenerallyfromto provide age—the birth considered an through presentations, overview age as ofindividuals 18 acne years. etiology, on the between pediatric differential 12 age anddiagnosis, spectrum, 18 years recent*Professornberg the Schoolevidence past, of Pediatrics of one Medicine, has of and led the Dermatology,Head, to challenges Division growing Northwestern of Pediatricin consensus managing Dermatology, University’s about pediatric Fein-Chil- age ofafrom problem age—the birth through in presentations, the group age 18 of years. etiology,patients variously differential described diagnosis, as groupingsberg School and of whatMedicine, to call Head, them. Division Although of Pediatric this Dermatology, has not been Chil- and management issues that affect pediatric patients less than groupingsacnedren’sberg School has Memorial and been of whatMedicine, the Hospital, lack to call Head, Chicago,of them.consensus Division IL Although of Pediatricon how this Dermatology, to has organize not been Chil- the andadolescents, management teenagers, issues postadolescents, that affect pediatric and patients young adults—less than n the past, one of the challenges in managing pediatric Ia problemdren’s Memorial in the Hospital, group Chicago, of patients IL variously described as 12 years of age are not so clear-cut. The goal of this article is discussion†Associate Professor of the and disease Vice Chair,by age Department groups. Accumulating of Dermatology SUNY and 12generallyAge-Based years of considered age are not asEpidemiology so individuals clear-cut. between The goal 12 of andthis article18 years is Iacne has been the lack of consensus on how to organize the adolescents,†AssociateDownstate, Professor Brooklyn,teenagers, and NY Vice postadolescents, Chair, Department and of Dermatology young adults— SUNY toAge-Based provide an overview Epidemiology Epidemiology of acne on the pediatric age spectrum, discussion of the disease by age groups. Accumulating and *Professorrecentgenerally‡ClinicalDownstate, evidence Professor of considered Pediatrics Brooklyn, of has Pediatrics and NYas led Dermatology, individuals to and growing Medicine Northwestern between (Dermatology), consensus 12 University’s and about Chief, 18 years Fein- Pedi- age fromtoofPediatric provide age—the birth acne an through presentations, overviewis the ageterm of 18 used acne years. etiology, toon describe the pediatric differential the presentation age spectrum,diagnosis, of ‡Clinical Professor of Pediatrics and Medicine (Dermatology), Chief, Pedi- Pediatric acne is the term used to describe the presentation of recent evidence has led to growing consensus about age *Professorgroupingsof‡Clinicalbergatric age—the School and Professor ofand Adolescent Pediatrics of presentations, Medicine,what of Pediatrics and Dermatology, to Dermatology,callHead, and them. Division etiology, Medicine Children’s Although Northwestern of Pediatric (Dermatology), differential Hospital this Dermatology, University’s hasSan diagnosis, Chief, Diego, not been Fein-Chil- Pedi- Uni- fromanddiseasePediatric management birth from acne through birthis the issues through ageterm 18that used years. 11affect to years describe pediatric of age; the patients the presentation term lessadoles- than of dren’sbergatric School and Memorial Adolescent of Medicine, Hospital, Dermatology, Head, Chicago, Division Children’s IL of Pediatric Hospital Dermatology, San Diego, Chil- Uni- disease from birth through 11 years of age; the term adoles- groupings and what to call them. Although this has not been andversity management of California, issues San Diego that affect School pediatric of Medicine, patients San Diego, less CA than 12centdisease years acne from ofincludes age birth are notpatientsthrough so clear-cut. from 11 years age The of 12 age; goal to adulthood the of this term articleadoles-1 (Fig- is †Associate§Clinicaldren’sversity Professor Memorial ofProfessor California, of Hospital, and Pediatrics San Vice Diego Chicago, Chair, and School Medicine, Department IL of Medicine, Dermatology, of Dermatology San Diego, University CA SUNY of Age-Basedtocent provide acne includes an overview patients Epidemiology of acne from on agethe pediatric 12 to adulthood age spectrum,1 (Fig- †Associate12§ClinicalDownstate, years Professor ofProfessor age Brooklyn, are of and Pediatrics not NY Vice so Chair, clear-cut. and Medicine, Department The Dermatology, goal of Dermatology of this University article SUNY isof ure). Under the designation of pediatric acne, four subgroups *ProfessorCalifornia, of Pediatrics San Diego, and Rady Dermatology, Childrens Hospital,Northwestern San Diego, University’s CA Fein- Age-Basedure). Under the designation Epidemiology of pediatric acne, four subgroups ‡Clinicalto provideDownstate,California, Professor an San Brooklyn, overview Diego,of Pediatrics NY Rady of acne Childrens and Medicine on the Hospital, pediatric (Dermatology), San Diego, age spectrum, Chief, CA Pedi- fromure). birthUnder through the designation age 18 years. of pediatric acne, four subgroups ¶Chief,berg Pediatric School of Dermatology, Medicine, Head, Children’s Division Hospital of Pediatric of Philadelphia, Dermatology, Associ- Chil- Pediatricwill be considered acne is the here: termneonatal used to describe acne (0 through the presentation 4 weeks of of *Professor of Pediatrics and Dermatology, Northwestern University’s Fein- ‡Clinical¶Chief,atric Pediatric and Professor Adolescent Dermatology, of Pediatrics Dermatology, Children’s and Medicine Children’s Hospital (Dermatology), Hospital of Philadelphia, San Chief, Diego, Associ- Pedi- Uni- will be considered here: neonatal acne (0 through 4 weeks of fromdren’sate birth Professor, Memorial through Pediatrics Hospital, age and 18 Chicago, Dermatology years. IL Perelman School of Medicine diseasePediatricage), infantile from acne birthis acne the through(1 term through used 11 to 12years describe months of age; the of the age),presentation termmid-child-adoles- of berg School of Medicine, Head, Division of Pediatric Dermatology, Chil- versityatricate Professor, and of Adolescent California, Pediatrics SanDermatology, and Diego Dermatology School Children’s of Medicine, Perelman Hospital SanSchool San Diego, Diego,of Medicine CA Uni- age), infantile acne (1 through 12 months of age), mid-child- †Associateat the University Professor of and Pennsylvania, Vice Chair, Philadelphia, Department PAof Dermatology SUNY centdiseasehoodage), acne acneinfantile fromincludes(�1 birth acne through patientsthrough(1 through 6 years from 11 12ofyears ageage), months of 12 and age; to ofpreadolescent adulthood the age), termmid-child-adoles-1 (Fig- acne dren’s Memorial Hospital, Chicago, IL §Clinicalversityat the Professor University of California, of of Pediatrics Pennsylvania, San Diego and School Medicine, Philadelphia, of Medicine, Dermatology, PA San Diego, University CA of Age-Basedhood acne (�1 through Epidemiology 6 years of age), and preadolescent1 acne PublicationDownstate, of this Brooklyn, CME article NY was jointly sponsored by the University of centhood� acne acneincludes(�1 through patients 6 years from1 of ageage), 12 and topreadolescent adulthood (Fig- acne †Associate Professor and Vice Chair, Department of Dermatology SUNY §ClinicalPublicationCalifornia, Professor of Santhis Diego, ofCME Pediatrics article Rady Childrens was and jointly Medicine, Hospital, sponsored Dermatology, San by Diego, the University CA of of ure).( 7 throughUnder the 11 designation years of age). of pediatric1 acne, four subgroups ‡ClinicalAge-BasedLouisville Professor Continuing of Pediatrics EpidemiologyHealth and Sciences Medicine Education (Dermatology), and Skin Chief, Disease Pedi- Ed- Pediatric(�7 through acne is 11 the years term of used age). to1 describe the presentation of Downstate, Brooklyn, NY ¶Chief,California,Louisville Pediatric Continuing San Dermatology, Diego, RadyHealth Children’s Childrens Sciences Hospital,Hospital Education of San andPhiladelphia, Diego, Skin CADisease Associ- Ed- willure). be Under considered the designation here: neonatal of pediatric acne (0 acne, through four 4subgroups weeks of atricucation and Foundation Adolescent and Dermatology, supported Children’s by an educational Hospital grant San Diego, from John- Uni- ‡Clinical Professor of Pediatrics and Medicine (Dermatology), Chief, Pedi- ¶Chief,Pediatricateucation Professor, Pediatric acne Foundation Dermatology,is Pediatrics the andterm and supported used Children’s Dermatology to by describe Hospital an Perelmaneducational of the Philadelphia, School presentation grant of from Medicine Associ- John- of diseaseage),willNeonatal beinfantile considered from birthAcne acne here:(1through and throughneonatal Infantile 11 12 years acne months of(0 Acne age; through of the age), term 4mid-child- weeksadoles- of versityson & Johnsonof California, Consumer San Diego & Personal School Productsof Medicine, Worldwide San Diego, Division CA of 1 atric and Adolescent Dermatology, Children’s Hospital San Diego, Uni- atateson the Professor, & University Johnson Pediatrics Consumer of Pennsylvania, and & Dermatology Personal Philadelphia, Products Perelman PA Worldwide School of Division Medicine of centage),Neonatal acneinfantileincludes Acne Acne acne patients(1and and through Infantile Infantile from 12 age months Acne 12 Acne to of adulthood age), mid-child-(Fig- §ClinicaldiseaseJohnson Professorfrom & Johnson birth of Pediatrics through Consumer and 11 Companies, Medicine, years of Dermatology, Inc. age; the term Universityadoles- of hoodUp to acne 20%(�1 of through newborns 6 years present of age), with and neonatalpreadolescent acneiform acne versity of California, San Diego School of Medicine, San Diego, CA PublicationatJohnson the University of & this Johnson CME of Pennsylvania, Consumer article was Companies, jointly Philadelphia, sponsored Inc. PA by the University of centAnthonyCalifornia, acne J. Mancini,includes San Diego, MD, patients Rady FAAP, Childrens has from served age Hospital, as 12 a consultant to San adulthood Diego, for CA Galderma,1 (Fig- (hoodure).Up�7 to throughacne Under 20%(� the1 of 11 through designation newborns years of 6 yearsage). present of1 pediatric of age), with and acne, neonatalpreadolescent four subgroups acneiform acne §Clinical Professor of Pediatrics and Medicine, Dermatology, University of PublicationAnthonyLouisville J. Mancini,of Continuing this CME MD, article Health FAAP, was Sciences has jointly served Education sponsored as a consultant and by theSkin for University Disease Galderma, Ed- of eruptions. The characteristic lesions are erythematous pap- ¶Chief,Medicis, Pediatric and Dermatology,Stiefel. He has Children’s also been aHospital speaker of for Philadelphia, Galderma. Associ- (willeruptions.�7 be through considered The 11 characteristic years here: ofneonatal age). lesions1 acne are(0 through erythematous 4 weeks pap- of California, San Diego, Rady Childrens Hospital, San Diego, CA ure).ucationLouisvilleMedicis, Under Foundation and Continuing the Stiefel. designation and He Health has supported also Sciences of been pediatric by a anEducation speaker educational acne, for and Galderma. four grantSkin subgroups Disease from John- Ed- ules and papulopustules, although some neonates may occa- Hilaryate Professor,E. Baldwin, Pediatrics MD, has and served Dermatology as a consultant Perelman and School speaker of Medicinefor Aller- age),ules andinfantile papulopustules, acne (1 through although 12 months some neonates of age), maymid-child- occa- ¶Chief, Pediatric Dermatology, Children’s Hospital of Philadelphia, Associ- willHilarysonucation be E. & considered Baldwin, Johnson Foundation Consumer MD, here: and has supported served &neonatal Personal as aby consultant acne Productsan educational(0 through Worldwide and speaker grant 4 fromDivision weeks for John-Aller- of of Neonatalsionallyules and present papulopustules, Acne with and comedones. although Infantile some The Acne lesions neonates are may typically occa- atgan, the Galderma, University Medicis,of Pennsylvania, and Onset. Philadelphia, She has also PA been a speaker for � ate Professor, Pediatrics and Dermatology Perelman School of Medicine age),Johnsonsongan,infantile & Galderma, Johnson & Johnson acne Consumer Medicis,(1 Consumer through and & Personal Onset. Companies, 12 monthsProductsShe has Inc. also Worldwide of beenage), amid-child- speaker Division for of Neonatalhoodsionally acne present( 1 Acne through with and comedones. 6 years Infantile of age), The andAcne lesionspreadolescent are typically acne PublicationGlaxoSmithKline of this CME and article Ortho was Dermatologics. jointly sponsored by the University of Uplocated to 20% on the of newborns face, usually present the1 cheeks, with neonatal chin, eyelids, acneiform and at the University of Pennsylvania, Philadelphia, PA AnthonyJohnsonGlaxoSmithKline J. Mancini, & Johnson MD, and Consumer FAAP, Ortho has Dermatologics. Companies, served as Inc.a consultant for Galderma, (Acnelocated�7 through life on cycle the 11 face, years usually of age). the cheeks, chin, eyelids, and S3 hoodLawrenceLouisville acne F. Eichenfield,(� Continuing1 through MD, Health has 6 years served Sciences of as an age), Education investigator and preadolescent and for Skin Galderma, Disease Glaxo- acne Ed- eruptions.Upforehead,located to 20% on although The the of characteristicnewborns face, they usually sometimes present thelesions cheeks, with extend are neonatal erythematous chin, to the eyelids, scalp, acneiform neck, pap- and Publication of this CME article was jointly sponsored by the University of AnthonyLawrenceMedicis, J. F. Mancini, Eichenfield, and Stiefel. MD, MD, He FAAP, has has alsoserved has been served as an a speakerinvestigator as a consultant for forGalderma. Galderma, for Galderma, Glaxo- (�ucation7SmithKline, through Foundation Johnson 11 years and& Johnson, of supported age). Neutrogena,1 by an educational and Stiefel. grant He has from also John- been eruptions.forehead, although The characteristic they sometimes lesions extend are erythematous to the scalp, neck, pap- Louisville Continuing Health Sciences Education and Skin Disease Ed- HilaryMedicis,SmithKline, E. Baldwin, and Johnson Stiefel. MD, &He has Johnson, has served also Neutrogena, asbeen a consultant a speaker and for andStiefel. Galderma. speaker He has for also Aller- been ulesand upperand papulopustules, chest. The condition, although which some appears neonates more may often occa- in sonconsultant & Johnson and/or Consumer served on & the Personal advisory Products board for Worldwide Coria and DivisionGalderma, of Neonataland upper chest. Acne The and condition, Infantile which Acne appears more often in ucation Foundation and supported by an educational grant from John- Hilarygan,consultant E. Galderma, Baldwin, and/or MD, Medicis, served has onserved and the Onset. advisoryas a consultant She board has also for and Coria been speaker and a speaker forGalderma, Aller- for sionallyulesboys and than present papulopustules, in girls, with is self-limited comedones. although and some The usually lesions neonates mild. are may typically In occa- most JohnsonGlaxoSmithKline, & Johnson Intendis, Consumer Medicis, Companies, Ortho Dermatologics, Inc. Stiefel, and Valeant. boys than in girls, is self-limited and usually mild. In most son & Johnson Consumer & Personal Products Worldwide Division of NeonatalGlaxoSmithKlinegan,GlaxoSmithKline, Galderma, Acne Medicis,Intendis, and and Ortho Medicis, and InfantileDermatologics. Onset. Ortho She Dermatologics, has Acne also been Stiefel, a speaker and Valeant. for sionallyUpboys to than 20% present in of girls, newborns with is self-limited comedones. present andwith The usually lesions neonatal mild. are acneiform typically In most AnthonySheila F. J. Friedlander, Mancini, MD, MD, FAAP, has served has served on an as advisory a consultant board for for Galderma, Galderma locatedcases, the on lesions the face, resolve usually spontaneously the cheeks, within chin, 1 eyelids, to 3 months and Johnson & Johnson Consumer Companies, Inc. LawrenceSheilaGlaxoSmithKline F. F. Friedlander, Eichenfield, and MD, MD, Ortho has served served Dermatologics. as on an an investigator advisory for board Galderma, for Galderma Glaxo- eruptions.cases, the lesions The characteristic resolve spontaneously lesions are within erythematous 1 to 3 months pap- UpMedicis,and to Onset. 20% and of Stiefel. newborns He has also present been a speakerwith neonatal for Galderma. acneiform forehead,locatedbut, in some on although the cases, face, maythey usuallypersist sometimes the for cheeks, longer, extend up chin, to tothe 12 eyelids, scalp, months neck, and of Anthony J. Mancini, MD, FAAP, has served as a consultant for Galderma, LawrenceSmithKline,and Onset. F. Eichenfield, Johnson MD, & Johnson, has served Neutrogena, as an investigator and Stiefel. for Galderma, He has also Glaxo- been but, in some cases, may persist for longer, up to 12 months of Hilaryeruptions.Albert C.E. Yan,Baldwin, The MD, hasMD,characteristic no has relevant served financial as lesions a consultant relationships are erythematous and speakerwith any for commer-Aller- pap- andforehead,ulesage.but,2 upper andinNeonatal some papulopustules, although chest. cases, acne The maythey is condition, believedpersist sometimes although forto which be longer, some extend caused appears neonates up to by tothe stimulation more 12 scalp, may months often neck,occa- in of Medicis, and Stiefel. He has also been a speaker for Galderma. AlbertconsultantSmithKline, C. Yan, and/orMD, Johnson has served no & relevantJohnson, on the financial Neutrogena, advisory relationships board and for Stiefel. Coria with He and anyhasGalderma, alsocommer- been 2 gan,cial interests. Galderma, Medicis, and Onset. She has also been a speaker for andsionallyage. upperNeonatal present chest. acne withThe is condition, believedcomedones. to which be The caused appears lesions by stimulation more are typically often in of Hilary E. Baldwin, MD, has served as a consultant and speaker for Aller- ulesconsultantGlaxoSmithKline,cial and interests. papulopustules, and/or Intendis, served onMedicis, althoughthe advisory Ortho Dermatologics, some board neonates for Coria Stiefel, and may andGalderma, Valeant. occa- boyssebaceous than inglands girls, by is maternal self-limited . and usually mild. In most CorrespondingGlaxoSmithKline author: Anthony and Ortho J. Mancini, Dermatologics. MD, Professor of Pediatrics and Derma- locatedsebaceous on glands the face, bymaternal usually the androgens. cheeks, chin, eyelids, and gan, Galderma, Medicis, and Onset. She has also been a speaker for SheilasionallyCorrespondingGlaxoSmithKline, F. Friedlander, present author: Intendis, withAnthony MD, hascomedones. Medicis, J. Mancini, served Ortho on MD, an Dermatologics, The Professor advisory lesions of boardPediatrics Stiefel, are for andand typically Galderma Valeant. Derma- cases,boysMore than the recently, lesions in girls, theresolve is term self-limited spontaneouslyneonatal andcephalicFigure usually within pustulosis mild. 1 to(NCP) 3In months most has Lawrencetology, F. Northwestern Eichenfield,MD, University’s has served Feinberg as an Schoolinvestigator of Medicine; for Galderma, Head, Division Glaxo- More recently, the term neonatal cephalicSpectrum pustulosis of(NCP) Acne has Vulgaris in Children and Adolescents. GlaxoSmithKline and Ortho Dermatologics. Sheilaandtology, F. Onset. Friedlander, Northwestern MD, University’s has served Feinberg on an School advisory of Medicine; board forHead, Galderma Division cases,forehead,More the recently, lesionsalthough theresolve they term sometimes spontaneouslyneonatal cephalic extend within pustulosis to the 1 to scalp,(NCP) 3 months neck, has locatedSmithKline,of Pediatric on theDermatology; Johnson face, &Johnson, usually Director, Neutrogena, Children’s the cheeks, Memorial and Stiefel. chin, Hospital, He eyelids, has Chicago, also beenand IL. but,been in used some by cases, some may to describe persist for a similar longer, process up to 12 in months newborns of Lawrence F. Eichenfield, MD, has served as an investigator for Galderma, Glaxo- Albertandof PediatricC. Onset. Yan, MD, Dermatology; has no relevant Director, financial Children’s relationships Memorial Hospital, with any Chicago, commer- IL. andbeen2 upper used chest.by some The to condition, describe a which similar appears process more in newborns often in forehead,consultantE-mail: [email protected] although and/or served they on sometimes the advisory extend board for to Coria the scalp,and Galderma, neck, age.but,and inyoungNeonatal some infants. cases, acne mayThis is believed persistentity is forto considered be longer, caused up synonymous by to stimulation 12 months with of SmithKline, Johnson & Johnson, Neutrogena, and Stiefel. He has also been AlbertcialE-mail: C. interests. Yan, [email protected] MD, has no relevant financial relationships with any commer- and2 young infants. This entity is considered synonymous with andGlaxoSmithKline, upper chest. Intendis, The condition, Medicis, Ortho which Dermatologics, appears Stiefel, more and often Valeant. in sebaceousage.boysand youngNeonatal than glandsin infants. girls, acne by This is is maternal self-limited believed entity is androgens. to considered be and caused usually synonymous by mild.stimulation In most with of consultant and/or served on the advisory board for Coria and Galderma, Correspondingcial interests. author: Anthony J. Mancini, MD, Professor of Pediatrics and Derma- Sheila F. Friedlander, MD, has served on an advisory board for Galderma sebaceouscases,neonatal the acne lesions glands by resolve bysome; maternal spontaneouslyhowever, androgens. others within distinguish 1 to 3 months NCP as of sulfate (DHEA-S) in preadoles- GlaxoSmithKline, Intendis, Medicis, Ortho Dermatologics, Stiefel, and Valeant. Correspondingboystology, than Northwestern in author: girls, Anthony University’s is self-limited J. Mancini, Feinberg MD, and School Professor usually of Medicine; of Pediatrics mild. Head, and In Division Derma- most More recently, the term neonatal cephalic pustulosis (NCP) has S2 and1085-5629/11/$-see Onset. front matter © 2011 Elsevier Inc. All rights reserved. but,presenting in some with cases, a larger may persist number for of longer, inflammatory up to 12 monthspapules, of a cent girls and boys, indicating that adrenal androgens are a Sheila F. Friedlander, MD, has served on an advisory board for Galderma cases,oftology, Pediatric the Northwestern lesions Dermatology; resolve University’s Director, spontaneously Feinberg Children’s School Memorialwithin of Medicine; Hospital, 1 to Head, 3 Chicago, months Division IL. beenMore used recently, by some the to term describeneonatal a similar cephalic process pustulosis in(NCP) newborns has AlbertS2 C.doi:10.1016/j.sder.2011.07.0031085-5629/11/$-see Yan, MD, has no relevant front matterfinancial © relationships 2011 Elsevier with Inc. any All commer- rights reserved. 2 and Onset. E-mail:of Pediatric [email protected] Dermatology; Director, Children’s Memorial Hospital, Chicago, IL. beenage.prominentNeonatal used bypustular some acne component, tois believed describe to aand similar be the caused absence process by stimulationof in comedones. newborns of major determinant of acne during this phase. but,cial indoi:10.1016/j.sder.2011.07.003 interests. some cases, may persist for longer, up to 12 months of and young infants. This entity is considered synonymous with Albert C. Yan, MD, has no relevant financial relationships with any commer- E-mail:2 [email protected] sebaceousNCP has been glands attributed by maternal to Malassezia androgens. furfur or M. sympodialis Correspondingage. Neonatal author: acne Anthony is believed J. Mancini, to MD, be Professor caused of by Pediatrics stimulation and Derma- of and young infants. This entity is considered synonymous with cial interests. yeasts,More and recently, tends the to respond term neonatal well to cephalic topically pustulosis applied(NCP) azole has an- sebaceoustology, Northwestern glands by University’s maternal Feinberg androgens. School of Medicine; Head, Division Adolescent Acne Corresponding author: Anthony J. Mancini, MD, Professor of Pediatrics and Derma- 3-5 S2 of Pediatric1085-5629/11/$-see Dermatology; Director, front matter Children’s © 2011 Memorial Elsevier Hospital, Inc. All Chicago, rights reserved.IL. beentifungal used agents. by someThe to presence describe of a comedonessimilar process may in actually newborns rep- tology, Northwestern University’s Feinberg School of Medicine; Head, Division More recently, the term neonatal cephalic pustulosis (NCP) has Acne vulgaris is one of the most common skin problems in S2 E-mail:doi:10.1016/j.sder.2011.07.0031085-5629/11/$-see [email protected] front matter © 2011 Elsevier Inc. All rights reserved. andresent young early infants. infantile This acne, entity supporting is considered the view synonymous of experts with who of Pediatric Dermatology; Director, Children’s Memorial Hospital, Chicago, IL. been used by some to describe a similar process in newborns the United States, affecting an estimated 15% of individuals doi:10.1016/j.sder.2011.07.003 suggest that neonatal acne and NCP are different terms for the E-mail: [email protected] 4 and young infants. This entity is considered synonymous withglobalacademycme.com/sdef • Pediatric Acne Management: Optimizing Outcomes of all ages and 85% of adolescents.7 same entity. S2 1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. Infantile acne is also more common in boys than in girls. doi:10.1016/j.sder.2011.07.003 S2 1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. Although a prevalence has not been estimated by epidemio- The Changing Demographics doi:10.1016/j.sder.2011.07.003 logic data, it is seen more rarely than is neonatal acne. The usual age of onset is between 3 and 6 months of age, but of Puberty and Acne Onset infantile acne may occur anywhere from 0 to 12 months of The timing of onset of puberty has followed a downward age (hence, the potential for overlap in the presentation trend for many years. In the 19th century, the average age of of neonatal and infantile acne) and occasionally up to 16 onset of puberty was 17 years. By the 1940s, the average age months of age. The lesions of infantile acne typically involve of puberty onset was about 13 years, which remained rela- the face, usually the cheeks. Unlike neonatal acne, infantile tively unchanged for the next 3 to 4 decades. Since that time, acne is usually a more inflammatory process, and patients the downward trend in age of onset of puberty has resumed, may present with comedones, , and pustules, and particularly with regard to breast development and menarche 6 also with occasional nodules and . in girls. Studies from the mid- to late 20th century indicate that Mid-Childhood Acne breast and pubic hair development in American girls—espe- In general, acne is very rare in children from 1 to 6 years of cially African Americans—is occurring at younger ages.8 As a age. When it does occur, the term used to describe the con- result, regional definitions of precocious puberty have been dition is mid-childhood acne. The reason for the relatively rare revised. Puberty is considered to be precocious if it occurs occurrence of mid-childhood acne is that, normally, adrenal before 6 years of age in African American girls, before 7 years secretion virtually ceases after the first year of life until of age in white girls in the United States, and before 8 years of around 7 years of age, when an increase occurs in adrenal age in European girls.9 production. Thus, in a child with mid-childhood A similar trend has not been apparent in boys. An expert acne, should be suspected and ruled out. panel, convened to analyze puberty timing data from 1940 to The potential underlying causes include premature adre- 1994,10 evaluated the data for a secular trend (defined as a narche, Cushing’s syndrome, congenital adrenal hyperplasia, change in the distribution of an outcome in a population gonadal or adrenal tumors, and frank precocious puberty. during a specified time frame). The majority of these experts Referral to a pediatric endocrinologist should be considered. agreed that sufficient data exist on earlier breast development and onset of menarche in girls to support a secular trend. Preadolescent Acne However, they determined that there were not sufficient data Acne in a child between 7 and 11 years of age is termed to suggest a secular trend for an alteration of puberty timing preadolescent (or prepubertal) acne, referring to an age group- in boys. The cutoff age for the consideration of precocious ing rather than to a maturational stage. During these years, puberty in boys remains at 9 years. acne can appear as the first sign of impending pubertal mat- Numerous hypotheses exist to explain the reasons for ear- uration, before pubic hair or areolar development in girls and lier puberty onset. The factors that are perhaps most fre- before pubic hair or testicular enlargement in boys. Most quently proposed include improved nutrition, obesity, and authors consider its appearance as a normal variant, without so-called endocrine-disrupting chemicals, which have been sus- concerns for an underlying endocrinopathy. The typical pre- pected as culprits in both early and delayed puberty. The sentation is comedonal lesions in the T zone of the face chemicals implicated include polychlorinated biphenyls, (across the forehead, on and near the nose, and on the chin), polybrominated biphenyls, and phthalates.11 although inflammatory lesions also may appear. The trend toward earlier onset of acne has mirrored the As is well known, sebum production correlates with levels downward trend in puberty timing, demonstrated by two Acne life cycle S3

Acne life cycle S3

Figure Spectrum of Acne Vulgaris in Children and Adolescents.

neonatal acne by some; however, others distinguish NCP as of dehydroepiandrosterone sulfate (DHEA-S) in preadoles- presenting with a larger number ofFigure inflammatorySpectrum of papules, Acne Vulgaris a incent Children girls and Adolescents. boys, indicating that adrenal androgens are a prominent pustular component, and the absence of comedones. major determinant of acne during this phase. NCP has been attributed to Malassezia furfur or M. sympodialis neonatalyeasts,Figure. and acneSpectrum tends by to some; of respond Acne however, Vulgaris well to others topicallyin Children distinguish applied and Adolescents azole NCP an- as ofAdolescent dehydroepiandrosterone Acne sulfate (DHEA-S) in preadoles- presentingtifungal agents. with3-5 aThe larger presence number of comedones of inflammatory may actually papules, rep a- cent girls and boys, indicating that adrenal androgens are a presenting with a larger number of inflammatory papules, a centAcne girls vulgaris and boys,is one indicating of the most that common adrenal skin androgens problems are in a prominentresent early pustular infantile component, acne, supporting and the the absence viewPediatric of of expertscomedones. Acne who major determinant of acne duringAdolescent this phase. Acne prominent pustular component, and the absence of comedones. majorthe United determinant States, affecting of acne during an estimated this phase. 15% of individuals NCPsuggest has that been neonatal attributed acne to andMalassezia NCP are furfur differentor M. terms sympodialis for the NCP has been attributed to Malassezia furfur or M. sympodialis of all ages and 85% of adolescents.7 yeasts,same entity. and(0-4 tends weeks) to respond(1-12 well months) to topically applied(1-6 azole years) an- (7-11 years) (≥12 years) Neonatal3-5 Acne Infantile Acne Mid-Childhood AcneAdolescentPreadolescent Acne Acne tifungalInfantile agents. acne3-5 The is also presence more commonof comedones in boys may than actually in girls. rep- Acne vulgaris is one of the most common skin problems in resentAlthough early a infantile prevalence acne, has supporting not been estimatedthe view of by experts epidemio- who theThe United Changing States, affecting Demographics an estimated 15% of individuals suggestlogic data, that it neonatal is seen acne more and rarely NCP than are isdifferent neonatal terms acne. for The the the United States, affecting an estimated 15% of individuals suggest that neonatal acne and NCP are different terms for the The Changing Demographics7 usual age of onset is between 3 and 6 months of age, but of all Puberty ages and 85% of and adolescents. Acne7 Onset same entity. of Puberty and Acne Onset infantileInfantile acne acne may is also occur more anywhere common from in 0boys to 12 than months in girls. of The timing of onset of puberty has followed a downward Althoughage (hence, a prevalence the potential has not for been overlap estimated in the by presentation epidemio- Although a prevalence has not been estimated by epidemio- Thetrend for Changing many years. In the Demographics 19th century, the average age of logicof neonatal data, it and is seen infantile moreacne) rarelyand than occasionally is neonatal acne. up to The 16 onset of puberty was 17 years. By the 1940s, the average age usualmonths age of of age. onset The is lesions between of infantile 3 and 6 acne months typically of age, involve but of puberty Puberty onset was and about Acne 13 years, which Onset remained rela- infantilethe face, acne usually may the occur cheeks. anywhere Unlike from neonatal 0 to acne, 12 months infantile of infantile acne may occur anywhere from 0 to 12 months of Thetively timing unchanged of onset for the of puberty next 3 to has 4 decades. followed Since a downward that time, ageacne (hence, is usually the a potential more inflammatory for overlap process, in the presentationand patients age (hence, the potential for overlap in the presentation trendthe downward for many trend years. in In age the of 19th onset century, of puberty the average has resumed, age of ofmay neonatal present and with infantile comedones, acne) papules, and occasionally and pustules, up to and 16 particularly with regard to breast development and menarche 6 onset of puberty was 17 years. By the 1940s, the average age monthsalso with of occasional age. The lesions nodules of and infantile cysts. acne typically involve months of age. The lesions of infantile acne typically involve ofinpuberty girls. onset was about 13 years, which remained rela- the face, usually the cheeks. Unlike neonatal acne, infantile the face, usually the cheeks. Unlike neonatal acne, infantile tivelyStudies unchanged from the for mid- the next to late 3 to20th 4 decades. century Since indicate that time, that acneMid-Childhood is usually a more Acne inflammatory process, and patients acne is usually a more inflammatory process, and patients thebreast downward and pubic trend hair in development age of onset in of American puberty has girls—espe- resumed, mayIn general, present acne with is verycomedones, rare in children papules, from and 1 pustules, to 6 years and of 8 may present with comedones, papules, and pustules, and particularlycially African with Americans—is regard to breast occurring development at younger and ages.menarcheAs a alsoage. with When occasional it does occur, nodules the and term cysts. used6 to describe the con- also with occasional nodules and cysts. inresult, girls. regional definitions of precocious puberty have been dition is mid-childhood acne. The reason for the relatively rare revised.Studies Puberty from the is considered mid- to late to 20th be precocious century indicate if it occurs that Mid-Childhoodoccurrence of mid-childhood Acne Acne acne is that, normally, adrenal Mid-Childhood Acne breastbefore and 6 years pubic of agehair in development African American in American girls, before girls—espe- 7 years secretion virtually ceases after the first year of life until 8 In general, acne is very rare in children from 1 to 6 years of ciallyof age African in white Americans—is girls in the United occurring States, at and younger before ages. 8 years8 As of a around 7 years of age, when an increase occurs in adrenal 9 age. When it does occur, the term used to describe the con- result,age in Europeanregional definitions girls. of precocious puberty have been androgen production. Thus, in a child with mid-childhood dition is mid-childhood acne. The reason for the relatively rare revised.A similar Puberty trend is has considered not been to apparent be precocious in boys. if An it occurs expert acne, hyperandrogenism should be suspected and ruled out. occurrence of mid-childhood acne is that, normally, adrenal beforepanel, 6convened years of age to analyze in African puberty American timing girls, data before from 1940 7 years to The potential underlying causes include premature adre- 10 secretion virtually ceases after the first year of life until of1994, age inevaluated white girls the in the data United for a States, secular and trend before (defined 8 years as of a narche, Cushing’s syndrome, congenital adrenal hyperplasia, 9 around 7 years of age, when an increase occurs in adrenal agechange in European in the distribution girls.9 of an outcome in a population gonadal or adrenal tumors, and frank precocious puberty. androgen production. Thus, in a child with mid-childhood duringA similar a specified trend has time not frame). been The apparent majority in boys. of these An experts expert Referral to a pediatric endocrinologist should be considered. acne, hyperandrogenism should be suspected and ruled out. panel,agreed convened that sufficient to analyze data exist puberty on earlier timing breast data fromdevelopment 1940 to The potential underlying causes include premature adre- 1994,and onset10 evaluated of menarche the data in forgirls a to secular support trend a secular (defined trend. as a Preadolescent Acne 1994, evaluated the data for a secular trend (defined as a narche, Cushing’s syndrome, congenital adrenal hyperplasia, changeHowever, in they the distributiondetermined that of an there outcome were not in sufficient a population data gonadalAcne in or a child adrenal between tumors, 7 and frank11 years precocious of age is puberty. termed duringto suggest a specified a secular time trend frame). for an The alteration majority of of puberty these experts timing Referralpreadolescent to a pediatric(or prepubertal) endocrinologist acne, referring should to be an considered. age group- agreedin boys. that The sufficient cutoff age data for exist the on consideration earlier breast of development precocious ing rather than to a maturational stage. During these years, andpuberty onset in of boys menarche remains in at girls 9 years. to support a secular trend. Preadolescentacne can appear as Acne the Acne first sign of impending pubertal mat- However,Numerous they hypotheses determined exist that to there explain were the not reasons sufficient for data ear- Acneuration, in before a child pubic between hair or 7 areolarand 11 development years of age in is girls termed and tolier suggest puberty a secular onset. trend The factors for an alteration that are perhaps of puberty most timing fre- Acne life cycle preadolescentbefore pubic(or hair prepubertal) or testicular acne enlargement, referring to in an boys. age group- MostS3 inquently boys. proposed The cutoff include age for improved the consideration nutrition, of obesity, precocious and ingauthors rather consider than to its aappearance maturational as stage. a normal During variant, these without years, pubertyso-called inendocrine-disrupting boys remains at 9 chemicals,years. which have been sus- acneconcerns can appear for an underlying as the first endocrinopathy.sign of impending The pubertal typical mat- pre- pectedNumerous as culprits hypotheses in both exist early to explain and delayed the reasons puberty. for ear-The uration,sentation before is comedonal pubic hair lesions or areolar in development the T zone ofin girls the andface lierchemicals puberty implicated onset. The include factors polychlorinatedthat are perhaps biphenyls, most fre- (across the forehead, on and near the nose, and on the chin), polybrominated biphenyls, and phthalates.11 before pubic hair or testicular enlargement in boys. Most quentlyS4 proposed include improved nutrition, obesity, and A.J. Mancini et al authorsalthough consider inflammatory its appearance lesions also as a may normal appear. variant, without so-calledThe trendendocrine-disrupting toward earlier onset chemicals, of acnewhich has have mirrored been sus- the concernsAs is well for known, an underlying sebum endocrinopathy. production correlates The typical with levels pre- pecteddownward as culprits trend in in puberty both early timing, and delayeddemonstrated puberty. by The two seminal studies by Lucky and colleagues12,13 that were pub- Table Summary of Current Concepts in Acne Etiology15-17 sentation is comedonal lesions in the T zone of the face chemicals implicated include polychlorinated biphenyls, Figure Spectrum of Acne Vulgaris in Children and Adolescents. lished in the early 1990s. The first of these11 was the study of Figure Spectrum of Acne Vulgaris in(across Children the and forehead, Adolescents. on and near the nose, and on the chin), polybrominated biphenyls, and phthalates.11 ● Sebum overproduction acne in adolescent boys 9 to 15 years of age.12 These investi- although inflammatory lesions also may appear. The trend toward earlier onset of acne has mirrored the – expresses functional receptors for gators found that the severity of acne correlated with pubertal As is well known, sebum production correlates with levels downward trend in puberty timing, demonstrated by two neuropeptides maturation, and almost 50% of 10- and 11-year-old boys had – Sebaceous gland as “immunocompetent organ” neonatal acne by some; however, others distinguish NCP as of dehydroepiandrosterone sulfate (DHEA-S) in preadoles- presenting with a larger number of inflammatory papules, a cent girls and boys, indicating that adrenal androgens are a more than 10 comedones (grade 2 or 3 comedonal acne) even – Toll-like receptor (TLR)-2 and TLR-4, CD1d and CD14 presenting with a larger number of inflammatory papules, a cent girls and boys, indicating that adrenal androgens are a are expressed by sebocytes prominent pustular component, and the absence of comedones. major determinant of acne during this phase. before either testicular enlargement occurred or pubic hair prominent pustular component, and the absence of comedones. major determinant of acne during this phase. – May be activated by Propionibacterium acnes, with NCP has been attributed to Malassezia furfur or M. sympodialis developed. Mean acne scores correlated better with Tanner NCP has been attributed to Malassezia furfur or M. sympodialis stage in pubic hair than with age. Inflammatory lesions were production of inflammatory cytokines yeasts, and tends to respond well to topically applied azole an- – Histamine-1 receptor expressed in sebocytes 3-5 Adolescent Acne Acne markedly less common during early pubertal development tifungaltifungal agents. agents.3-5 The presence of comedones may actually rep- – Acetylcholine may modulate differentiation and sebum Acne vulgaris is one of the most common skin problems in than were comedonal lesions. African American boys in this resent early infantile acne, supporting the view of experts who production/composition thethe United United States, States, affecting affecting an an estimated estimated 15% 15% of of individuals individuals cohort who were in early stages of pubertal development had suggest that neonatal acne and NCP are different terms for the ● Hyperkeratosis of all ages and 85% of adolescents.7 same entity. of all ages and 85% of adolescents. more comedones than did Caucasian boys. – Hyperkeratinization (retention hyperkeratosis), a same entity. In 1997, this group published a study of pubertal matura- Infantile acne is also more common in boys than in girls. Pediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdef 5 crucial event in acne tion and sex steroid hormones in relationship to acne in – Pathogenesis remains unclear Although a prevalence has not been estimated by epidemio- The Changing Demographics prepubertal girls.13 The age range of the study population – Interleukin (IL)-1� induces hyperkeratinization in vitro logiclogic data, data, it it is is seen seen more more rarely rarely than than is is neonatal neonatal acne. acne. The The usual age of onset is between 3 and 6 months of age, but of Puberty and Acne Onset was 8.5 to 12.2 years. Lucky and colleagues found that and in vivo usual age of onset is between 3 and 6 months of age, but of Puberty and Acne Onset – Increased dihydrotestosterone levels may stimulate infantile acne may occur anywhere from 0 to 12 months of 77.8% of the girls had some acne, of whom nearly half had infantile acne may occur anywhere from 0 to 12 months of The timing of onset of puberty has followed a downward only comedonal lesions. Acne increased with advancing ma- hyperkeratinization age (hence, the potential for overlap in the presentation age (hence, the potential for overlap in the presentation trendtrend for for many many years. years. In In the the 19th 19th century, century, the the average average age age of of turity on examination, and DHEA-S levels were significantly ● Microbial flora of neonatal and infantile acne) and occasionally up to 16 of neonatal and infantile acne) and occasionally up to 16 onset of puberty was 17 years. By the 1940s, the average age higher in the prepubertal girls with acne. – Significance of P. acnes still controversial months of age. The lesions of infantile acne typically involve months of age. The lesions of infantile acne typically involve of puberty onset was about 13 years, which remained rela- No similar epidemiologic data have been published in the – Part of resident microflora the face, usually the cheeks. Unlike neonatal acne, infantile – Induces expression of antimicrobial peptides and the face, usually the cheeks. Unlike neonatal acne, infantile tivelytively unchanged unchanged for for the the next next 3 3 to to 4 4 decades. decades. Since Since that that time, time, United States since these studies from Lucky’s group, so it is acne is usually a more inflammatory process, and patients proinflammatory cytokines acne is usually a more inflammatory process, and patients thethe downward downward trend trend in in age age of of onset onset of of puberty puberty has has resumed, resumed, not known if the epidemiology of acne has changed in this may present with comedones, papules, and pustules, and – Activates TLR-2, which induces cytokine synthesis may present with comedones, papules, and pustules, and particularly with regard to breast development and menarche country in the intervening years. However, in 2008, a group also with occasional nodules and cysts.6 ● Immunoinflammatory mechanisms also with occasional nodules and cysts. in girls. 14 in girls. of investigators from Taiwan published data on the preva- – Upregulated expression of multiple cytokines in Studies from the mid- to late 20th century indicate that Mid-Childhood Acne Studies from the mid- to late 20th century indicate that lence of skin diseases in a cohort of 3,200 children between 6 presence of P. acnes and lipopolysaccharides Mid-Childhood Acne breast and pubic hair development in American girls—espe- and 11 years of age. In that study, the overall prevalence of – TLRs (transmembrane proteins serving as part of In general, acne is very rare in children from 1 to 6 years of 8 In general, acne is very rare in children from 1 to 6 years of cially African Americans—is occurring at younger ages.8 As a acne was 17%, and comedones were the earliest manifesta- innate immune response) linked to acne inflammation age. When it does occur, the term used to describe the con- age. When it does occur, the term used to describe the con- result, regional definitions of precocious puberty have been tion. Extrapolating from this study, it seems reasonable to – Reduction of anti-inflammatory IL-10 in patients with dition is . The reason for the relatively rare dition is mid-childhood acne. The reason for the relatively rare revised. Puberty is considered to be precocious if it occurs suspect that a similar trend in younger American children acne occurrence of mid-childhood acne is that, normally, adrenal occurrence of mid-childhood acne is that, normally, adrenal before 6 years of age in African American girls, before 7 years might be occurring as well. The available data highlight the secretion virtually ceases after the first year of life until secretion virtually ceases after the first year of life until of age in white girls in the United States, and before 8 years of common occurrence of acne, primarily comedonal acne, in around 7 years of age, when an increase occurs in adrenal 9 around 7 years of age, when an increase occurs in adrenal age in European girls.9 preadolescent patients. been implicated in the pathogenesis of acne and probably androgen production. Thus, in a child with mid-childhood A similar trend has not been apparent in boys. An expert exert an effect primarily on the sebaceous glands by increas- acne, hyperandrogenism should be suspected and ruled out. panel, convened to analyze puberty timing data from 1940 to ing the production of sebum. The potential underlying causes include premature adre- 10 Current Perspectives The potential underlying causes include premature adre- 1994,10 evaluated the data for a secular trend (defined as a However, more recent evidence demonstrates that these narche, Cushing’s syndrome, congenital adrenal hyperplasia, 15-17 narche, Cushing’s syndrome, congenital adrenal hyperplasia, change in the distribution of an outcome in a population of Acne Etiology glands may have immunologic functions that play a role in gonadal or adrenal tumors, and frank precocious puberty. gonadal or adrenal tumors, and frank precocious puberty. during a specified time frame). The majority of these experts The traditional four-factor cascade of events that have been the pathogenesis of acne. For example, sebocytes have been Referral to a pediatric endocrinologist should be considered. Referral to a pediatric endocrinologist should be considered. agreed that sufficient data exist on earlier breast development identified in the etiology of acne vulgaris is familiar to most found to express functional receptors for neuropeptides, as and onset of menarche in girls to support a secular trend. well as toll-like receptors 2 and 4, and CD markers 1d and Preadolescent Acne clinicians who see patients with acne: sebum overproduc- Preadolescent Acne However, they determined that there were not sufficient data tion, follicular hyperkeratosis, altered microbial flora and the 14. Histamine-1 receptor has been demonstrated in these Acne in a child between 7 and 11 years of age is termed toto suggest suggest a a secular secular trend trend for for an an alteration alteration of of puberty puberty timing timing role of Propionibacterium acnes, and immunologic/inflamma- cells, and it has been shown that sebaceous glands produce preadolescent (or prepubertal) acne,,referring to an age group- inin boys. boys. The The cutoff cutoff age age for for the the consideration consideration of of precocious precocious tory processes. It is important to consider that the role of each inflammatory cytokines in the presence of P. acnes. Further, inging rather rather than than to to a a maturational maturational stage. stage. During During these these years, years, puberty in boys remains at 9 years. of these factors may vary, depending on the age of onset of acetylcholine may modulate differentiation, sebum produc- acne can appear as the first sign of impending pubertal mat- Numerous hypotheses exist to explain the reasons for ear- —that is, the pathogenesis of disease in a 7- or tion, and composition. This neurotransmitter may act in a uration, before pubic hair or areolar development in girls and lierlier puberty puberty onset. onset. The The factors factors that that are are perhaps perhaps most most fre- fre- 9-year-old patient may differ from that in a 15-year-old. In paracrine manner or may be stimulated in exogenous fashion before pubic hair or testicular enlargement in boys. Most quently proposed include improved nutrition, obesity, and addition, the progression of acne varies from patient to pa- by nicotine, which might suggest a role for the cholinergic authors consider its appearance as a normal variant, without so-called endocrine-disrupting chemicals, which have been sus- tient, even among those at the same stage of maturational system in acne and suggests that smoking may play an etio- concerns for an underlying endocrinopathy. The typical pre- pected as culprits in both early and delayed puberty. The development, and the pathophysiology changes over time. logic role in acne as well as other follicular disorders, such as sentation is comedonal lesions in the T zone of the face chemicals implicated include polychlorinated biphenyls, As new research information has become available regard- suppurativa.18 11 (across the forehead, on and near the nose, and on the chin), polybrominated biphenyls, and phthalates.11 ing acne pathogenesis, the breadth, complexity, and interre- although inflammatory lesions also may appear. The trend toward earlier onset of acne has mirrored the latedness of these four categories have become more fully Hyperkeratosis As is well known, sebum production correlates with levels downward trend in puberty timing, demonstrated by two appreciated and understood (Table).15-17 Hyperkeratosis or hyperkeratinization (also known as reten- tion hyperkeratosis) is a crucial event in the development of Sebum Overproduction acne lesions, but the pathogenesis remains unclear. Some It was once thought that the sebaceous gland’s function was recent research has shown that interleukin (IL)-1� induces limited to the production of sebum. Androgens have long hyperkeratinization, both in vitro and in vivo, and that in- S4 A.J. Mancini et al S4 A.J. Mancini et al

seminal studies by Lucky and colleagues12,13 that were pub- Table Summary of Current Concepts in Acne Etiology15-17 seminal studies by Lucky and colleagues12,13 that were pub- Table Summary of Current Concepts in Acne Etiology15-17 lished in the early 1990s. The first of these was the study of ● Sebum overproduction lished in the early 1990s. The first of these was12 the study of ● Sebum overproduction acne in adolescent boys 9 to 15 years of age.12 These investi- – Sebaceous gland expresses functional receptors for acne in adolescent boys 9 to 15 years of age. These investi- – Sebaceous gland expresses functional receptors for gators found that the severity of acne correlated with pubertal neuropeptides gators found that the severity of acne correlated with pubertal neuropeptides maturation,S4 and almost 50% of 10- and 11-year-old boys had – Sebaceous gland as “immunocompetentA.J. organ” Mancini et al maturation,S4 and almost 50% of 10- and 11-year-old boys had – Sebaceous gland as “immunocompetentA.J. organ” Mancini et al – Toll-like receptor (TLR)-2 and TLR-4, CD1d and CD14 moreS4 than 10 comedones (grade 2 or 3 comedonal acne) even – Toll-like receptor (TLR)-2 and TLR-4, CD1dA.J. Mancini and CD14 et al more than 10 comedones (grade 2 or 3 comedonal acne) even are expressed by sebocytes before either testicular enlargement occurred12,13 or pubic hair TableareSummary expressed of Current by sebocytes Concepts in Acne Etiology15-17 beforeseminal either studies testicular by Lucky enlargement and colleagues occurred12,13 that or pubic were pub- hair Table– MaySummary be activated of Current by Propionibacterium Concepts in Acne acnes Etiology, with15-17 developed.seminal studies Mean by acne Lucky scores and correlated colleagues betterthat with were Tanner pub- – May be activated by Propionibacterium acnes, with developed.seminallished in studies the Mean early by acne 1990s. Lucky scores and The correlated colleagues first of these12,13 better wasthat with the were study Tanner pub- of Table● SebumproductionSummary overproduction of of Current inflammatory Concepts cytokines in Acne Etiology15-17 stagelished in in pubic the early hairthan 1990s. with The age. first Inflammatory of these was12 lesions the study were of ● Sebumproduction overproduction of inflammatory cytokines stageacne in pubicadolescent hair than boys with 9 to 15age. years Inflammatory of age.12 These lesions investi- were –– Histamine-1 Sebaceous gland receptor expresses expressed functional in sebocytes receptors for markedlylishedacne in in adolescent the less early common 1990s. boys during9 Theto 15 first earlyyears of pubertalof these age. wasThese development the study investi- of ● –Sebum– Histamine-1 Sebaceous overproduction gland receptor expresses expressed functional in sebocytes receptors for markedlygators found less that common the severity during of acne early correlated pubertal12 developmentwith pubertal – Acetylcholineneuropeptides may modulate differentiation and sebum thanacnegators were in found adolescent comedonal that the boys severity lesions. 9 to 15 of African acne years correlated of American age. These with boys pubertal investi- in this –– Acetylcholine Sebaceousneuropeptides gland may expresses modulate functionaldifferentiation receptors and sebum for thanmaturation, were comedonal and almost lesions. 50% of African 10- and American 11-year-old boys boys in this had –production/composition Sebaceous gland as “immunocompetent organ” cohortgatorsmaturation, found who were and that almost in the early severity 50% stages of of10-acne pubertal and correlated 11-year-old development with boys pubertal had had –production/compositionneuropeptides Sebaceous gland as “immunocompetent organ” cohortmore than who 10 were comedones in early stages (grade of 2 pubertal or 3 comedonal development acne) even had ● Hyperkeratosis– Toll-like receptor (TLR)-2 and TLR-4, CD1d and CD14 maturation,more than 10 and comedones almost 50% (grade of 10- 2 or and 3 comedonal 11-year-old acne) boys even had ● Hyperkeratosis–– Sebaceous Toll-like receptor gland (TLR)-2as “immunocompetent and TLR-4, CD1d organ” and CD14 more comedones than did Caucasian boys. – Hyperkeratinizationare expressed by sebocytes (retention hyperkeratosis), a moremorebefore comedonesthan either 10 comedones testicular than did enlargement (grade Caucasian 2 or 3 occurred boys. comedonal or acne)pubic even hair –– Hyperkeratinization Toll-likeare expressed receptor by (TLR)-2 sebocytes (retention and TLR-4,hyperkeratosis), CD1d and a CD14 beforeIn 1997, either this testicular group published enlargement a study occurred of pubertal or pubic matura- hair –crucial May be event activated in acne by Propionibacterium acnes, with beforedeveloped.In 1997, either this Mean testicular group acne published scoresenlargement correlated a study occurred of better pubertal or with pubic matura- Tanner hair –crucialare May expressed be event activated in by acne sebocytes by Propionibacterium acnes, with tiondeveloped. and sex Mean hormones scores correlated in relationship better with to acne Tanner in – Pathogenesisproduction of remains inflammatory unclear cytokines tionstage and in pubic sex steroid hair than hormones with age. in Inflammatory relationship lesions to acne were in –– Pathogenesis Mayproduction be activated of remains inflammatory by Propionibacterium unclear cytokines acnes, with prepubertaldeveloped.stage in pubic Mean girls. hair13 acne thanThe scores with age range age. correlated Inflammatory of the better study with lesions population Tanner were –– Interleukin Histamine-1 (IL)-1 receptor� induces expressed hyperkeratinization in sebocytes in vitro prepubertalmarkedly less girls. common13 The ageduring range early of pubertalthe study development population –– Interleukinproduction Histamine-1 (IL)-1 of receptor inflammatory� induces expressed hyperkeratinization cytokines in sebocytes in vitro wasstagemarkedly 8.5 in pubic to less 12.2 hair common years. than with during Lucky age. earlyand Inflammatory colleagues pubertal development lesions found were that –and Acetylcholine in vivo may modulate differentiation and sebum wasthan 8.5 were to comedonal 12.2 years. lesions. Lucky African and colleagues American foundboys in that this ––and Histamine-1 Acetylcholine in vivo receptor may modulate expressed differentiation in sebocytes and sebum 77.8%markedlythan were of the less comedonal girls common had lesions. some during acne, African early of whompubertal American nearly development boys half in had this – Increasedproduction/composition dihydrotestosterone levels may stimulate 77.8%cohort of who the were girls in had early some stages acne, of pubertal of whom development nearly half had had –– Increased Acetylcholineproduction/composition dihydrotestosterone may modulate differentiation levels may stimulate and sebum thancohort were who comedonal were in early lesions. stages African of pubertal American development boys in thishad ● Hyperkeratosishyperkeratinization only comedonal lesions. Acne increased with advancing ma- ● Hyperkeratosishyperkeratinizationproduction/composition onlycohortmore comedonal comedones who were lesions. in than early did Acne stages Caucasian increased of pubertal boys. with development advancing ma- had ● Microbial– Hyperkeratinization flora (retention hyperkeratosis), a turitymore oncomedones examination, than and did DHEA-SCaucasian levels boys. were significantly ●● MicrobialHyperkeratosis– Hyperkeratinization flora (retention hyperkeratosis), a turitymoreIn 1997, comedoneson examination, this group than publishedand didCaucasian DHEA-S a study levels boys. of were pubertal significantly matura- – Significancecrucial event of inP. acne acnes still controversial higherIn 1997, in the this prepubertal group published girls with a study acne. of pubertal matura- –– Significance Hyperkeratinizationcrucial event of inP. acne acnes (retentionstill controversial hyperkeratosis), a highertionIn 1997,and in the sex this prepubertal steroid group hormonespublished girls with a in study acne. relationship of pubertal to matura- acne in –– Part Pathogenesis of resident remains microflora unclear tionNo and similar sex epidemiologic steroid hormones data have in relationship been published to acne in the in –– Partcrucial Pathogenesis of resident event in remains microfloraacne unclear 15-17 prepubertalNo similar girls. epidemiologic13 The age data range have of been the study published population in the Table.–– Induces Interleukin Summary expression (IL)-1of Current� induces of Concepts antimicrobial hyperkeratinization in Acne peptides Etiology and in vitro Unitedtionprepubertal and States sex girls. since steroid13 theseThe hormones studiesage range from in of relationship Lucky’s the study group, populationto acne so it inis ––– Induces Pathogenesis Interleukin expression (IL)-1 remains� induces of antimicrobial unclear hyperkeratinization peptides and in vitro Unitedwas 8.5 States to 12.2 since13 years. these studies Lucky from and colleaguesLucky’s group, found so itthat is proinflammatoryand in vivo cytokines notprepubertalwas known 8.5 to if girls.12.2 the epidemiology years.The age Lucky range of and acne of colleagues the has study changed populationfound in thisthat • – Sebumproinflammatory Interleukinand overproduction in vivo (IL)-1� cytokinesinduces hyperkeratinization in vitro not77.8% known of the if the girls epidemiology had some acne, of acne of whom has changed nearly half in this had –– Activates Increased TLR-2, dihydrotestosterone which induces levels cytokine may synthesis stimulate was77.8% 8.5 of to the 12.2 girls years. had some Lucky acne, and of colleagues whom nearly found half that had ––– Activatesand Increased Sebaceous in vivo TLR-2,gland dihydrotestosterone expresses which functional induces levelsreceptors cytokine may for synthesis neuropeptides stimulate countryonly comedonal in the intervening lesions. Acne years. increased However, with in advancing2008, a group ma- ● Immunoinflammatoryhyperkeratinization mechanisms country77.8% of in the the girls intervening had some years.14 acne, However, of whom in nearly 2008, half a group had ● Immunoinflammatory–– IncreasedhyperkeratinizationSebaceous gland dihydrotestosterone as “immunocompetent mechanisms levels organ” may stimulate ofonly investigators comedonal from lesions. Taiwan Acne14 increasedpublished with data advancing on the preva- ma- ● –Microbial Upregulated flora expression of multiple cytokines in ofonlyturity investigators comedonal on examination, from lesions. Taiwan and Acne DHEA-S increasedpublished levels with data were advancing on significantly the preva- ma- ● –Microbial– Upregulatedhyperkeratinization Toll-like receptor flora expression (TLR)-2 and ofTLR-4, multiple CD1d and cytokines CD14 are in lenceturity of on skin examination, diseases in and a cohort DHEA-S of 3,200 levels children were significantly between 6 –presence Significanceexpressed by of sebocytesP. of acnesP. acnesandstill lipopolysaccharides controversial lencehigher of in skin the diseases prepubertal in a cohort girls with of 3,200 acne. children between 6 ● Microbial–presence Significance flora of P. of acnesP. acnesandstill lipopolysaccharides controversial andturityhigher 11 on in years examination, the of prepubertal age. In and that girls DHEA-S study, with the acne. levels overall were prevalence significantly of ––– TLRs Part May be of (transmembrane activated resident by microfloraPropionibacterium proteins servingacnes, with as production part of of andNo 11 similar years of epidemiologic age. In that study, data have the been overall published prevalence in the of ––– TLRs Significance Part of (transmembrane resident of P. microflora acnes proteinsstill controversial serving as part of acnehigherNo was similar in 17%,the prepubertal epidemiologic and comedones girls data with were have acne. the been earliest published manifesta- in the –innate Inducesinflammatory immune expression cytokines response) of antimicrobial linked to acne peptides inflammation and acneUnited was States 17%, since and these comedones studies were from the Lucky’s earliest group, manifesta- so it is ––innate Part Induces of immune resident expression response) microflora of antimicrobial linked to acne peptides inflammation and tion.UnitedNo Extrapolating similar States epidemiologic since fromthese thisstudies data study, fromhave it beenLucky’s seems published reasonable group, so in itthe to is –– ReductionproinflammatoryHistamine-1α of receptor anti-inflammatory cytokines expressed in sebocytes IL-10 in patients with S4 tion.not known Extrapolating if the epidemiology from this study, of acne it seems hasA.J. changed reasonable Mancini in et this to al –– Reduction Inducesproinflammatory expression of anti-inflammatory cytokines of antimicrobial IL-10 peptides in patients and with suspectUnitednot known States that if a since the similar epidemiology these trend studies in younger of from acne Lucky’s has American changed group, children soin itthis is –– acne Activates Acetylcholine TLR-2, may modulate which differentiation induces cytokine and sebum synthesis suspectcountry that in the a similarintervening trend years. in younger However, American in 2008, children a group –acneproinflammatory Activatesproduction/composition TLR-2, cytokines which induces cytokine synthesis mightnotcountry known be in occurring the if the intervening epidemiology as well. years. The of available However, acne has data in changed 2008, highlight a in group this the ● Immunoinflammatory mechanisms 14 15-17 ●• –Immunoinflammatory Hyperkeratosis Activates TLR-2, which mechanisms induces cytokine synthesis seminal studies by Lucky and colleagues12,13 that were pub- mightcountryofTable investigatorsSummary be in occurring the intervening of from Current as Taiwan well. years.Concepts The14 published available However, in Acne data in Etiology2008, onhighlight the a preva-group the – Upregulated expression of multiple cytokines in commonof investigators occurrence from of Taiwan acne, primarilypublished comedonal data on the acne, preva- in ● Immunoinflammatory–– UpregulatedHyperkeratinization expression (retention mechanisms hyperkeratosis), of multiple a cytokines crucial event inin acne commonlence of skin occurrence diseases of in acne,a cohort14 primarily of 3,200 comedonal children between acne, in 6 presence of P. acnes and lipopolysaccharides lished in the early 1990s. The first of these was the study of preadolescentoflence● investigatorsSebum of skin overproduction diseases patients. fromTaiwan in a cohortpublished of 3,200 children data on the between preva- 6 been–– UpregulatedpresencePathogenesis implicated of remains inP. expression the acnes unclear pathogenesisand of lipopolysaccharides multiple of cytokinesacne and probablyin 12 preadolescentand 11 years of patients. age. In that study, the overall prevalence of been– TLRs implicated (transmembrane in the pathogenesis proteins serving of acne as and part probably of acne in adolescent boys 9 to 15 years of age. These investi- lenceand– 11Sebaceous of yearsskin diseases of age.gland Inin expresses a that cohort study, of functional 3,200 the overall children receptors prevalence between for of 6 exert–– presence TLRs Interleukinan effect (transmembrane (IL)-1 primarily of P. induces acnes on hyperkeratinizationand the proteins lipopolysaccharidessebaceous serving in glands vitro as and part by in increas- ofvivo acne was 17%, and comedones were the earliest manifesta- exertinnate an effect immune primarily response) on the sebaceouslinked to acne glands inflammation by increas- gators found that the severity of acne correlated with pubertal andacne 11neuropeptides was years 17%, of and age. comedones In that study, were the the overall earliest prevalence manifesta- of ing–– the TLRsinnate Increased production (transmembrane immune dihydrotestosterone of response) sebum. proteins levels linked may serving to stimulate acne as inflammation part of Currenttion. Extrapolating Perspectives from this study, it seems reasonable to ing– the Reduction production of anti-inflammatory of sebum. IL-10 in patients with maturation, and almost 50% of 10- and 11-year-old boys had Currentacnetion.– Sebaceous was Extrapolating 17%, Perspectives and gland fromcomedones as this“immunocompetent study, were it the seems earliest organ” reasonable manifesta- to However,–innate Reductionhyperkeratinization immune more of anti-inflammatory recent response) evidence linked demonstrates IL-10 to acne in patients inflammation that with these suspect– Toll-like that areceptor similar (TLR)-2 trend in and15-17 younger TLR-4, American CD1d and children CD14 • However, Microbialacne flora more recent evidence demonstrates that these more than 10 comedones (grade 2 or 3 comedonal acne) even oftion.suspect Acne Extrapolating that a similar Etiology from trend this in study,15-17 younger it seems American reasonable children to glands– Reductionacne may have of immunologic anti-inflammatory functions IL-10 that in patients play a role with in before either testicular enlargement occurred or pubic hair ofsuspectmight Acneare be that expressed occurring a similar Etiology by as trendsebocyteswell. The in younger available American data highlight children the glands– acne Significance may have of immunologicP. acnes still controversial functions that play a role in Themight traditional be occurring four-factor as well. cascade The available of events data that highlight have been the the– pathogenesis Part of resident of microflora acne. For example, sebocytes have been developed. Mean acne scores correlated better with Tanner Themightcommon– traditional May beoccurring occurrencebe activated four-factor as of well. by acne,Propionibacterium cascade The primarily available of events comedonal data that acnes highlight have,acne, with been the in the pathogenesis of acne. For example, sebocytes have been identifiedcommon occurrencein the etiology of acne, of acne primarily vulgaris comedonal is familiar toacne, most in found– Induces to express expression functional of antimicrobial receptors peptides for and neuropeptides, as stage in pubic hair than with age. Inflammatory lesions were identifiedcommonpreadolescentproduction occurrence in the patients. ofetiology inflammatory of acne, of acne primarily cytokines vulgaris comedonal is familiar acne,to most in foundbeen implicated to express functionalin the pathogenesis receptors offor acne neuropeptides, and probably as clinicianspreadolescent– Histamine-1 who patients. see receptor patients expressed with acne: in sebum sebocytes overproduc- wellbeen asproinflammatory implicated toll-like receptors in cytokines the pathogenesis 2 and 4, and of CD acne markers and probably 1d and markedly less common during early pubertal development clinicianspreadolescent who patients. see patients with acne: sebum overproduc- wellbeenexert– as Activates implicatedan toll-like effect TLR-2, primarily receptors in which the induces pathogenesis on 2 theand cytokine sebaceous 4, and synthesis of CD acne glands markers and by probably increas-1d and tion,– follicularAcetylcholine hyperkeratosis, may modulate altered differentiation microbial flora and and sebum the 14.exert Histamine-1 an effect primarily receptor on has the been sebaceous demonstrated glands by in increas- these than were comedonal lesions. African American boys in this tion, follicular hyperkeratosis, altered microbial flora and the 14.ing• Immunoinflammatory Histamine-1the production receptor of mechanisms sebum. has been demonstrated in these Currentproduction/composition Perspectives cells,exerting the andan production effect it has primarily been of shown sebum. on the that sebaceous sebaceous glands glands by produce increas- roleCurrent of Propionibacterium Perspectives acnes, and immunologic/inflamma- However,– Upregulated more expression recent of evidencemultiple cytokines demonstrates in presence that of these cohort who were in early stages of pubertal development had roleCurrent of Propionibacterium Perspectives acnes, and15-17 immunologic/inflamma- cells,ingHowever, the and production it has more been recentof shown sebum. evidence that sebaceous demonstrates glands that produceP. these toryCurrentof● Hyperkeratosis processes. Acne It Perspectives Etiology is important to15-17 consider that the role of each inflammatory and cytokineslipopolysaccharides in the presence of P. acnes. Further, more comedones than did Caucasian boys. toryof processes. Acne It Etiology is important15-17 to consider that the role of each inflammatoryglandsHowever,acnes may have more cytokines immunologic recent in evidence the presence functions demonstrates of thatP. acnes play that. Further, a role these in ofof these– Acne Hyperkeratinization factors Etiology may vary, (retention depending15-17 hyperkeratosis), on the age of onset a of acetylcholineglands– TLRs may (transmembrane have may immunologic modulate proteins differentiation, serving functions as part thatof sebuminnate play immune produc-a role in In 1997, this group published a study of pubertal matura- ofofThe these traditionalAcne factors may four-factorEtiology vary, depending cascade of on events the age that of have onset been of acetylcholinethe pathogenesis may of modulate acne. For differentiation, example, sebocytes sebum have produc- been adrenarche—thatThe traditionalcrucial event four-factor is, in acnethe pathogenesis cascade of events of disease that in have a 7- been or tion,glandsthe pathogenesis andresponse) may composition. have linked ofimmunologic to acne. acne This For neurotransmitter example, functions sebocytes that play may have a act role been in in a tion and sex steroid hormones in relationship to acne in adrenarche—thatidentified in the etiology is, the pathogenesis of acne vulgaris of disease is familiar in ato 7- most or tion,found and to expresscomposition. functional This receptors neurotransmitter for neuropeptides, may act in as a 9-year-oldTheidentified– traditional Pathogenesis in patient the four-factor etiology may remains differ of cascade unclear acne from vulgaris thatof events in is a familiar15-year-old. that have to beenmost In paracrinethefound– pathogenesis Reduction tomanner express of anti-inflammatory ofor functional acne. may be For stimulated receptors example,IL-10 in patients forin sebocytes exogenous neuropeptides, with acne have fashion been as prepubertal girls.13 The age range of the study population 9-year-oldclinicians who patient see may patients differ with from acne: that in sebum a 15-year-old. overproduc- In paracrinewell as toll-like manner receptors or may be 2 stimulated and 4, and in CD exogenous markers fashion 1d and addition,identifiedclinicians– Interleukin the in who the progression see (IL)-1 etiology patients� induces of of acne acnewith hyperkeratinization vulgaris variesacne: sebumfrom is familiar patient overproduc- in to to vitro most pa- byfoundwell nicotine, as to toll-like express which receptors functional might suggest2and receptors 4, a and role for CD for neuropeptides, markers the cholinergic 1d and as was 8.5 to 12.2 years. Lucky and colleagues found that addition,tion,and follicular inthe vivo progression hyperkeratosis, of acne altered varies microbial from patient flora and to pa- the by14. nicotine, Histamine-1 which receptor might suggest has been a role demonstrated for the cholinergic in these tient,clinicianstion, follicular even who among hyperkeratosis, see those patients at the with altered same acne: microbial stage sebum of maturationaloverproduc- flora and the systemwell14. Histamine-1 as in toll-like acne and receptors receptor suggests 2 has and that been 4, smoking and demonstrated CD may markers play inan 1d theseetio- and 77.8% of the girls had some acne, of whom nearly half had tient,role– ofIncreased evenPropionibacterium among dihydrotestosterone thoseacnes at the, and same immunologic/inflamma- levels stage may of maturational stimulate systemcells, and in acne it has and been suggests shown that that smoking sebaceous may glands play producean etio- development,tion,role of follicularPropionibacterium and hyperkeratosis, the pathophysiology acnes altered, and immunologic/inflamma- microbial changes flora over and time. the logic14.cells, Histamine-1 role and in it acne has been as receptor well shown as otherhas that been follicular sebaceous demonstrated disorders, glands inproduce such these as only comedonal lesions. Acne increased with advancing ma- development,tory processes.hyperkeratinization and It is the important pathophysiology to consider changes that the over roletime. of each logicinflammatory role in acne cytokines as well as in other the presence follicular of disorders,P. acnes. Further, such as roletoryAs of processes. newPropionibacterium research It is information important acnes to,has and consider become immunologic/inflamma- that available the role regard- of each hidradenitiscells,inflammatory and it hassuppurativa. cytokines been shown in18 the that presence sebaceous of P. glands acnes. produce Further, turity on examination, and DHEA-S levels were significantly of● AsMicrobial these new factors research flora may information vary, depending has become on the available age of onset regard- of hidradenitisacetylcholine suppurativa. may modulate18 differentiation, sebum produc- ingtoryof these acne processes. pathogenesis,factors It may is important vary, the breadth, depending to consider complexity, on that the the age and role of onsetinterre- of each of inflammatoryacetylcholine maycytokines modulate in the differentiation, presence of P. sebum acnes. Further, produc- higher in the prepubertal girls with acne. ingadrenarche—that– acne Significance pathogenesis, of is,P. the the acnes pathogenesis breadth,still controversial complexity, of disease and in interre- a 7- or tion, and composition. This neurotransmitter may act in a latednessofadrenarche—that these factors of these may is, four vary, the categories pathogenesis depending have on of become the disease age moreof in onset a7- fully ofor Hyperkeratosisacetylcholinetion, and composition. may modulate This differentiation, neurotransmitter sebum may produc- act in a No similar epidemiologic data have been published in the latedness9-year-old– Part of patient resident these four may microflora categoriesdiffer from have that becomein a 15-year-old. more fully In Hyperkeratosisparacrine manner or may be stimulated in exogenous fashion appreciatedadrenarche—that9-year-old– Induces patient and expression understood is, may the differ of pathogenesis antimicrobial (Table). from that15-17 of in peptides disease a 15-year-old. in and a 7- orIn tion,paracrine and mannercomposition. or may This be stimulated neurotransmitter in exogenous may act fashion in a United States since these studies from Lucky’s group, so it is appreciatedaddition, the and progression understood of (Table). acne varies15-17 from patient to pa- Hyperkeratosisby nicotine, which or hyperkeratinization might suggest a role (also for known the cholinergic as reten- 9-year-oldaddition,proinflammatory the patient progression may cytokines differ of acne from varies that in from a 15-year-old. patient to pa- In HyperkeratosisAcneparacrineby nicotine, life cycle manner which or orhyperkeratinization might may be suggest stimulated a role (also in forexogenous known the cholinergic as fashion reten- S5 not known if the epidemiology of acne has changed in this tient, even among those at the same stage of maturational tionsystem hyperkeratosis) in acne and suggests is a crucial that event smoking in the may development play an etio- of Sebumaddition,tient,– Activates even the Overproduction among progression TLR-2, those which at of theinduces acne same varies cytokine stage from of patient synthesis maturational to pa- tionAcnebysystem nicotine, hyperkeratosis) life in cycle acne which andmight suggests is a crucial suggest that event smoking a role in the for may development the play cholinergic an etio- of S5 Sebumdevelopment, Overproduction and the pathophysiology changes over time. acnelogic lesions, role in acne but as the well pathogenesis as other follicular remains disorders, unclear. such Some as country in the intervening years. However, in 2008, a group tient,development,● Immunoinflammatory even among and the those pathophysiology mechanisms at the same stage changes of maturational over time. acneAcnesystemlogic life lesions, role in cycle in acne acne but and as the suggests well pathogenesis as other that follicularsmoking remains disorders,may unclear. play an such Some etio- as S5 14 It was once thought that the sebaceous gland’s function was recent research has shown18 that interleukin (IL)-1� induces 2. Cantatore-Francis JL, Glick SA: Childhood acne: Evaluation and man- of investigators from Taiwan published data on the preva- Itdevelopment, was–As Upregulated new once research thought and expression the information that pathophysiology the sebaceous of has multiple become gland’s changes cytokines available function over in regard- time. was recentcreasedlogichidradenitis role research levels in acne suppurativa. of has dihydrotestosterone as shownwell as18 other that interleukin follicular also disorders,may (IL)-1 stimulate� induces such its as limitedAs new to research the production information of sebum. has become Androgens available have regard- long hyperkeratinization,. both in vitro and in vivo, and that in- agement. Dermatol Ther 19:202-209, 2006 lence of skin diseases in a cohort of 3,200 children between 6 ing acnepresence pathogenesis, of P. acnes theand breadth, lipopolysaccharides complexity, and interre- production.creased levels of dihydrotestosterone18 also may stimulate its 2. Cantatore-Francis JL, Glick SA: Childhood acne: Evaluation and man- limitedingAs acne new to pathogenesis, research the production information the of breadth, sebum. has become complexity, Androgens available and have regard-interre- long hyperkeratinization,hidradenitis suppurativa. both in vitro and in vivo, and that in- 2. Cantatore-Francis JL, Glick SA: Childhood acne: Evaluation and man- and 11 years of age. In that study, the overall prevalence of latedness of these four categories have become more fully production.creasedHyperkeratosis levels of dihydrotestosterone also may stimulate its 3.agement. Niamba P, Dermatol Weill FX, Ther Sarlangue 19:202-209, J, Labreze 2006 C, Couprie B, Tiaeh A: Is ing– acne TLRs pathogenesis, (transmembrane the breadth, proteins complexity, serving as part andof interre- agement. Dermatol Ther 19:202-209, 2006 latedness of these four categories have15-17 become more fully production.Hyperkeratosis 3. Niambacommon P, neonatal Weill FX, cephalic Sarlangue pustolosis J, Labreze (neonatal C, Couprie acne) B, triggered Tiaeh A: by Is acne was 17%, and comedones were the earliest manifesta- appreciatedinnate immune and understood response) (Table). linked to acne inflammation MicrobialHyperkeratosis Flora or hyperkeratinization (also known as reten- latednessappreciated of and these understood four categories (Table). have15-17 become more fully Hyperkeratosis or hyperkeratinization (also known as reten- 3.commonMalassezia Niamba P, neonatal sympodialis? Weill FX, cephalic Sarlangue Arch pustolosis Dermatol J, Labreze 134:995-998,(neonatal C, Couprie acne) 1998 B, triggered Tiaeh A: by Is tion. Extrapolating from this study, it seems reasonable to – Reduction of anti-inflammatory IL-1015-17 in patients with Microbialtion hyperkeratosis) Flora Flora is a crucial event in the development of appreciated and understood (Table). MicrobialTheHyperkeratosistion significance hyperkeratosis) Flora or of hyperkeratinizationP. is acnes a crucialis still event somewhat in (also the known development controversial, as reten- of 4.Malassezia Sancakcommon B, neonatal Ayhan sympodialis? M, cephalic Karaduman Arch pustolosis Dermatol A, Arikan 134:995-998,(neonatal S: In vitro acne) activity 1998 triggered of keto- by suspect that a similar trend in younger American children Sebumacne Overproduction Overproduction Theacne significance lesions, but of theP. acnes pathogenesisis still somewhat remains unclear. controversial, Some 4. Sancakconazole,Malassezia B, itraconazoleAyhan sympodialis? M, Karaduman and Arch terbinafine Dermatol A, Arikan against 134:995-998, S: In Malassezia vitro activity 1998 strains of keto- iso- Sebum Overproduction withtionacne hyperkeratosis) some lesions, arguing but the against is pathogenesisa crucial its role event in remains inpathogenesis the development unclear. because Some of might be occurring as well. The available data highlight the It was once thought that the sebaceous gland’s function was withTherecent significance some research arguing has of againstP. shown acnes its thatisrole still interleukin somewhatin pathogenesis (IL)-1 controversial,� becauseinduces 4.conazole,lated Sancak from B, itraconazoleAyhan neonates M, [in Karaduman and Turkish]. terbinafine A, Microbiyol Arikan against S: Bul In Malassezia vitro 39:301-308, activity strains of 2005 keto- iso- SebumIt was once Overproduction thought that the sebaceous gland’s function was theacnerecent organism lesions, research is but part has the shown of pathogenesis the resident that interleukin microflora. remains (IL)-1 unclear. However,� induces Some it common occurrence of acne, primarily comedonal acne, in limited to the production of sebum. Androgens have long hasthewithhyperkeratinization, organismbeen some shown arguing is part that against ofP. both theacnes in residentitscan vitro role induce and in microflora. pathogenesis in expression vivo, However,and because ofthat anti- in- it 5.lated Bergmanconazole, from J, itraconazole neonates Eichenfield [in and Turkish].LF: terbinafineNeonatal Microbiyol acne against and Bul Malasseziacephalic 39:301-308, pustulosis: strains 2005 iso- Is Itlimited was once to the thought production that the of sebaceous sebum. Androgens gland’s function have long was recenthyperkeratinization, research has shown both in that vitro interleukin and in vivo, (IL)-1 and� induces that in- 5. BergmanMalassezialated from J, neonatesthe Eichenfield whole [in story? Turkish].LF: NeonatalArchDermatol Microbiyol acne and 138:255-257, Bul cephalic 39:301-308, pustulosis: 2002 2005 Is preadolescent patients. been implicated in the pathogenesis of acne and probably hasthemicrobial organismbeen shown peptides is part that and ofP. theacnes proinflammatory residentcan induce microflora. expression cytokines However, and of anti- has it limited to the production of sebum. Androgens have long hyperkeratinization, both in vitro and in vivo, and that in- 6.5.Malassezia TomBergman WL, J, Friedlander the Eichenfield whole story? SF: LF: Acne NeonatalArch through Dermatol acne the and 138:255-257, ages: cephalic Case-based pustulosis: 2002 observa- Is exert an effect primarily on the sebaceous glands by increas- hasmicrobial been shown peptides that andP. acnesproinflammatorycan induce expression cytokines and of anti- has an effect on toll-like receptor 2, leading to increased synthesis 6. TomtionsMalasseziaWL, through Friedlander the childhood whole story? SF: and Acne Arch adolescence. through Dermatol the Clin 138:255-257, ages: Pediatr Case-based (Phila) 2002 observa- 47:639- ing the production of sebum. microbial peptides and proinflammatory cytokines and has Current Perspectives ofan cytokines. effect on toll-like receptor 2, leading to increased synthesis 6.tions651, Tom 2008WL, through Friedlander childhood SF: and Acne adolescence. through the Clin ages: Pediatr Case-based (Phila) observa- 47:639- However, more recent evidence demonstrates that these an effect on toll-like receptor 2, leading to increased synthesis 15-17 of cytokines. 7.651, Nationaltions 2008 through Campaign childhood to Control and adolescence. Acne: Secaucus Clin Pediatr(NJ): Thomson (Phila) 47:639- Profes- of Acne Etiology glands may have immunologic functions that play a role in ImmunoinflammatoryImmunoinflammatoryof cytokines. MechanismsMechanisms 7. Nationalsional651, 2008 Postgraduate Campaign Services.to Control 2003 Acne: Secaucus (NJ): Thomson Profes- 7. National Campaign to Control Acne: Secaucus (NJ): Thomson Profes- The traditional four-factor cascade of events that have been the pathogenesis of acne. For example, sebocytes have been AImmunoinflammatory great deal of research has focused Mechanisms on immunoinflammatory 8.sional Golub PostgraduateMS, Collman Services.GW, Foster 2003 PM, et al: Public health implications of alteredsional Postgraduate puberty timing. Services. Pediatrics 2003 121:S218-S230, 2008 (suppl 3) identified in the etiology of acne vulgaris is familiar to most found to express functional receptors for neuropeptides, as AImmunoinflammatory great deal of research has focused Mechanisms on immunoinflammatory 8. Golub MS, Collman GW, Foster PM, et al: Public health implications of pathways of acne pathogenesis, including demonstration of 9.8. ToppariGolub MS, J, Juul Collman A: Trends GW, in Foster puberty PM, timing et al: Public in human health and implications environmen- of clinicians who see patients with acne: sebum overproduc- well as toll-like receptors 2 and 4, and CD markers 1d and A great deal of research has focused on immunoinflammatory altered puberty timing. Pediatrics 121:S218-S230, 2008 (suppl 3) thepathways upregulation of acne ofpathogenesis, multiple cytokines including in demonstration the presence of 9. Topparitalaltered modifiers. puberty J, Juul Mol A: timing. Trends Cell Endocrinol Pediatrics in puberty 121:S218-S230, 324:39-44, timing in human 2010 2008 and (suppl environmen- 3) 14. Histamine-1 receptor has been demonstrated in these pathways of acne pathogenesis, including demonstration of tion, follicular hyperkeratosis, altered microbial flora and the boththe upregulationP. acnes, as previously of multiple mentioned, cytokines and in the lipopolysaccha- presence of 10.9.tal ToppariEuling modifiers. SY, J, Juul Herman-Giddens Mol A: Trends Cell Endocrinol in puberty ME, 324:39-44, Lee timing PA, in et human 2010 al: Examination and environmen- of US role of Propionibacterium acnes, and immunologic/inflamma- cells, and it has been shown that sebaceous glands produce rides.boththe upregulationP. Here acnes, again, as previously of toll-like multiple mentioned, receptors cytokines haveand in the lipopolysaccha- been presence innately of 10.tal Eulingpuberty-timing modifiers. SY, Herman-Giddens Mol data Cell from Endocrinol 1940 ME, to 1994 324:39-44, Lee PA, for secular et 2010 al: Examination trends: Panel of find- US tory processes. It is important to consider that the role of each inflammatory cytokines in the presence of P. acnes. Further, linkedrides.both P.Here to acnes acne, again, as inflammation. previously toll-like mentioned,receptors In addition, haveand it has lipopolysaccha- been been innately shown 10.puberty-timingings. Euling Pediatrics SY, Herman-Giddens 121:S172-S191,data from 1940 ME, to 2008 1994 Lee (suppl PA, for secular et 3) al: Examination trends: Panel of find- US puberty-timing data from 1940 to 1994 for secular trends: Panel find- of these factors may vary, depending on the age of onset of acetylcholine may modulate differentiation, sebum produc- thatlinkedrides. patientsHere to acne again, with inflammation. acne toll-like tendreceptorsto In haveaddition, reduced have it has been expression been innately shown of 11.ings. Mouritsen Pediatrics A, Aksglaede 121:S172-S191, L, Sørensen 2008 K, (suppl et al:Hypothesis: 3) Exposure to ings. Pediatrics 121:S172-S191, 2008 (suppl 3) adrenarche—that is, the pathogenesis of disease in a 7- or tion, and composition. This neurotransmitter may act in a thatlinked patients to acne with inflammation. acne tend toIn haveaddition, reduced it has expression been shown of 11. Mouritsenendocrine-disrupting A, Aksglaede chemicals L, Sørensen may K,interfere et al: Hypothesis: with puberty Exposure timing. Int to anti-inflammatory cytokines, such as IL-10. 11. Mouritsen A, Aksglaede L, Sørensen K, et al: Hypothesis: Exposure to 9-year-old patient may differ from that in a 15-year-old. In paracrine manner or may be stimulated in exogenous fashion that patients with acne tend to have reducedcontinued expression on page of23 endocrine-disruptingJ Androl 33:346-359, chemicals 2010 may interfere with puberty timing. Int anti-inflammatory cytokines, such as IL-10. 12.J Luckyendocrine-disrupting Androl AW, 33:346-359, Biro FM, Huster chemicals 2010 GA, mayMorrison interfere JA, Elder with puberty N: Acne timing. vulgaris Int in addition, the progression of acne varies from patient to pa- by nicotine, which might suggest a role for the cholinergic anti-inflammatory cytokines, such as IL-10. 6 globalacademycme.com/sdef • Pediatric Acne Management: Optimizing Outcomes 12. LuckyearlyJ Androl adolescent AW, 33:346-359, Biro FM, boys: Huster 2010 Correlations GA, Morrison with pubertal JA, Elder maturation N: Acne vulgaris and age. in tient, even among those at the same stage of maturational system in acne and suggests that smoking may play an etio- Conclusion Conclusion 12.earlyArch Lucky Dermatoladolescent AW, Biro 127:210-216, FM, boys: Huster Correlations GA, 1991 Morrison with pubertal JA, Elder maturation N: Acne vulgaris and age. in development, and the pathophysiology changes over time. logic role in acne as well as other follicular disorders, such as The epidemiology, demographics, and pathophysiology of 13.Arch Luckyearly Dermatoladolescent AW, Biro 127:210-216, FM,boys: Simbart Correlations LA, 1991 Morrison with pubertal JA, Sorg maturation NW: Predictors and age. of 18 Conclusion As new research information has become available regard- hidradenitis suppurativa. acneThe epidemiology,in adolescents have demographics, been well described and pathophysiology in the literature. of 13. LuckyseverityArch Dermatol AW, of acne Biro127:210-216, vulgaris FM, Simbart in young LA, 1991 adolescent Morrison JA, girls: Sorg Results NW: Predictorsof a five-year of 13. Lucky AW, Biro FM, Simbart LA, Morrison JA, Sorg NW: Predictors of ing acne pathogenesis, the breadth, complexity, and interre- FeweracneThe epidemiology,in studies adolescents have have demographics, focused been on well acne described and and pathophysiology acneiform in the literature. condi- of severitylongitudinal of acne study. vulgaris J Pediatr in young 130:30-39, adolescent 1997 girls: Results of a five-year latedness of these four categories have become more fully Hyperkeratosis acne in adolescents have been well described in the literature. 14.longitudinal Chenseverity GY, of acne Cheng study. vulgaris YW, J Pediatr inWang young 130:30-39, CY, adolescent et al: 1997 Prevalence girls: Results of skin of a five-year diseases tionsFewer in studies pediatric have patients focused less on than acne 12 yearsand acneiform of age. True condi- acne longitudinal study. J Pediatr 130:30-39, 1997 appreciated and understood (Table).15-17 Fewer studies have focused on acne and acneiform condi- 14. Chenamong GY, schoolchildren Cheng YW, in Wang Magong, CY, et Penghu, al: Prevalence Taiwan: of A skin community- diseases Hyperkeratosis or hyperkeratinization (also known as reten- istions rarely in pediatric seen in patients patients less less than than about 12 years 6 or of 7 age. years True of acne age, 14.amongbased Chen clinicalGY, schoolchildren Cheng survey. YW, J Formos in Wang Magong, CY, Med et Penghu,Assoc al: Prevalence 107:21-29, Taiwan: of A2008 skin community- diseases tions in pediatric patients less than 12 years of age. True acne tion hyperkeratosis) is a crucial event in the development of butis rarely it is seen important in patients to note—and less than about to educate 6 or 7 parents—that years of age, 15.based Bhambriamong clinical schoolchildren S, Del survey. Rosso J JQ, Formos in Magong, Bhambri Med A:Penghu,Assoc Pathogenesis 107:21-29, Taiwan: of A2008 acne community- vulgaris: Sebum Overproduction acne lesions, but the pathogenesis remains unclear. Some acnebutis rarely it may is seen important be the in first patients to sign note—and ofless onset than of about to puberty educate 6 or in 7 preadolescentparents—that years of age, 15. BhambriRecentbased clinical advances. S, Del survey. Rosso J Drugs J JQ, Formos Dermatol Bhambri Med 8:615-618, A:Assoc Pathogenesis 107:21-29, 2009 of 2008 acne vulgaris: It was once thought that the sebaceous gland’s function was recent research has shown that interleukin (IL)-1� induces childrenacnebut it may is (ie, important be the those first from to sign note—and 7 of through onset of 11to puberty educateyears of in age). preadolescentparents—that Ongoing 16.15.Recent CaillonBhambri advances. F, S, O’Connell Del Rosso J Drugs M, JQ, Eady Dermatol Bhambri EA, et 8:615-618, A: al: Pathogenesis Interleukin-10 2009 of secretion acne vulgaris: from Recent advances. J Drugs Dermatol 8:615-618, 2009 limited to the production of sebum. Androgens have long hyperkeratinization, both in vitro and in vivo, and that in- researchchildrenacne may (ie,continues be the those first from to sign elucidate 7 of through onset and of 11 puberty expand years of in on age). preadolescent the Ongoing etiologic 16. CaillonCD14� F,peripheral O’Connell blood M, Eady mononuclear EA, et al: Interleukin-10 cells is downregulated secretion in from pa- 16.CD14tients Caillon� with F,peripheral O’Connell acne vulgaris. blood M, Eady Br mononuclear J Dermatol EA, et al: 162:296-303, Interleukin-10 cells is downregulated 2010 secretion in from pa- factorsresearchchildren involved (ie,continues those in from the to elucidate development 7 through and 11 expand of years acne. of on age). the Ongoing etiologic research continues to elucidate and expand on the etiologic 17.tients DegitzCD14� with K,peripheral Placzek acne vulgaris. M, blood Borelli Br mononuclear J C, Dermatol Plewig G:162:296-303, cells Pathophysiology is downregulated 2010 of acne. in pa- J factors involved in the development of acne. tients with acne vulgaris. Br J Dermatol 162:296-303, 2010 factors involved in the development of acne. 17. DegitzDtsch Dermatol K, Placzek Ges M, 5:316-323, Borelli C, Plewig2007 G: Pathophysiology of acne. J References 18.17.Dtsch KurokawaDegitz Dermatol K, Placzek I, Danby Ges M, FW, 5:316-323, Borelli Ju Q, C, et Plewig2007 al: New G: developments Pathophysiology in our of under-acne. J References1. Friedlander SF, Eichenfield LF, Fowler JF Jr, et al: Acne epidemiology 18. KurokawastandingDtsch Dermatol of I, acne Danby Ges pathogenesis FW, 5:316-323, Ju Q,et and 2007 al: treatment. New developments Exp Dermatol in our 18:821- under- References1. Friedlanderand pathophysiology. SF, Eichenfield Semin LF, Cutan Fowler Med JF Surg Jr, et 29:2-4, al: Acne 2010 epidemiology 18.standing832, Kurokawa 2009 of I, acne Danby pathogenesis FW, Ju Q,et and al: treatment. New developments Exp Dermatol in our 18:821- under- 1.and Friedlander pathophysiology. SF, Eichenfield Semin LF, Cutan Fowler Med JF Surg Jr, et 29:2-4, al: Acne 2010 epidemiology 832,standing 2009 of acne pathogenesis and treatment. Exp Dermatol 18:821- and pathophysiology. Semin Cutan Med Surg 29:2-4, 2010 832, 2009 The Acne Continuum: An Age-Based Approach to Therapy The Acne Continuum: Sheila Fallon Friedlander, MD,* Hilary E. Baldwin, MD,† Anthony J. Mancini, MD,‡ An Age-Based§ Approach to Therapy¶ TheAlbert Acne C. Yan, Continuum: MD, and Lawrence F. Eichenfield, MD Sheila Fallon Friedlander, MD,* Hilary E. Baldwin, MD,† Anthony J. Mancini, MD,‡ An Age-Based§ Approach to Therapy¶ AnTheAlbert Age-Based C. Acne Yan, MD, Continuum:and Lawrence Approach F. Eichenfield, to Therapy MD † ‡ Sheila Fallon Friedlander, MD,* Hilary E. Baldwin, MD,† Anthony J. Mancini, MD,‡ Sheila Fallon Friedlander,§ MD,* Hilary E. Baldwin, MD,¶ Anthony J. Mancini, MD, AnAlbert Age-Based C. Yan,Acne MD, vulgarisand is Lawrence classically Approach considered F. Eichenfield, a disease to ofTherapy MD adolescence. Although it most commonly Albert C. Yan, MD,§ and Lawrence F. Eichenfield, MD¶ occurs and has been best studied in that age group, it can develop† at any time during childhood. It ‡ Sheila Fallonis Friedlander, important that health MD,* care Hilary practitioners E. Baldwin, recognize the MD, manifestationsAnthony of neonatal, J. Mancini, infantileMD, and Acne vulgaris is classically considered a disease of adolescence. Although it most commonly childhood§ acne, as well as the differential diagnosis and best¶ therapeutic approach in the younger Albert C. Yan,occursAcne MD, vulgaris andand has is been Lawrence classically best studied considered F. in Eichenfield, that aage disease group, of it MDcan adolescence. develop at Although any time during it most childhood. commonly It child. Acneiform eruptions in infants and toddlers can occasionally be associated with scarring or isoccurs important and has that been health best care studied practitioners in that age recognize group, it the can manifestations develop at any of time neonatal, during infantilechildhood. and It with other significant disorders that may be life-threatening. In this article, the authors draw on their Acnechildhoodis important vulgaris acne, that is as healthclassically wellas care the considered practitioners differential a diagnosis recognize disease of and the adolescence. best manifestations therapeutic Although of approach neonatal, it most in infantile the commonly younger and own clinical experience as well as the available literature to suggest an age-based approach to occurschild.childhood Acneiform and acne, has been as eruptions well best as studied inthe infants differential in thatand agetoddlers diagnosis group, can andit canoccasionally best develop therapeutic at be any associated approachtime during with in childhood. the scarring younger or It managing acne in children from the neonatal period through age 11 years. iswithchild. important other Acneiform significant that eruptions health disorders care in practitionersinfants that may and be toddlers recognize life-threatening. can the occasionally manifestations In this article, be associated of the neonatal, authors with draw infantile scarring on their and or Semin Cutan Med Surg 30:S6-S11 © 2011 Published by Elsevier Inc. childhoodownwith other clinical significantacne, experience as well disorders as as the well differentialthat as may the availablebe diagnosis life-threatening. literature and best Into therapeuticthis suggest article, an the approach age-based authors in draw approachthe younger on their to child.managingown clinical Acneiform acne experience in eruptions children as in from well infants theas the neonatal and available toddlers period literature can through occasionally to age suggest 11 be years. associated an age-based with approach scarring orto withSeminmanaging other Cutan significantacne Med in children Surg disorders 30:S6-S11 from that the may © neonatal 2011 be life-threatening. Published period through by Elsevier In age this 11article, Inc. years. the authors draw on their ownSemin clinical Cutan experience Med Surg 30:S6-S11as well as ©the 2011 available Published literature bycne Elsevier to is suggest an Inc. “equal an opportunity”age-based approach disorder, to affecting not only managing acne in children from the neonatal periodA throughthe ageadolescent 11 years. and middle-aged adult, but also children Semin Cutan Med Surg 30:S6-S11 © 2011 Published by Elsevier1 Inc. of allcne ages. is anClinical “equal and opportunity” epidemiologic disorder, studies affecting over the not past only 2 *Clinical Professor of Pediatrics and Medicine, Dermatology, University of decadesthecne adolescentis have an “equal helped and opportunity” refine middle-aged the diagnosis disorder, adult, andaffecting but also treatment childrennot only of California, San Diego, Rady Childrens Hospital, San Diego, CA A acneofA allthe inages. children adolescent1 Clinical less and than epidemiologicmiddle-aged 12 years of age.adult, studies Studies but over also document- the children past 2 †Associate Professor and Vice Chair, Department of Dermatology, SUNY ingof all thecne ages. changing is1 anClinical “equal demographics and opportunity” epidemiologic of disorder, acne studies in preadolescent affecting over the not past chil-only 2 *ClinicalDownstate, Professor Brooklyn, of Pediatrics NY and Medicine, Dermatology, University of decades have helped refine the diagnosis and treatment of *Clinical‡ProfessorCalifornia, Professor of Pediatrics San Diego, of Pediatrics and Rady Dermatology, Childrens and Medicine, Northwestern Hospital, Dermatology, San University’s Diego, University CA Feinberg of acnedecadesdren,Athe in as children adolescent wellhave as helped the less and nature than refine middle-aged 12 of theyears neonatal diagnosis of age.adult, and Studies and butinfantile also treatment document- children disease, of †AssociateSchoolCalifornia, of Professor Medicine, San Diego, and Head, ViceRady Division Chair, Childrens of Department Pediatric Hospital, Dermatology, of San Dermatology, Diego, Children’s CA SUNY Me- acnehaveof all inages.provided children1 Clinical the less information and than epidemiologic 12 years necessary of age. studies Studiesto develop over document- the rational past 2 †Associate Professor and Vice Chair, Department of Dermatology, SUNY ing the changing demographics of acne in preadolescent chil- *ClinicalmorialDownstate, Professor Hospital, Brooklyn, Chicago, of Pediatrics NY IL and Medicine, Dermatology, University of decadesingapproaches the changing have to helped evaluation demographics refine and the of treatment diagnosis acne in preadolescent and in our treatment youngest chil- of Downstate, Brooklyn, NY dren, as well as the nature of neonatal and infantile disease, §Chief,‡ProfessorCalifornia, Pediatric of Pediatrics San Dermatology, Diego, and Rady Dermatology, Children’s Childrens HospitalNorthwestern Hospital, of San Philadelphia, University’s Diego, CA Associate Feinberg ‡Professor of Pediatrics and Dermatology, Northwestern University’s Feinberg haveacnedren,patients. inprovided as children well as the the less information nature than 12 of years neonatal necessary of age. and Studiesto infantile develop document- disease,rational †AssociateProfessor,School of Professor Medicine, Pediatrics and Head, and Vice Dermatology Division Chair, of Department Pediatric Perelman Dermatology, School of Dermatology, of Medicine Children’s SUNY at Me- the School of Medicine, Head, Division of Pediatric Dermatology, Children’s Me- inghave the provided changing the demographics informationnecessary of acne in preadolescentto develop rational chil- Downstate,Universitymorial Hospital, of Brooklyn, Pennsylvania, Chicago, NY IL Philadelphia, PA approaches to evaluation and treatment in our youngest morial Hospital, Chicago, IL ‡Professor¶Clinical§Chief, Pediatric Professor of Pediatrics Dermatology, of Pediatrics and Dermatology, Children’s and Medicine HospitalNorthwestern (Dermatology), of Philadelphia, University’s Chief, Associate Feinberg Pedi- patients.dren,approaches as well to as evaluation the nature ofand neonatal treatment and in infantile our youngest disease, §Chief, Pediatric Dermatology, Children’s Hospital of Philadelphia, Associate SchoolatricProfessor, and of Medicine,Adolescent Pediatrics Head, and Dermatology, Dermatology Division of Children’s Pediatric Perelman Dermatology, Hospital School of San Medicine Children’s Diego, at Uni- Me- the havepatients.Neonatal provided the Acne information necessary to develop rational Professor, Pediatrics and Dermatology Perelman School of Medicine at the morialversityUniversity Hospital, of California, of Pennsylvania, Chicago, San IL Diego Philadelphia, School of PA Medicine, San Diego, CA approaches to to evaluation evaluation and andtreatment treatment in our inyoungest our youngest patients. University of Pennsylvania, Philadelphia, PA The term neonatal acne has historically been used as an um- §Chief,Publication¶Clinical Pediatric Professor of this Dermatology, CME of Pediatrics article Children’s was and jointly Medicine Hospital sponsored (Dermatology), of Philadelphia, by the University Chief, Associate Pedi- of ¶Clinical Professor of Pediatrics and Medicine (Dermatology), Chief, Pedi- patients.brellaNeonatal term to describe Acne a variety of lesions occurring in new- Professor,Louisvilleatric and Adolescent Pediatrics Continuing and Dermatology, Health Dermatology Sciences Children’s Perelman Education Hospital School and of Skin San Medicine DiseaseDiego, at Uni- Ed- the atric and Adolescent Dermatology, Children’s Hospital San Diego, Uni- Neonatal Acne Acne Universityucationversity of Foundation California, of Pennsylvania, and San supported Diego Philadelphia, School by anof PA Medicine, educational San grant Diego, from CA John- Theborns. term Oneneonatal variant acne seenhas in historically neonates been is characterized used as an um- by versity of California, San Diego School of Medicine, San Diego, CA ¶ClinicalPublicationson & Professor Johnson of this CME ofConsumer Pediatrics article & was and Personal jointly Medicine Products sponsored (Dermatology), Worldwide by the University Chief, Division Pedi- of Thecomedonal term neonatal or only acne mildlyhas erythematous historically been papular used lesions as an (Fig- um- Publication of this CME article was jointly sponsored by the University of brella term to describe a variety of lesions occurring in new- atricJohnsonLouisville and & Adolescent Continuing Johnson Consumer Dermatology, Health Sciences Companies, Children’s Education Inc. Hospital and Skin San DiseaseDiego, Uni- Ed- Neonatal Acne Louisville Continuing Health Sciences Education and Skin Disease Ed- borns.brellaure 1), term a One distribution to variant describe seenthat a variety may in neonates include of lesions the is occurring face, characterized scalp, in chest, new- by Hilaryversityucation E. Baldwin, of Foundation California, MD, and Sanhas supported Diegoserved School as a by consultant anof Medicine, educational and San speaker grant Diego, from for CA Aller-John- ucation Foundation and supported by an educational grant from John- Theborns.and back,term Oneneonatal and variant a course acne seen lastinghas in historically neonates up to a year been is orcharacterized used more. as In an some um- by Publicationgan,son & Galderma, Johnson of this CME Consumer Medicis, article and & was Personal Onset. jointly She Products sponsored has also Worldwide by been the a University speaker Division for of comedonal or only mildly erythematous papular lesions (Fig- son & Johnson Consumer & Personal Products Worldwide Division of patients, inflammatory and even nodulocystic lesions may LouisvilleGlaxoSmithKlineJohnson & Continuing Johnson and Consumer Health Ortho SciencesDermatologics. Companies, Education Inc. and Skin Disease Ed- urebrellacomedonal 1), term a distribution orto onlydescribe mildly that a variety erythematousmay include of lesions the papular occurring face, scalp,lesions in chest, new-(Fig- Johnson & Johnson Consumer Companies, Inc. LawrenceHilaryucation E. Baldwin, F. Foundation Eichenfield, MD, and has MD, supported served has served as a by consultant asan an educational investigator and speaker grant for from Galderma, for Aller-John- andborns.ureappear 1), back, anda One distribution and increase variant a course in seenthat severity lasting may in neonates up includewith to time. a year the is It face,or characterized is more. suggested scalp, In chest, some that by Hilary E. Baldwin, MD, has served as a consultant and speaker for Aller- sonGlaxoSmithKline,gan, & Galderma, Johnson Consumer Medicis, Johnson and & & Personal Johnson, Onset. She Products Neutrogena, has also Worldwide been and Stiefel. a speaker Division He has for of comedonalandthe term back,infantile and or only a course acne mildlybe lasting used erythematous to up describe to a year papular this or condition, more. lesions In some (Fig- as it gan, Galderma, Medicis, and Onset. She has also been a speaker for patients, inflammatory and even nodulocystic lesions may JohnsonalsoGlaxoSmithKline been & consultant Johnson and Consumer and/or Ortho served Dermatologics. Companies, on the advisory Inc. board for Coria and GlaxoSmithKline and Ortho Dermatologics. appearurepatients,is not 1), limited anda distribution inflammatory increase to the in neonatal that severity and may even period; includewith nodulocystic time. accordingly, the It face, is suggested scalp,lesions it will chest, may that be HilaryLawrenceGalderma, E. Baldwin, F. Eichenfield, GlaxoSmithKline, MD, has MD, served has Intendis, served as a consultant as Medicis, an investigator and Ortho speaker Dermatologics, for Galderma, for Aller- Lawrence F. Eichenfield, MD, has served as an investigator for Galderma, andappeardiscussed back, and under and increase a coursethat in heading, severity lasting in up with the to time.next a year section. It or is more. suggested More In somecom- that gan,Stiefel,GlaxoSmithKline, Galderma, and Valeant. Medicis, Johnson and & Johnson, Onset. She Neutrogena, has also been and Stiefel. a speaker He has for the term infantile acne be used to describe this condition, as it GlaxoSmithKline, Johnson & Johnson, Neutrogena, and Stiefel. He has monly seen in the neonatal period is a condition that has been SheilaGlaxoSmithKlinealso F. been Friedlander, consultant and MD, and/or Ortho has served Dermatologics. on thean advisory advisory board for CoriaGalderma and patients,theis not term limitedinfantile inflammatory to theacne neonatalbe and used even to period; describe nodulocystic accordingly, this condition, lesions it will may as be it also been consultant and/or served on the advisory board for Coria and LawrenceandGalderma, Onset. F. Eichenfield, GlaxoSmithKline, MD, has Intendis, served as Medicis, an investigator Ortho Dermatologics, for Galderma, appeardiscussediscalled notneonatal limited and under increase to cephalic that the in neonatalheading, severitypustulosis inperiod; with the(NCP). time.next accordingly, Inflammatory, section. It is suggested More it will com-often that be Galderma, GlaxoSmithKline, Intendis, Medicis, Ortho Dermatologics, AnthonyGlaxoSmithKline,Stiefel, J. and Mancini, Valeant. MD, Johnson FAAP, & hasJohnson, served Neutrogena, as a consultant and Stiefel.for Galderma, He has thediscussedpustular term infantile lesions under appearthat acne heading,be very used early toin describethe and next tend section.this to condition, resolve More spon- com- as it Stiefel, and Valeant. monly seen in the neonatal period is a condition that has been SheilaalsoMedicis, F. been Friedlander, and consultant Stiefel. MD,He and/or has servedalso been on a thean speaker advisory advisory for board Galderma. for CoriaGalderma and Sheila F. Friedlander, MD, has served on an advisory board for Galderma calledismonlytaneously notneonatal limited seen within inthe to cephalic the neonatal first neonatal pustulosis 4 period to 8 period; weeks(NCP). is a condition of accordingly, Inflammatory,life. Male that infants it has will often been are be AlbertGalderma,and C. Onset. Yan, MD, GlaxoSmithKline, has no relevant Intendis, financial relationshipsMedicis, Ortho with Dermatologics, any commer- and Onset. discussedcalledaffectedneonatal five under times cephalic that more heading, pustulosis often in than the(NCP). next female Inflammatory, section. infants More and com-often the AnthonyStiefel,cial interests. J. and Mancini, Valeant. MD, FAAP, has served as a consultant for Galderma, pustular lesions appear very early and tend to resolve spon- Anthony J. Mancini, MD, FAAP, has served as a consultant for Galderma, lesions are characteristically limited to the face (Figure 2). It SheilaCorrespondingMedicis, F. Friedlander, and author: Stiefel. Sheila MD, He Fallon has servedalso Friedlander, been on a an speaker MD, advisory Clinical for board Galderma. Professor for Galderma of Pediat- taneouslymonlypustular seen lesions within in the appear the neonatal first very 4 period to early 8 weeks is and a condition of tend life. to Male resolve that infants has spon- been are Medicis, and Stiefel. He has also been a speaker for Galderma. Albertandrics C. and Onset. Yan, Medicine MD, has (Dermatology), no relevant University financialrelationships of California San with Diego. any Rady commer- Chil- affectedcalledtaneouslyhas beenneonatal five estimated within times cephalic the more that first pustulosis up 4 often to to 8 20% weeks than(NCP). of female of newborns Inflammatory,life. Maleinfants experience infants and often theare Albert C. Yan, MD, has no relevant financial relationships with any commer- Anthonydren’scial interests. J.Hospital, Mancini, San MD, Diego, FAAP, CA. E-mail: has served [email protected] as a consultant for Galderma, pustularaffectedthis form five lesions of neonatal times appear more acne. very often2 early than and female tend to infants resolve and spon- the cial interests. lesions are characteristically limited to the face (Figure 2). It CorrespondingMedicis, and author: Stiefel. Sheila He Fallon has also Friedlander, been a speaker MD, Clinical for Galderma. Professor of Pediat- Corresponding author: Sheila Fallon Friedlander, MD, Clinical Professor of Pediat- hastaneouslylesions been are estimated within characteristically the that first up 4 to to limited 8 20% weeksof to ofnewborns the life. face Male (Figure experience infants 2). are It Albertrics C. and Yan, Medicine MD, has (Dermatology), no relevant University financialrelationships of California San with Diego. any Rady commer- Chil- dren’srics and Hospital, Medicine San (Dermatology), Diego, CA. E-mail: University [email protected] of California San Diego. Rady Chil- affectedhas been five estimated times more that up often2 to 20% than of female newborns infants experience and the S6 cial1085-5629/11/$-see interests. front matter © 2011 Published by Elsevier Inc. this form of neonatal acne. dren’s Hospital, San Diego, CA. E-mail: [email protected] lesionsthis form are of characteristically neonatal acne.2 limited to the face (Figure 2). It Correspondingdoi:10.1016/j.sder.2011.07.002 author: Sheila Fallon Friedlander, MD, Clinical Professor of Pediat- has been estimated that up to 20% of newborns experience Pediatricrics and Acne Medicine Management: (Dermatology), Optimizing University Outcomes of California • globalacademycme.com/sdef San Diego. Rady Chil- 7 S6 dren’s1085-5629/11/$-see Hospital, San Diego, frontCA. E-mail: matter [email protected] © 2011 Published by Elsevier Inc. this form of neonatal acne.2 S6 doi:10.1016/j.sder.2011.07.0021085-5629/11/$-see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.sder.2011.07.002 S6 1085-5629/11/$-see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.sder.2011.07.002 TheThe acne acne continuum continuum S7S7 The acne continuum S7

S8 S.F. Friedlander et al

Table 1 Differential Diagnosis of Pediatric Acne in Patients <12 Years of Age1 Condition Comment Angiofibromas (adenoma sebaceum) ● Associated with tuberous sclerosis ● Mid-facial clustering of lesions, often in the alar creases ● Typically initially pink, then white ● Check for hypopigmented macules (ash-leaf spots); Wood’s lamp examination may be helpful to demonstrate these macules ● Query regarding family history of angiofibromas, seizures, and hypopigmented spots ● Signs other than hypopigmented macules are usually not present in early Figure 3 Figure 3 Enlargement. This photomicrographchildhood dem- Figureonstratesonstrates 3 Adrenal enlargement—suggesting enlargement—suggesting Gland Enlargement. hyperactivity— hyperactivity— This photomicrograph of of the the zona zona dem- re- re- Aseptic facial granuloma ● Usually an isolated, painless nodule on the cheek onstratesticularisticularis of of enlargement—suggesting the the adrenal adrenal gland gland in in a a newborn. newborn. hyperactivity— (elsevier.com) (elsevier.com) of the zona re- ticularisDrugFigure exposure of 3. the Adrenal adrenal Gland gland Enlargement in a newborn. (elsevier.com)● Phenytoin and other anticonvulsants This photomicrograph demonstrates enlargement—● Lithium suggesting hyperactivity—of the zona reticularis ●of Isoniazidthe adrenal gland in a newborn. (elsevier.com) with topical 2% cream twice daily● and the le- (oral, topical, inhaled) The acne continuum S7 withsionsEosinophilicsions topical resolved resolved ketoconazole pustular rapidly. rapidly. 2% cream twice daily● Scalp and the lesions le- common sionsErythemaHowever, resolved toxicum subsequent rapidly. neonatorum studies of the possible● Seen correlation commonly in neonates betweenHowever,M. subsequentfurfur andand pustular pustularstudies of lesions lesions the possible in in neonates● neonatesCan correlation be havepustular have betweenyieldedyielded conflicting conflictingM. furfur and results. results. pustular Some Some lesions have have shown shown in neonates● Usually that that not not have disappears all all within the first week of life yieldedpatientsHormonal conflicting with pathology: pustulosis results.adrenal have disease Some positive have cultures, shown● Uncommon that and not some all patientspatients(particularly whowith congenital are pustulosis culture adrenal have positive positive do not cultures, have● Must any and skin be some ruled le- out when acneiform lesions occur in mid-childhood (1 through patientssions.sions.hyperplasia), One One who explanation explanation are adrenal culture tumors, for for positive these these true findings findings do not have is is that that6 any years such such skin ofout- out- le- age) precocious puberty, premature sions.breaks One may explanationrepresent a hypersensitivity for these findings reaction is that to such the pres- out- adrenarche, gonadal tumors, early FigureFigure 1 1 InfantileInfantile acne. acne. (A) (A) Infantile Infantile acne acne with with erythematous erythematous papules papules breaksence of mayM. furfur representrather ahypersensitivity than a disease caused reaction by toan the absolute pres- enceonset of M. of polycystic furfur rather ovarian than syndrome a disease caused by an absolute Figureandand comedones comedones 1 Infantile acne. present. present. (A) (B)Infantile (B) Infantile Infantile acne acne acnewith erythematouswith with comedones comedones papules and and enceincreaseincrease of M. in in furfur the the number numberrather thanof of organisms. organisms. a disease4-64-6 caused by an absolute Infections ● Staphylococcal andinflammatoryinflammatory comedones papules. papules. present. Photos Photos (B) courtesyInfantile courtesy of of acne Sheila Sheila with Fallon Fallon comedones Friedlander, Friedlander, and increaseIt has been in the proposed number that of organisms. some cases4-6 of comedonal disease Figure 1. Infantile Acne It has been proposed that some cases of comedonal● Pityrosporum disease folliculitis inflammatoryMD. papules. Photos courtesy of Sheila Fallon Friedlander, inIt neonates has been may, proposed in fact, that be some a less cases inflammatory of comedonal response disease to A. With Erythematous Papules and Comedones Present in neonates may, in fact, be a less inflammatory● Herpes response simplex to MD. in neonates may, in fact, be a less inflammatory response to B. With Comedones and Inflammatory Papules M. furfur, althoughalthough this this would would not not explain explain the the● clinical clinicalAtypical obser- obser- mycobacteria Photos courtesy of Sheila Fallon Friedlander, MD. M.vationvation furfur, that thatalthough comedonal comedonal this disease disease would tends tends not explain to to persist persist the longer longer● clinicalCandida than than obser-species the the Some evidence suggests that in a subset of patients, NCP vationpustularKeratosis that condition. pilaris comedonal Until disease further tends research to persist clarifies longer● Gray-white, this than issue, the hyperkeratotic, follicular papules maySome be associated evidence suggestswith Malassezia that in furfur a subsetcolonization.colonization. of patients, In In NCP one one pustularitit seems seems reasonable reasonable condition. to toUntil assume assume further that that research there there may may clarifies be be● some someMost this overlap overlap commonly issue, occur on the extensor surfaces of the upper arms, thighs, Figure 3 Adrenal Gland Enlargement. This photomicrograph dem-3 maystudystudy be published published associated in in with 1996, 1996,Malassezia a a group group furfur of of French Frenchcolonization. investigators investigators In one3 itof seems conditions reasonable (NCP to and assume infantile that thereacne) may in some be someand patients, cheeks overlap in onstrates enlargement—suggesting hyperactivity— of the zona re-3 studysampledticularissampled published of and and the examined examined adrenal in 1996, gland smears smears in a agroup newborn.from from ofthe the French faces (elsevier.com)faces and and investigators necks necks of of 13 13 ofwhom conditions the conditions (NCP and may infantile occur acne) simultaneously. in some● Papules patients, Once may at- in occasionally be inflammatory sampledneonates. and In 8 examined of the samples, smears neutrophils from the faces and andM. necksfurfur ofyeastyeast 13 whomtributedMiliatributed the to to conditionsmaternal maternal placental placental may occur androgens, androgens, simultaneously. the the● more moreCharacteristically Once recently recently at- small (1 to 2 mm), white, globoid, noninflammatory papules neonates.were identified. In 8 of The the infants samples, with neutrophils positive smears and M. were furfur treatedyeast tributedacceptedaccepted to hypothesis hypothesis maternal placentalfor for true true neonatal neonatal androgens, acne acne the is is● anmore anExtremely increase increase recently incommon in in newborns but may be seen in older children and adults were identified. The infants with positive smears were treated accepteddehydroepiandrosteroneMiliaria hypothesis for true (DHEA) neonatal production acne is● anCaused causes causesincrease by en- in sweat retention; often occurs in covered areas with topical ketoconazole 2% cream twice daily and the le- dehydroepiandrosteronelargementlargement and, and, in in some some cases, cases, (DHEA) hyperactivity hyperactivity production of of● the theCommon causes fetal fetal adre- adre- en- in first few weeks of life sions resolved rapidly. largementnal gland (Figure and, in some3). An cases, association hyperactivity with severe of● theFine adolescent fetal vesicles, adre- papules, or papulovesicles However, subsequent studies of the possible correlation nalacneMolluscumacne gland later later in(Figure in contagiosum life life has has 3). been been An associationsuggested, suggested, but but with the the severe data data● Often supporting supportingadolescent looks like acne when inflamed between M. furfur and pustular lesions in neonates have 2 acnesuchsuch later a a link link in are are life not not has robust. robust. been suggested,2 but the data● In supporting most patients, presents with classic umbilicated, pearly papules yielded conflicting results. Some have shown that not all suchPeriorificial a link are dermatitis not robust.2 ● Noncomedonal patients with pustulosis have positive cultures, and some ● Classic distribution around mouth, eyes, and nose patients who are culture positive do not have any skin le- DiagnosisDiagnosis and and Treatment Treatment of of Neonatal Neonatal● DoesAcne Acne not respond to standard acne therapy sions. One explanation for these findings is that such out- DiagnosisThe first goal in and a neonate Treatment with pustular of Neonatal lesions● isMay to Acne rule represent out a juvenile form of acne rosacea breaks may represent a hypersensitivity reaction to the pres- Thebacterial,Pomade first goalacne viral, in or a fungalneonate infections. with pustular The differential lesions● isForm to diagnosis rule of occlusion out folliculitis Figure 1 Infantile acne. (A) Infantile acne with erythematous papules ence of M. furfur rather than a disease caused by an absolute bacterial,includesincludes erythema erythema viral, or fungal toxicum toxicum infections. neonatorum neonatorum The differential (seen (seen● commonly commonlyQuestion diagnosis patient in in and/or parents about the use of hair styling or other and comedones present. (B) Infantile acne with comedones and increase in the number of organisms.4-6 includesneonates, erythema it usually toxicum disappears neonatorum within the (seen first week commonlycosmetic or two products inof on or near the face inflammatory papules. Photos courtesy of Sheila Fallon Friedlander, It has been proposed that some cases of comedonal disease neonates,life),Verrucaelife), milia, milia, planaeit ,usually miliaria, (flat disappears sebaceous sebaceous warts) within gland gland the hyperplasia, hyperplasia, first week● Koebner and andor two drug drug phenomenon of (appearance of lesions along a site of trauma), when MD. in neonates may, in fact, be a less inflammatory response to life),reactionreaction milia, (to (to miliaria, either either maternal maternal sebaceous medications medications gland hyperplasia, or or to to topical topicalpresent, and or or drug sys- sys-is a useful distinguishing feature ● Typically noninflammatory M. furfur, although this would not explain the clinical obser- reactiontemictemic drugs drugs (to either administered administered maternal to to medications the the baby). baby). orIn In to almost almost topical all all or cases, cases, sys- ● Common warts may be present elsewhere vation that comedonal disease tends to persist longer than the temicthesethese other other drugs conditions conditions administered can can to be be the ruled ruled baby). out out based Inbased almost on on the the all age agecases, of of Some evidence suggests that in a subset of patients, NCP FigurepustularFigure 2 2 InfantInfant condition. with with Until superficial superficial further pustules pustules research of of clarifies neonatal neonatal this cephalic cephalic issue, thesethethe patient, patient, other conditions the the distribution distribution can be and and ruled morphology morphology out based of of on the the the lesions, lesions, age of may be associated with Malassezia furfur colonization. In one Figurepustulosis.it seems 2 Infant reasonable with to superficial assume that pustules there may of neonatal be some cephalic overlap theandand patient, results results ofof the laboratory laboratory distribution evaluations. evaluations. and morphology (Differential (Differential of the diagnosis diagnosis lesions, 3 Figure 2. Infant With Superficial Pustules of Neonatal study published in 1996, a group of French investigators pustulosis.ofCephalic conditions Pustulosis (NCP and infantile acne) in some patients, in andis shown results in of Tables laboratory 1 and evaluations. 2; features of (Differential neonatal vs diagnosis those of cated unless height, weight, or maturational abnormalities sampled and examined smears from the faces and necks of 13 whom the conditions may occur simultaneously. Once at- infantile acne are listed in Table 3.) are noted (this does not include neonatal gynecomastia, neonates. In 8 of the samples, neutrophils and M. furfur yeast tributed to maternal placental androgens, the more recently Significant hormonal abnormalities may rarely be a cause which is a normal variant). 8 globalacademycme.com/sdef • Pediatric Acne Management: Optimizing Outcomes were identified. The infants with positive smears were treated accepted hypothesis for true neonatal acne is an increase in of lesions in this age group; a laboratory workup is not indi- Because NCP is self-limited and transient, treatment is not dehydroepiandrosterone (DHEA) production causes en- largement and, in some cases, hyperactivity of the fetal adre- nal gland (Figure 3). An association with severe adolescent acne later in life has been suggested, but the data supporting such a link are not robust.2

Diagnosis and Treatment of Neonatal Acne The first goal in a neonate with pustular lesions is to rule out bacterial, viral, or fungal infections. The differential diagnosis includes erythema toxicum neonatorum (seen commonly in neonates, it usually disappears within the first week or two of life), milia, miliaria, sebaceous gland hyperplasia, and drug reaction (to either maternal medications or to topical or sys- temic drugs administered to the baby). In almost all cases, these other conditions can be ruled out based on the age of Figure 2 Infant with superficial pustules of neonatal cephalic the patient, the distribution and morphology of the lesions, pustulosis. and results of laboratory evaluations. (Differential diagnosis S8 S.F. Friedlander et al

Table 1 Differential Diagnosis of Pediatric Acne in Patients <12 Years of Age1 S8S8 Condition S.F.S.F. Friedlander Friedlander et et al al Comment Angiofibromas (adenoma sebaceum) ● Associated with tuberous sclerosis ● Mid-facial clustering of lesions, often in the alar creases TableTable 1 1 DifferentialDifferential Diagnosis Diagnosis of of Pediatric Pediatric Acne Acne in in Patients Patients<<1212 Years Years of of Age Age11 ● Typically initially pink, then white ConditionCondition CommentComment ● Check for hypopigmented macules (ash-leaf spots); Wood’s lamp AngiofibromasAngiofibromas (adenoma (adenoma sebaceum) sebaceum) ●●AssociatedAssociated with with tuberous tuberous sclerosis sclerosis examination may be helpful to demonstrate these macules ●●Mid-facialMid-facial clustering clustering of of lesions, lesions, often often in in the the alar alar creases creases ● Query regarding family history of angiofibromas, seizures, and ●●TypicallyTypically initially initially pink, pink, then then white white hypopigmented spots ●●CheckCheck for for hypopigmented hypopigmented macules macules (ash-leaf (ash-leaf spots); spots); Wood’s Wood’s lamp lamp● Signs other than hypopigmented macules are usually not present in early examinationexamination may may be be helpful helpful to to demonstrate demonstrate these these macules macules childhood 1 ●●QueryQuery regarding regarding family familyAsepticTable history history 1. facialDifferential of of granuloma angiofibromas, angiofibromas, Diagnosis of seizures, seizures, Pediatric and andAcne● inUsually Patients an ≤12 isolated, Years of painless Age nodule on the cheek hypopigmentedhypopigmented spots spotsDrugCondition exposure ●CommentPhenytoin and other anticonvulsants ●●SignsSigns other other than than hypopigmented hypopigmented macules macules are are usually usually not not present present in in early early Angiofibromas (adenoma sebaceum) ●• Lithium Associated with tuberous sclerosis childhoodchildhood ●• Isoniazid Mid-facial clustering of lesions, often in the alar creases AsepticAseptic facial facial granuloma granuloma ●●UsuallyUsually an an isolated, isolated, painless painless nodule nodule on on the the cheek cheek ●• Corticosteroids Typically initially pink, (oral, then topical,white inhaled) • Check for hypopigmented macules (ash-leaf spots); Wood’s lamp examination may be DrugDrug exposure exposure ●●PhenytoinPhenytoin and and other otherEosinophilic anticonvulsants anticonvulsants pustular folliculitis ● Scalp lesions common helpful to demonstrate these macules ●●LithiumLithium Erythema toxicum neonatorum ●• Seen Query regarding commonly family in history neonates of angiofibromas, seizures, and hypopigmented spots ●●IsoniazidIsoniazid ●• Can Signs beother pustular than hypopigmented macules are usually not present in earlychildhood ●●CorticosteroidsCorticosteroids (oral, (oral, topical, topical, inhaled) inhaled) Aseptic facial granuloma ●• Usually Usually an disappears isolated, painless within nodule the on first the cheek week of life EosinophilicEosinophilic pustular pustular folliculitis folliculitis ●●ScalpScalp lesions lesions common commonHormonal pathology: adrenal disease ● Uncommon Drug exposure • Phenytoin and other anticonvulsants ErythemaErythema toxicum toxicum neonatorum neonatorum ●●SeenSeen commonly commonly in in neonates neonates(particularly congenital adrenal ●• Must Lithium be ruled out when acneiform lesions occur in mid-childhood (1 through ●●CanCan be be pustular pustular hyperplasia), adrenal tumors, true • 6 Isoniazid years of age) ●●UsuallyUsually disappears disappears within withinprecocious the the first first puberty, week week premature of of life life • Corticosteroids (oral, topical, inhaled) HormonalHormonal pathology: pathology: adrenal adrenal disease disease ●●UncommonUncommon Eosinophilicadrenarche, pustular gonadal folliculitis tumors, early • Scalp lesions common onset of polycystic ovarian syndrome (particularly(particularly congenital congenital adrenal adrenal ●●MustMust be be ruled ruled out out when whenErythema acneiform acneiform toxicum neonatorum lesions lesions occur occur in in mid-childhood mid-childhood• Seen (1 (1 throughthrough commonly in neonates hyperplasia),hyperplasia), adrenal adrenal tumors, tumors, true true 66 years years of of age) age) Infections ●• Staphylococcal Can be pustular precociousprecocious puberty, puberty, premature premature ●• Pityrosporum Usually disappears folliculitis within the first week of life adrenarche,adrenarche, gonadal gonadal tumors, tumors, early early Hormonal pathology: adrenal disease (particularly ●• Herpes Uncommon simplex onsetonset of of polycystic polycystic ovarian ovarian syndrome syndrome congenital adrenal hyperplasia), adrenal tumors, true ●• Atypical Must be ruled mycobacteria out when acneiform lesions occur in mid-childhood (1 through 6 years of age) InfectionsInfections ●●StaphylococcalStaphylococcal precocious puberty, premature adrenarche, gonadal ● Candida species ●●PityrosporumPityrosporum folliculitis folliculitisKeratosistumors, early pilaris onset of polycystic ovarian syndrome ● Gray-white, hyperkeratotic, follicular papules ●●HerpesHerpes simplex simplex Infections ●• Most Staphylococcal commonly occur on the extensor surfaces of the upper arms, thighs, ●●AtypicalAtypical mycobacteria mycobacteria • and Pityrosporum cheeks folliculitis • Herpes simplex ●●CandidaCandidaspeciesspecies ● Papules may occasionally be inflammatory • Atypical mycobacteria KeratosisKeratosis pilaris pilaris ●●Gray-white,Gray-white, hyperkeratotic, hyperkeratotic,Milia follicular follicular papules papules ●• CharacteristicallyCandida species small (1 to 2 mm), white, globoid, noninflammatory papules ● Extremely common in newborns but may be seen in older children and adults ●●MostMost commonly commonly occur occurKeratosis on on the the pilaris extensor extensor surfaces surfaces of of the the upper upper arms, arms,• Gray-white, thighs, thighs, hyperkeratotic, follicular papules andand cheeks cheeks Miliaria ●• Caused Most commonly by sweat occur retention;on the extensor often surfaces occurs of the in upper covered arms,areas thighs, and cheeks ●●PapulesPapules may may occasionally occasionally be be inflammatory inflammatory ●• Common Papules may in occasionally first few weeksbe inflammatory of life MiliaMilia ●●CharacteristicallyCharacteristically small smallMilia (1 (1 to to 2 2 mm), mm), white, white, globoid, globoid, noninflammatory noninflammatory●• Fine Characteristically papules papules vesicles, papules,small (1 to 2 or mm), papulovesicles white, globoid, noninflammatory papules ●●ExtremelyExtremely common commonMolluscum in in newborns newborns contagiosum but but may may be be seen seen in in older older children children●• Often Extremely and and adults adultslooks common like in acne newborns when but inflamed may be seen in older children and adults MiliariaMiliaria ●●CausedCaused by by sweat sweat retention; retention;Miliaria often often occurs occurs in in covered covered areas areas ●• In Caused most by patients, sweat retention; presents often withoccurs classic in covered umbilicated, areas pearly papules ●●CommonCommon in in first first few fewPeriorificial weeks weeks of of lifedermatitis life ●• Noncomedonal Common in first few weeks of life ●●FineFine vesicles, vesicles, papules, papules, or or papulovesicles papulovesicles ●• Classic Fine vesicles, distribution papules, or aroundpapulovesicles mouth, eyes, and nose MolluscumMolluscum contagiosum contagiosum ●●OftenOften looks looks like like acne acneMolluscum when when inflamed inflamedcontagiosum ●• Does Often looks not like respond acne when to standard inflamed acne therapy ●●InIn most most patients, patients, presents presents with with classic classic umbilicated, umbilicated, pearly pearly papules papules●• May In most represent patients, presents a juvenile with classic form ofumbilicated, acne rosacea pearly papules PeriorificialPeriorificial dermatitis dermatitis ●●NoncomedonalNoncomedonal ThePomadePeriorificial acne continuum acne dermatitis ●• Form Noncomedonal of occlusion folliculitis S9 ●●ClassicClassic distribution distribution around around mouth, mouth, eyes, eyes, and and nose nose ●• Question Classic distribution patient around and/or mouth, parents eyes, and about nose the use of hair styling or other • Does not respond to standard acne therapy ●●DoesDoes not not respond respond to to standard standard acne acne therapy therapy cosmetic products on or near the face Table 2 Differential Diagnosis of Neonatal Acne• 1 May represent a juvenileTable form 4 ofEvaluation acne rosacea When Hyperandrogenism Is Suspected1 ●●MayMay represent represent a a juvenile juvenileVerrucae form form planae of of acne acne (flat rosacea rosacea warts) ● Koebner phenomenon (appearance of lesions along a site of trauma), when MorePomade common: acne • present, Form of occlusion is a useful folliculitis● distinguishingFamily & drug featureexposure history PomadePomade acne acne ●●FormForm of of occlusion occlusion folliculitis folliculitis • Question patient and/or parents about the use of hair styling or other cosmetic products ●●QuestionQuestion patient patient and/or and/or● Drug parents parents reaction about about (to maternal the the use use of medicationsof hair hair styling styling or or or to● other otherTypically topicalon or near or the noninflammatory face ● Search for axillary, genital odor/hair cosmeticcosmetic products products on onsystemic or or near near thedrugs the face face administered to the baby) ● Common warts may● Assess be present breast elsewhere & testicular development Verrucae planae (flat warts) • Koebner phenomenon (appearance of lesions along a site of trauma), when present, ● Erythema toxicum neonatorum ● Laboratory considerations: VerrucaeVerrucae planae planae (flat (flat warts) warts) ●●KoebnerKoebner phenomenon phenomenon (appearance (appearance of of lesions lesions along along a a site site of of trauma), trauma),is a useful when when distinguishing feature present,present, is is a a useful useful● distinguishing distinguishingMilia feature feature • Typically noninflammatory– (free and total) ● Miliaria • Common warts may be present–Dehydroepiandrosterone elsewhere sulfate (DHEA-S) ●●TypicallyTypically noninflammatory noninflammatoryis shown in Tables 1 and 2; features of neonatal vs those of cated unless height, weight, or maturational abnormalities ●●CommonCommon warts warts may may● beSebaceous be present present elsewhere gland elsewhere hyperplasia – infantile acne are listed in Table 3.) are–Follicle-stimulating noted (this does nothormone include neonatal gynecomastia, LessSignificant common: hormonal abnormalities may rarely be a cause which–Prolactin is a normal variant). Table 2. Differential Diagnosis of Neonatal Acne1 ●ofViral, lesions bacterial, in this age fungal group; infection a laboratory workup is not indi- –17-HydroxyprogesteroneBecause NCP is self-limited and transient, treatment is not isis shown shown in in Tables Tables 1 1 and and 2; 2; features features of of neonatal neonatal vs vs those those of of cated●catedEndocrinopathy unless unless height, height, weight, weight, or or maturational maturational abnormalities abnormalities More–Bone Common: age infantileinfantile acne acne are are listed listed in in Table Table 3.) 3.) areare noted noted (this (this does does not not include include neonatal neonatal gynecomastia, gynecomastia, • Drug reaction (to maternal medications or to topical or SignificantSignificant hormonal hormonal abnormalities abnormalities may may rarely rarely be be a a cause cause whichwhich is is a a normal normal variant). variant). systemic drugs administered to the baby) ofof lesions lesions in in this this age age group; group; a a laboratory laboratory workup workup is is not not indi- indi- BecauseBecause NCP NCP is is self-limited self-limited and and transient, transient, treatment treatment is is not not • Erythema toxicum neonatorum Diagnosis• Milia and Treatment of Infantile Acne necessary. However, when parents are concerned and a discus- The• Miliaria more common conditions that should be considered in sion about the condition fails to reassure them, some providers the• Sebaceousdifferential gland diagnosis hyperplasia are listed in Table 1. The physical prescribe topical ketoconazole 2% cream twice daily for 1 week. examination should always include assessment of growth No clinical trials support such use of ketoconazole; however, its Less Common: and• Viral, charting bacterial, of the fungal infant’s infection height and weight. Blood pressure use is based on the clinical experience of the authors, which has also• Endocrinopathy should be measured and monitored to rule out cortico- shown that this therapy may sometimes be helpful. steroid or androgen-secreting disorders. Accelerated growth If the lesions are still present after 4 weeks of age or if Pediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdef of hands and feet suggests the need for further workup. In9 comedonal lesions are prominent, the patient may have addition, the clinician should be alert for androgen effects, infantile acne and may require more aggressive therapy such as odor, changes in areolae and testes, and the presence over time. In cases in which comedones persist and the of axillary and/or genital hair. Children in whom these signs family desires treatment, topical or a are noted should have a complete laboratory workup, as topical retinoid is appropriate. For persistent inflamma- listed in Table 4. tory disease, a topical ( or erythro- Children whose clinical examination is within normal lim- mycin) should be added. its generally do not require further workup and may be treated with the standard regimens shown in Table 5. How- Infantile Acne ever, a high index of suspicion for underlying pathology must be maintained for acne that presents after the first year of life Infantile acne, which—like neonatal acne—is more common and before 6 to 7 years of age, and more aggressive evaluation in male infants, may be seen in children from birth to approx- is required in that age group (see the following section on imately 12 months of age. However, it more commonly pre- “Mid-Childhood Acne”). Careful follow-up is mandatory and sents after the neonatal period. The classic presentation is should include continued monitoring and charting of matu- predominantly comedonal, but inflammatory lesions may be rational milestones and observation for features of viriliza- present (either inflammatory comedones or—particularly in tion. If the condition proves refractory to standard therapy or young infants—concomitant pustular neonatal acne le- any evidence of virilization occurs, a complete laboratory sions). Infantile acne also may be nodular. The lesions most workup and bone age assessment are appropriate. commonly appear on the face, but lesions also may be seen Topical treatment is the initial therapy for significant, on the neck, back, and chest. Although infantile acne usually comedonal infantile acne, including benzoyl peroxide and resolves by 1 year of age, the condition can persist for several as monotherapy or combination therapy. If inflam- months or even years.7 matory lesions are present, topical may be added

Table 3 Neonatal vs Infantile Acne1 Neonatal Infantile Onset Often 2 to 3 weeks of age Often 3 to 6 months of age Lesions Pustules; less likely, comedones Comedones, pustules, cysts Possible etiology Malassezia species colonization (neonatal cephalic Androgens may play a role pustulosis) Course Spontaneous resolution, usually by about 1 month of age Can persist for months to years Sequelae None Scarring possible with inflammatory disease; possible association with severe acne in adolescence The acne continuum S9 The acne continuum S9 Table 2 Differential Diagnosis of Neonatal Acne1 Table 4 Evaluation When Hyperandrogenism Is Suspected1 MoreTable 2 common:Differential Diagnosis of Neonatal Acne1 ●TableFamily 4 Evaluation & drug exposure When Hyperandrogenism history Is Suspected1 ● Drug reaction (to maternal medications or to topical or ● Search for axillary, genital odor/hair Moresystemic common: drugs administered to the baby) ● AssessFamily & breast drug exposure& testicular history development ● ErythemaDrug reaction toxicum (to maternal neonatorum medications or to topical or ● LaboratorySearch for axillary, considerations: genital odor/hair ● Miliasystemic drugs administered to the baby) ● Assess–Testosterone breast &(free testicular and total) development ● MiliariaErythema toxicum neonatorum ● Laboratory–Dehydroepiandrosterone considerations: sulfate (DHEA-S) ● SebaceousMilia gland hyperplasia –Luteinizing–Testosterone hormone (free and total) ● Miliaria –Follicle-stimulating–Dehydroepiandrosterone hormone sulfate (DHEA-S) ● Sebaceous gland hyperplasia –Luteinizing hormone Less common: –Prolactin ● Viral, bacterial, fungal infection –17-Hydroxyprogesterone–Follicle-stimulating hormone ●LessEndocrinopathy common: –Bone–Prolactin age ● Viral, bacterial, fungal infection –17-Hydroxyprogesterone ● Endocrinopathy –Bone age Diagnosis and Treatment of Infantile Acne necessary. However, when parents are concerned and a discus- The more common conditions that should be considered in sion about the condition fails to reassure them, some providers Diagnosis and Treatment of Infantile Acne necessary. However, when parents are concerned and a discus- the differential diagnosis are listed in Table 1. The physical prescribe topical ketoconazole 2% cream twice daily for 1 week. The more common conditions that should be considered in sion about the condition fails to reassure them, some providers examination should always include assessment of growth No clinical trials support such use of ketoconazole; however, its the differential diagnosis are listed in Table 1. The physical prescribe topical ketoconazole 2% cream twice daily for 1 week. and charting of the infant’s height and weight. Blood pressure use is based on the clinical experience of the authors, which has examination should always include assessment of growth No clinical trials support such use of ketoconazole; however, its also should be measured and monitored to rule out cortico- shown that this therapy may sometimes be helpful. and charting of the infant’s height and weight. Blood pressure use is based on the clinical experience of the authors, which has steroid or androgen-secreting disorders. Accelerated growth If the lesions are still present after 4 weeks of age or if also should be measured and monitored to rule out cortico- shown that this therapy may sometimes be helpful. of hands and feet suggests the need for further workup. In comedonalThe acne continuum lesions are prominent, the patient may have steroid or androgen-secreting disorders. Accelerated growthS9 If the lesions are still present after 4 weeks of age or if addition, the clinician should be alert for androgen effects, of hands and feet suggests the need for further workup.1 In infantile acne and may require more aggressive therapy suchTable as 4. odor, Evaluation changes When in areolaeHyperandrogenism and testes, I ands Suspected the presence comedonal lesions are prominent, the patient may have addition, the clinician should be alert for androgen effects, overTable 2 time.Differential In cases Diagnosis in which of comedones Neonatal Acne persist1 and the ofTable axillary 4 Evaluation and/or genital When Hyperandrogenismhair. Children in whom Is Suspected these signs1 infantile acne and may require more aggressive therapy such• Family as odor, & drug changes exposure in history areolae and testes, and the presence family desires treatment, topical benzoyl peroxide or a are• Search noted for should axillary, havegenital aodor/hair complete laboratory workup, as overMore time. common: In cases in which comedones persist and the of● Family axillary & and/or drug exposure genital hair. history Children in whom these signs topical retinoid is appropriate. For persistent inflamma- listed• Assess in Table breast 4.& testicular development family● Drug desires reaction treatment, (to maternal topical medications benzoyl or peroxideto topical or a are● Search noted for should axillary, have genital a complete odor/hair laboratory workup, as torysystemic disease, drugs a topical administered antibiotic to (clindamycin the baby) or erythro- ●• AssessChildren Laboratory breast whose considerations: & clinical testicular examination development is within normal lim- topical retinoid is appropriate. For persistent inflamma- listed– Testosterone in Table 4. (free and total) mycin)● Erythema should toxicum be added. neonatorum its● Laboratory generally considerations:do not require further workup and may be tory disease, a topical antibiotic (clindamycin or erythro- Children– Dehydroepiandrosterone whose clinical sulfate examination (DHEA-S) is within normal lim- ● Milia treated–Testosterone with the standard (free and regimens total) shown in Table 5. How- mycin) should be added. itsS10 generally– Luteinizing do hormone not require further workup and may be S.F. Friedlander et al ● Miliaria ever,–Dehydroepiandrosterone– aFollicle-stimulating high index of suspicion hormone sulfate for underlying (DHEA-S) pathology must Infantile Acne treated with the standard regimens shown in Table 5. How- Infantile● Sebaceous gland Acne hyperplasia be–Luteinizing maintained– Prolactin for hormone acne that presents after the first year of life ever, a high index of suspicion for underlying pathology must Infantile acne, which—like Acne neonatal acne—is more common andTable–Follicle-stimulating– before 517-HydroxyprogesteroneGeneral 6 to 7 Approach years of hormone age, for and Treating more Acne aggressive evaluation (such as phenytoin) and isoniazid, as well as topical, sys- Less common: be–Prolactin maintained– Bone age for acne that presents after the first year of life in male infants, may be seen in children from birth to approx- is● Mild required (comedonal in that age or mixed group comedonal (see the following and inflammatory section on temic, and inhaled corticosteroids. Infantile● Viral, bacterial, acne, which—like fungal infection neonatal acne—is more common and–17-Hydroxyprogesterone before 6 to 7 years of age, and more aggressive evaluation imately 12 months of age. However, it more commonly pre- “Mid-Childhoodlesions) Acne”). Careful follow-up is mandatory and Although underlying hormonal pathology occurs less in● Endocrinopathy male infants, may be seen in children from birth to approx- is–Bone required age in that age group (see the following section on sents after the neonatal period. The classic presentation is shouldTable– Topical 5. include General benzoyl continued Approach peroxide for monitoring Treating or topical Acne and retinoid charting OR of matu- commonly than do the dermatologic diseases mentioned imately 12 months of age. However, it more commonly pre- “Mid-Childhood Acne”). Careful follow-up is mandatory and predominantly comedonal, but inflammatory lesions may be rational– Topical milestones combination and observation therapy (benzoyl for features peroxide of plus viriliza- above, such pathology should be seriously considered when sents after the neonatal period. The classic presentation is should• Mildretinoid, include(comedonal benzoyl continued or mixed peroxide monitoringcomedonal plus topicaland and inflammatory charting antibiotic, oflesions) matu-or present (either inflammatory comedones or—particularly in tion.– If Topical the condition benzoyl peroxide proves or topical refractory retinoid to OR standard therapy or children in this age group present with acneiform lesions. predominantly comedonal, but inflammatory lesions may be rationalDiagnosisbenzoyl milestones peroxide and and Treatment plus observation both topical of for Infantile antibiotic features ofand Acne viriliza- young infants—concomitant pustular neonatal acne le- any– evidence Topical combination of virilization therapy (benzoyl occurs, peroxide a complete plus retinoid, laboratory The possible hormonal conditions include adrenal disease presentnecessary. (either However, inflammatory when parents comedones are concerned or—particularly and a discus- in tion.retinoid) If the condition OR proves refractory to standard therapy or sions). Infantile acne also may be nodular. The lesions most workupThe morebenzoyl and common peroxide bone age plus conditions assessment topical antibiotic, that are should or appropriate. benzoyl be peroxide considered plus in (particularly congenital adrenal hyperplasia), adrenal tu- youngsion about infants—concomitant the condition fails to reassure pustular them, neonatal some providers acne le- any– Topical evidence sulfacetamide of virilization occurs, a complete laboratory The acne continuum commonly appear on the face, but lesions also may be seenS9 theTopical differentialboth topical treatment diagnosisantibiotic is and the are retinoid) initial listed OR in therapy Table 1. for The significant, physical mors, true precocious puberty, premature adrenarche, go- sions).prescribe Infantile topical ketoconazoleacne also may 2% be cream nodular. twice The daily lesions for 1 week. most workup– Topical and dapsone bone age assessment are appropriate. on the neck, back, and chest. Although infantile acne usually comedonalexamination– Topical sulfacetamide infantile should acne, always including include benzoylassessment peroxide of growth and nadal tumors, and early onset of polycystic ovarian syn- commonlyNo clinical trials appear support on the such face, use but of ketoconazole; lesions also may however, be seen its If responseTopical– Topicaltreatment dapsone is inadequate is the, consider initialtherapy adding a for retinoid significant, Table 2 Differential Diagnosis of Neonatal Acne1 resolvesTable 4 Evaluation by 1 year ofWhen age,Hyperandrogenism the condition can persist Is Suspected for several1 tretinoinand charting as monotherapy of the infant’s or height combination and weight. therapy. Blood If pressure inflam- drome. use is based on the clinical experience of the authors, which has product to a regimen, consider that adding does nota retinoid already product include to a it, on the neck, back, and7 chest. Although infantile acne usually comedonalalsoIf response should is infantile be inadequate measured acne, and including monitored benzoyl to rule peroxide out cortico- and The clinician should ask about a family history of partial More common: ●monthsshownFamily that or & even thisdrug therapy years. exposure may history sometimes be helpful. matoryregimenchanging lesions that does the are not concentrationpresent, already include topical it, and/or changing antibiotics type the ofconcentration may vehicle be added in resolves by 1 year of age, the condition can persist for several tretinoinsteroid or as androgen-secreting monotherapy or combination disorders. Accelerated therapy. If inflam- growth congenital adrenal hyperplasia. A careful review of medica- ● Drug reaction (to maternal medications or to topical or ● SearchIf the lesions for axillary, are still genital7 present odor/hair after 4 weeks of age or if and/orthe type retinoid of vehicle product, in the retinoid or changing product, toor changing a combination to a monthsTable 3. or Neonatal even years. vs Infantile Acne1 matoryof hands lesions and feet are suggestspresent, topicalthe need antibiotics for further may workup. be added In tions should be performed. In addition, blood pressure systemic drugs administered to the baby) ●comedonalAssess breast lesions & testicular are prominent, development the patient may have combinationproduct product that has that not has beennot been tried. tried. addition, the clinician should be alert for androgen effects, should be measured. Unless medication reaction is identified ● Erythema toxicum neonatorum ●infantileLaboratory acneNeonatal considerations: and may require1 moreInfantile aggressive therapy • Moderate (combined comedonal and inflammatory) Table 3 Neonatal vs Infantile Acne ●suchModerate as odor, (combined changes in comedonal areolae and and testes, inflammatory) and the presence as the cause, the patient should be assessed for abnormal ● Milia overOnset–Testosterone time. Often In 2 cases to (free 3 weeks in and which of total) age comedonesOften 3 topersist 6 monthsand of age the – Add oral antibiotic (, macrolide derivatives such ● Miliaria Lesions–Dehydroepiandrosterone Pustules; less likely, comedones sulfate1 (DHEA-S) Comedones, pustules,Neonatal cysts of– axillary Add oral and/or antibiotic genital (erythromycin, hair. ChildrenInfantile macrolide in whom derivativesthese signs maturation, as described above. A full hormonal laboratory Tablefamily 3 Neonatal desires treatment, vs Infantile topical Acne benzoyl peroxide or a as clarithromycin; in patients >8 years of age, doxycycline ● Sebaceous gland hyperplasia Possible–Luteinizing Malassezia hormone species colonization Androgens may play are notedsuchor minocycline)* as should clarithromycin; have a complete in patients laboratory>8 years workup, of age, as workup and bone age assessment are indicated for any pa- Onsettopical retinoid is appropriate.Often 2 to For 3 weeks persistent of ageNeonatal inflamma- Often 3 to 6 monthsInfantile of age etiology–Follicle-stimulating(neonatal cephalic hormone pustulosis) a role listed– doxycycline Increase in Table strength 4. orminocycline)* of topical retinoid tient with mid-childhood acne. Lesions Pustules; less likely, comedones Comedones, pustules, cysts Less common: OnsettoryCourse–Prolactin disease,Spontaneous a topical resolution, antibioticOften 2 to (clindamycin 3Can weeks persist of for age ormonths erythro- In–Children older Increase girls who whose strength do not clinical respond ofOften topical examination to 3other to retinoid 6treatment, months is within consider of age normal hormonal lim- usually by about 1 month of age to years ● Viral, bacterial, fungal infection Possiblemycin)–17-Hydroxyprogesterone should etiology be added.Malassezia species colonization (neonatalIntherapy cephalic older with girls a combinationwho do not Androgensoral respond contraceptive to may other play treatment, a role LesionsSequelae None Pustules; lessScarring likely, possible comedones with its generally do not requireComedones, further pustules, workup cysts and may be ● Endocrinopathy –Bone age pustulosis) consider hormonal therapy with a combination oral Preadolescent Acne Possible etiology Malassezia speciesinflammatory colonization disease; (neonataltreated• cephalic Severe with the standardAndrogens regimens may shown play in a Table role 5. How- possible association with contraceptive Course Spontaneouspustulosis) resolution, usually by aboutever, 1 month– a Combination high of index age topical of suspicion therapy Can persistwith for retinoid underlying for and/or months benzoyl pathology to years peroxide must Many children between 7 and 11 years of age are in various Infantile Acne severe acne in adolescence and/or antibiotic AND Sequelae None ●beSevere maintained for acne thatScarring presents possible after thewith first inflammatory year of life stages of puberty, so the term preadolescent is now preferred Course Spontaneous resolution, usually by about 1 month– Oral antibiotic of age Can persist for months to years DiagnosisInfantile acne, and and which—like Treatment Treatment neonatal of of Infantile acne—is Infantile more Acne Acne common and– Combinationbefore 6 to 7 years topical of age, therapydisease; and withmore possible retinoid aggressive association and/or evaluation when considering acne in children who are in this age range. If no response, switch to a different oral antibiotic and/or increase necessary. However, when parents are concerned and a discus- TheSequelaein male more infants, common may conditions be seenNone in children that should from be birth considered to approx- in is requiredbenzoyl in peroxide that age and/orScarring groupwith antibiotic severe(see possible the acne ANDfollowing with in adolescence inflammatory section on The appearance of comedonal, only mildly inflammatory le- sion about the condition fails to reassure them, some providers topical product strengths or combinationsdisease; possibleIf no response, association consider theimately differential 12 months diagnosis of age. are However, listed in it Table more 1. commonly The physical pre- “Mid-Childhoodoral– Oral . antibiotic Acne”). Careful follow-up is mandatory and sions in children in this age group represents what might be prescribe topical ketoconazole 2% cream twice daily for 1 week. If no response, switch towith a different severe oral acne antibiotic in adolescence and/or examinationsents after the should neonatal always period. include The assessment classic presentation of growth is should* Experience include with other continuedoral antibiotics has monitoring been reported, including and trimethoprim- charting of matu- called adrenal awakening and is generally not a sign of worri- No clinical trials support such use of ketoconazole; however, its andpredominantly charting of the comedonal, infant’s height but inflammatory and weight. Blood lesions pressure may be rationalsulfamethoxazoleincrease milestones topicaland cephalexin. and product (Fenner observation JA, strengths Wiss K, Levin for NA. or featuresOral combinations cephalexin of for viriliza-acne some pathology. If novulgaris: response, Clinical experience consider with 93 patients. oral isotretinoinPediatr Dermatol. 2008;25:179-183.) use is based on the clinical experience of the authors, which has alsopresent should (either be measured inflammatory and comedones monitored to or—particularly rule out cortico- in tion. If the condition proves refractory to standard therapy or The seminal studies on this topic by Lucky and col- shown that this therapy may sometimes be helpful. steroidyoung or infants—concomitant androgen-secreting disorders. pustular Accelerated neonatal acne growth le- *Experienceany evidence with of other virilization oral antibiotics occurs, has a been complete reported, laboratory including leagues8,9 showed that comedonal acne may be seen in chil- If the lesions are still present after 4 weeks of age or if ofsions). hands Infantile and feet acne suggests also may the be need nodular. for further The lesions workup. most In workuptrimethoprim-sulfamethoxazole and bone age assessment and are cephalexin. appropriate. (Fenner JA, dren as young as 7 years of age and that girls are more likely Wiss K, Levin NA. Oral cephalexin for acne vulgaris: Clinical comedonal lesions are prominent, the patient may have addition,commonly the appear clinician on the should face, be but alert lesions for androgen also may be effects, seen Topical treatment is the initial therapy for significant, to be affected than are boys in the preadolescent age group. infantile acne and may require more aggressive therapy experience with 93 patients. Pediatr Dermatol. 2008;25:179- suchon the as neck, odor, back, changes and in chest. areolae Although and testes, infantile and the acne presence usually comedonal183.) infantile acne, including benzoyl peroxide and The prevalence of comedonal acne among all children in the over time. In cases in which comedones persist and the ofresolves axillary by and/or 1 year genital of age,hair. the condition Children can in whom persist these for several signs tretinoin as monotherapy or combination therapy. If inflam- United States 11 years of age or younger is 47.3%. Come- family desires treatment, topical benzoyl peroxide or a aremonths noted or should even years. have7 a complete laboratory workup, as matory lesions are present, topical antibiotics may be added donal acne is the most common form seen in the preadoles- topical retinoid is appropriate. For persistent inflamma- listed in Table 4. to the therapeutic regimen. If necessary, systemic antibiotics cent age group, with a typical mid-face distribution. Other tory disease, a topical antibiotic (clindamycin or erythro- Children whose clinical examination is within normal lim- can be added as well. Drugs in the tetracycline class should sites, such as the conchal bowl of the ears, also may be in- mycin) should be added. itsTable generally 3 Neonatal do vs not Infantile require Acne further1 workup and may be not be administered to children less than 8 years of age. volved. Typically, the condition is mild in this age group. treated with the standard regimens shown in Table 5. How- In severe, refractory cases involving large, nodular lesions, Severe comedonal disease in girls has been associated with Neonatal Infantile Infantile Acne ever, a high index of suspicion for underlying pathology must scarring is a potential long-term risk. In such cases, clinicians severe acne in adolescence. beOnset maintained for acne thatOften presents 2 to 3 after weeks the of first age year of life have used intralesionalOften corticosteroids 3 to 6 months as well of age as low-dose The dermatologic conditions and possible drug reactions Infantile acne, which—like neonatal acne—is more common andLesions before 6 to 7 years ofPustules; age, and more less aggressive likely, comedones evaluation systemic isotretinoin withComedones, good effect. pustules, A suggested cysts dosage for that should be considered in the differential diagnosis are the in male infants, may be seen in children from birth to approx- is required in that age group (see the following section on isotretinoin is 0.2 to 1 mg/kg/day for 4 to 14 months. If same as for patients with mid-childhood acne (particularly Possible etiology Malassezia species colonization (neonatal cephalic Androgens may play a role imately 12 months of age. However, it more commonly pre- “Mid-Childhood Acne”). Carefulpustulosis) follow-up is mandatory and isotretinoin is considered, the patient’s family should be cau- including angiofibromas, , perioral dermati- sents after the neonatal period. The classic presentation is should include continued monitoring and charting of matu- tioned about possible adverse effects. Intralesional injection tis, and pityrosporum folliculitis). predominantly comedonal, but inflammatory lesions may be rationalCourse milestones and observationSpontaneous for resolution, features of usually viriliza- by aboutof 1 a month of age (1 to Can 2.5 persistmg/kg triamcinolone) for months to years is a non- In the absence of findings suggesting hyperandrogenism, a present (either inflammatory comedones or—particularly in tion.Sequelae If the condition provesNone refractory to standard therapy or systemic alternative to manageScarring nodules. possible with inflammatory thorough physical examination and family history are suffi- young infants—concomitant pustular neonatal acne le- any evidence of virilization occurs, a complete laboratory disease; possible association cient to rule out other dermatologic conditions in the differ- 10 globalacademycme.com/sdef • Pediatricwith Acne severe Management: acne Optimizing in adolescence Outcomes sions). Infantile acne also may be nodular. The lesions most workup and bone age assessment are appropriate. Mid-Childhood Acne ential and establish the diagnosis of preadolescent acne. commonly appear on the face, but lesions also may be seen Topical treatment is the initial therapy for significant, Physical findings that suggest an underlying hormonal on the neck, back, and chest. Although infantile acne usually comedonal infantile acne, including benzoyl peroxide and The age range for mid-childhood acne is 1 to 7 years of age. pathologic process as the cause of acneiform lesions in pre- resolves by 1 year of age, the condition can persist for several tretinoin as monotherapy or combination therapy. If inflam- The most common conditions to consider in the differential adolescent patients include recalcitrant disease, significant months or even years.7 matory lesions are present, topical antibiotics may be added diagnosis (Table 1) are angiofibromas, keratosis pilaris, milia, and/or rapid development of pustular nodular lesions, and miliaria, flat warts, molluscum contagiosum, pityrosporum lack of response to standard acne therapy. Signs of abnormal folliculitis, and periorificial dermatitis. Also, certain medica- hormonal stimulation also include signs of sexual develop- tions to which children in this age group may be exposed may ment or virilization.10,11 In such cases, further workup is Table 3 Neonatal vs Infantile Acne1 induce an . These include anticonvulsants indicated; laboratory tests should include those listed in Ta- Neonatal Infantile Onset Often 2 to 3 weeks of age Often 3 to 6 months of age Lesions Pustules; less likely, comedones Comedones, pustules, cysts Possible etiology Malassezia species colonization (neonatal cephalic Androgens may play a role pustulosis) Course Spontaneous resolution, usually by about 1 month of age Can persist for months to years Sequelae None Scarring possible with inflammatory disease; possible association with severe acne in adolescence S10 S.F. Friedlander et al S10 S.F. Friedlander et al

Table 5 General Approach for Treating Acne (such as phenytoin) and isoniazid, as well as topical, sys- Table 5 General Approach for Treating Acne (such as phenytoin) and isoniazid, as well as topical, sys- ● Mild (comedonal or mixed comedonal and inflammatory temic, and inhaled corticosteroids. temic, and inhaled corticosteroids. ● Mildlesions) (comedonal or mixed comedonal and inflammatory Although underlying hormonal pathology occurs less lesions)– Topical benzoyl peroxide or topical retinoid OR commonlyAlthough than underlying do the hormonal dermatologic pathology diseases occurs mentioned less –– Topical Topical benzoyl combination peroxide therapy or topical (benzoyl retinoid peroxide OR plus commonlyabove, such than pathology do the should dermatologic be seriously diseases considered mentioned when – Topicalretinoid, combination benzoyl peroxide therapy plus (benzoyl topical peroxide antibiotic, plus or above,children such in pathologythis age group should present be seriously with acneiform considered lesions. when retinoid,benzoylperoxide benzoyl peroxide plus both plus topical topical antibiotic antibiotic, and or childrenThe possible in this hormonal age group conditions present with include acneiform adrenal lesions. disease benzoyl peroxide plus both topical antibiotic and retinoid) OR The(particularly possible hormonalcongenital conditions adrenal hyperplasia), include adrenal adrenal disease tu- retinoid) OR – Topical sulfacetamide (particularlymors, true precocious congenital puberty, adrenal premature hyperplasia), adrenarche, adrenal tu-go- –– Topical Topical sulfacetamide dapsone mors, true precocious puberty, premature adrenarche, go- – Topical dapsone nadal tumors, and early onset of polycystic ovarian syn- If response is inadequate, consider adding a retinoid nadal tumors, and early onset of polycystic ovarian syn- If responseproduct is to inadequate a regimen, that consider does addingnot already a retinoid include it, drome. product to a regimen that does not already include it, drome.The clinician should ask about a family history of partial changing the concentration and/or type of vehicle in The clinician should ask about a family history of partial changingthe retinoid the product, concentration or changing and/or to type a combination of vehicle in congenital adrenal hyperplasia. A careful review of medica- congenital adrenal hyperplasia. A careful review of medica- theproduct retinoid that product, has not or been changing tried. to a combination tions should be performed. In addition, blood pressure product that has not been tried. tionsshould should be measured. be performed. Unless medication In addition, reaction blood is identified pressure ● Moderate (combined comedonal and inflammatory) shouldas the because, measured. the patient Unless should medication be assessed reaction for is identified abnormal ● Moderate– Add oral (combined antibiotic comedonal(erythromycin, and macrolide inflammatory) derivatives asmaturation, the cause, as the described patient above. should A be full assessed hormonal for laboratory abnormal – Add oral antibiotic (erythromycin, macrolide derivatives such as clarithromycin; in patients >8 years of age, maturation,workup and as bone described age assessment above. A fullare indicatedhormonal for laboratory any pa- such as clarithromycin; in patients >8 years of age, doxycycline or minocycline)* workuptient with and mid-childhood bone age assessment acne. are indicated for any pa- –doxycycline Increase strength or minocycline)* of topical retinoid tient with mid-childhood acne. In– older Increase girls strengthwho do not of topical respond retinoid to other treatment, In olderconsider girls who hormonal do not therapy respond with to aother combination treatment, oral Preadolescent Acne considercontraceptive hormonal therapy with a combination oral Preadolescent Acne contraceptive Many children between 7 and 11 years of age are in various ● Severe Manystages children of puberty, between so the 7 term andpreadolescent 11 years of ageis now are in preferred various ● Severe– Combination topical therapy with retinoid and/or stageswhen consideringof puberty, so acne the in term childrenpreadolescent who areis in now this age preferred range. – Combinationbenzoyl peroxide topical and/or therapy antibiotic with retinoid AND and/or whenThe appearance considering of acne comedonal, in children only who mildly are in inflammatory this age range. le- –benzoyl Oral antibiotic peroxide and/or antibiotic AND Thesions appearance in children of in comedonal, this age group only represents mildly inflammatory what might le- be – Oral antibiotic If no response, switch to a different oral antibiotic and/or sionscalled inadrenal children awakening in this ageand group is generally represents not a what sign might of worri- be If no response, switch to a different oral antibiotic and/or increase topical product strengths or combinations calledsome pathology.adrenal awakening and is generally not a sign of worri- If noincrease response, topical consider product oral strengths isotretinoin or combinations some pathology. If no response, consider oral isotretinoin The seminal studies on this topic by Lucky and col- *Experience with other oral antibiotics has been reported, including leaguesThe8,9 seminalshowed studies that comedonal on this topic acneby may Lucky be seen and in chil- col- *Experience with other oral antibiotics has been reported, including 8,9 trimethoprim-sulfamethoxazole and cephalexin. (Fenner JA, leaguesdren as youngshowed as 7 that years comedonal of age and acne that may girls be are seen more in likely chil- trimethoprim-sulfamethoxazoleWiss K, Levin NA. Oral cephalexin and for cephalexin. acne vulgaris: (Fenner Clinical JA, dren as young as 7 years of age and that girls are more likely Wissexperience K, Levin with NA. 93 Oral patients. cephalexinPediatr for Dermatol acne vulgaris:. 2008;25:179- Clinical to be affected than are boys in the preadolescent age group. experience183.) with 93 patients. Pediatr Dermatol. 2008;25:179- toThe be prevalence affected than of comedonal are boys in acne the preadolescent among all children age group. in the 183.) TheUnited prevalence States 11 of yearscomedonal of age acne or younger among all is children47.3%. Come- in the Uniteddonal acne States is the 11 yearsmost common of age or form younger seen is in 47.3%. the preadoles- Come- to the therapeutic regimen. If necessary, systemic antibiotics donalcent age acne group, is the with most a common typical mid-face form seen distribution. in the preadoles- Other tocan the be therapeutic added as well. regimen. Drugs If in necessary, the tetracycline systemic class antibiotics should centsites, age such group, as the with conchal a typical bowl mid-face of the ears, distribution. also may Other be in- cannot be addedadministered as well. to Drugs children in the less tetracycline than 8 years class of age. should sites,volved. such Typically, as the conchal the condition bowl of is the mild ears, in also this may age group. be in- notIn be severe, administered refractory to cases children involving less than large, 8 years nodular of age. lesions, volved.Severe comedonal Typically, the disease condition in girls is has mild been in this associated age group. with scarringIn severe, is a potentialrefractory long-term cases involving risk. In large, such nodular cases, clinicians lesions, Severesevere acnecomedonal in adolescence. disease in girls has been associated with scarringhave used is a intralesional potential long-term corticosteroids risk. In such as well cases, as clinicians low-dose severeThe acne dermatologic in adolescence. conditions and possible drug reactions havesystemic used isotretinoin intralesional with corticosteroids good effect. A assuggested well as dosage low-dose for thatThe should dermatologic be considered conditions in the and differential possible diagnosis drug reactions are the systemicisotretinoin isotretinoin is 0.2 to with 1 mg/kg/day good effect. for A suggested 4 to 14 months. dosage for If thatsame should as for be patients considered with in mid-childhood the differential acne diagnosis (particularly are the isotretinoinisotretinoin is is considered, 0.2 to 1 mg/kg/day the patient’s for family 4 to 14 should months. be cau- If sameincluding as for angiofibromas, patients with keratosis mid-childhood pilaris, acne perioral (particularly dermati- isotretinointioned about is possible considered, adverse the patient’s effects. Intralesional family should injection be cau- includingtis, and pityrosporum angiofibromas, folliculitis). keratosis pilaris, perioral dermati- tionedof a corticosteroid about possible (1 toadverse 2.5 mg/kg effects. triamcinolone) Intralesional injectionis a non- tis,In and the pityrosporum absence of findings folliculitis). suggesting hyperandrogenism, a ofsystemic a corticosteroid alternative (1 to to manage 2.5 mg/kg nodules. triamcinolone) is a non- thoroughIn the absence physical of examination findings suggesting and family hyperandrogenism, history are suffi- a systemic alternative to manage nodules. thoroughcient to rule physical out other examination dermatologic and familyconditions history in the are differ- suffi- cient to rule out other dermatologic conditions in the differ- Mid-Childhood Acne ential and establish the diagnosis of preadolescent acne. Mid-Childhood Acne Acne entialPhysical and establish findings the that diagnosis suggest of an preadolescent underlying hormonalacne. The age range for mid-childhood acne is 1 to 7 years of age. pathologicPhysical processfindings as that the suggest cause of an acneiform underlying lesions hormonal in pre- TheThe age most range common for mid-childhood conditions to acneconsider is 1 into the7 years differential of age. pathologicadolescent process patients as include the cause recalcitrant of acneiform disease, lesions significant in pre- Thediagnosis most common(Table 1) areconditions angiofibromas, to consider keratosis in the pilaris, differential milia, adolescentand/or rapid patients development include of recalcitrant pustular nodular disease, lesions, significant and diagnosismiliaria, flat (Table warts, 1) are molluscum angiofibromas, contagiosum, keratosis pityrosporum pilaris, milia, and/orlack of rapidresponse development to standard of acne pustular therapy. nodular Signs lesions, of abnormal and miliaria,folliculitis, flat and warts, periorificial molluscum dermatitis. contagiosum, Also, certain pityrosporum medica- lackhormonal of response stimulation to standard also include acne therapy. signs of Signs sexual of abnormal develop- S10 S.F. Friedlander et al The acne continuum S11 folliculitis,tions to which and children periorificial in this dermatitis. age group Also, may certainbe exposed medica- may hormonalment or virilization. stimulation10,11 alsoIn include such cases, signs of further sexual workup develop- is S10 S.F. Friedlander et al The acne continuum 10,11 S11 tionsinduce to an which acneiform children eruption. in this age These group include may be anticonvulsants exposed may mentindicated; or virilization. laboratory testsIn should such include cases, further those listed workup in Ta- is Table 5 General Approach for Treating Acne Table 5 General Approach for Treating Acne (suchinduce as an phenytoin) acneiform eruption. and isoniazid, These include as well anticonvulsants as topical, sys- indicated;ble 4. Bone laboratory age should tests also should be evaluated. include In those addition, listed if in Cush- Ta- present with mild, usually comedonal disease, which most Table 5 General Approach for Treating Acne (such as phenytoin) and isoniazid, as well as topical, sys- ble 4. Bone age should also be evaluated. In addition, if Cush- present with mild, usually comedonal disease, which most ● Mild (comedonal or mixed comedonal and inflammatory temic, and inhaled corticosteroids. ing’s syndrome is suspected, adrenocorticotropic hormone often is a normal physiologic occurrence. ● Mildlesions) (comedonal or mixed comedonal and inflammatory temic,Although and inhaled underlying corticosteroids. hormonal pathology occurs less stimulationing’s syndrome testing is suspected, can be considered. adrenocorticotropic hormone oftenTreatment is a normal at any physiologic age depends occurrence. on the type and severity of lesions)– Topical benzoyl peroxide or topical retinoid OR commonlyAlthough than underlying do the hormonaldermatologic pathology diseases occurs mentioned less stimulationSome clinicians testing recommend can be considered. initial therapy with a benzoyl involvement.Treatment at Comedonal any age depends disease on responds the type best and severity to topical of – Topical benzoylcombination peroxide therapy or topical (benzoyl retinoid peroxide OR plus above,commonly such than pathology do the should dermatologic be seriously diseases considered mentioned when peroxideSome clinicians wash for recommend patients with initial very therapy mild comedonal with a benzoyl acne, benzoylinvolvement. peroxide Comedonal and topical disease retinoid responds products; best inflamma- to topical retinoid, benzoyl peroxide plus topical antibiotic, or – Topicalretinoid, combination benzoyl peroxide therapy plus (benzoyl topical peroxide antibiotic, plus or childrenabove, such in this pathology age group should present be seriously with acneiform considered lesions. when butperoxide all of wash the topical for patients medications with very that mild are comedonal used for acne acne, in torybenzoyl disease peroxide usually and benefits topical from retinoid the addition products; of inflamma- topical or retinoid,benzoyl peroxide benzoyl peroxide plus both plus topical topical antibiotic antibiotic, and or benzoyl peroxide plus both topical antibiotic and Thechildren possible in this hormonal age group conditions present includewith acneiform adrenal lesions. disease patientsbut all of 12 the years topical of age medications or older also that are appropriate are used for for acne use in systemictory disease antibiotics. usually benefits Severe disease from the may addition warrant of treatmenttopical or benzoylretinoid) peroxide OR plus both topical antibiotic and (particularlyThe possible congenital hormonal conditions adrenal hyperplasia), include adrenal adrenal disease tu- preadolescents.patients 12 years The of age efficacy or older and also safety are data appropriate on these for younger use in withsystemic systemic antibiotics. isotretinoin, Severe regardless disease may of age. warrant Families treatment should –retinoid) Topical sulfacetamide OR mors,(particularly true precocious congenital puberty, adrenal premature hyperplasia), adrenarche, adrenal go- tu- preadolescents. The efficacy and safety data on these younger with systemic isotretinoin, regardless of age. Families should – Topical dapsone mors, true precocious puberty, premature adrenarche, go- patients are limited: tretinoin has been tested in children as always be counseled regarding the risks and benefits of any – Topical sulfacetamidedapsone nadalmors, tumors,true precocious and early puberty, onset prematureof polycystic adrenarche, ovarian syn- go- patients are limited: tretinoin has been tested in children as always be counseled regarding the risks and benefits of any If response– Topical isdapsone inadequate, consider adding a retinoid nadal tumors, and early onset of polycystic ovarian syn- young as 8 years of age,11 and a benzoyl peroxide/ therapeutic option. If response is inadequate, consider adding a retinoid drome.nadal tumors, tumors, and and early early onset onset of polycystic of polycystic ovarian ovarian syndrome. syn- young as 8 years of age,11 and a benzoyl peroxide/adapalene therapeutic option. If responseproduct is to inadequate a regimen, that consider doesnot adding already a retinoid include it, drome. combination topical agent has been tested in children as drome.The clinician should ask about a family history of partial combination topical agent has been tested in children as productchanging to the a regimen concentration that does and/or not type already of vehicle include in it, The clinician should ask about a family history of partial young as 10 years of age. Based on the large body of efficacy References congenitalThe clinician adrenal should hyperplasia. ask about A acareful family review history of of medica- partial young as 10 years of age. Based on the large body of efficacy changingthe retinoid the product, concentration or changing and/or to type a combination of vehicle in congenital adrenal hyperplasia. A careful review of medica- and safety data from older pediatric patients (ie, those from References1. Tom WL, Friedlander SF: Acne through the ages: Case-based observa- theproduct retinoid that product, has not beenor changing tried. to a combination tionscongenital should adrenal be performed. hyperplasia. In A addition, careful review blood of pressure medica- 12and through safety data 17 years from of older age)—and, pediatric as patients extensive (ie, clinical those expe- from 1.tions Tom WL,through Friedlander childhood SF: and Acne adolescence. through the Clin ages: Pediatr Case-based (Phila) observa- 47:639- product that has not been tried. shouldtions should be measured. be performed. Unless medication In addition, reaction blood is identified pressure 12 through 17 years of age)—and, as extensive clinical expe- 651,tions 2008 through childhood and adolescence. Clin Pediatr (Phila) 47:639- rience has shown—it is reasonable to presume similar effi- 651, 2008 ● Moderate (combined comedonal and inflammatory) asshould the cause, be measured. the patient Unless should medication be assessed reaction for is abnormalidentified rience has shown—it is reasonable to presume similar effi- 2. Antoniou C, Dessinioti C, Stratigos AJ, Katsambas AD: Clinical and as the cause, the patient should be assessed for abnormal cacy and safety in younger children. However, because pre- 2. Antoniou C, Dessinioti C, Stratigos AJ, Katsambas AD: Clinical and ● Moderate– Add oral (combined antibiotic (erythromycin, comedonal and macrolide inflammatory) derivatives as the cause, the patient should be assessed for abnormal therapeutic approach to childhood acne: An update. Pediatr Dermatol maturation, as described above. A full hormonal laboratory adolescentcacy and safety patients in younger tend to produce children. less However, sebum than because do older pre- therapeutic approach to childhood acne: An update. Pediatr Dermatol – Addsuch oral as clarithromycin; antibiotic (erythromycin, in patients macrolide>8 years derivatives of age, maturation, as described above. A full hormonal laboratory 26:373-380, 2009 workup and bone age assessment are indicated for any pa- patients,adolescent their patients skin tend tends to to produce be more less sensitive. sebum than To improvedo older 3. Rapelanoro26:373-380, R, 2009 Mortureux P, Couprie B, Maleville J, Taieb A: Neonatal suchdoxycycline as clarithromycin; or minocycline)* in patients >8 years of age, tientworkup with and mid-childhood bone age assessment acne. are indicated for any pa- patients, their skin tends to be more sensitive. To improve 3.Malassezia Rapelanoro furfur R, Mortureuxpustulosis. P, Arch Couprie Dermatol B, Maleville 132:190-193, J, Taieb A:1996 Neonatal –doxycycline Increase strength or minocycline)* of topical retinoid tolerance, it is often helpful to initiate therapy with decreased – Increase strength of topical retinoid tient with mid-childhood acne. tolerance, it is often helpful to initiate therapy with decreased 4. NiambaMalassezia P, furfur Weillpustulosis. FX, Sarlangue Arch J, Dermatol Labrèze C, 132:190-193, Couprie B, 1996Taïeh A: Is In– older Increase girls strengthwho do not of topical respond retinoid to other treatment, frequency of application (for example, twice weekly or every In older girls who do not respond to other treatment, frequency of application (for example, twice weekly or every 4.common Niamba P, neonatal Weill FX, cephalic Sarlangue pustulosis J, Labrèze (neonatal C, Couprie acne) B, triggered Taïeh A: by Is In olderconsider girls hormonalwho do not therapy respond with to a other combination treatment, oral Preadolescent Acne other day), and application of smaller amounts of the medi- common neonatal cephalic pustulosis (neonatal acne) triggered by Preadolescent Acne Acne other day), and application of smaller amounts of the medi- Malassezia sympodialis? Arch Dermatol 134:995-998, 1998 considercontraceptive hormonal therapy with a combination oral Preadolescent Acne cation. In addition, the daily application of a noncomedo- 5. BernierMalassezia V, Weill sympodialis FX, Hirigoyen? Arch Dermatol V, et al. Skin 134:995-998, colonization 1998 by Malassezia contraceptive Many children between 7 and 11 years of age are in various geniccation. moisturizer In addition, may the be daily useful. application of a noncomedo- 5.species Bernier in V, neonates: Weill FX, A Hirigoyen prospective V, et study al. Skin and colonization relationship withby Malassezia neonatal ● Severe stagesMany children of puberty, between so the 7 term andpreadolescent 11 years of ageis now are in preferred various genicWhen moisturizer necessary may for bethe useful. treatment of severe, nodulocystic cephalicspecies in pustulosis. neonates: A Arch prospective Dermatol study 138:215-218, and relationship 2002 with neonatal cephalic pustulosis. Arch Dermatol 138:215-218, 2002 ● Severe– Combination topical therapy with retinoid and/or stageswhen considering of puberty, soacne the in term childrenpreadolescent who are inis nowthis age preferred range. acneWhen in preadolescent necessary for patients,the treatment systemic of severe, agents—including nodulocystic 6. Ayhan M, Sancak B, Karaduman A, Arikan S, Sahin S: Colonization of benzoyl peroxide and/or antibiotic AND 6.neonate Ayhan M, skin Sancak by Malassezia B, Karaduman species: A, Relationship Arikan S, Sahin with S: neonatal Colonization cephalic of – Combinationbenzoyl peroxide topical and/or therapy antibiotic with retinoid AND and/or Thewhen appearance considering of acne comedonal, in children only who mildly are ininflammatory this age range. le- oralacne isotretinoin—should in preadolescent patients, be considered. systemic agents—including –benzoyl Oral antibiotic peroxide and/or antibiotic AND pustulosis.neonate skin J Amby Malassezia Acad Dermatol species: 57:1012-1018, Relationship with 2007 neonatal cephalic – Oral antibiotic sionsThe appearance in children of in comedonal, this age group only represents mildly inflammatory what mightle-be oral isotretinoin—should be considered. pustulosis. J Am Acad Dermatol 57:1012-1018, 2007 If no– Oral response, antibiotic switch to a different oral antibiotic and/or sions in children in this age group represents what might be 7. Chew EW, Bingham A, Burrows D: Incidence of acne vulgaris in pa- called adrenal awakening and is generally not a sign of worri- 7.tients Chew with EW, infantile Bingham acne. A, Burrows Clin Exp D: Dermatol Incidence 15:376-377, of acne vulgaris 1990 in pa- If noincrease response, topical switch product to a different strengths oral or antibiotic combinations and/or calledsome pathology.adrenal awakening and is generally not a sign of worri- Summary 8. Luckytients with AW, infantile Biro FM, acne. Huster Clin GA, Exp Morrison Dermatol JA, Elder15:376-377, N: Acne 1990 vulgaris in If noincrease response, topical consider product oral strengths isotretinoin or combinations Summary someThe pathology. seminal studies on this topic by Lucky and col- Summary 8.early Lucky adolescent AW, Biro FM, boys. Huster Correlations GA, Morrison with pubertal JA, Elder maturation N: Acne vulgaris and age. in If no response, consider oral isotretinoin Acne can occur at any time in life; cause for concern differs early adolescent boys. Correlations with pubertal maturation and age. *Experience with other oral antibiotics has been reported, including leaguesThe8,9 seminalshowed studies that comedonal on this topic acne mayby Lucky be seen and in chil- col- Acne can occur at any time in life; cause for concern differs Arch Dermatol 127:210-216, 1991 leagues showed that comedonal acne may be seen in chil- depending on age of presentation. Neonatal disease is often Arch Dermatol 127:210-216, 1991 *Experiencetrimethoprim-sulfamethoxazole with other oral antibiotics and has cephalexin. been reported, (Fenner including JA, drenleagues as8,9 youngshowed as 7 that years comedonal of age and acne that may girls be are seen more in likely chil- depending on age of presentation. Neonatal disease is often 9. Lucky AW, Biro FM, Huster GA, Leach AD, Morrison JA, Ratterman J: Wiss K, Levin NA. Oral cephalexin for acne vulgaris: Clinical dren as young as 7 years of age and that girls are more likely transient and may be related to pityrosporum disease. Acne 9.Acne Lucky vulgaris AW, Biro in premenarchal FM, Huster GA, girls: Leach An early AD, Morrison sign of puberty JA, Ratterman associated J: trimethoprim-sulfamethoxazoleWiss K, Levin NA. Oral cephalexin and for cephalexin. acne vulgaris: (Fenner Clinical JA, todren be as affected young than as 7 yearsare boys of age in the and preadolescent that girls are more age group. likely transient and may be related to pityrosporum disease. Acne Wissexperience K, Levin with NA. 93 Oral patients. cephalexinPediatr for Dermatol acne vulgaris:. 2008;25:179- Clinical to be affected than are boys in the preadolescent age group. that presents in the postneonatal period but before 1 year of withAcne rising vulgaris levels in premenarchal of dehydroepiandrosterone. girls: An early sign Arch of Dermatol puberty associated 130:308- experience183.) with 93 patients. Pediatr Dermatol. 2008;25:179- Theto be prevalence affected than of comedonal are boys in acne the preadolescentamong all children age group. in the agethat is presents usually indefined the postneonatal as infantile disease period butand before generally 1 year is not of 314,with rising1994 levels of dehydroepiandrosterone. Arch Dermatol 130:308- 314, 1994 183.) UnitedThe prevalence States 11 of years comedonal of age acne or younger among all is 47.3%.children Come- in the associatedage is usually with defined underlying as infantile pathology. disease In and contrast, generally disease is not 10. Krakowski AC, Eichenfield LF: Pediatric acne: Clinical presentations, donalUnited acne States is the 11 most years common of age or form younger seen is in 47.3%. the preadoles- Come- associated with underlying pathology. In contrast, disease 10.evaluation, Krakowski AC,and management.Eichenfield LF: J Drugs Pediatric Dermatol acne: Clinical 6:589-593, presentations, 2007 donal acne is the most common form seen in the preadoles- that presents between 1 and 7 years of life is of more concern, evaluation, and management. J Drugs Dermatol 6:589-593, 2007 donal acne is the most common form seen in the preadoles- 11. Eichenfield LF, Matiz C, Funk A, Dill SW: Study of the efficacy and to the therapeutic regimen. If necessary, systemic antibiotics cent age group, with a typical mid-face distribution. Other andthat presentsa full evaluation betweenfor 1 and possible 7 years underlying of life is of more hormonal concern, pa- 11. Eichenfield LF, Matiz C, Funk A, Dill SW: Study of the efficacy and to the therapeutic regimen. If necessary, systemic antibiotics centThe acne age continuumgroup, with a typical mid-face distribution. Other S11 tolerability of 0.4% tretinoin microsphere gel for preadolescent acne. can be added as well. Drugs in the tetracycline class should sites, such as the conchal bowl of the ears, also may be in- thologyand a full is warranted. evaluation Children for possible as young underlying as 7 years hormonal of age can pa- Pediatricstolerability 125:e1316-e1323, of 0.4% tretinoin 2010 microsphere gel for preadolescent acne. notcan be administered added as well. to Drugs children in the less tetracycline than 8 years class of age. should volved.sites, such Typically, as the conchal the condition bowl of is the mild ears, in also this mayage group. be in- thology is warranted. Children as young as 7 years of age can Pediatrics 125:e1316-e1323, 2010 notIn be severe, administered refractory to cases children involving less than large, 8 years nodular of age. lesions, Severevolved.ble 4. Bone comedonal Typically, age should thedisease also condition inbe girlsevaluated. is has mild been In in addition, thisassociated age if group. Cush- with present with mild, usually comedonal disease, which most scarringIn severe, is a potential refractory long-term cases involving risk. In large, such nodular cases, clinicians lesions, severeSevereing’s syndrome acne comedonal in adolescence. is suspected,disease in girls adrenocorticotropic has been associated hormone with often is a normal physiologic occurrence. havescarring used is a intralesional potential long-term corticosteroids risk. In such as well cases, as clinicians low-dose severestimulationThe acne dermatologic in testing adolescence. can conditions be considered. and possible drug reactions Treatment at any age depends on the type and severity of systemichave used isotretinoin intralesional with corticosteroids good effect. A suggested as well as dosage low-dose for thatTheSome should dermatologic clinicians be considered recommend conditions in the initial differentialand possible therapy diagnosis drugwith areactions benzoyl are the involvement. Comedonal disease responds best to topical isotretinoinsystemic isotretinoin is 0.2 to with 1 mg/kg/day good effect. for A suggested 4 to 14 months. dosage for If samethatperoxide should as for wash be patients considered for patients with in mid-childhood with the differential very mild acnecomedonal diagnosis (particularly are acne, the benzoyl peroxide and topical retinoid products; inflamma- isotretinoin is is considered, 0.2 to 1 mg/kg/day the patient’s for family 4 to should 14 months. be cau- If includingsamebut all as of for angiofibromas, the patients topical with medications keratosis mid-childhood that pilaris, are acne perioral used (particularly for dermati- acne in tory disease usually benefits from the addition of topical or tionedisotretinoin about is possible considered, adverse the patient’s effects. Intralesional family should injection be cau- tis,includingpatients and pityrosporum 12 angiofibromas, years of age folliculitis). or olderkeratosis also pilaris, are appropriate perioralfor dermati- use in systemic antibiotics. Severe disease may warrant treatment oftioned a corticosteroid about possible (1 to adverse 2.5 mg/kg effects. triamcinolone) Intralesional isinjection a non- tis,preadolescents.In and the pityrosporum absence The of findings efficacy folliculitis). suggesting and safety data hyperandrogenism, on these younger a with systemic isotretinoin, regardless of age. Families should systemicof a corticosteroid alternative (1 to to manage 2.5 mg/kg nodules. triamcinolone) is a non- thoroughpatientsIn the absenceare physical limited: of examination findings tretinoin suggesting has and been family hyperandrogenism, tested history in children are suffi- as a always be counseled regarding the risks and benefits of any systemic alternative to manage nodules. cientthoroughyoung to as rule 8 physical years out other of examination age, dermatologic11 and a and benzoyl conditions family peroxide/adapalene history in the are differ- suffi- therapeutic option. cient to rule out other dermatologic conditions in the differ- Mid-Childhood Acne entialcombination and establish topical the agent diagnosis has been of preadolescent tested in children acne. as references on page 20 entialyoungPhysical and as 10 establish findings years of the thatage. diagnosis Based suggest on of an the preadolescent underlying large body hormonalof acne. efficacy References Mid-Childhood Acne Pediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdef 11 The age range for mid-childhood acne is 1 to 7 years of age. pathologicandPhysical safety dataprocess findings from as that older the causesuggest pediatric of an acneiform patients underlying (ie,lesions those hormonal in from pre- 1. Tom WL, Friedlander SF: Acne through the ages: Case-based observa- The agemost range common for mid-childhood conditions to consider acne is 1 in to the 7 years differential of age. adolescentpathologic12 through process patients 17 years as include of the age)—and, cause recalcitrant of asacneiform extensive disease, lesions clinical significant in expe- pre- tions through childhood and adolescence. Clin Pediatr (Phila) 47:639- diagnosisThe most (Table common 1) are conditions angiofibromas, to consider keratosis in the pilaris, differential milia, and/oradolescentrience has rapid shown—itpatients development include is reasonable of recalcitrant pustular to nodularpresume disease, lesions, similar significant andeffi- 651, 2008 miliaria,diagnosis flat (Table warts, 1) are molluscum angiofibromas, contagiosum, keratosis pityrosporum pilaris, milia, lackand/or of response rapid development to standard of acne pustular therapy. nodular Signs lesions,of abnormal and 2. Antoniou C, Dessinioti C, Stratigos AJ, Katsambas AD: Clinical and miliaria, flat warts, molluscum contagiosum, pityrosporum lackcacy of and response safety in to younger standard children. acne therapy. However, Signs because of abnormal pre- therapeutic approach to childhood acne: An update. Pediatr Dermatol folliculitis,miliaria, flat and warts, periorificial molluscum dermatitis. contagiosum, Also, certain pityrosporum medica- hormonallackadolescent of response stimulation patients to standard tend also to produce include acne therapy. signsless sebum of Signs sexual than of abnormal develop- do older 26:373-380, 2009 tionsfolliculitis, to which and children periorificial in this dermatitis. age group Also, may be certain exposed medica- may menthormonalpatients, or virilization.their stimulation skin tends10,11 alsoIn to include such be more cases, signs sensitive. furtherof sexual To workup develop- improve is 3. Rapelanoro R, Mortureux P, Couprie B, Maleville J, Taieb A: Neonatal inducetions to an which acneiform children eruption. in this age These group include may beanticonvulsants exposed may mentindicated;tolerance, or virilization. itlaboratory is often helpful10,11 testsIn should to such initiate include cases, therapy further those with listed workup decreased in Ta- is Malassezia furfur pustulosis. Arch Dermatol 132:190-193, 1996 induce an acneiform eruption. These include anticonvulsants indicated;frequency laboratory of application tests (for should example, include twice those weekly listed or in every Ta- 4. Niamba P, Weill FX, Sarlangue J, Labrèze C, Couprie B, Taïeh A: Is common neonatal cephalic pustulosis (neonatal acne) triggered by other day), and application of smaller amounts of the medi- Malassezia sympodialis? Arch Dermatol 134:995-998, 1998 cation. In addition, the daily application of a noncomedo- 5. Bernier V, Weill FX, Hirigoyen V, et al. Skin colonization by Malassezia genic moisturizer may be useful. species in neonates: A prospective study and relationship with neonatal When necessary for the treatment of severe, nodulocystic cephalic pustulosis. Arch Dermatol 138:215-218, 2002 acne in preadolescent patients, systemic agents—including 6. Ayhan M, Sancak B, Karaduman A, Arikan S, Sahin S: Colonization of neonate skin by Malassezia species: Relationship with neonatal cephalic oral isotretinoin—should be considered. pustulosis. J Am Acad Dermatol 57:1012-1018, 2007 7. Chew EW, Bingham A, Burrows D: Incidence of acne vulgaris in pa- tients with infantile acne. Clin Exp Dermatol 15:376-377, 1990 Summary 8. Lucky AW, Biro FM, Huster GA, Morrison JA, Elder N: Acne vulgaris in Acne can occur at any time in life; cause for concern differs early adolescent boys. Correlations with pubertal maturation and age. Arch Dermatol 127:210-216, 1991 depending on age of presentation. Neonatal disease is often 9. Lucky AW, Biro FM, Huster GA, Leach AD, Morrison JA, Ratterman J: transient and may be related to pityrosporum disease. Acne Acne vulgaris in premenarchal girls: An early sign of puberty associated that presents in the postneonatal period but before 1 year of with rising levels of dehydroepiandrosterone. Arch Dermatol 130:308- age is usually defined as infantile disease and generally is not 314, 1994 associated with underlying pathology. In contrast, disease 10. Krakowski AC, Eichenfield LF: Pediatric acne: Clinical presentations, evaluation, and management. J Drugs Dermatol 6:589-593, 2007 that presents between 1 and 7 years of life is of more concern, 11. Eichenfield LF, Matiz C, Funk A, Dill SW: Study of the efficacy and and a full evaluation for possible underlying hormonal pa- tolerability of 0.4% tretinoin microsphere gel for preadolescent acne. thology is warranted. Children as young as 7 years of age can Pediatrics 125:e1316-e1323, 2010 The Effects of Culture, Skin Color, and Other Nonclinical Issues on Acne Treatment Hilary E. Baldwin, MD,* Sheila Fallon Friedlander, MD,† Lawrence F. Eichenfield, MD,‡ Hilary E. Baldwin, MD,* Sheila Fallon Friedlander, MD,† Lawrence F. Eichenfield, MD,‡ Anthony J. Mancini, MD,§ and Albert C. Yan, MD¶ AnthonyThe J. Mancini, Effects MD, of§ and Culture, Albert C. Yan,Skin MD Color,¶ and

The Effects of Culture, SkinThe Color,Other EffectsThe Nonclinical effective of and Culture, safe treatment Issues of Skin acne vulgarison Color,Acne often is affectedTreatment by individual patient characteristics,The effective and including safe treatment skin color of acneand cultural vulgaris background. often is affected Skin of by color individual is especially patient and Other Nonclinical Issuesand on Other Acnepronecharacteristics, to TreatmentNonclinical hyperpigmentation, including skin both color from Issues and lesions cultural and background. from on irritating Acne Skin therapy. of color Treatment Clinicians is especially also shouldprone to be hyperpigmentation, aware of cultural attitudes both from and lesions folk remedies and from that irritating may adverselytherapy. Clinicians affect derma- also † ‡ † ‡ Hilary E. Baldwin, MD,* Sheila Fallon Friedlander, MD, HilaryLawrence E.tologicshould Baldwin, F. beconditions Eichenfield, aware MD,* of suchSheila cultural as MD,F acne.allon attitudes Friedlander, and folk remedies MD, L†awrence that may adverselyF. Eichenfield, affect derma-MD, ‡ Hilary E. Baldwin,tologic MD,* conditions Sheila§ such Fallon as acne. Friedlander,¶ MD, Lawrence F. Eichenfield, MD, § ¶ AnthonySemin J. Mancini, Cutan MedM§D, Surg and 30:S12-S15Albert C. Yan, © 2011 MD Elsevier¶ Inc. All rights reserved. Anthony J. Mancini, MD, and Albert C. Yan, MDAnthonyThe Effects J. Mancini,Semin Cutan ofMD, Med Culture,and Surg Albert 30:S12-S15 C. Skin Yan,© 2011 MD Elsevier Color, Inc. All rights reserved. and Other Nonclinical Issues on Acne Treatment The effective and safe treatment of acne vulgaris often is affectedThe by effective individual and patient safe treatment of acne vulgaris often is affected by individual patient characteristics, including skin color and cultural background. Skin of color is especially linicians who treat patients with acne vulgaris must con- Hilary E. Baldwin,characteristics, MD,* Sheila including Fallon skin color Friedlander, and cultural background.MD,siderlinicians† Lawrence factors who Skin other treat ofcolor patientsthan F. Eichenfield, accurate is withespecially acne diagnosis vulgaris MD, and‡ must the con- pre- prone to hyperpigmentation, both from lesions and from irritatingprone therapy. to Clinicianshyperpigmentation, also both from lesions andC from irritating therapy. Clinicians also § Cscription¶ sider of factors an appropriate other than treatment accurate plan. diagnosis Complicating and the pre- the should be aware of cultural attitudes and folk remediesAnthony that J. may Mancini,should adversely be MD, affectaware derma- ofand cultural Albert attitudes C. Yan, and folk MD remedies that may adversely affect derma- clinicalscription picture of an appropriate in patients with treatment acne vulgaris plan. Complicating is the need to the be tologic conditions such as acne. tologic conditions such as acne. Semin Cutan Med Surg 30:S12-S15 © 2011 Elsevier Inc. All rights reserved. awareclinical of picture variations in patients in skin with color, acne culture, vulgaris and is the attitudes need to be of Semin Cutan Med Surg 30:S12-S15 © 2011 Elsevieraware Inc. of variations All rights reserved. in skin color, culture, and attitudes of *Associate Professor andThe Vice effective Chair, Department and safe of treatment Dermatology, of acne SUNY vulgarisboth often patients is affected and their by parents. individual patient *AssociateDownstate, Professor Brooklyn, andcharacteristics, NYVice Chair, Department including of Dermatology, skin colorand SUNY culturalboth background. patients and Skin their of color parents. is especially †ClinicalDownstate, Professor Brooklyn, ofprone Pediatrics NY to and hyperpigmentation, Medicine, Dermatology, both University from lesions of and from irritating therapy. Clinicians also †ClinicalCalifornia,linicians Professor San who Diego, ofshould Pediatrics treat Rady patients be Childrens and aware Medicine, with Hospital, of acne cultural Dermatology, vulgaris San Diego, attitudes Universitymust CA con- and of folk remediesAcnelinicians that andmay who adverselytreat Skin patients of affect with Color derma- acne vulgaris must con- California, San Diego, Rady Childrens Hospital, San Diego, CA Acne and Skin Color ‡Clinicalsider Professor factors of othertologic Pediatrics than conditions and accurate Medicine such diagnosis (Dermatology), as acne. and Chief, the pre- Pedi- Acnesider factors and other Skin than of accurate Color diagnosis and the pre- C‡Clinical Professor of Pediatrics and Medicine (Dermatology), Chief, Pedi- CThere is little epidemiologic evidence demonstrating that scriptionatric and of Adolescent an appropriateSemin Dermatology, Cutan treatment Children’s Med plan.Surg Hospital 30:S12-S15Complicating San Diego, © Uni-the 2011 Elsevier Inc. All rights reserved. atric and Adolescent Dermatology, Children’s Hospital San Diego, Uni- scriptionThere is of little an appropriate epidemiologic treatment evidence plan. demonstrating Complicating that the clinicalversity picture of California, in patients San Diego with School acne of vulgaris Medicine, is San the Diego, need CA to be acne occurs earlier, is more aggressive, or is more likely to §Professorversity of California,Pediatrics and San Dermatology, Diego School ofNorthwestern Medicine, San University’s Diego, CA Fein- clinicalpersistacne occurs longerpicture earlier, in in anypatients is particular more with aggressive, acne ethnic vulgaris group. or is is more the An need exception likely to be to aware§Professor of of variations Pediatrics and in skinDermatology, color, Northwestern culture, and University’s attitudes Fein- of berg School of Medicine, Head, Division of Pediatric Dermatology, Chil- awarepersist of longer variations in any in particular skin color, ethnic culture,1 group. and An attitudes exception of *Associate Professor and Vice Chair, Department of Dermatology, SUNY bothberg patients School of and Medicine, their Head,parents. Division of Pediatric Dermatology, Chil- comes from Perkins and colleagues, who reported that acne *Associatedren’s Memorial Professor Hospital, and Vice Chicago, Chair, Department IL of Dermatology, SUNY bothcomeslinicians patients from Perkins whoand their treat and patientsparents. colleagues, with1 acnewho vulgaris reported must that con-acne Downstate, Brooklyn, NY ¶Chief,dren’s Pediatric Memorial Dermatology, Hospital, Chicago, Children’s IL Hospital of Philadelphia, Associate was more common in the darker-skinned individuals among Downstate, Brooklyn, NY was moresider commonfactors other in the than darker-skinned accurate diagnosis individuals and the among pre- †Clinical Professor of Pediatrics and Medicine, Dermatology, University of ¶Chief,Professor, Pediatric Pediatrics Dermatology, and Dermatology Children’s Perelman Hospital of School Philadelphia, of Medicine Associate at the Cthe populations they studied (Caucasian, Asian, Continental †Clinical Professor of Pediatrics and Medicine, Dermatology, University of Professor, Pediatrics and Dermatology Perelman School of Medicine at the scriptionthe populations of an appropriate they studied treatment (Caucasian, plan. Asian, Complicating Continental the California, San Diego, Rady Childrens Hospital, San Diego, CA AcneCalifornia,University and of San Pennsylvania, Diego, Skin Rady Philadelphia, Childrens of Color Hospital, PA San Diego, CA Indian, and African American women). University of Pennsylvania, Philadelphia, PA Acne and Skin of Color ‡Clinical Professor of Pediatrics and Medicine (Dermatology), Chief, Pedi- ‡ClinicalPublication Professor of this CME of Pediatrics article was and jointly Medicine sponsored (Dermatology), by the University Chief, of Pedi- Lou- clinicalIndian,A commonly picture and African in cited patients American study with by women). acneLucky vulgaris and colleagues is the need showed to be atric and Adolescent Dermatology, Children’s Hospital San Diego, Uni- TherePublication is oflittle this CME epidemiologic article was jointly evidence sponsored demonstrating by the University of that Lou- atricisville and Continuing Adolescent Health Dermatology, Sciences Education Children’s and Hospital Skin Disease San Diego, Education Uni- ThereawarethatA pubertal commonly ofis littlevariations maturation epidemiologic cited in study skin may by color, occur evidence Lucky earlier culture, and demonstrating in colleagues African and attitudes American showed that of versity of California, San Diego School of Medicine, San Diego, CA acneFoundationisville occurs Continuing earlier,and supported Health is more Sciences by an aggressive, educational Educationgrant and or Skin from is more Disease Johnson likely Education & John- to *Associateversity of Professor California, and San Vice Diego Chair, School Department of Medicine, of Dermatology, San Diego, CA SUNY acneboththat pubertal patientsoccurs earlier, maturation and their is more parents. may occuraggressive, earlier or2 in is African more American likely to §Professor of Pediatrics and Dermatology, Northwestern University’s Fein- sonFoundation Consumer and & supported Personal by Products an educational Worldwide grant Division from Johnson of Johnson & John- & girls, so acne vulgaris also may occur earlier. However, the differ- persist§ProfessorDownstate, longer of Pediatrics Brooklyn, in any and NY particular Dermatology, ethnic Northwestern group. University’s An exception Fein- persistgirls, so longeracne vulgaris in any also particular may occur ethnic earlier. group.2 However, An exception the differ- berg School of Medicine, Head, Division of Pediatric Dermatology, Chil- Johnsonson Consumer Consumer & Personal Companies, Products Inc. Worldwide1 Division of Johnson & ences between racial groups in acne age of onset was not clearly seen comes†Clinicalberg from School Professor Perkins of Medicine, of Pediatrics and Head, colleagues, and Division Medicine, ofwho Pediatric Dermatology, reported Dermatology, University that acne Chil- of 1 dren’s Memorial Hospital, Chicago, IL HilaryJohnson E. Baldwin, Consumer MD, Companies, has served Inc. as a consultant and speaker for Aller- comesences between from Perkins racial groups and colleagues, in acne age ofwho onset reported was not clearly that acne seen California,dren’s Memorial San Diego, Hospital, Rady Chicago, Childrens IL Hospital, San Diego, CA when the data were controlled for pubertal development. ¶Chief, Pediatric Dermatology, Children’s Hospital of Philadelphia, Associate wasHilarygan, more E. Galderma, Baldwin, common MD, Medicis, in has the served and darker-skinned Onset. as a consultant She has also individuals and been speaker a speaker for among Aller- for wasAcnewhen more the data common and were Skincontrolled in the darker-skinned of for pubertal Color development. individuals among ‡Clinical¶Chief, Pediatric Professor Dermatology, of Pediatrics Children’s and Medicine Hospital (Dermatology), of Philadelphia, Chief, Associate Pedi- In addition, there is no evidence that acne therapy works Professor, Pediatrics and Dermatology Perelman School of Medicine at the theGlaxoSmithKlinegan, populations Galderma, they Medicis, and studied Ortho and Dermatologics. Onset. (Caucasian, She has also Asian, been Continental a speaker for atricProfessor, and Adolescent Pediatrics and Dermatology, Dermatology Children’s Perelman Hospital School of San Medicine Diego, at Uni- the theTheremoreIn populations addition, effectively is little thereepidemiologic they in any isstudied no particular evidence (Caucasian, evidenceethnic that demonstratingacne Asian, group(s) therapy Continental than works that in University of Pennsylvania, Philadelphia, PA Indian,SheilaGlaxoSmithKline F. and Friedlander, African and MD, American Ortho has served Dermatologics. women). on an advisory board for Galderma versityUniversity of California, of Pennsylvania, San Diego Philadelphia, School of PA Medicine, San Diego, CA Indian,acnemore occurs effectively and African earlier, in American isany more particular aggressive, women). ethnic or group(s)is more likely than to in Publication of this CME article was jointly sponsored by the University of Lou- Sheilaand F. Onset. Friedlander, MD, has served on an advisory board for Galderma others. What is seen more frequently in people of color than §ProfessorPublicationA commonly of Pediatricsthis CME cited article and study Dermatology, was jointly by Lucky sponsored Northwestern and by colleagues the University’sUniversity showed of Fein- Lou- others.A commonly What is citedseen more study frequently by Lucky andin people colleagues of color showed than isville Continuing Health Sciences Education and Skin Disease Education Lawrenceand Onset. F. Eichenfield, MD, has served as an investigator for Galderma, persistin Caucasians longer is in postinflammatory any particular ethnic hyperpigmentation group. An exception (PIH). thatbergisville pubertal School Continuing maturationof Medicine, Health SciencesHead, mayDivision occur Education earlier of Pediatric and in Skin African Dermatology, Disease American Education Chil- Foundation and supported by an educational grant from Johnson & John- LawrenceGlaxoSmithKline, F. Eichenfield, Johnson MD, &has Johnson, served as Neutrogena, an investigator and Stiefel.for Galderma, He has thatcomesin Caucasians pubertal from Perkins maturation is postinflammatory and may colleagues, occur earlierhyperpigmentation1 who in reported African American that (PIH). acne dren’sFoundation Memorial and supported Hospital, byChicago, an educational IL grant2 from Johnson & John- Scarring tendencies may differ and keloid formation is more son Consumer & Personal Products Worldwide Division of Johnson & girls,alsoGlaxoSmithKline, so beenacne consultant vulgaris Johnson also and/or may & served Johnson, occur on earlier.the Neutrogena, advisoryHowever, board and Stiefel. for the Coria differ- He and has girls,Scarring so acne tendencies vulgaris also may may differ occur and earlier. keloid2 However, formation the is differ- more ¶Chief,son Pediatric Consumer Dermatology, & Personal Children’s Products Worldwide Hospital of Division Philadelphia, of Johnson Associate & waslikely more in patients common of in color. the darker-skinned individuals among Johnson Consumer Companies, Inc. encesGalderma,also between been consultant GlaxoSmithKline, racial groups and/or in served acneIntendis, onage the ofMedicis, onsetadvisory was Ortho board not Dermatologics, clearlyfor Coria seen and Professor,Johnson Consumer Pediatrics Companies, and Dermatology Inc. Perelman School of Medicine at the theenceslikely populations between in patients racial they of groups color. studied in acne (Caucasian, age of onset Asian, was not Continental clearly seen Hilary E. Baldwin, MD, has served as a consultant and speaker for Aller- whenStiefel,Galderma, thedata and GlaxoSmithKline, Valeant. were controlled Intendis, for pubertal Medicis, development. Ortho Dermatologics, HilaryUniversity E. Baldwin, of Pennsylvania, MD, has served Philadelphia, as a consultant PA and speaker for Aller- Indian,when the and data African were controlled American for women). pubertal development. gan, Galderma, Medicis, and Onset. She has also been a speaker for AnthonyStiefel, J. and Mancini, Valeant. MD, FAAP, has served as a consultant for Galderma, Postinflammatory Hyperpigmentation PublicationIngan, addition, Galderma, of this CME there Medicis, article is no was and evidence jointly Onset. sponsored She that has acne alsoby the been therapy University a speaker works of Lou- for In addition, there is no evidence that acne therapy works GlaxoSmithKline and Ortho Dermatologics. AnthonyMedicis, J. Mancini, and Stiefel. MD, He FAAP, has also has been served a speaker as a consultant for Galderma. for Galderma, PostinflammatoryPostinflammatoryA commonly cited study HyperpigmentationHyperpigmentation by Lucky and colleagues showed moreisvilleGlaxoSmithKline effectively Continuingin Health and any Ortho Sciences particular Dermatologics. Education ethnic and Skin group(s) Disease Educationthan in Manipulation of lesions is associated with an increase in PIH, Sheila F. Friedlander, MD, has served on an advisory board for Galderma AlbertMedicis, C. Yan, and MD, Stiefel. has no He relevant has also financial been a relationshipsspeaker for Galderma. with any commer- thatmore pubertal effectively maturation in any may particular occur earlier ethnic in group(s) African American than in SheilaFoundation F. Friedlander, and supported MD, has by served an educational on an advisory grant from board Johnson for Galderma & John- underscoringManipulation the of lesions importance is associated of early with and effectivean increase therapy in PIH, to and Onset. others.Albertcial C. interests. What Yan, MD, is seenhas no more relevant frequently financial relationships in people with of colorany commer- than others. What is seen more frequently in people2 of color than sonand ConsumerOnset. & Personal Products Worldwide Division of Johnson & girls,underscoring so acne vulgaris the importance also may occur of early earlier. and effectiveHowever, therapy the differ- to Lawrence F. Eichenfield, MD, has served as an investigator for Galderma, inCorresponding Caucasianscial interests. author: is postinflammatory Hilary E. Baldwin,MD, hyperpigmentation Associate Professor and (PIH). Vice eliminate acne lesions. The tendency to develop PIH appears LawrenceJohnson F. Consumer Eichenfield, Companies, MD, has Inc. served as an investigator for Galderma, encesineliminate Caucasians between acne racial is lesions. postinflammatory groups The in acnetendency age hyperpigmentation of toonset develop was not PIH clearly appears (PIH). seen GlaxoSmithKline, Johnson & Johnson, Neutrogena, and Stiefel. He has ScarringCorrespondingChair, tendencies Department author: Hilary of may Dermatology, E. differ Baldwin, and SUNY MD, keloid Associate Downstate, formation Professor Brooklyn, is and more Vice NY. to be genetically determined. It is not limited to cystic lesions, HilaryGlaxoSmithKline, E. Baldwin, MD, Johnson has served & Johnson, as a consultant Neutrogena, and and speaker Stiefel. for He Aller- has whenScarringEffects the of tendenciesdata nonclinical were controlled mayissues differ on for acne and pubertal treatment keloid development. formation is more S13 also been consultant and/or served on the advisory board for Coria and E-mail:Chair, Department [email protected] of Dermatology, SUNY Downstate, Brooklyn, NY. to be genetically determined. It is not3 limited to cystic lesions, likelygan,also in been Galderma, patients consultant Medicis, of color.and/or and served Onset. on Shethe advisory has also board been afor speaker Coria and for but is seen with lesions of all types. Galderma, GlaxoSmithKline, Intendis, Medicis, Ortho Dermatologics, E-mail: [email protected] likelybutIn is addition, in seen patients with there lesions of color. is no of evidence all types.3 that acne therapy works GlaxoSmithKlineGalderma, GlaxoSmithKline, and Ortho Intendis,Dermatologics. Medicis, Ortho Dermatologics, Stiefel, and Valeant. more effectively in any particular ethnic group(s) than in SheilaStiefel, F. Friedlander, and Valeant. MD, has served on an advisory board for Galderma In a study of acne in African American women, Halder and Acne-Related Scarring Anthony J. Mancini, MD, FAAP, has served as a consultant for Galderma, Postinflammatory Hyperpigmentation AnthonyS12and1085-5629/11/$-see Onset. J. Mancini, MD, FAAP, front has matter served © 2011 as aconsultant Elsevier Inc. for All Galderma, rights reserved. Postinflammatoryothers.colleagues What4 compared is seen more the Hyperpigmentation clinical frequently appearance in people of offacial color acne than le- Medicis, and Stiefel. He has also been a speaker for Galderma. S12 1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. Acne can also be associated with keloidal scars in skin of ManipulationLawrenceMedicis,doi:10.1016/j.sder.2011.07.005 F. and Eichenfield, Stiefel.of lesions He MD, has is has alsoassociated served been a as speaker anwith investigator an for increaseGalderma. for Galderma, in PIH, Manipulationin Caucasians ofis postinflammatory lesions is associated hyperpigmentation with an increase in (PIH). PIH, Albert C. Yan, MD, has no relevant financial relationships with any commer- doi:10.1016/j.sder.2011.07.005 sions of all types (comedones, papules, pustules, hyperpig- color, with acne lesions often transforming almost impercep- underscoringAlbertGlaxoSmithKline, C. Yan, MD, the has importance Johnson no relevant & Johnson, financial of early Neutrogena,relationships and effective and with Stiefel. any therapy commer- He has to cial interests. underscoringScarringmented macules, tendencies the importanceand may depressed differ of and earlyscars) keloid and with effective formation histologic therapy isfindings more to alsocial interests. been consultant and/or served on the advisory board for Coria and tibly into keloids. In some cases, the only indication that acne Corresponding author: Hilary E. Baldwin, MD, Associate Professor and Vice eliminate acne lesions. The tendency to develop PIH appears eliminatelikely in patients acne lesions. of color. The tendency to develop PIH appears CorrespondingGalderma, GlaxoSmithKline, author: Hilary E. Baldwin, Intendis, MD, Medicis, Associate Ortho Professor Dermatologics, and Vice of 3-mm punch biopsies. The investigators found that the de- is the underlying cause of keloids is the distribution of the Chair, Department of Dermatology, SUNY Downstate, Brooklyn, NY. to be genetically determined. It is not limited to cystic lesions, togree beof genetically inflammation determined. in all types It is of not lesions limited was to “marked cystic lesions, and out Stiefel,Chair, Departmentand Valeant. of Dermatology, SUNY3 Downstate, Brooklyn, NY. lesions over the chest, back, upper arms, and jaw. In such E-mail: [email protected] but is seen with lesions of all types. 3 AnthonyE-mail: J. [email protected], MD, FAAP, has served as a consultant for Galderma, butPostinflammatoryof proportion” is seen with to lesions their clinical of Hyperpigmentation all appearance. types. This was not the case cases, aggressive therapy with isotretinoin might be war- Medicis, and Stiefel. He has also been a speaker for Galderma. Manipulationin light-skinned of individuals. lesions is associated According with to the an authors, increase this in PIH, sug- ranted, even in younger adolescents. New acne/keloid lesion Albert C. Yan, MD, has no relevant financial relationships with any commer- underscoringgests that acne the vulgaris importance in African of early Americans and effective is clinically therapy and to S12 1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. S12cial1085-5629/11/$-see interests. front matter © 2011 Elsevier Inc. All rights reserved. formation will stop and the keloids can subsequently be doi:10.1016/j.sder.2011.07.005 Correspondingdoi:10.1016/j.sder.2011.07.005 author: Hilary E. Baldwin, MD, Associate Professor and Vice eliminatehistopathologically acne lesions. different The tendency from the to disease develop found PIH in appears Cauca- treated. Chair, Department of Dermatology, SUNY Downstate, Brooklyn, NY. tosians, be genetically which may determined. explain why It hyperpigmentation is not limited to cystic and lesions, scarring E-mail: [email protected] butis more is seen common with lesions in darker-skinned of all types. persons.3 No acne treatments have been identified as causal for PIH. 12 globalacademycme.com/sdef • Pediatric Acne Management: Optimizing Outcomes Perceptions, However, the irritation associated with topical therapy can in- Customs, Habits, and Fads S12 1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. crease the risk of PIH in skin of color. To minimize irritation, doi:10.1016/j.sder.2011.07.005 treatment of patients with skin of color should be approached Some patients and/or their parents hold the perception and with this in mind. Specifically, acute irritation from topical ben- belief that “natural” agents are superior to “drugs” in the zoyl peroxide and retinoid preparations should be avoided, if treatment of a variety of diseases, including acne vulgaris. In possible. When initiating topical retinoid therapy, lower con- fact, the only such product on which there are even meager centrations can be used, cream formulations rather than gels data regarding benefit in acne is tea-tree oil, which may be of utilized, and applications decreased to every other day. The minor benefit in mild acne. Patients who resist topical phar- concentration of medication and frequency of application can macotherapy are often even more resistant to the use of oral be increased gradually, in a stepwise fashion. The need for a medications, which they perceive as dangerous. gentle introduction to topical care must be balanced with the Sometimes these individuals attempt to be well informed, knowledge that acne lesions themselves are a source of PIH. but the source of their information is deficient—for example, When acne is severe, prompt clearing of lesions is neces- Internet sites and blogs that are opinion-rich and fact-poor, sary to avoid lesion-related PIH, so such a slow, stepwise resulting in the dissemination of incorrect notions and the approach to topical therapy may not be advisable as mono- perpetuation of myths. Parental fears arising from misinfor- therapy. In such cases, it may be prudent to initiate oral mation can interfere with the appropriate treatment of ado- therapy earlier than one might have ordinarily. Acne surgery lescents with moderate to severe acne. Countering the effects is useful for eradicating closed and open comedones, but of erroneous notions and beliefs requires a great deal of pa- overly aggressive extraction can cause long-lasting PIH. In tience, discussion, and education. patients with skin of color, anecdotal experience shows that 1 month of treatment with topical retinoids prior to acne sur- Tanning gery is beneficial. Comedones are more easily extracted with Artificial and natural sunlight may improve the appearance of less pigment-producing trauma. acne temporarily. Tan skin provides some camouflage for the Hyperpigmentation often is more of a problem for patients redness of acne lesions. In addition, as it is a crude form of than is acne itself. Treatment options for PIH include hydro- light therapy, sun exposure may also result in an short-term quinones, topical retinoids, and multiple types of cosmeceu- improvement in lesions, and the observation that sunlight tical products.5-7 Chemical peels8 and laser and light therapy9 improves acne is not lost on patients. In colder climates, can be effective but must be approached cautiously to avoid some patients prolong their suntans by using tanning beds. further hyperpigmentation and the possibility of scarring. Unfortunately, the temporary improvement in appearance makes it difficult for clinicians to convince patients of the Preadolescent Patients long-term skin damage associated with ultraviolet light ex- posure. It is common for preadolescents and early adolescent pa- tients—particularly girls—to seek treatment for “blemishes” rather than acne itself. Many are noncompliant with acne Culture, Doctors, treatment regimens because they are more concerned with and Medication Adherence the appearance of PIH. It is important to stress to these pa- In a recent meta-analysis of adherence of people of color tients that control of acne, using the prescribed therapeutic and language diversities to medications in general, Manias regimens, will decrease the amount of PIH in the future as it and Williams10 failed to identify any factors that would be decreases new lesion formation. Meanwhile, the offer of treat- helpful in improving adherence to medication regimens ment of PIH often helps promote adherence to acne therapy. among these populations. Thus, it is up to the clinician’s The data are sparse on specific treatments for acne in younger awareness and sensitivity to work with individual patients patients with skin of color, but it is reasonable to extrapolate and their families. from efficacy and safety studies that included patients between Some patients distrust authority, in general; others have a 12 and 17 years of age with similar skin colors. particular bias against doctors whose cultural or racial back- Effects of nonclinical issuesEffects on acne of nonclinical treatment issues on acne treatment S13 S13 EffectsEffects of of nonclinical nonclinical issues issues on on acne acne treatment treatment S13S13 Effects of nonclinical issues on acne treatment S13 In a study of acne in AfricanIn a Americanstudy of acne women, in African Halder American and women,Acne-Related Halder and ScarringAcne-Related Scarring colleaguesInIn a a study study4 compared of of acne acne in in the African Africancolleagues clinical American American appearance4 compared women, women, of the facial Halderclinical Halder acne and andappearance le- of facial acne le- In a study of acne in African American women, Halder and Acne-RelatedAcne can also be associated ScarringAcne withcan also keloidal be associated scars in skin with of keloidal scars in skin of sions of all44 types (comedones,sions of papules, all types pustules, (comedones, hyperpig- papules, pustules,Acne-Related hyperpig- Scarring colleaguescolleagues4 comparedcompared the the clinical clinical appearance appearance of of facial facial acne acne le le-- Acnecolor, can with also acne be lesions associated oftencolor, transforming with with acnekeloidal lesions almost scars often impercep-in skintransforming of almost impercep- mentedcolleagues macules,compared and depressed themented clinical scars) macules, appearance with and histologic of depressed facial findings acne scars) le- withAcne histologic can findings also be associated with keloidal scars in skin of sionssions of of all all types types (comedones, (comedones, papules, papules, pustules, pustules, hyperpig- hyperpig- color,tiblycolor, into with with keloids. acne acne lesions lesions In some oftentibly often cases, into transforming transforming the keloids. only indication In almost almost some impercep-cases, impercep- that acne the only indication that acne ofsions 3-mm of all punch types biopsies. (comedones,of The 3-mm investigators papules, punch biopsies. pustules, found that The hyperpig- the investigators de- color, found with that the acne de- lesions often transforming almost impercep- mented macules, and depressed scars) with histologic findings tiblyistibly the into into underlying keloids. keloids. In In cause some someis of cases, cases,the keloids underlying the the is only only the indication indication distribution cause of keloidsthat that of acne acne the is the distribution of the greemented of inflammation macules, and in depressed allgree types of inflammationof scars) lesions with was histologic in“marked all types findings and of outlesions wastibly “marked into keloids. and out In some cases, the only indication that acne of 3-mm punch biopsies. The investigators found that the de- islesionsis the the underlying underlying over the chest, cause cause back,lesions of of keloids keloids upper over is is arms, the the the chest, distribution distribution and back,jaw. In upper of of such the the arms, and jaw. In such of proportion” 3-mm punch to biopsies.their clinicalof The proportion” appearance. investigators to theirThis found wasclinical thatnot appearance. the the case de- Thisis the was underlying not the case cause of keloids is the distribution of the greegree of of inflammation inflammation in in all all types types of of lesions lesions was was “marked “marked and and out out lesionscases,lesions aggressive over over the the chest, chest, therapy back, back,cases, with upper upper aggressive isotretinoin arms, arms, therapy and and might jaw. jaw. with be In In suchwar- such isotretinoin might be war- ingree light-skinned of inflammation individuals. in allin types light-skinned According of lesions to individuals.was the authors, “marked According this and sug- out to thelesions authors, over this the sug- chest, back, upper arms, and jaw. In such of proportion” to their clinical appearance. This was not the case cases,ranted,cases, aggressive aggressive even in younger therapy therapyranted, adolescents. with with even isotretinoin isotretinoin inNew younger acne/keloid might might adolescents. be be lesion war- war- New acne/keloid lesion gestsof proportion” that acne to vulgaris their clinical ingests African appearance. that acneAmericans vulgaris This iswas clinicallyin not African the case and Americanscases, is clinically aggressive and therapy with isotretinoin might be war- inin light-skinned light-skinned individuals. individuals. According According to to the the authors, authors, this this sug- sug- ranted,formationranted, even even will in in youngeryounger stop andformation adolescents. adolescents. the keloids will New New can stop acne/keloid acne/keloid subsequently and thelesion keloidslesion be can subsequently be histopathologicallyin light-skinned individuals. differenthistopathologically Accordingfrom the disease to the different authors, found in from this Cauca- sug- the diseaseranted, found even in Cauca- in younger adolescents. New acne/keloid lesion gestsgests that that acne acne vulgaris vulgaris in in African African Americans Americans is is clinically clinically and and formationtreated.formation will will stop stop and andtreated. the the keloids keloids can can subsequently subsequently be be sians,gests that which acne may vulgaris explain insians, why African hyperpigmentation which Americans may explain is clinically and why scarring hyperpigmentation and formation and scarring will stop and the keloids can subsequently be histopathologically different from the disease found in Cauca- treated.treated. ishistopathologically more common in different darker-skinnedis more from common the persons. disease in darker-skinned found in Cauca- persons.treated. sians,sians, which which may may explain explain why why hyperpigmentation hyperpigmentation and and scarring scarring sians,No which acne treatments may explain have whyNo been hyperpigmentation acne identified treatments as causal have and been for scarring PIH. identifiedPerceptions, as causal for PIH. Perceptions, isis more more common common in in darker-skinned darker-skinned persons. persons. isHowever, more common the irritation in darker-skinned associatedHowever, with the persons. irritation topical therapy associated can with in- topical therapy can in- No acne treatments have been identified as causal for PIH. Perceptions,Customs, Habits,Customs, and Fads Habits, and Fads creaseNo acne the risk treatments of PIH in havecrease skin been of the color. identified risk To of PIHminimize as causalin skin irritation, for of color.PIH. To minimizePerceptions, irritation, Customs, However, the irritation associated with topical therapy can in- Customs, Habits, and Fads treatmentHowever, ofthe patients irritation with associatedtreatment skin of colorwith of patients topical should with therapy be approached skin can of color in- shouldCustoms,Some be patients approached and/or Habits, theirSome parents patients and hold and/or Fads the perception their parents and hold the perception and creasecrease the the risk risk of of PIH PIH in in skin skin of of color. color. To To minimize minimize irritation, irritation, Habits, and Fads withcrease this the in risk mind. of PIHSpecifically, inwith skin this ofacute color. in irritation mind. To minimizeSpecifically, from topical irritation, acute ben- irritationSomebelief from patients thattopical “natural” ben- and/or agents theirbelief parents are that superior “natural” hold the to perception agents“drugs” are in and superiorthe to “drugs” in the treatmenttreatment of of patients patients with with skin skin of of color color should should be be approached approached Some patients and/or their parents hold the perception and zoyltreatment peroxide of patients and retinoid withzoyl skin preparations peroxide of color and should should retinoid be be approached avoided, preparations if shouldbelieftreatment be that avoided, of “natural” a variety if agents oftreatment diseases, are superior including of a variety to acne “drugs” of diseases, vulgaris. in the including In acne vulgaris. In with this in mind. Specifically, acute irritation from topical ben- belief that “natural” agents are superior to “drugs” in the possible.with this in When mind. initiating Specifically,possible. topical acute retinoid When irritation initiating therapy, from topical topical lower ben-con- retinoid therapy,treatmentfact,treatment the lower only of of a a con- such variety variety product of offact, diseases, diseases, on the which only including including such there product acneare acne even vulgaris. vulgaris. on meager which In In there are even meager zoylzoyl peroxide peroxide and and retinoid retinoid preparations preparations should should be be avoided, avoided, if if treatment of a variety of diseases, including acne vulgaris. In centrationszoyl peroxide can and be retinoid used,centrations cream preparations formulations can shouldbe used, rather be cream avoided, than formulations gels if fact,datafact, ratherregarding the the only onlythan such suchgels benefit product product indata acne on on regarding is which which tea-tree there there benefit oil, whichare are in even even acne may meager meager is be tea-tree of oil, which may be of possible. When initiating topical retinoid therapy, lower con- fact, the only such product on which there are even meager utilized,possible. and When applications initiatingutilized, topical decreased retinoidand to applications every therapy, other lowerdecreased day. con- The to everydataminor other regarding benefit day. Thein benefit mild acne.in minor acne Patients is benefit tea-tree who in oil, mild resist which acne. topical may Patients phar- be of who resist topical phar- centrationscentrations can can be be used, used, cream cream formulations formulations rather rather than than gels gels data regarding benefit in acne is tea-tree oil, which may be of concentrationcentrations can of be medication used,concentration cream and formulations frequency of medication of rather application than and frequencygels can minormacotherapy of application benefit arein can mild often acne. evenmacotherapy Patients more resistant who are oftenresist to the even topical use more of phar- oral resistant to the use of oral utilized, and applications decreased to every other day. The minor benefit in mild acne. Patients who resist topical phar- beutilized, increased and gradually, applications inbe decreased a increased stepwise to gradually,fashion. every otherThe in needa day. stepwise for The a fashion.macotherapymedications, The need forwhich are a often they evenmedications, perceive more asresistant dangerous. which to they the perceive use of oral as dangerous. concentrationconcentration of of medication medication and and frequency frequency of of application application can can macotherapy are often even more resistant to the use of oral gentleconcentration introduction of medication to topicalgentle and care introduction frequency must be balancedof to application topical with care can the must bemedications, balancedSometimes with which these the individuals they perceiveSometimes attempt as dangerous. these to be individuals well informed, attempt to be well informed, be increased gradually, in in a stepwise fashion. The need for a medications, which they perceive as dangerous. knowledgebe increased that gradually, acne lesions inknowledge a themselves stepwise that fashion. are acne a source lesions The need of themselves PIH. for a are abut sourceSometimes the source of PIH. these of their individuals informationbut the sourceattempt is deficient—for of to their be well information informed, example, is deficient—for example, gentlegentle introduction introduction to to topical topical care care must must be be balanced balanced with with the the Sometimes these individuals attempt to be well informed, gentleWhen introduction acne is severe, to topical promptWhen care clearing acne must is be severe, of balanced lesions prompt is with neces- clearing the ofbutInternet lesions the source sites is neces- and of their blogs informationInternet that are opinion-richsites is deficient—for and blogs and that fact-poor, example, are opinion-rich and fact-poor, knowledge that acne lesions themselves are a source of PIH. but the source of their information is deficient—for example, saryknowledge to avoid that lesion-related acne lesionssary themselves toPIH, avoid so such lesion-relatedare a asource slow, of stepwise PIH.PIH, so suchInternetresultingInternet a slow, sites sites stepwise in the and and dissemination blogs blogsresulting that that are are of opinion-rich opinion-rich in incorrect the dissemination notions and and fact-poor, fact-poor, and of the incorrect notions and the When acne is severe, prompt clearing of lesions is neces- Internet sites and blogs that are opinion-rich and fact-poor, approachWhen acne to topical is severe, therapyapproach prompt may clearing not to topical be advisable oflesions therapy as is may mono- neces- not be advisableresultingperpetuationresulting as in in mono- the the of myths. dissemination dissemination Parentalperpetuation of of fears incorrect incorrect of arising myths. notions notions from Parental misinfor- and and fears the the arising from misinfor- sarysary to to avoid avoid lesion-related lesion-related PIH, PIH, so so such such a a slow, slow, stepwise stepwise resulting in the dissemination of incorrect notions and the therapy.sary to avoid In such lesion-related cases,therapy. it may PIH, be In so prudent such such cases, a toslow, initiate it may stepwise oral be prudentperpetuationmation to initiate can interfere of oral myths. with Parentalmation the appropriate can fears interfere arising treatment with from the misinfor- of appropriate ado- treatment of ado- approachapproach to to topical topical therapy therapy may may not not be be advisable advisable as as mono- mono- perpetuation of myths. Parental fears arising from misinfor- therapyapproach earlier to topical than one therapytherapy might may have earlier not ordinarily. be than advisable one Acne might as surgery mono- have ordinarily.mationlescents Acne can with surgery interfere moderate with tolescents severe the appropriate with acne. moderate Countering treatment to severe the of effects ado- acne. Countering the effects therapy.therapy. In In such such cases, cases, it it may may be be prudent prudent to to initiate initiate oral oral mation can interfere with the appropriate treatment of ado- istherapy. useful In for such eradicating cases,is it closed useful may be and for prudent eradicating open comedones, to initiate closed oral butand openlescentsoflescents comedones, erroneous with with moderatenotions moderate but and to toof severe severebeliefs erroneous acne. acne. requires notions Countering Countering a great and dealbeliefs the the effects effectsof pa-requires a great deal of pa- therapytherapy earlier earlier than than one one might might have have ordinarily. ordinarily. Acne Acne surgery surgery lescents with moderate to severe acne. Countering the effects overlytherapy aggressive earlier than extraction oneoverly might can haveaggressive cause ordinarily. long-lasting extraction AcnePIH. surgerycan cause In long-lastingoftience, erroneous discussion, PIH. notions In and and education.tience, beliefs discussion, requires a and great education. deal of pa- isis useful useful for for eradicating eradicating closed closed and and open open comedones, comedones, but but of erroneous notions and beliefs requires a great deal of pa- patientsis useful with forskin eradicating of color,patients closed anecdotal with and experience skin open of comedones, color, shows anecdotal that but 1 experiencetience,tience, shows discussion, discussion, that 1 and and education. education. overly aggressive extraction can cause long-lasting PIH. In tience, discussion, and education. monthoverly aggressive of treatment extraction withmonth topical can of retinoids cause treatment long-lasting prior with to topical acne PIH. sur- retinoids In Tanning prior to acne sur- Tanning patients with skin of color, anecdotal experience shows that 1 gerypatients is beneficial. with skin Comedonesof color,gery anecdotal is are beneficial. more experience easily Comedones extracted shows are that with more 1 easily extracted with month of treatment with topical retinoids prior to acne sur- TanningArtificialTanning and natural sunlightArtificial may and improve natural the sunlight appearance may improve of the appearance of lessmonth pigment-producing of treatment withless trauma. topical pigment-producing retinoids prior totrauma. acne sur- Tanning gerygery is is beneficial. beneficial. Comedones Comedones are are more more easily easily extracted extracted with with Artificialacne temporarily. and natural Tan sunlight skinacne provides temporarily. may improve some Tancamouflage the skin appearance provides for the of some camouflage for the geryHyperpigmentation is beneficial. Comedones oftenHyperpigmentation is moreare more of a easilyproblem extracted often for ispatients more with of a problemArtificial for and patients natural sunlight may improve the appearance of lessless pigment-producing pigment-producing trauma. trauma. acnerednessacne temporarily. temporarily. of acne lesions. Tan Tan skin skinredness In providesprovides addition, of acne some some as it lesions. camouflage iscamouflage a crude In addition, form for for the the of as it is a crude form of thanless pigment-producing is acne itself. Treatmentthan trauma. is options acne itself. for PIH Treatment include optionshydro- for PIHacne include temporarily. hydro- Tan skin provides some camouflage for the Hyperpigmentation often is more of a problem for patients rednesslightredness therapy, of of acne acne sun lesions. lesions. exposurelight In In addition, addition, may therapy, also as asresult sun it it is exposureis in a a crude ancrude short-term may form form also of of result in an short-term quinones,Hyperpigmentation topical retinoids, oftenquinones, and is more multiple topical of a problem types retinoids, of for cosmeceu- and patients multiple typesredness of cosmeceu- of acne lesions. In addition, as it is a crude form of thanthan is is acne acne itself. itself. Treatment Treatment options options for for PIH PIH include include hydro- hydro- lightimprovementlight therapy, therapy, sun sunin lesions, exposure exposureimprovement and may may the also also observation result result in lesions, in in an an that short-term andshort-term sunlight the observation that sunlight ticalthan products. is acne itself.5-7 Chemical Treatmenttical peels products. options8 and forlaser5-7 PIHChemical and include light peels therapy hydro-8 and9 laserlight and light therapy, therapy sun9 exposure may also result in an short-term quinones, topical retinoids, and multiple types of cosmeceu- improvementimprovesimprovement acne in in is lesions, lesions, not lostimproves and and on the the patients. acne observation observation is In not colder lost that that climates, on sunlight sunlight patients. In colder climates, quinones, topical5-75-7 retinoids, and88 multiple types of cosmeceu-99 improvement in lesions, and the observation that sunlight ticalcantical be products. products. effective5-7 butChemical mustcan be peels be approached effective8 andand laser laser but cautiously and and must light light be therapy therapyto approached avoid9 cautiouslyimprovessomeimproves patients to acne acne avoid prolong is is not not lost losttheirsome on on suntans patients patients. patients. by prolong using In In colder colder tanning their climates, climates, suntans beds. by using tanning beds. tical products.5-7 Chemical peels8 and laser and light therapy9 improves acne is not lost on patients. In colder climates, canfurthercan be be effective effective hyperpigmentation but but must mustfurther be be and approached approached hyperpigmentation the possibility cautiously cautiously of scarring. and to to avoid avoid the possibilitysomeUnfortunately,some of patients patients scarring. prolong prolong the temporary their theirUnfortunately, suntans suntans improvement by by the using using temporary in tanning tanning appearance beds. beds.improvement in appearance can be effective but must be approached cautiously to avoid some patients prolong their suntans by using tanning beds. furtherfurther hyperpigmentation hyperpigmentation and and the the possibility possibility of of scarring. scarring. Unfortunately,makes it difficult the for temporary cliniciansmakes itimprovement to difficult convince for patients inclinicians appearance of to the convince patients of the further hyperpigmentation and the possibility of scarring. Unfortunately, the temporary improvement in appearance makeslong-term it difficult skin damage for clinicianslong-term associated to skin withconvince damage ultraviolet patients associated light of theex- with ultraviolet light ex- Preadolescent PatientsPreadolescent Patients makes it difficult for clinicians to convince patients of the long-termposure.long-term skin skin damage damageposure. associated associated with with ultraviolet ultraviolet light light ex- ex- PreadolescentItPreadolescent is common for Patients preadolescents PatientsIt is common and for early preadolescents adolescent pa- and earlylong-term adolescent skin pa- damage associated with ultraviolet light ex- Preadolescent Patients posure. Ittients—particularlyIt is is common common for for preadolescents preadolescents girls—totients—particularly seek treatmentand and early early girls—to for adolescent adolescent “blemishes” seek pa- pa- treatmentposure. for “blemishes” It is common for preadolescents and early adolescent pa- Culture, Doctors, Culture, Doctors, tients—particularlyrathertients—particularly than acne itself. girls—to girls—torather Many seek seek thanare treatment treatmentnoncompliant acne itself. for for Many“blemishes” “blemishes” with are acne noncompliant with acne tients—particularly girls—to seek treatment for “blemishes” rathertreatmentrather than than regimens acne acne itself. itself. becausetreatment Many Many they are are areregimens noncompliant noncompliant more concernedbecause with with they acnewith acne are moreCulture,andCulture, concerned Medication Doctors, Doctors, with Adherenceandand Medication Medication Adherence Adherence rather than acne itself. Many are noncompliant with acne Culture, Doctors, treatmentthetreatment appearance regimens regimens of PIH. because becausethe It is appearance important they they are are more more to of stress PIH. concerned concerned It to is these important with with pa- to stressandIn a recent Medicationto these meta-analysis pa- AdherenceIn a of recent adherence meta-analysis of people of of adherence color of people of color treatment regimens because they are more concerned with and Medication Adherence thetientsthe appearance appearance that control of of PIH. ofPIH. acne,tients It It is is using important important that the control prescribed to to stress stress of acne, to to therapeutic these theseusing pa- pa- the prescribedInandIn a a language recent recent therapeutic meta-analysis meta-analysis diversitiesand to of of medications language adherence adherence diversities inof of general, people people to medicationsof of Manias color color in general, Manias the appearance of PIH. It is important to stress to these pa- In a recent meta-analysis of adherence of people of color tientsregimens,tients that that will control control decrease of of acne, acne, theregimens, usingamount using the the will of prescribed prescribed PIHdecrease in the the therapeutic therapeutic future amount as it of PIHandand in the languageWilliams language future10 as diversities diversitiesfailed it toand identifyto to medications medicationsWilliams any10 factorsfailed in in general, general, that to identify would Manias Manias beany factors that would be tients that control of acne, using the prescribed therapeutic and language diversities to medications in general, Manias decreases new lesion formation.decreases Meanwhile, new lesion the formation. offer of treat- Meanwhile,helpful the offer in of improving treat-1010 adherencehelpful in to improving medication adherence regimens to medication regimens regimens,regimens, will will decrease decrease the the amount amount of of PIH PIH in in the the future future as as it it andand Williams Williams10 failedfailed to to identify identify any any factors factors that that would would be be mentregimens, of PIH will often decrease helps thement promote amount of PIH adherence of often PIH helps in to the acne promote future therapy. as adherence it andamong to Williamsacne these therapy. populations.failed toamong identify Thus, these any it is populations. factors up to thethat clinician’s would Thus, be it is up to the clinician’s decreases new lesion formation. Meanwhile, the offer of treat- helpful in improving adherence to medication regimens decreasesThe data new are lesionsparse formation.on specificThe data treatments Meanwhile, are sparse for the on acne offer specific in younger of treat- treatments forawarenesshelpful acne in in younger and improving sensitivity adherenceawareness to work toand with medication sensitivity individual toregimens patients work with individual patients ment of PIH often helps promote adherence to acne therapy. amongamong these these populations. populations. Thus, Thus, it it is is up up to to the the clinician’s clinician’s patientsment of PIHwith often skin ofhelps color,patients promote but it with adherenceis reasonable skin of to color, acneto extrapolate but therapy. it is reasonableandamong totheir extrapolate these families. populations.and Thus, their families. it is up to the clinician’s The data are sparse on specific treatments for acne in younger awarenessS14awareness and and sensitivity sensitivity to to work work with with individual individual patients patients H.E. Baldwin et al fromThe efficacy data are and sparse safety on studies specificfrom efficacy that treatments included and safety for patients acne studies in betweenyounger that includedawareness patientsSome patients between and sensitivity distrust authority,Some to work patients with in general; individual distrust others authority, patients have a in general; others have a patients with skin of color, but it is reasonable to extrapolate andand their their families. families. 12patients and 17 with years skin of ageof color, with12 similarand but 17it is skin years reasonable colors. of age with to extrapolate similar skin colors.particularand their families.bias against doctorsparticular whose bias cultural against or doctors racial whoseback- cultural or racial back- fromfrom efficacy efficacy and and safety safety studies studies that that included included patients patients between between Some patients distrust authority, in general; others have a from efficacy and safety studies that included patients between groundsSome patients are dissimilar distrust to authority, their own. in It general; is likely others that derma- have a pharmacologic treatment, because they have a more im- Effects of nonclinical issues on acne treatment 12 and 17 years of age with similar skin colors. S13 particular bias against doctors whose cultural or racial back- 12 and 17 years of age with similar skin colors. particulartologists see bias this against more doctors than clinicians whose cultural in other or racial specialties back- mediate effect on appearance. because racial differences are readily apparent. It often be- Physical scarring is a tendency that is unique to the indi- In a study of acne in African American women, Halder and Acne-Related Scarring Scarring hooves the clinician to address possible concerns in an open vidual. Furthermore, the severity of the lesions does not nec- 4 colleagues compared the clinical appearance of facial acne le- Acne can also be associated with keloidal scars in skin of and direct manner at the initial visit. essarily correlate with the risk for scarring. Some patients sions of all types (comedones, papules, pustules, hyperpig- color, with acne lesions often transforming almost impercep- At the other end of the spectrum are patients who embrace with very small papules and comedones develop “icepick” mented macules, and depressed scars) with histologic findings tibly into keloids. In some cases, the only indication that acne authority literally without question. In some cultures, asking scars, whereas some others with nodulocystic acne eventu- of 3-mm punch biopsies. The investigators found that the de- is the underlying cause of keloids is the distribution of the questions of an authority figure, such as a physician, is con- ally clear with no visible sequelae. It is not possible to predict gree of inflammation in all types of lesions was “marked and out lesions over the chest, back, upper arms, and jaw. In such sidered to be an insult. When dealing with such patients, it is which patients or which lesions will develop acne scars; how- of proportion” to their clinical appearance. This was not the case cases, aggressive therapy with isotretinoin might be war- incumbent on the physician to draw out questions during a ever, the more lesions occur, the greater the risk for scarring. in light-skinned individuals. According to the authors, this sug- ranted, even in younger adolescents. New acne/keloid lesion clinical encounter, or the patient may leave with inadequate Prompt, effective treatment is the best way to prevent scar- gests that acne vulgaris in African Americans is clinically and formation will stop and the keloids can subsequently be information or understanding of his or her condition or the ring. The development of scarring in a patient with acne histopathologically different from the disease found in Cauca- treated. prescribed treatment regimen. constitutes a cutaneous emergency and merits aggressive sians, which may explain why hyperpigmentation and scarring treatment to reduce the risk of further scarring.14,15 is more common in darker-skinned persons. Pediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdef 13 Folk Remedies No acne treatments have been identified as causal for PIH. Perceptions, Recent Evidence on Folk remedies for dermatologic and other conditions are However, the irritation associated with topical therapy can in- Customs, Habits, and Fads Mental Health and Suicide crease the risk of PIH in skin of color. To minimize irritation, commonly used, particularly by patients of Hispanic, Asian, 16 treatment of patients with skin of color should be approached Some patients and/or their parents hold the perception and and Caribbean descent. As many as 50% of inner-city pa- A recently published study by Halvorsen and colleagues with this in mind. Specifically, acute irritation from topical ben- belief that “natural” agents are superior to “drugs” in the tients use folk remedies on a regular basis, either as replace- provides evidence supporting the observation that suicidal zoyl peroxide and retinoid preparations should be avoided, if treatment of a variety of diseases, including acne vulgaris. In ments for or adjuncts to prescribed medications. These prac- ideation and mental health problems are increased in teen- possible. When initiating topical retinoid therapy, lower con- fact, the only such product on which there are even meager tices are often not mentioned and may interfere with the agers with acne. Of almost 5,000 adolescents enrolled in that centrations can be used, cream formulations rather than gels data regarding benefit in acne is tea-tree oil, which may be of intended treatment plan. The folk remedies may cause irrita- study, 14% self-identified as having substantial acne (de- utilized, and applications decreased to every other day. The minor benefit in mild acne. Patients who resist topical phar- tion and, thus, increase the risk for hyperpigmentation in scribed by study participants as “a lot” or “very much acne”). concentration of medication and frequency of application can macotherapy are often even more resistant to the use of oral patients of color, as well as decreasing the acceptance and use Suicidal ideation was reported more than twice as frequently be increased gradually, in a stepwise fashion. The need for a medications, which they perceive as dangerous. of topical medications that would otherwise be effective. by girls and more than three times as frequently in boys with gentle introduction to topical care must be balanced with the Sometimes these individuals attempt to be well informed, substantial acne than by the patients who reported no or little knowledge that acne lesions themselves are a source of PIH. but the source of their information is deficient—for example, acne. The study also demonstrated a strong association be- When acne is severe, prompt clearing of lesions is neces- Internet sites and blogs that are opinion-rich and fact-poor, Consequences of tween substantial acne and an increase in mental health prob- sary to avoid lesion-related PIH, so such a slow, stepwise resulting in the dissemination of incorrect notions and the Ineffective/Delayed Treatment lems, such as poor social interactions, lack of thriving in approach to topical therapy may not be advisable as mono- perpetuation of myths. Parental fears arising from misinfor- school, and increased bullying. This study supports a long history of experience with ad- therapy. In such cases, it may be prudent to initiate oral mation can interfere with the appropriate treatment of ado- Numerous articles have been published regarding the nega- olescents with acne and indicates that it would be appropri- therapy earlier than one might have ordinarily. Acne surgery lescents with moderate to severe acne. Countering the effects tive psychological impact of acne vulgaris. Layton and col- 11 ate for all clinicians to consider the psychological impact of is useful for eradicating closed and open comedones, but of erroneous notions and beliefs requires a great deal of pa- leagues showed that emotional scarring often persists into the disease. At the very least, clinicians should have a height- overly aggressive extraction can cause long-lasting PIH. In tience, discussion, and education. adulthood, long after acne has resolved, even in the absence ened awareness about and establish an informal assessment patients with skin of color, anecdotal experience shows that 1 of physical scarring. of the psychosocial impact of acne on each patient. Patients month of treatment with topical retinoids prior to acne sur- Tanning In addition to their medical benefits, interventions to im- prove appearance are important to patient comfort and qual- with severe acne (or any patients with acne, regardless of gery is beneficial. Comedones are more easily extracted with Artificial and natural sunlight may improve the appearance of 12 severity) who have any indication of mental health problems less pigment-producing trauma. ity of life. Dalgard et al showed that the appearance of the acne temporarily. Tan skin provides some camouflage for the may benefit from a more formal evaluation and possible Hyperpigmentation often is more of a problem for patients skin is important in social interactions, as well as having a redness of acne lesions. In addition, as it is a crude form of counseling. than is acne itself. Treatment options for PIH include hydro- crucial impact on self-image and self-worth. In current Amer- light therapy, sun exposure may also result in an short-term For many years, drugs like isotretinoin were implicated in quinones, topical retinoids, and multiple types of cosmeceu- ican culture, with society’s ongoing emphasis on beauty (if improvement in lesions, and the observation that sunlight increasing the risk of depression and suicidal ideations in tical products.5-7 Chemical peels8 and laser and light therapy9 not outright physical perfection), teenagers and even pread- improves acne is not lost on patients. In colder climates, patients with acne. The study by Halvorsen and col- can be effective but must be approached cautiously to avoid olescent patients may interpret acne as life-altering if not some patients prolong their suntans by using tanning beds. leagues16,17 supports the view of many clinicians that such further hyperpigmentation and the possibility of scarring. life-ending. Unfortunately, the temporary improvement in appearance problems in patients with acne exist exclusive of any thera- makes it difficult for clinicians to convince patients of the It has been well documented that acne is associated with social dysfunction—including decreased dating, participa- peutic intervention. As the authors of this study conclude: Preadolescent Patients long-term skin damage associated with ultraviolet light ex- “Adverse events including suicidal ideation and depression posure. tion in sports, and social interactions with peers—as well as It is common for preadolescents and early adolescent pa- having an adverse effect on academic performance.13 that have been associated with therapies for acne may reflect tients—particularly girls—to seek treatment for “blemishes” There is evidence that psychological problems caused the burden of substantial acne rather than the effects of med- rather than acne itself. Many are noncompliant with acne Culture, Doctors, by acne decrease with treatment and that identifying early ication.” This evidence should be communicated to patients treatment regimens because they are more concerned with and Medication Adherence acne and treating it improve quality of life.14 Several stud- and their parents when oral therapy—including isotreti- the appearance of PIH. It is important to stress to these pa- In a recent meta-analysis of adherence of people of color ies have shown that rapid improvement with treatment is noin—is indicated as a treatment of choice. tients that control of acne, using the prescribed therapeutic and language diversities to medications in general, Manias particularly important in the pediatric population. Thera- regimens, will decrease the amount of PIH in the future as it and Williams10 failed to identify any factors that would be peutic strategies that result in rapid improvement have the decreases new lesion formation. Meanwhile, the offer of treat- helpful in improving adherence to medication regimens greatest beneficial effect on the psychological well-being of Conclusion ment of PIH often helps promote adherence to acne therapy. among these populations. Thus, it is up to the clinician’s patients with acne. For example, acne surgery and injec- Acne is commonly associated with postinflammatory hyper- The data are sparse on specific treatments for acne in younger awareness and sensitivity to work with individual patients tions of existing lesions can be helpful adjuncts to initial pigmentation in patients of color, which often can be more patients with skin of color, but it is reasonable to extrapolate and their families. from efficacy and safety studies that included patients between Some patients distrust authority, in general; others have a 12 and 17 years of age with similar skin colors. particular bias against doctors whose cultural or racial back- S14 H.E. Baldwin et al S14S14 H.E.H.E. Baldwin Baldwin et et al al grounds are dissimilar to their own. It is likely that derma- pharmacologic treatment, because they have a more im- grounds are dissimilar to their own. It is likely that derma- pharmacologic treatment, because they have a more im- tologistsgrounds seearedissimilar this more to than their clinicians own. It is in likely other that specialties derma- mediatepharmacologic effect on treatment, appearance. because they have a more im- tologists see this more than clinicians in other specialties mediate effect on appearance. becausetologists racial see this differences more than are readilyclinicians apparent. in other It specialties often be- mediatePhysical effect scarring on appearance. is a tendency that is unique to the indi- because racial differences are readily apparent. It often be- Physical scarring is a tendency that is unique to the indi- hoovesbecause the racial clinician differences to address are readilypossible apparent. concerns It in often an open be- vidual.Physical Furthermore, scarring is the a tendency severity of that the is lesions unique does to thenot indi-nec- hooves the clinician to address possible concerns in an open vidual.vidual. Furthermore, Furthermore, the the severity severity of of the the lesions lesions does does not not nec- nec- andhooves direct the manner clinician at to the address initial possiblevisit. concerns in an open essarilyvidual. Furthermore, correlate with the the severity risk for of scarring.the lesions Some does patientsnot nec- and direct manner at the initial visit. essarilyessarily correlate correlate with with the the risk risk for for scarring. scarring. Some Some patients patients andAt direct the other manner end of at the the spectrum initial visit. are patients who embrace withessarily very correlate small papules with the and risk comedones for scarring. develop Some “icepick” patients At the other end of the spectrum are patients who embrace with very small papules and comedones develop “icepick” authorityAt the other literally end without of the spectrum question. are In some patients cultures, who embrace asking scars,with very whereas small some papules others and with comedones nodulocystic develop acne “icepick” eventu- authority literally without question. In some cultures, asking scars,scars, whereas whereas some some others others with with nodulocystic nodulocystic acne acne eventu- eventu- questionsauthority literallyof an authority without figure, question. such In as some a physician, cultures, is asking con- allyscars, clear whereas with no some visible others sequelae. with Itnodulocystic is not possible acne to predicteventu- questions of an authority figure, such as a physician, is con- allyally clear clear with with no no visible visible sequelae. sequelae. It It is is not not possible possible to to predict predict sideredquestions to be of an insult. authority When figure, dealing such with as a such physician, patients, is con- it is whichally clear patients with noor which visible lesions sequelae. will It develop is not possible acne scars; to predict how- sidered to be an insult. When dealing with such patients, it is which patients or which lesions will develop acne scars; how- incumbentsidered to be on an the insult. physician When to dealing draw out with questions such patients, during it isa ever,which the patients more lesions or which occur, lesions the will greater develop the risk acne for scars; scarring. how- incumbent on the physician to draw out questions during a ever, the more lesions occur, the greater the risk for scarring. incumbent on the physician to draw out questions during a Prompt,ever, the effective more lesions treatment occur, is the the greater best way the torisk prevent for scarring. scar- clinical encounter, or the patient may leave with inadequate Prompt, effective treatment is the best way to prevent scar- clinicalclinical encounter, encounter, or or the the patient patient may may leave leave with with inadequate inadequate ring.Prompt, The effective development treatment of scarring is the best in away patient to prevent with acne scar- information or understanding of his or her condition or the ring. The development of scarring in a patient with acne informationinformation or or understanding understanding of of his his or or her her condition condition or or the the constitutesring. The development a cutaneous of emergency scarring in and a patientmerits aggressive with acne prescribed treatment regimen. constitutes a cutaneous emergency and merits aggressive prescribed treatment regimen. constitutes a cutaneous emergency and merits14,15 aggressive prescribed treatment regimen. treatment to reduce the risk of further scarring. 14,15 treatmenttreatment to to reduce reduce the the risk risk of of further further scarring. scarring.14,15 Folk Remedies FolkFolk Remedies Recent Evidence Evidence on on Mental Health FolkFolk remedies Remedies for dermatologic and other conditions are Recent Evidence on Folk remedies for dermatologic and other conditions are Recent Evidence on commonlyFolk remedies used, for particularly dermatologic by patients and other of Hispanic, conditions Asian, are Mentaland Suicide Health and Suicide commonlycommonly used, used, particularly particularly by by patients patients of of Hispanic, Hispanic, Asian, Asian, Mental Health and Suicide 16 andcommonly Caribbean used, descent. particularly As many by patients as 50% of of Hispanic, inner-city Asian, pa- A recently published study by Halvorsen and colleagues 16 and Caribbean descent. As many as 50% of inner-city pa- A recently published study by Halvorsen and colleagues 16 tientsand Caribbean use folk remedies descent. on As a many regular as basis, 50% either of inner-city as replace- pa- providesA recently evidence published supporting study by the Halvorsen observation and that colleagues suicidal tients use folk remedies on a regular basis, either as replace- provides evidence supporting the observation that suicidal mentstients usefor or folk adjuncts remedies to prescribed on a regular medications. basis, either These as replace- prac- ideationprovides and evidence mental supporting health problems the observation are increased that in suicidal teen- ments for or adjuncts to prescribed medications. These prac- ideationideation and and mental mental health health problems problems are are increased increased in in teen- teen- ticesments are for often or adjuncts not mentioned to prescribed and medications. may interfere These with prac- the agersideation with and acne. mental Of almost health 5,000 problems adolescents are increased enrolled in in teen- that tices are often not mentioned and may interfere with the agersagers with with acne. acne. Of Of almost almost 5,000 5,000 adolescents adolescents enrolled enrolled in in that that intendedtices are treatment often not plan. mentioned The folk and remedies may interfere may cause with irrita- the study,agers with 14% acne. self-identified Of almost 5,000 as having adolescents substantial enrolled acne in (de- that study,study, 14% 14% self-identified self-identified as as having having substantial substantial acne acne (de- (de- intendedintended treatment treatment plan. plan. The The folk folk remedies remedies may may cause cause irrita- irrita- scribedstudy, 14%by study self-identified participants as as having “a lot” or substantial “very much acne acne”). (de- tion and, thus, increase the risk for hyperpigmentation in scribedscribed by by study study participants participants as as “a “a lot” lot” or or “very “very much much acne”). acne”). tiontion and, and, thus, thus, increase increase the the risk risk for for hyperpigmentation hyperpigmentation in in Suicidalscribed by ideation studywas participants reported as more “a lot” than ortwice “very asmuch frequently acne”). patients of color, as well as decreasing the acceptance and use Suicidal ideation was reported more than twice as frequently patients of color, as well as decreasing the acceptance and use bySuicidal girls and ideation more wasthan reported three times more as thanfrequently twice asin frequentlyboys with of topical medications that would otherwise be effective. by girls and more than three times as frequently in boys with of topical medications that would otherwise be effective. substantialby girls and acne more than than by three the patients times as who frequently reported in no boys or little with of topical medications that would otherwise be effective. substantial acne than by the patients who reported no or little acne.substantial The study acne than also demonstratedby the patients a who strong reported association no or little be- acne. The study also demonstrated a strong association be- tweenacne. substantialThe studyalso acne demonstrated and an increase a in strong mental association health prob- be- Consequences of tween substantial acne and an increase in mental health prob- Consequences of lems,tween such substantial as poor acne social and an interactions, increase in lackmental of health thriving prob- in Consequences of of Ineffective/ lems, such as poor social interactions, lack of thriving in Ineffective/Delayed Treatment school,lems, such and increased as poor social bullying. interactions, lack of thriving in Ineffective/DelayedDelayed Treatment Treatment school,school, and and increased increased bullying. bullying. Numerous articles have been published regarding the nega- school,This study and increased supports bullying. a long history of experience with ad- Numerous articles have been published regarding the nega- This study supports a long history of experience with ad- tiveNumerous psychological articles impact have been of acne published vulgaris. regarding Layton the and nega- col- olescentsThis study with supports acne and a indicates long history that of it wouldexperience be appropri- with ad- tive psychological impact of acne vulgaris. Layton and col- olescents with acne and indicates that it would be appropri- leaguestive psychological11 showed that impact emotional of acne scarring vulgaris. often Layton persists and into col- ateolescents for all withclinicians acne toand consider indicates the that psychological it would be impact appropri- of leagues1111 showed that emotional scarring often persists into ateate for for all all clinicians clinicians to to consider consider the the psychological psychological impact impact of of adulthood,leagues11 showed long after that acne emotional has resolved, scarring even often in persiststhe absence into theate disease. for all clinicians At the very to least, consider clinicians the psychological should have impact a height- of adulthood, long after acne has resolved, even in the absence thethe disease. disease. At At the the very very least, least, clinicians clinicians should should have have a a height- height- ofadulthood, physical scarring. long after acne has resolved, even in the absence enedthe disease. awareness At the about very and least, establish clinicians an should informal have assessment a height- of physical scarring. enedened awareness awareness about about and and establish establish an an informal informal assessment assessment ofIn physical addition scarring. to their medical benefits, interventions to im- ofened the awareness psychosocial about impact and of establish acne on an each informal patient. assessment Patients In addition to their medical benefits, interventions to im- of the psychosocial impact of acne on each patient. Patients proveIn addition appearance to their are important medical benefits, to patient interventions comfort and to qual- im- withof the severe psychosocial acne (or impact any patients of acne with on each acne, patient. regardless Patients of prove appearance are important to patient comfort and qual- with severe acne (or any patients with acne, regardless of ityprove of life. appearance Dalgard are et al important12 showed to that patient the appearance comfort and of qual- the severity)with severe who acne have (or any any indication patients of with mental acne, health regardless problems of ity of life. Dalgard et al1212 showed that the appearance of the severity)severity) who who have have any any indication indication of of mental mental health health problems problems skinity of is life. important Dalgard in et social al12 showed interactions, that the as appearance well as having of the a mayseverity) benefit who from have a any more indication formal of evaluation mental health and problems possible skin is important in social interactions, as well as having a may benefit from a more formal evaluation and possible crucialskin is impact important on self-image in social andinteractions, self-worth. as In well current as having Amer- a counseling.may benefit from a more formal evaluation and possible crucial impact on self-image and self-worth. In current Amer- counseling.counseling. icancrucial culture, impact with on self-image society’s ongoing and self-worth. emphasis In current on beauty Amer- (if counseling.For many years, drugs like isotretinoin were implicated in ican culture, with society’s ongoing emphasis on beauty (if For many years, drugs like isotretinoin were implicated in notican outright culture, physical with society’s perfection), ongoing teenagers emphasis and on even beauty pread- (if increasingFor many the years, risk drugs of depression like isotretinoin and suicidal were implicated ideations in in increasingincreasing the the risk risk of of depression depression and and suicidal suicidal ideations ideations in in not outright physical perfection), teenagers and even pread- patientsincreasing with the acne.risk of The depression study byand Halvorsen suicidal ideations and col- in olescent patients may interpret acne as life-altering if not patients with acne. The study by Halvorsen and col- olescent patients may interpret acne as life-altering if not patients16,17 with acne. The study by Halvorsen and col- life-ending.olescent patients may interpret acne as life-altering if not leagues 16,17 supports the view of many clinicians that such life-ending. leaguesleagues16,17 supportssupports the the view view of of many many clinicians clinicians that that such such life-ending.It has been well documented that acne is associated with problemsleagues insupports patients with the view acne of exist many exclusive clinicians of any that thera- such It has been well documented that acne is associated with problems in patients with acne exist exclusive of any thera- socialIt has dysfunction—including been well documented decreased that acne dating, is associated participa- with peuticproblems intervention. in patients As with the acne authors exist of exclusive this study of conclude:any thera- social dysfunction—including decreased dating, participa- peutic intervention. As the authors of this study conclude: tionsocial indysfunction—including sports, and social interactions decreased with peers—asdating, participa- well as “Adversepeutic intervention. events including As the suicidal authors ideation of this study and depression conclude: tion in sports, and social interactions with peers—as well as “Adverse“Adverse events events including including suicidal suicidal ideation ideation and and depression depression havingtion in an sports, adverse and effect social on interactions academic performance. with peers—as13 well as that“Adverse have been events associated including with suicidal therapies ideation for acne and may depression reflect having an adverse effect on academic performance.1313 thatthat have have been been associated associated with with therapies therapies for for acne acne may may reflect reflect havingThere an is adverse evidence effect that on psychological academic performance. problems13 caused thethat burden have been of substantial associated acne with rather therapies than for the acne effects may of reflect med- There is evidence that psychological problems caused thethe burden burden of of substantial substantial acne acne rather rather than than the the effects effects of of med- med- byThere acne decrease is evidence with that treatment psychological and that problems identifying caused early ication.”the burden This of evidence substantial should acne ratherbe communicated than the effects to patients of med- by acne decrease with treatment and that identifying early ication.”ication.” This This evidence evidence should should be be communicated communicated to to patients patients by acne decrease with treatment and that identifying14 early andication.” their This parents evidence when should oral betherapy—including communicated to isotreti- patients acne and treating it improve quality of life. 14 Several stud- and their parents when oral therapy—including isotreti- acne and treating it improve quality of life. 14 Several stud- and their parents when oral therapy—including isotreti- iesacne have and shown treating that it improve rapid improvement quality of life. withSeveral treatment stud is- noin—is indicated as a treatment of choice. ies have shown that rapid improvement with treatment is noin—is indicated as a treatment of choice. particularlyies have shown important that rapid in the improvement pediatric population. with treatment Thera- is particularly important in the pediatric population. Thera- peuticparticularly strategies important that result in the in rapidpediatric improvement population. have Thera- the peutic strategies that result in rapid improvement have the greatestpeutic strategies beneficial that effect result on the in rapid psychological improvement well-being have the of Conclusion greatest beneficial effect on the psychological well-being of ConclusionConclusion patientsgreatest beneficialwith acne. effect For example, on the psychological acne surgery well-being and injec- of Acne is commonly associated with postinflammatory hyper- S14 patients with acne. For example, acne surgeryH.E. Baldwin and injec- et al EffectsAcne is of commonly nonclinical associated issues on acne with treatment postinflammatory hyper- S15 tionspatients of existing with acne. lesions For canexample, be helpful acne surgeryadjuncts and to initial injec- pigmentationAcne is commonly in patients associated of color, with which postinflammatory often can be hyper- more tionstions of of existing existing lesions lesions can can be be helpful helpful adjuncts adjuncts to to initial initial pigmentation in patients of color, which often can be more grounds are dissimilar to their own. It is likely that derma- pharmacologic treatment, because they have a more im- bothersome to patients than are the acne lesions that caused 6. Shah SK, Alexis AF: Acne in skin of color. J Dermatol Treat 21:206-211, the dyschromia. In skin of color, PIH can occur secondary to 2010 tologists see this more than clinicians in other specialties mediate effect on appearance. 7. Taylor SC, Cook-Bolden F, Rahman Z, Strachan D: Acne vulgaris in because racial differences are readily apparent. It often be- Physical scarring is a tendency that is unique to the indi- any acne lesion, even comedonal lesions with no clinical skin of color. J Am Acad Dermatol 46:S98-S106, 2002 (2 suppl) hooves the clinician to address possible concerns in an open vidual. Furthermore, the severity of the lesions does not nec- appearance of inflammation. 8. Roberts WE. Chemical peeling in ethnic/dark skin. Dermatol Ther 17: and direct manner at the initial visit. essarily correlate with the risk for scarring. Some patients Early and effective therapy, tailored not only to the acne 196-205, 2004 9. Terrell S, Aires D, Schweiger ES: Treatment of acne vulgaris using blue At the other end of the spectrum are patients who embrace with very small papules and comedones develop “icepick” severity but also to the level of psychological distress, is ex- tremely important. light photodynamic therapy in an African-American patient. J Drugs authority literally without question. In some cultures, asking scars, whereas some others with nodulocystic acne eventu- Dermatol 8:669-671, 2009 questions of an authority figure, such as a physician, is con- ally clear with no visible sequelae. It is not possible to predict In determining treatment regimens, clinicians must take 10. Manias E, Williams A: Medication adherence in people of culturally and sidered to be an insult. When dealing with such patients, it is which patients or which lesions will develop acne scars; how- into consideration the widely varying differences that exist linguistically diverse backgrounds: A meta-analysis. Ann Pharmacother 44:964-982, 2010 incumbent on the physician to draw out questions during a ever, the more lesions occur, the greater the risk for scarring. among patients of different ages and of different ethnic and cultural backgrounds. 11. Layton AM, Seukeran D, Cunliffe WJ: Scarred for life? Dermatology clinical encounter, or the patient may leave with inadequate Prompt, effective treatment is the best way to prevent scar- 195:15-21, 1997 (suppl 1) information or understanding of his or her condition or the ring. The development of scarring in a patient with acne 12. Dalgard F, Gieler U, Holm JØ, Bjertness E, Hauser S: Self-esteem prescribed treatment regimen. constitutes a cutaneous emergency and merits aggressive References and body satisfaction among late adolescents with acne: Results treatment to reduce the risk of further scarring.14,15 continued on page 23 from a population survey. J Am Acad Dermatol 59:746-751, 2008 1. Perkins A, Cheng C, Hillebrand G, Miyamoto K, Kimball A: Compari- 13. Krakowski AC, Stendardo S, Eichenfield LF: Practical considerations in son of the epidemiology of acne vulgaris among Caucasian, Asian, Folk Remedies 14 globalacademycme.com/sdef • Pediatric Acne Management: Optimizing Outcomes acne treatment and the clinical impact of topical combination therapy. Recent Evidence on Continental Indian, and African American women. J Eur Acad Derma- Pediatr Dermatol 25:1-14, 2008 (suppl 1) Folk remedies for dermatologic and other conditions are tol Venereol November 25, 2010 [Epub ahead of print] 14. Gollnick H, Cunliffe W, Berson D, et al: Management of acne: A report commonly used, particularly by patients of Hispanic, Asian, Mental Health and Suicide 2. Lucky AW: A review of infantile and pediatric acne. Dermatology 196: from a Global Alliance to improve outcomes in acne. J Am Acad Der- and Caribbean descent. As many as 50% of inner-city pa- A recently published study by Halvorsen and colleagues16 95-97, 1998 matol 49:S1-S38, 2003 provides evidence supporting the observation that suicidal 3. Halder RM, Brooks HL, Callender VD: Acne in ethnic skin. Dermatol 15. Layton AM: Optimal management of acne to prevent scarring and psy- tients use folk remedies on a regular basis, either as replace- Clin 21:609-615, 2003 ideation and mental health problems are increased in teen- chological sequelae. Am J Clin Dermatol 2:135-141, 2001 ments for or adjuncts to prescribed medications. These prac- 4. Halder RM, Holmes YC, Bridgeman-Shah S, Kligman AM: A clinico- 16. Halvorsen JA, Stern RS, Dalgard F, Thoresen M, Bjertness E, Lien L: tices are often not mentioned and may interfere with the agers with acne. Of almost 5,000 adolescents enrolled in that pathological study of acne vulgaris in black females [abstract]. J Invest Suicidal ideation, mental health problems, and social impairment are intended treatment plan. The folk remedies may cause irrita- study, 14% self-identified as having substantial acne (de- Dermatol 106:888, 1996 increased in adolescents with acne: A population-based study. J Invest tion and, thus, increase the risk for hyperpigmentation in scribed by study participants as “a lot” or “very much acne”). 5. Davis EC, Callender VD: A review of acne in ethnic skin: Pathogenesis, Dermatol 131:363-370, 2011 Suicidal ideation was reported more than twice as frequently clinical manifestations, and management strategies. J Clin Aesthet Der- 17. Misery L: Consequences of psychological distress in adolescents with patients of color, as well as decreasing the acceptance and use matol 3:24-38, 2010 acne [editorial]. J Invest Dermatol 131:290-292, 2011 of topical medications that would otherwise be effective. by girls and more than three times as frequently in boys with substantial acne than by the patients who reported no or little acne. The study also demonstrated a strong association be- Consequences of tween substantial acne and an increase in mental health prob- lems, such as poor social interactions, lack of thriving in Ineffective/Delayed Treatment school, and increased bullying. Numerous articles have been published regarding the nega- This study supports a long history of experience with ad- tive psychological impact of acne vulgaris. Layton and col- olescents with acne and indicates that it would be appropri- leagues11 showed that emotional scarring often persists into ate for all clinicians to consider the psychological impact of adulthood, long after acne has resolved, even in the absence the disease. At the very least, clinicians should have a height- of physical scarring. ened awareness about and establish an informal assessment In addition to their medical benefits, interventions to im- of the psychosocial impact of acne on each patient. Patients prove appearance are important to patient comfort and qual- with severe acne (or any patients with acne, regardless of ity of life. Dalgard et al12 showed that the appearance of the severity) who have any indication of mental health problems skin is important in social interactions, as well as having a may benefit from a more formal evaluation and possible crucial impact on self-image and self-worth. In current Amer- counseling. ican culture, with society’s ongoing emphasis on beauty (if For many years, drugs like isotretinoin were implicated in not outright physical perfection), teenagers and even pread- increasing the risk of depression and suicidal ideations in olescent patients may interpret acne as life-altering if not patients with acne. The study by Halvorsen and col- life-ending. leagues16,17 supports the view of many clinicians that such It has been well documented that acne is associated with problems in patients with acne exist exclusive of any thera- social dysfunction—including decreased dating, participa- peutic intervention. As the authors of this study conclude: tion in sports, and social interactions with peers—as well as “Adverse events including suicidal ideation and depression having an adverse effect on academic performance.13 that have been associated with therapies for acne may reflect There is evidence that psychological problems caused the burden of substantial acne rather than the effects of med- by acne decrease with treatment and that identifying early ication.” This evidence should be communicated to patients acne and treating it improve quality of life.14 Several stud- and their parents when oral therapy—including isotreti- ies have shown that rapid improvement with treatment is noin—is indicated as a treatment of choice. particularly important in the pediatric population. Thera- peutic strategies that result in rapid improvement have the greatest beneficial effect on the psychological well-being of Conclusion patients with acne. For example, acne surgery and injec- Acne is commonly associated with postinflammatory hyper- tions of existing lesions can be helpful adjuncts to initial pigmentation in patients of color, which often can be more Approach to Pediatric Acne Treatment: An Update Albert C. Yan, MD,* Hilary E. Baldwin, MD,† Lawrence F. Eichenfield, MD,‡ Sheila Fallon Friedlander, MD,§ and Anthony J. Mancini, MD¶

ApproachBy late adolescence, to Pediatric almost all individuals Acne have experiencedTreatment: some degree An of acne. Update A broad range of acne treatments has been shown to be safe and effective in adults. While still sparse, emerging data now also document similar safety and efficacy of these agents for Approach to Pediatric Acne Treatment:children > An12 years Update of age. For younger children with preadolescent acne, where data are Approachmore limitedto Pediatric or unavailable, it seems Acne reasonable Treatment: to extrapolate from the findings An of studies Update † Albert C. Yan, MD,* Hilary‡ E. Baldwin, MD,† Lawrence F. Eichenfield, MD,‡ Albert C. Yan, MD,* Hilary E. Baldwin, MD, Lawrence F. Eichenfield,involving older MD, children >12 years of age.† This article reviews the latest evidence‡ and § AlbertSheila C. Yan, F¶allon MD,* Friedlander, Hilary E. M Baldwin,D,§ and Anthony MD, J.Lawrence Mancini, M F.D¶ Eichenfield, MD, Sheila Fallon Friedlander, MD, and Anthony J. Mancini, MD current expert opinions§ on acne therapies in the pediatric age group.¶ SheilaApproach FallonSemin Friedlander, to Cutan Pediatric Med MD, Surg 30:S16-S21and Anthony Acne © 2011 J. Elsevier Mancini, Treatment: Inc. All MD rights reserved. An Update † ‡ By late adolescence, almost all individuals have experiencedAlbert C. some Yan, degree MD,* of Hilary acne. A broad E. Baldwin, MD, Lawrence F. Eichenfield, MD, By late adolescence, almost§ all individuals have experienced some¶ degree of acne. A broad range of acne treatments has been shown to beSheila safe and Fallon effective Friedlander, in adults. While MD, still and Anthony J. Mancini, MD range of acne treatments has been shown to be safe and effective in adults. While still sparse, emerging data now also document similar safety and efficacy of these agents for cne is a nearly universal phenomenon typically affecting sparse, emerging data now also document similar safety and efficacy of these agents for children >12 years of age. For younger children with preadolescent acne, where data are American children between the ages of 12 and 17 years childrenBy late adolescence,>12 years of almost age. For all individuals younger children have experiencedA with preadolescent some degree acne, of where acne. data A broad are more limited or unavailable, it seems reasonable to extrapolate from the findings of studies 1 rangemore limited of acne or treatments unavailable, has it seems been shown reasonable to beof to safe age. extrapolate andGiven effective fromthis high the in findings adults. prevalence, While of studies it stillis not surprising then involving older children >12 years of age. This article reviews the latest evidence and sparse,involving emerging older children data now>12 also years document of age. similar Thisthat article safety the 2005 reviews and report efficacy the on latest ofThe these Burden evidence agents of Skin and for Diseases estimated current expert opinions on acne therapies in the pediatric age group. childrencurrent expert>12 years opinions of age. on acneFor younger therapies children in thethat with pediatric total preadolescent direct age group. costs acne, associated where with data the are treatment of acne Semin Cutan Med Surg 30:S16-S21 © 2011 Elsevier Inc. All rights reserved. *Chief, Pediatric Dermatology,moreSemin limited Cutan Children’s or Med unavailable, Hospital Surg of 30:S16-S21 Philadelphia, it seems Associ- ©reasonable 2011 Elseviervulgaris to extrapolate Inc. in All the rights Unitedfrom thereserved. States findings exceeded of studies $2.2 billion, including ate Professor, Pediatricsinvolving and Dermatology older children Perelman>12 School years of Medicine of age. Thisthe article substantial reviews costs the of latest both evidence over-the-counter and and prescrip- at the University ofcurrent Pennsylvania, expert Philadelphia, opinions PA on acne therapies in thetion pediatric products. age1 group. †Associatecne is Professor a nearly andSemin universal Vice Cutan Chair, phenomenon Department Med Surg of 30:S16-S21typically Dermatology, affecting © SUNY 2011 ElsevierAcne Inc. vulgaris All rights is traditionallyreserved. managed with a variety of Downstate, Brooklyn, NY cne is a nearly universal phenomenon typically affecting American children between the ages of 12 and 17 years A‡Clinical Professor of Pediatrics and Medicine (Dermatology), Chief, Pedi- topicalAmerican and systemic children medications between the (Table agesof 1), 12 as and well 17 as years acne of age.1 Given this high prevalence, it is not surprising then A atric and Adolescent Dermatology, Children’s Hospital San Diego, Uni- ofsurgery age.1 Given techniques. this high Although prevalence, the disease it is not is surprising commonly then en- thatversity the 2005 of California, report San on DiegoThe Burden School of of Medicine, Skin Diseases San Diego,estimated CA thatcountered thecne 2005 is a by nearly reportpediatric universal on specialists,The Burden phenomenon other of Skin primary Diseases typically careestimated affecting practi- that§Clinical total Professor direct of costs Pediatrics associated and Medicine, with Dermatology,the treatment University of acne of thatAtioners,American total and direct dermatologists, children costs associated between it is the withinteresting ages the of treatment 12 to noteand 17 that of years acne dif- California, San Diego, Rady Childrens Hospital, San Diego, CA *Chief, Pediatric Dermatology, Children’s Hospital of Philadelphia, Associ- vulgaris in the United States exceeded $2.2 billion, including offerences age.1 Given in prescribing this high prevalence, practices it have is not been surprising described then *Chief,¶Professor Pediatric of Pediatrics Dermatology, and Dermatology, Children’s Hospital Northwestern of Philadelphia, University’s Associ- Fein- vulgaris in the United States exceeded $2.2 billion, including ate Professor, Pediatrics and Dermatology Perelman School of Medicine the substantial costs of both over-the-counter and prescrip- ateberg Professor, School of Pediatrics Medicine, and Head, Dermatology Division of Perelman Pediatric School Dermatology, of Medicine Chil- thatbetween the 2005 different report practitioners. on The Burden In oneof Skin analysis Diseases of nationallyestimated at the University of Pennsylvania, Philadelphia, PA 1 the substantial costs of both over-the-counter and prescrip- tionatdren’s products. the University Memorial ofHospital, Pennsylvania, Chicago, Philadelphia, IL PA thatrepresentative total direct1 data costs regarding associated the with prescribing the treatment patterns of of acne pe- †Associate Professor and Vice Chair, Department of Dermatology, SUNY tion products. †AssociatePublicationAcne vulgaris Professor of this CME andis article traditionally Vice was Chair, jointly Department sponsored managed byof with theDermatology, University a variety of SUNY Lou- of vulgaris in the United States exceeded $2.2 billion,2 including Downstate, Brooklyn, NY *Chief, Pediatric Dermatology, Children’s Hospital of Philadelphia, Associ- diatriciansAcne vulgaris and dermatologists, is traditionally Yentzer managed et al withfound a variety that der- of Downstate,isville Continuing Brooklyn, Health NY Sciences Education and Skin Disease Education ‡Clinical Professor of Pediatrics and Medicine (Dermatology), Chief, Pedi- topicalate Professor, and systemic Pediatrics medications and Dermatology (Table Perelman 1), School as well of Medicine as acne thematologists substantial prescribe costs of topical bothretinoids over-the-counter most, followed and prescrip- by top- ‡ClinicalFoundation Professor and of supported Pediatrics by and an educational Medicine (Dermatology), grant from Johnson Chief, & Pedi-John- topical and systemic medications (Table 1), as well as acne atric and Adolescent Dermatology, Children’s Hospital San Diego, Uni- surgeryat the University techniques. of Pennsylvania, Although Philadelphia, the disease PA is commonly en- tionical products. clindamycin,1 oral minocycline, and topical benzoyl atricson Consumer and Adolescent & Personal Dermatology, Products Children’s Worldwide Hospital Division San of Diego, Johnson Uni- & surgery techniques. Although the disease is commonly en- versity of California, San Diego School of Medicine, San Diego, CA †Associate Professor and Vice Chair, Department of Dermatology, SUNY counteredversityJohnson of Consumer byCalifornia, pediatric Companies, San Diegospecialists, Inc. School of other Medicine, primary San Diego, care practi- CA peroxideAcne vulgaris (BP) for is the traditionally treatment of managed acne. Pediatricians with a variety rely on of §Clinical Professor of Pediatrics and Medicine, Dermatology, University of Downstate, Brooklyn, NY countered by pediatric specialists, other primary care practi- §Clinicaltioners,Albert C. ProfessorYan, and MD, dermatologists, hasof Pediatrics no relevant and financial it Medicine, is interesting relationships Dermatology, to with note Universityany that commer- dif- of topicalBP most, and followed systemic by medications topical clindamycin, (Table 1), topical as well tretinoin, as acne California, San Diego, Rady Childrens Hospital, San Diego, CA ‡Clinical Professor of Pediatrics and Medicine (Dermatology), Chief, Pedi- tioners, and dermatologists, it is interesting to note that dif- California,cial interests. San Diego, Rady Childrens Hospital, San Diego, CA ¶Professor of Pediatrics and Dermatology, Northwestern University’s Fein- ferencesatric and in Adolescent prescribing Dermatology, practices Children’s have Hospital been San describedDiego, Uni- surgeryand oral techniques. erythromycin Although (Table 2). the There disease appears is commonly to be consid- en- ¶ProfessorHilary E. Baldwin, of Pediatrics MD, and has Dermatology, served as a consultant Northwestern and speakerUniversity’s forAller- Fein- ferences in prescribing practices have been described berg School of Medicine, Head, Division of Pediatric Dermatology, Chil- betweenversity of different California, practitioners. San Diego School In of one Medicine, analysis San of Diego, nationally CA counterederable overlap by pediatric in terms specialists, of employment other of primary retinoids, care BP, practi- top- berggan, School Galderma, of Medicine, Medicis, Head, and Onset. Division She of Pediatric has also Dermatology, been a speaker Chil- for between different practitioners. In one analysis of nationally dren’s Memorial Hospital, Chicago, IL §Clinicalrepresentative Professor data of Pediatrics regarding and Medicine,the prescribing Dermatology, patterns University of pe- of tioners, and dermatologists, it is interesting to note that dif- dren’sGlaxoSmithKline Memorial Hospital, and Ortho Chicago, Dermatologics. IL ical clindamycin, as well as fixed combination topical prod- Publication of this CME article was jointly sponsored by the University of Lou- California, San Diego, Rady Childrens Hospital, San2 Diego, CA representative data regarding the prescribing patterns of pe- PublicationdiatriciansLawrence F. of Eichenfield, thisand CME dermatologists, article MD, was has jointly served Yentzer sponsored as an investigator et by al thefound University for that Galderma, of der- Lou- ferencesucts such inas BP prescribing� clindamycin practices and BP have� erythromycin.2 been described Both isville Continuing Health Sciences Education and Skin Disease Education ¶Professor of Pediatrics and Dermatology, Northwestern University’s Fein- diatricians and dermatologists, Yentzer et al found that der- matologistsisvilleGlaxoSmithKline, Continuing prescribe Health Johnson topical Sciences & Johnson, retinoids Education Neutrogena, most, and Skin followed and Disease Stiefel. Education by He top- has between different practitioners. In one analysis of nationally Foundation and supported by an educational grant from Johnson & John- berg School of Medicine, Head, Division of Pediatric Dermatology, Chil- matologistsgroups of practitioners prescribe topical utilize retinoids BP equally, most, followed with this by agent top- Foundationalso been consultant and supported and/or by served an educational on the advisory grant from board Johnson for Coria & John- and son Consumer & Personal Products Worldwide Division of Johnson & icaldren’s clindamycin, Memorial Hospital, oral Chicago, minocycline, IL and topical benzoyl representativerepresenting about data regarding 11% of prescriptions the prescribing for patterns dermatologists of pe- sonGalderma, Consumer GlaxoSmithKline, & Personal Products Intendis, Worldwide Medicis, Division Ortho Dermatologics, of Johnson & ical clindamycin, oral minocycline, and topical benzoyl Johnson Consumer Companies, Inc. Publicationperoxide of (BP) this CMEfor the article treatment was jointly of sponsored acne. Pediatricians by the University rely of Lou- on diatriciansand 17% for and pediatricians. dermatologists, Yentzer et al2 found that der- JohnsonStiefel, and Consumer Valeant. Companies, Inc. peroxide (BP) for the treatment of acne. Pediatricians rely on Albert C. Yan, MD, has no relevant financial relationships with any commer- BPisville most, Continuing followed Health by topical Sciencesclindamycin, Education and Skin topical Disease tretinoin, Education AlbertSheila C. F. Yan, Friedlander, MD, has MD,no relevant has served financial on an relationships advisory board with anyfor Galderma commer- matologistsHowever, prescribe there are topical some distinct retinoids differences most, followed in prescribing by top- cial interests. Foundation and supported by an educational grant from Johnson & John- BP most, followed by topical clindamycin, topical tretinoin, andcialand oral interests. Onset. erythromycin (Table 2). There appears to be consid- icalpatterns. clindamycin, Althoughretinoids oral minocycline, have demonstrated and topical good benzoyl efficacy Hilary E. Baldwin, MD, has served as a consultant and speaker for Aller- son Consumer & Personal Products Worldwide Division of Johnson & and oral erythromycin (Table 2). There appears to be consid- HilaryerableAnthony E. overlap J.Baldwin, Mancini, in MD, MD,terms has FAAP, served of employment has as served a consultant as a of consultant andretinoids, speaker for Galderma,BP, for Aller- top- peroxide (BP) for the treatment of acne. Pediatricians rely on gan, Galderma, Medicis, and Onset. She has also been a speaker for Johnson Consumer Companies, Inc. erablefor comedonal overlapin asterms well as of mildly employment inflammatory of retinoids, acne and BP, repre- top- gan,Medicis, Galderma, and Stiefel. Medicis, He has and also Onset. been Shea speaker has also for Galderma.been a speaker for GlaxoSmithKline and Ortho Dermatologics. Albertical clindamycin, C. Yan, MD, has as no well relevant as financial fixed combination relationships with topical any commer- prod- BPsent most, about followed 46% of prescribed by topical acne clindamycin, products among topical dermatolo- tretinoin, CorrespondingGlaxoSmithKline author: and Albert Ortho C. Dermatologics. Yan, MD, Chief, Pediatric Dermatology, ical clindamycin, as well as fixed combination topical prod- Lawrence F. Eichenfield, MD, has served as an investigator for Galderma, uctscial such interests. as BP � clindamycin and BP � erythromycin. Both andgists, oral retinoids erythromycin represent (Table only 2). about There 12% appears of pediatrician-pre- to be consid- LawrenceChildren’s F. Eichenfield, Hospital of MD, Philadelphia, has served Associate as an investigator Professor, forPediatrics Galderma, and ucts such as BP � clindamycin and BP � erythromycin. Both GlaxoSmithKline, Johnson & Johnson, Neutrogena, and Stiefel. He has Hilarygroups E. Baldwin,of practitioners MD, has served utilize as a BP consultant equally, and with speaker this for agent Aller- Approach to pediatric2 acne treatment S17 GlaxoSmithKline,Dermatology Perelman Johnson School & Johnson, of Medicine Neutrogena, at the University and Stiefel. of Pennsyl- He has erablescribed overlap agents. inGiven terms that of employment pediatricians of likely retinoids, manage BP, a large top- also been consultant and/or served on the advisory board for Coria and gan, Galderma, Medicis, and Onset. She has also been a speaker for groups of practitioners utilize BP equally, with this agent representingalsovania, been Philadelphia, consultant about PA. and/or11% E-mail: of served prescriptions [email protected] on the advisory for board dermatologists for Coria and icalcohort clindamycin, of patients as with well comedonal as fixed combination and mildly topical inflammatory prod- Galderma, GlaxoSmithKline, Intendis, Medicis, Ortho Dermatologics, GlaxoSmithKline and Ortho Dermatologics. representing about 11% of prescriptions for dermatologists andGalderma, 17% for GlaxoSmithKline, pediatricians. Intendis, Medicis, Ortho Dermatologics, � � Table 2 Most Frequently Prescribed Medications by Specialty Stiefel, and Valeant. Lawrence F. Eichenfield, MD, has served as an investigator for Galderma, uctsandacne, 17%such these foras data BP pediatricians. suggestclindamycin that topical and retinoids BP erythromycin. may be somewhat Both Stiefel, and Valeant. Sheila F. Friedlander, MD, has served on an advisory board for Galderma However,GlaxoSmithKline, there Johnson are some & Johnson, distinct Neutrogena, differences and in Stiefel. prescribing He has groupsunderutilized of practitioners by pediatricians utilize for BP acne equally, management. with this The agent de- Sheila F. Friedlander, MD, has served on an advisory board for Galderma However, there are some distinct differences in prescribing Pediatricians Dermatologists and Onset. patterns.S16also1085-5629/11/$-see been Although consultant retinoids and/or front served matter have on ©demonstrated the 2011 advisory Elsevier board Inc. good for All Coria efficacyrights and reserved. representingcreased ratesof about topical 11% retinoid of prescriptions utilization among for dermatologists pediatricians and Onset. patterns. Although retinoids have demonstrated good efficacy Anthony J. Mancini, MD, FAAP, has served as a consultant for Galderma, Galderma,doi:10.1016/j.sder.2011.07.004 GlaxoSmithKline, Intendis, Medicis, Ortho Dermatologics, Benzoyl peroxide Adapalene Anthonyfor comedonal J. Mancini, as MD, well FAAP, as mildly has served inflammatory as a consultant acne for and Galderma, repre- andhave 17% been for attributed pediatricians. to a heightened sensitivity to potential ad- Medicis, and Stiefel. He has also been a speaker for Galderma. Stiefel, and Valeant. for comedonal as well as mildly inflammatory acne and repre- Clindamycin Tretinoin sentMedicis, about and 46% Stiefel. of prescribed He has also acne been productsa speaker for among Galderma. dermatolo- verseHowever, effects or there less are familiarity some distinct with topical differences retinoids. in prescribing Corresponding author: Albert C. Yan, MD, Chief, Pediatric Dermatology, Sheila F. Friedlander, MD, has served on an advisory board for Galderma sent about 46% of prescribed acne products among dermatolo- Tretinoin Clindamycin Corresponding author: Albert C. Yan, MD, Chief, Pediatric Dermatology, Children’s Hospital of Philadelphia, Associate Professor, Pediatrics and gists,and retinoids Onset. represent only about 12% of pediatrician-pre- patterns.In addition Although to retinoidsthe selection have ofdemonstrated appropriate good therapeutic efficacy Erythromycin Minocycline Children’s Hospital2 of Philadelphia, Associate Professor, Pediatrics and gists, retinoids represent only about 12% of pediatrician-pre- Dermatology Perelman School of Medicine at the University of Pennsyl- Anthonyscribed J.agents. Mancini,Given MD, FAAP, that pediatricianshas served as a likelyconsultant manage for Galderma, a large foragents, comedonal the choice2 as well of asvehicle mildly is inflammatory important because acne and cosmetic repre- Clindamycin 1%/benzoyl Benzoyl peroxide Dermatology Perelman School of Medicine at the University of Pennsyl- scribed agents. Given that pediatricians likely manage a large vania, Philadelphia, PA. E-mail: [email protected] cohortMedicis, of patientsand Stiefel. with He has comedonal also been a speaker and mildly for Galderma. inflammatory senttolerability about 46% favorably of prescribed influences acne products adherence among (compliance) dermatolo- peroxide 5% topical gel Correspondingvania, Philadelphia, author: PA.Albert E-mail: C. Yan, [email protected] MD, Chief, Pediatric Dermatology, cohort of patients with comedonal and mildly inflammatory with treatment regimens. Ointments, creams, gels, and solu- Erythromycin 3%/benzoyl Doxycycline Children’s Hospital of Philadelphia, Associate Professor, Pediatrics and gists, retinoids represent only about 12% of pediatrician-pre- 2 Dermatology Perelman School of Medicine at the University of Pennsyl- scribedtions have agents. beenGiven among that those pediatricians most commonly likely manage employed; a large peroxide 5% topical gel S16 1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. S16vania,1085-5629/11/$-see Philadelphia, PA. E-mail: front matter [email protected] © 2011 Elsevier Inc. All rights reserved. cohorthowever, of patients several new with vehicle comedonal formulations and mildly as inflammatorywell as novel Adapalene Erythromycin 3%/benzoyl doi:10.1016/j.sder.2011.07.004 doi:10.1016/j.sder.2011.07.004 delivery options have been introduced and should be consid- peroxide 5% topical gel Pediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdef 15 ered among the therapeutic options to individualize treat- Doxycyline Tetracycline Tetracycline Clindamycin 1%/benzoyl S16 1085-5629/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. ment and, thereby, optimize treatment outcomes. doi:10.1016/j.sder.2011.07.004 peroxide 5% topical gel A number of new topical products for acne treatment have Minocycline Erythromycin been developed and introduced recently. These include Source: Adapted from Yentzer BA, Irby CE, Fleischer AB Jr, Feld- man SR. Pediatr Dermatol 25:635-639, 2008. Table 1 Acne Medications Currently Available Topical agents, by class products formulated with foam and hydrogel vehicles, novel ● Retinoid agents fixed combinations of components, and a recently intro- – Adapalene duced topical gel formulation of the sulfone antibiotic/anti- – Tazarotene inflammatory dapsone. – Tretinoin Foam and hydrogel vehicles have the advantage of easy ● Benzoyl peroxide formulations (numerous over-the- counter and prescription products) spreadability with little residue. These vehicle formulations may ● Antibiotics be especially suited to treatment of hair-bearing areas (such as in – Clindamycin male patients) or applied more easily over larger body surface – Erythromycin areas such as on the chest and back. Clindamycin is available in – Sodium sulfacetamide a hydroethanolic foam, and a new tretinoin 0.025% � clinda- – Sulfur mycin 1.2% fixed combination product is available in a hydro- ● Combination products gel formulation. Other novel fixed combinations include those – Antibiotic-benzoyl peroxide fixed combinations containing antibiotic � BP, antibiotic � retinoid, and BP � – Antibiotic-retinoid fixed combinations retinoid (Table 3). Although use of the component agents – Benzoyl peroxide-retinoid fixed combinations separately may be more economical, fixed-combination ● Keratolytic agents (eg, salicylic acid) products guarantee the stability of the components within ● Anti-inflammatory agents (eg, dapsone) these formulations and improve adherence to therapy be- Systemic agents, by class cause fewer applications are needed during the day. ● Oral antibiotics Systemic antibiotic therapy has been a mainstay of treat- – Tetracycline derivatives ment for acne. These agents include primarily tetracycline X Doxycycline derivatives in patients 8 years of age and older; the age re- X Minocycline striction reflects concerns about dental enamel staining in X Tetracycline individuals younger than 8 years of age. Data on prescribing – Macrolide derivatives patterns show that dermatologists tend to favor doxycycline X Azithromycin and minocycline, whereas pediatricians frequently use tetra- X Erythromycin cycline.2 Tetracycline generally is less costly than the other – Cephalosporins derivatives, but the longer half-lives of doxycycline and mi- X Cephalexin – Penicillins nocycline permit once- or twice-daily dosing compared to X Amoxicillin the four-times-daily dosing typically required with tetracy- – Trimethoprim-sulfamethoxazole cline. Less frequent dosing of any medication is more likely to ● Combination oral contraceptives – Drospirenone Table 3 Novel Therapeutic Options – Drospirenone/levomefolate – Ethinyl estradiol/norethindrone ● Novel agent – Ethinyl estradiol/norgestimate – Dapsone ● Hormonal agents ● Novel combinations of components – Spironolactone – Antibiotic/benzoyl peroxide fixed combinations ● Systemic retinoids – Antibiotic/retinoid fixed combinations – Isotretinoin – Benzoyl peroxide/retinoid fixed combinations Approach to pediatric acne treatment S17 acne, these data suggest that topical retinoids may be somewhat Table 2 Most Frequently Prescribed Medications by Specialty Approach to pediatric acne treatment S17 underutilized by pediatricians for acne management. The de- ApproachPediatricians to pediatric acne treatment Dermatologists S17 creased rates of topical retinoid utilization among pediatricians Benzoyl peroxide Adapalene have been attributed to a heightened sensitivity to potential ad- acne, these data suggest that topical retinoids may be somewhat Table 2 Most Frequently Prescribed Medications by Specialty acne,Clindamycin these data suggest that topical retinoidsTretinoin may be somewhat Table 2 Most Frequently Prescribed Medications by Specialty verse effects or less familiarity with topical retinoids. underutilized by pediatricians for acne management. The de- underutilizedTretinoin by pediatricians for acneClindamycin management. The de- Pediatricians Dermatologists In addition to the selection of appropriate therapeutic creased rates of topical retinoid utilization among pediatricians Pediatricians Dermatologists creasedErythromycin rates of topical retinoid utilizationMinocycline among pediatricians Benzoyl peroxide Adapalene agents, the choice of vehicle is important because cosmetic have been attributed to a heightened sensitivity to potential ad- Benzoyl peroxide Adapalene haveClindamycin been attributed 1%/benzoyl to a heightenedBenzoyl sensitivity peroxide to potential ad- Clindamycin Tretinoin tolerability favorably influences adherence (compliance) verseperoxide effects 5% or less topical familiarity gel with topical retinoids. Clindamycin Tretinoin verse effects or less familiarity with topical retinoids. Tretinoin Clindamycin with treatment regimens. Ointments, creams, gels, and solu- ErythromycinIn addition 3%/benzoyl to the selection ofDoxycycline appropriate therapeutic Tretinoin Clindamycin In addition to the selection of appropriate therapeutic Erythromycin Minocycline tions have been among those most commonly employed; agents,peroxide the 5%choice topical of vehicle gel is important because cosmetic Erythromycin Minocycline agents, the choice of vehicle is important because cosmetic Clindamycin 1%/benzoyl Benzoyl peroxide however, several new vehicle formulations as well as novel tolerabilityAdapalene favorably influencesErythromycin adherence (compliance) 3%/benzoyl Clindamycinperoxide 5% 1%/benzoyl topical gel Benzoyl peroxide tolerability favorably influences adherence (compliance) delivery options have been introduced and should be consid- with treatment regimens. Ointments,peroxide creams, 5% gels, topical and solu- gel Erythromycinperoxide 5% 3%/benzoyl topical gel Doxycycline with treatment regimens. Ointments, creams, gels, and solu- Erythromycin 3%/benzoyl Doxycycline ered among the therapeutic options to individualize treat- tionsDoxycyline have been among those mostTetracycline commonly employed; peroxide 5% topical gel tionsTetracycline have been among those mostClindamycin commonly 1%/benzoyl employed; peroxide 5% topical gel ment and, thereby, optimize treatment outcomes. however, several new vehicle formulations as well as novel Adapalene Erythromycin 3%/benzoyl however, several new vehicle formulationsperoxide as 5% well topical as novel gel Adapalene Erythromycin 3%/benzoyl A number of new topical products for acne treatment have delivery options have been introduced and should be consid- peroxide 5% topical gel deliveryMinocycline options have been introducedErythromycin and should be consid- DoxycylineTable 2. Most Frequently Prescribed TetracyclineMedicationsperoxide 5%by Specialty topical gel been developed and introduced recently. These include ered among the therapeutic options to individualize treat- Doxycyline Tetracycline eredSource among: Adapted the from therapeutic Yentzer BA, options Irby CE, to Fleischerindividualize AB Jr, treat- Feld- Tetracycline Clindamycin 1%/benzoyl ment and, thereby, optimize treatment outcomes. TetracyclinePediatricians DermatologistsClindamycin 1%/benzoyl mentman and, SR. thereby, Pediatr Dermatol optimize 25:635-639, treatment 2008. outcomes. peroxide 5% topical gel A number of new topical products for acne treatment have peroxide 5% topical gel A number of new topical products for acne treatment have MinocyclineBenzoyl peroxide AdapaleneErythromycin Table 1 Acne Medications Currently Available been developed and introduced recently. These include Minocycline Erythromycin been developed and introduced recently. These include Clindamycin: Adapted from Yentzer BA,Tretinoin Irby CE, Fleischer AB Jr, Feld- Topical agents, by class Source products formulated with foam and hydrogel vehicles, novel Sourceman SR.: Adapted Pediatr from Dermatol Yentzer 25:635-639, BA, Irby CE, 2008. Fleischer AB Jr, Feld- ● Retinoid agents fixed combinations of components, and a recently intro- Tretinoinman SR. Pediatr Dermatol 25:635-639,Clindamycin 2008. Table 1 Acne Medications Currently Available – Adapalene ducedTable 1 topicalAcne Medications gel formulation Currently of the Available sulfone antibiotic/anti- Erythromycin Minocycline – Tazarotene Topicalinflammatory agents, dapsone. by class productsClindamycin formulated 1%/ with foamBenzoyl and hydrogel peroxide vehicles, novel – Tretinoin Topical agents, by class products formulated with foam and hydrogel vehicles, novel ● RetinoidFoam and agents hydrogel vehicles have the advantage of easy fixedbenzoyl combinations peroxide 5% topical of gel components, and a recently intro- ● Benzoyl peroxide formulations (numerous over-the- ● Retinoid– Adapalene agents fixed combinations of components, and a recently intro- spreadability with little residue. These vehicle formulations may ducedErythromycin topical 3%/ gel formulation ofDoxycycline the sulfone antibiotic/anti- counter and prescription products) – TazaroteneAdapalene duced topical gel formulation of the sulfone antibiotic/anti- be especially suited to treatment of hair-bearing areas (such as in inflammatorybenzoyl peroxide dapsone. 5% topical gel ● Antibiotics – TretinoinTazarotene inflammatory dapsone. male– patients) Tretinoin or applied more easily over larger body surface Foam and hydrogel vehicles have the advantage of easy – Clindamycin ● Benzoyl peroxide formulations (numerous over-the- AdapaleneFoam and hydrogel vehiclesErythromycin have the advantage3%/ of easy ●areasBenzoyl such as peroxide on the chest formulations and back. (numerous Clindamycin over-the- is available in spreadability with little residue. These vehicle formulations may – Erythromycin counter and prescription products) spreadability with little residue. Thesebenzoyl vehicle peroxide formulations 5% topical gel may – Sodium sulfacetamide a hydroethanoliccounter and prescription foam, and a products) new tretinoin 0.025% � clinda- be especially suited to treatment of hair-bearing areas (such as in ● Antibiotics beDoxycyline especially suited to treatment ofTetracycline hair-bearing areas (such as in – Sulfur ●mycinAntibiotics–1.2% Clindamycin fixed combination product is available in a hydro- male patients) or applied more easily over larger body surface maleTetracycline patients) or applied more easilyClindamycin over larger1%/ body surface ● Combination products gel formulation.– ErythromycinClindamycin Other novel fixed combinations include those areas such as on the chest and back. Clindamycin is available in areas such as on the chest and back.benzoyl Clindamycin peroxide 5% is topical available gel in – Antibiotic-benzoyl peroxide fixed combinations containing– SodiumErythromycin antibiotic sulfacetamide� BP, antibiotic � retinoid, and BP � a hydroethanolic foam, and a new tretinoin 0.025% � clinda- a hydroethanolic foam, and a new tretinoin 0.025% � clinda- – Antibiotic-retinoid fixed combinations retinoid– SulfurSodium (Table sulfacetamide 3). Although use of the component agents mycinMinocycline 1.2% fixed combination productErythromycin is available in a hydro- – Benzoyl peroxide-retinoid fixed combinations – Sulfur mycin 1.2% fixed combination product is available in a hydro- ●separatelyCombination may products be more economical, fixed-combination gelSource: formulation. Adapted from Yentzer Other BA, novel Irby CE, fixedFleischercombinations AB Jr, Feldman SR. Pediatr include Dermatol those. ● Keratolytic agents (eg, salicylic acid) ●TableCombination 1. Acne Medications products Currently Available gel25:635-639, formulation. 2008. Other novel fixed combinations include those products– Antibiotic-benzoyl guarantee the stability peroxide of fixed the combinationscomponents within containing antibiotic � BP, antibiotic � retinoid, and BP � ● Anti-inflammatory agents (eg, dapsone) – Antibiotic-benzoyl peroxide fixed combinations containing antibiotic � BP, antibiotic � retinoid, and BP � theseTopical– formulations Antibiotic-retinoid Agents, by class and improve fixed combinations adherence to therapy be- retinoid (Table 3). Although use of the component agents – Antibiotic-retinoid fixed combinations retinoid (Table 3). Although use of the component agents cause• Retinoid– fewer Benzoyl agents applications peroxide-retinoid are needed fixed during combinations the day. separately may be more economical, fixed-combination Systemic agents, by class ● Keratolytic– –Adapalene Benzoyl agents peroxide-retinoid (eg, salicylic fixed acid) combinations separately may be more economical, fixed-combination ● KeratolyticSystemic antibiotic agents (eg, therapy salicylic has acid)been a mainstay of treat- products guarantee the stability of the components within ● Oral antibiotics ● Anti-inflammatory– Tazarotene agents (eg, dapsone) products guarantee the stability of the components within ●mentAnti-inflammatory for acne. These agents agents (eg, include dapsone) primarily tetracycline these formulations and improve adherence to therapy be- – Tetracycline derivatives – Tretinoin these formulations and improve adherence to therapy be- X Doxycycline derivatives in patients 8 years of age and older; the age re- cause fewer applications are needed during the day. Systemic• Benzoyl peroxide agents, formulations by class cause fewer applications are needed during the day. X Minocycline Systemicstriction(numerous reflects agents, over-the-counter concerns by class and about prescription dental products) enamel staining in Systemic antibiotic therapy has been a mainstay of treat- ● Oral antibiotics Systemic antibiotic therapy has been a mainstay of treat- X Tetracycline ●individuals• Oral Antibiotics– younger derivatives than 8 years of age. Data on prescribing ment for acne. These agents include primarily tetracycline – Tetracycline derivatives ment for acne. These agents include primarily tetracycline – Macrolide derivatives patterns– ClindamycinX showDoxycycline that dermatologists tend to favor doxycycline derivatives in patients 8 years of age and older; the age re- Doxycycline derivatives in patients 8 years of age and older; the age re- X Azithromycin and– minocycline, ErythromycinX Minocycline whereas pediatricians frequently use tetra- striction reflects concerns about dental enamel staining in – SodiumMinocycline sulfacetamide X Erythromycin X2 Tetracycline striction reflects concerns about dental enamel staining in cycline.– SulfurTetracycline generally is less costly than the other individuals younger than 8 years of age. Data on prescribing – Cephalosporins –X MacrolideTetracycline derivatives individuals younger than 8 years of age. Data on prescribing derivatives,• Combination– Macrolide but products the derivatives longer half-lives of doxycycline and mi- patterns show that dermatologists tend to favor doxycycline X Cephalexin X Azithromycin patterns show that dermatologists tend to favor doxycycline nocycline– Antibiotic-benzoyl permit once- peroxide or fixed twice-daily combinations dosing compared to and minocycline, whereas pediatricians frequently use tetra- – Penicillins X ErythromycinAzithromycin and minocycline, whereas pediatricians frequently use tetra- the– four-times-daily Antibiotic-retinoidX fixed dosing combinations typically required with tetracy- cycline.2 Tetracycline generally is less costly than the other X Amoxicillin –X CephalosporinsErythromycin cycline.2 Tetracycline generally is less costly than the other cline.– – Benzoyl Less Cephalosporins frequent peroxide-retinoid dosing fixed of any combinations medication is more likely to derivatives, but the longer half-lives of doxycycline and mi- – Trimethoprim-sulfamethoxazole X Cephalexin derivatives, but the longer half-lives of doxycycline and mi- ● Combination oral contraceptives • KeratolyticX Cephalexin agents (eg, salicylic acid) nocycline permit once- or twice-daily dosing compared to • Anti-inflammatory– Penicillins agents (eg, dapsone) nocycline permit once- or twice-daily dosing compared to – Drospirenone – Penicillins theS18 four-times-daily dosing typically required with tetracy- A.C. Yan et al Table 3 XNovelAmoxicillin Therapeutic Options the four-times-daily dosing typically required with tetracy- – Drospirenone/levomefolate SystemicX Agents,Amoxicillin by class cline. Less frequent dosing of any medication is more likely to – Trimethoprim-sulfamethoxazole cline. Less frequent dosing of any medication is more likely to – Ethinyl estradiol/norethindrone ●• CombinationNovel Oral– Trimethoprim-sulfamethoxazoleantibiotics agent oral contraceptives – Tetracycline derivatives result in better treatment adherence. Moreover, data on an- This provides a rationale for incorporation of BP into acne – Ethinyl estradiol/norgestimate ● Combination– DrospirenoneDapsone oral contraceptives Doxycycline Table 3 Novel Therapeutic Options ● Hormonal agents ● Novel– Drospirenone/levomefolateDrospirenone combinations of components tibiotic resistance patterns of Propionibacterium acnes indicate therapeutic regimens where possible, either as a separate Minocycline Table 3 Novel Therapeutic Options – Spironolactone – EthinylDrospirenone/levomefolateAntibiotic/benzoyl estradiol/norethindrone peroxide fixed combinations ●thatNovel the proportion agent of organisms resistant to doxycycline and agent or as part of a fixed combination, particularly when Tetracycline ● Systemic retinoids – EthinylAntibiotic/retinoid estradiol/norgestimateestradiol/norethindrone fixed combinations ●minocyclineNovel– Dapsone agent are lower than with either erythromycin or tet- antibiotics are employed, as the use of BP has been associated – Isotretinoin – – Macrolide EthinylBenzoyl derivatives estradiol/norgestimate peroxide/retinoid fixed combinations – Dapsone with a reduction in development of antibiotic resistance ● Hormonal Azithromycin agents ●racycline.Novel combinations Finally, photosensitivity of components and gastrointestinal side ● Hormonal– Spironolactone agents ●effectsNovel– Antibiotic/benzoyltend combinations to be somewhat of peroxidecomponents lower with fixed doxycycline combinations and mi- among P. acnes. Likewise, use of subantimicrobial doses of – SpironolactoneErythromycin – Antibiotic/benzoyl peroxide fixed combinations ● Systemic retinoids nocycline– Antibiotic/retinoid compared to tetracycline. fixed combinations antibiotics has shown some limited benefit for patients with ● Systemic– Cephalosporins retinoids – Antibiotic/retinoid fixed combinations – Isotretinoin – Benzoyl peroxide/retinoid fixed combinations comedonal and inflammatory lesions, while at the same time – IsotretinoinCephalexin Alternative– Benzoyl agents peroxide/retinoid have been used fixed when combinations traditional tetra- – Penicillins cycline derivative agents have proved insufficiently effective not demonstrating a significant impact on altering native res- Amoxicillin or in cases in which side effects preclude the use of antibiotics ident microbial flora.20 – Trimethoprim-sulfamethoxazole in the tetracycline class. Although randomized clinical trial • Combination oral contraceptives – Drospirenone dataTable are 3. notNovel available Therapeutic for these Options alternative agents, case series Preadolescent Acne – Drospirenone/levomefolate have documented the efficacy and apparent tolerability of – Ethinyl estradiol/norethindrone amoxicillin,Novel Agent3 cephalexin,4 trimethoprim and trimethoprim- Data are limited on the use of acne medications in the pread- – Ethinyl estradiol/norgestimate sulfamethoxazole,• Dapsone 5 and azithromycin6 for patients with acne olescent population (ie, patients �7 to 11 years of age). A • Hormonal agents whoNovel were Combinations either unable of Components to take or had previously failed ther- number of case series highlight the heterogeneous group of – Spironolactone • Antibiotic/benzoyl peroxide fixed combinations apy with more conventional therapeutic agents. medications used for children with infantile acne. Two clin- • Systemic retinoids • Antibiotic/retinoid fixed combinations – Isotretinoin • The Benzoyl published peroxide/retinoid data on fixed amoxicillin combinations are scant and involve ical trials have evaluated the use of tretinoin for preadolescent assessments from retrospective chart reviews.3 One large case acne. In one open-label study involving 40 patients between 4 16 globalacademycme.com/sdefseries by Fenner and• Pediatric colleagues Acne Management:reviewed Optimizing the responses Outcomes of 8 and 12 years of age, tretinoin 0.04% in a microsphere gel 93 acne patients who received 98 courses of cephalexin. vehicle demonstrated good efficacy and safety, with patients These investigators reported that only 22% of patients showing both tolerability and also moderate improvement on showed no response or worsened with therapy, whereas the the Evaluator’s Global Severity Score.21 The U.S. Food and remaining patients were either somewhat improved (29%), Drug Administration granted an age indication of 10 years or much improved (45%), or cleared (4%). Trimethoprim and older for tretinoin 0.05% gel, based on the trial data submit- trimethoprim-sulfamethoxazole have seen considerable pe- ted. Otherwise, most acne medications are indicated for use diatric usage for treatment of a variety of both cutaneous and in individuals 12 years of age or older (Table 4). extracutaneous infections, but the use of these agents in acne Despite the limited data available for the use of these med- generally has been regarded as a third-line option.5,7 ications in infants and preadolescent patients, clinical judg- More extensive data are available regarding the use of azi- ment should be exercised to select appropriate therapies for thromycin for acne. A review of the available literature reveals children with acne. Topical BP, topical retinoids, and topical three randomized controlled trials8-10 and one nonrandom- antibiotics have been used with some success in younger 22 ized controlled trial11 that demonstrated noninferiority of children with acne. For those with more severe acne, sys- azithromycin to doxycycline; azithromycin also was not in- temic antibiotic therapy has included erythromycin and its ferior to minocycline in one open-label study.12 In addition, derivatives, trimethoprim, and cephalexin; these have been four open, noncontrolled studies13-16 and one retrospective used with success in cases in which tetracycline and its de- chart review17 indicated that azithromycin improved acne. rivatives are less desirable, given their propensity for dental However, there is heterogeneity in study design as well as enamel staining. Tetracycline and doxycycline are generally dosage regimens of the azithromycin and the control drug. recommended for children 8 years of age and older with Most of these studies acknowledged the long half-life of azi- severe acne; minocycline carries a recommendation for chil- thromycin and typically gave the drug as often as three to four dren 12 years of age and older with moderate-to-severe acne. times a week or as seldom as three times per month. Combination oral contraceptives may be helpful for post- menarchal adolescents and adults. However, because of con- Erythromycin, an older macrolide derivative, is used less cerns about premature epiphyseal closure, their use in pre- often now because of the emergence and establishment of menarchal patients generally is not advised except in antibiotic resistance among P. acnes organisms. There is evi- consultation with an endocrinologist. Spironolactone and its dence for significant antibiotic resistance among P. acnes, and analog, drospirenone, are sometimes used in the treatment of it is clear that erythromycin has been largely abandoned by adults and some adolescents, but these agents do not cur- both dermatologists (2.8%) and pediatricians (7.2%),2 ex- rently play a significant role in preadolescent acne. cept perhaps for use in prepubertal children or pregnant females in whom alternative agents may be less appropriate. Clinicians have become increasingly aware of the impact of Improving acne therapy on causing “ecological mischief.”18 Widespread use of antibiotics for acne has been presumed to be one Adherence in Pediatric Patients possible driving force for the selection of antibiotic-resistant A recent literature search using the key terms adherence, com- P. acnes species. Studies looking at P. acnes antibiotic resis- pliance, or concordance yielded a list of more than 168,000 tance profiles have indicated increasing rates of antibiotic articles. Although this is a highly heterogeneous group of resistance over time.19 articles, some key themes are highlighted in these references. S18 A.C. Yan et al S18 A.C. Yan et al S18 A.C. Yan et al result in better treatment adherence. Moreover, data on an- This provides a rationale for incorporation of BP into acne tibioticresult in resistance better treatment patterns adherence. of Propionibacterium Moreover, acnes dataindicate on an- therapeuticThis provides regimens a rationale where for possible, incorporation either of as BP a into separate acne result in better treatment adherence. Moreover, data on an- This provides a rationale for incorporation of BP into acne tibioticthat the resistance proportion patterns of organisms of Propionibacterium resistant to doxycycline acnes indicate and agenttherapeutic or aspart regimens of a fixed where combination, possible, either particularly as a separate when tibiotic resistance patterns of Propionibacterium acnes indicate therapeutic regimens where possible, either as a separate minocyclinethat the proportion are lower of organisms than with resistant either erythromycin to doxycycline or and tet- antibioticsagent or as are part employed, of a fixed as thecombination, use of BP has particularly been associated when that the proportion of organisms resistant to doxycycline and agent or as part of a fixed combination, particularly when racycline.minocycline Finally, are lower photosensitivity than with either and erythromycin gastrointestinal or side tet- withantibiotics a reduction are employed, in development as the use of of BP antibiotic has been associated resistance minocycline are lower than with either erythromycin or tet- antibiotics are employed, as the use of BP has been associated effectsracycline. tend Finally, to be somewhat photosensitivity lower with and doxycycline gastrointestinal and side mi- amongwith aP. reduction acnes. Likewise, in development use of subantimicrobial of antibiotic resistance doses of racycline. Finally, photosensitivity and gastrointestinal side with a reduction in development of antibiotic resistance nocyclineeffects tend compared to be somewhat to tetracycline. lower with doxycycline and mi- antibioticsamong P. acnes. has shownLikewise, some use limited of subantimicrobial benefit for patients doses with of effects tend to be somewhat lower with doxycycline and mi- among P. acnes. Likewise, use of subantimicrobial doses of nocyclineAlternative compared agents to have tetracycline. been used when traditional tetra- comedonalantibioticsApproach to has pediatricand shown inflammatory acne some treatment limited lesions, benefit while for at the patients same withtime S19 nocycline compared to tetracycline. antibiotics has shown some limited benefit for patients with cyclineAlternative derivative agents agents have have been proved used when insufficiently traditional effective tetra- notcomedonal demonstrating and inflammatory a significant lesions, impact while on altering at the nativesame time res- Alternative agents have been used when traditional tetra- comedonal and inflammatory20 lesions, while at the same time orcycline in cases derivative in which agents side effects have provedpreclude insufficiently the use of antibiotics effective identnot demonstrating microbial flora. a significant impact on altering native res- cycline derivative agents have proved insufficiently effective Tablenot demonstrating 4 FDA Approvals a significant20 and Pediatric impact Age on Indicationsaltering native for res- Medications Commonly Employed for Acne inorin the cases tetracycline in which class. side effects Although preclude randomized the use of clinical antibiotics trial ident microbial flora. or in cases in which side effects preclude the use of antibiotics ident microbial flora.20 datain the are tetracycline not available class. for Althoughthese alternative randomized agents, clinical case series trial Date of in the tetracycline class. Although randomized clinical trial Earliest FDA havedata are documented not available the for efficacy these alternative and apparent agents, tolerability case series of Preadolescent Acne Acne data are not available for these alternative agents, case series PreadolescentDrug Category Active Acne Drug Common Brand Names Approval Age Indication amoxicillin,have documented3 cephalexin, the efficacy4 trimethoprim and apparent and trimethoprim- tolerability of DataPreadolescent are limited on the use of Acne acne medications in the pread- amoxicillin,have documented3 cephalexin,5 the efficacy4 trimethoprim and apparent6 and trimethoprim- tolerability of DataTopical are retinoid limited on the Tretinoin use of acne medicationsRetin-A in the 0.025%, pread- 0.05%, 0.1% October 1971 >12 years sulfamethoxazole,3 and azithromycin4 for patients with acne olescent population (ie, patients �7 to 11 years of age). A amoxicillin, cephalexin,5 trimethoprim6 and trimethoprim- Avita 0.025% January 1997 >12 years Approachwhosulfamethoxazole, were to either pediatric unableand acne azithromycinto treatment take or had previouslyfor patients failed with ther- acne numberolescentData are of limitedpopulation case series on the (ie, highlight use patients of acne the� medications7 heterogeneous to 11 years in theof group age). pread-S19 of A sulfamethoxazole,5 and azithromycin6 for patients with acne � Atralin 0.05% July 2007 >10 years apywho with were more either conventional unable to take therapeutic or had previously agents. failed ther- medicationsnumberolescent of population case used series for (ie, children highlight patients with the infantile7 heterogeneous to 11 yearsacne. ofTwo group age). clin- of A who were either unable to take or had previously failed ther- Adapalene Differin 0.1%, 0.3% May 1996 >12 years apyThe with published more conventional data on amoxicillin therapeutic are agents. scant and involve icalmedicationsnumber trials of have case used evaluated series for children highlight the use with of the tretinoin infantile heterogeneous for acne. preadolescent Two group clin- of Tableapy with 4 FDA more Approvals conventional and Pediatric therapeutic Age agents. Indications for Medications Commonly EmployedTazarotene for Acne Tazorac 0.05%, 0.1% June 1997 >12 years assessmentsThe published from retrospective data on amoxicillin chart reviews. are scant3 One and large involve case acne.icalmedications trials In one have open-labelused evaluated for children study the use involving with of tretinoin infantile 40 for patients acne. preadolescent Two between clin- Date of assessmentsThe published from retrospective data on amoxicillin chart4 reviews. are scant3 One and large involve case acne.ical trials In one have open-label evaluated study the use involving of tretinoin 40 patientsfor preadolescent between series by Fenner and colleagues reviewed the3 responses of 8Topical and 12 antibiotic years of age, Erythromycin tretinoin 0.04% in a Akne-Mycin, microsphere Erygel, gel Emgel January 1985 Indicated for pediatric use; no assessments from retrospective chart4 reviews. One large case acne. In oneEarliest open-label FDA study involving 40 patients between 93series acne bypatients Fenner and who colleagues received 98reviewed courses the of responses cephalexin. of vehicle8 and 12 demonstrated years of age, good tretinoin efficacy 0.04% and in safety, a microsphere with patients gel specific age restrictions seriesDrug by Category Fenner and colleagues Active Drug4 reviewed the Common responses Brand of Names8 and 12 yearsApproval of age, tretinoin 0.04%Age in Indication a microsphere gel These93 acne investigators patients who reported received that 98 onlycourses 22% of cephalexin.of patients showingvehicle demonstrated both tolerabilityClindamycin good and efficacy also moderate and safety, Cleocin improvement with T patients on July 1980 >12 years Topical93 acne retinoid patients who Tretinoin received 98 coursesRetin-A of cephalexin. 0.025%, 0.05%,vehicle 0.1% demonstratedOctober 1971 good efficacy>12 years and safety, with patients showedThese investigators no response or reported worsened that with only therapy, 22% whereas of patients the theshowing Evaluator’s both tolerability Global Severity and also Score. moderate21 TheEvoclin improvement U.S. Food and on October 2004 >12 years Avita 0.025% January 1997 >12 years showedThese investigators no response or reported worsened that with only therapy, 22% whereas of patients the Drugtheshowing Evaluator’s Administration both tolerability Global granted Severity and an also Score. age moderate indication21 The improvement U.S. of 10 Food years and onor remaining patients were either somewhatAtralin improved 0.05% (29%), July 2007 >10 years21 remainingshowed no patients response were or worsened either somewhat with therapy, improved whereas (29%), the DrugTopicalthe Evaluator’s Administration anti- GlobalDapsone granted Severity an Score.age indicationTheAczone U.S. of 10 Food years and or July 2005 >12 years much improved (45%),Adapalene or cleared (4%). TrimethoprimDifferin 0.1%, and 0.3% older for tretinoinMay 1996 0.05% gel,> based12 years on the trial data submit- remaining patients were either somewhat improved (29%), olderDruginflammatory forAdministration tretinoin 0.05% granted gel, anbased age on indication the trial of data 10 submit- years or trimethoprim-sulfamethoxazolemuch improved (45%),Tazarotene or cleared have (4%). seen TrimethoprimTazorac considerable 0.05%, and pe- 0.1% ted. Otherwise,June 1997 most acne medications12 years are indicated for use much improved (45%), or cleared (4%). Trimethoprim and older for tretinoin 0.05% gel,> based on the trial data submit- diatrictrimethoprim-sulfamethoxazole usage for treatment of a variety have ofseen both considerable cutaneous and pe- inted. individuals Otherwise, 12 most years acne of age medications or older (Table are indicated 4). for use trimethoprim-sulfamethoxazole have seen considerable pe- Fixedted. Otherwise, most acne medications are indicated for use Topicalextracutaneousdiatric usage antibiotic for infections, treatment Erythromycin butof a thevariety use of boththese Akne-Mycin, cutaneous agents in acne Erygel, and EmgelinDespite individuals January thelimited 12 years 1985 data of age available Indicated or older for (Table the for usepediatric 4). of these use; med- no diatric usage for treatment of a variety of both cutaneous and incombination individuals 12 years of age or older (Table 4). generallyextracutaneous has been infections, regarded but as the a third-line use of these option. agents5,7 in acne icationsproduct:Despite in the infants limited and data preadolescent availablespecific for patients, the age use restrictionsof clinical these judg-med- extracutaneous infections, but the use of these agents5,7 in acne Despite the limited data available for the use of these med- generallyMore extensive has been data regardedClindamycin are available as a third-line regarding Cleocin option. the use T of azi- menticationsBP should� inAbxJuly infants be 1980 exercised andBP preadolescent� toerythromycin select>12 years appropriate patients, Benzamycin clinical therapies judg- for October 1984 >12 years generally has been regarded as a third-line option.5,7 ications in infants and preadolescent patients, clinical judg- thromycinMore extensive for acne. data A review are available of the available regardingEvoclin literature the use reveals of azi- childrenment should withOctober be acne. exercised 2004 TopicalBP � toclindamycin BP, select>12 topical years appropriate retinoids, Benzaclin therapies and topical for December 2000 >12 years More extensive data are available regarding the use of azi- ment should be exercised to select appropriate therapies for threethromycin randomized for acne. controlled A review of trials the8-10 availableand one literature nonrandom- reveals antibioticschildren with have acne. been Topical used BP, with topical some retinoids, successDuac inand younger topical August 2002 >12 years Topical anti- Dapsone Aczone children withJuly acne. 200522 Topical BP,>12 topical years retinoids, and topical threethromycin randomized for acne. controlled A11 review of trials the8-10 availableand one literature nonrandom- reveals childrenantibiotics with have acne. beenFor used those with with some more successAcanya severe in acne, younger sys- October 2008 >12 years ized controlled trial that demonstrated8-10 noninferiority of threeinflammatory randomized controlled11 trials and one nonrandom- antibioticsBP � retinoid have been22BP used� tretinoin with some success Epiduo in younger December 2008 12 years izedazithromycin controlled to trialdoxycycline;that demonstrated azithromycin noninferiority also was not in- of childrentemic antibiotic with acne. therapyFor has those included with more erythromycin severe acne, and sys- its > 11 childrenRetinoid with� Abx acne.22TretinoinFor those� with moreZiana severe acne, sys- November 2006 >12 years azithromycinized controlled to doxycycline;trial that demonstrated azithromycin noninferiority also12 was not in- of derivatives,temic antibiotic trimethoprim, therapy has and included cephalexin; erythromycin these have and been its Fixedferior to minocycline in one open-label study. In addition, temic antibiotic therapyclindamycin has included erythromycinVeltin and its July 2010 >12 years feriorazithromycin to minocycline to doxycycline; in one open-label azithromycin13-16 study. also12 In was addition, not in- usedderivatives, with success trimethoprim, in cases andin which cephalexin; tetracycline these and have its been de- fourcombination open, noncontrolled studies and one12 retrospective Oral antibiotic Erythromycin EES, Eryped, Ery-tab April 1965 Indicated for pediatric use; no 13-16 usedderivatives, with success trimethoprim, in cases inand which cephalexin; tetracycline these and have its been de- fourferiorproduct: open, to minocycline noncontrolled17 in one studies open-labeland study. one retrospectiveIn addition, rivatives are less desirable, given their propensity for dental chart review indicated that azithromycin13-16 improved acne. used with success in cases in which tetracycline and its de- specific age restrictions chartfourBP open,� reviewAbx noncontrolled17 indicatedBP � thaterythromycin studies azithromycinand Benzamycin one improved retrospective acne. enamelrivatives staining. areOctober less desirable,Tetracycline 1984 given> and12 their yearsdoxycycline propensity are for generally dental However, there17 is heterogeneity in study design as well as rivatives are less desirable,Tetracycline given their propensity Sumycin for and dental others September 1954 >8 years chart review indicatedBP � thatclindamycin azithromycin Benzaclin improved acne. recommendedenamel staining.December for Tetracycline children 2000 8> and years12 yearsdoxycycline of age and are older generally with dosageHowever, regimens there is of heterogeneity the azithromycin in study and thedesign control as well drug. as enamel staining. TetracyclineDoxycycline and doxycycline Vibramycin, are generally Doryx and Adoxa December 1967 >8 years However, there is heterogeneity in studyDuac design as well as severerecommended acne;August minocycline for 2002 children carries 8> years12 a recommendationyears of age and older for chil-with Mostdosage of regimens these studies of the acknowledged azithromycin the and long the half-life control of drug. azi- recommended for childrenMinocycline 8 years of age Dynacin, and older Minocin, with and others August 1982 >12 years dosage regimens of the azithromycin andAcanya the control drug. drensevere 12 acne; yearsOctober minocycline of age 2008 and older carries> with12 a recommendationyears moderate-to-severeSolodyn for acne. chil- May 2006 12 years thromycinMost of these and studies typically acknowledged gave the drug the as often long ashalf-life three to of four azi- severe acne; minocycline carries a recommendation for chil- > MostBP of� theseretinoid studiesBP acknowledged� tretinoin the long Epiduo half-life of azi- drenCombination 12 yearsDecember of ageoral andTrimethoprim- 2008contraceptives older> with12 years moderate-to-severe may beBactrim, helpful for Septra acne.post- July 1973 2 months timesthromycin a week and or typically as seldom gave as the three drug times as often per month. as three to four dren 12 years of age and older with moderate-to-severe acne. thromycinRetinoid and� Abx typicallyTretinoin gave the� drug as oftenZiana as three to four menarchalCombinationNovember adolescents oral 2006contraceptivessulfamethoxazole and adults.>12 However,years may be helpful because for of post- con- timesErythromycin, a week or as an seldom older macrolideas three times derivative, per month. is used less times a week or as seldomclindamycin as three times perVeltin month. cernsmenarchalCombination aboutJuly adolescents premature 2010 oralAmoxicillin contraceptives and epiphyseal adults.>12 However,years closure, may beAmoxil their helpful because use for ofin post- con- pre- November 1979 Indicated for pediatric use; no OraloftenErythromycin, antibiotic now because an Erythromycinof older the macrolideemergence derivative, and EES, establishment Eryped, is used Ery-tabless of menarchalApril adolescents 1965 and adults. Indicated However, for pediatric because use; of con- no Erythromycin, an older macrolide derivative, is used less menarchalcerns about patients premature generally epiphyseal is closure, not advised their use except in pre- in specific age restrictions antibioticoften now resistance because of among the emergenceP. acnes organisms. and establishment There is evi- of cerns about premature epiphysealspecific closure, age their restrictions use in pre- often now because of the emergence and establishment of consultationmenarchal patients with anCephalexin endocrinologist. generally is not Spironolactone advisedKeflex except and its in January 1971 Indicated for pediatric use; no denceantibiotic for significant resistanceTetracycline antibioticamong P. resistanceacnes organisms. among Sumycin ThereP. acnes and is, andevi-others menarchalSeptember patients 1954 generally>8 is years not advised except in antibiotic resistance among P. acnes organisms. There is evi- analog,consultation drospirenone, with an endocrinologist. are sometimes used Spironolactone in the treatment and its of specific age restrictions itdence is clear for significant that erythromycinDoxycycline antibiotic has resistance been largely among Vibramycin, abandonedP. acnes Doryx, and by and Adoxaconsultation December with anAzithromycin 1967 endocrinologist.>8 years Spironolactone Zithromax and its November 1991 >6 months dence for significant antibiotic resistance among P. acnes, and adultsanalog, and drospirenone, some adolescents, are sometimes but these used agents in the treatment do not cur- of bothit is clear dermatologists that erythromycinMinocycline (2.8%) has and been pediatricians largely Dynacin, abandoned (7.2%), Minocin,2 ex- by and othersanalog, drospirenone,August 1982 are sometimes>12 years used in the treatment of it is clear that erythromycin has been largely abandoned2 by rentlyadults play and a some significant adolescents, role in but preadolescent these agents acne. do not cur- ceptboth perhaps dermatologists for use (2.8%) in prepubertal and pediatricians childrenSolodyn (7.2%), or pregnantex- Systemicadults andMay retinoid some 2006 adolescents, Isotretinoin> but12 years these agents Accutane do not cur- May 1982 >12 years both dermatologistsTrimethoprim- (2.8%) and pediatriciansBactrim, (7.2%), Septra2 ex- rently playJuly a significant 1973 role in 2 preadolescent months acne. femalescept perhaps in whom for alternative use in prepubertal agents may children be less appropriate.or pregnant rently play a significant role in preadolescentAmnesteem acne. November 2002 >12 years femalescept perhaps in whom for alternative usesulfamethoxazole in prepubertal agents may children be less appropriate. or pregnant Sotret December 2002 >12 years Clinicians have becomeAmoxicillin increasingly awareAmoxil of the impact of ImprovingNovember 1979 Indicated for pediatric use; no Cliniciansfemales in have whom become alternative increasingly agents may aware be lessof18 the appropriate. impact of Claravis April 2003 >12 years acne therapy on causing “ecological mischief.” Widespread Improving Adherencespecific age restrictions Clinicians have become increasingly aware of18 the impact of AdherenceAbx antibiotics; BP inbenzoyl Pediatric peroxide. Patients acneuse of therapy antibiotics on causing forCephalexin acne “ecological has been mischief.” presumedKeflexWidespread to be one Improving� January 1971� Indicated for pediatric use; no acne therapy on causing “ecological mischief.”18 Widespread inAdherenceSource: PediatricDrugs@FDA (http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm).Patients in Pediatric Patients possibleuse of antibiotics driving force for for acne the has selection been presumedof antibiotic-resistant to be one A recent literature search using thespecific key terms age restrictionsadherence, com- use of antibiotics for acne has been presumed to be one Adherence in Pediatric Patients P.possible acnes species. driving force StudiesAzithromycin for looking the selection at P. acnesof antibiotic-resistant Zithromaxantibiotic resis- Apliance, recentor literatureNovemberconcordance search 1991yielded using> the6 a months list key of terms moreadherence than 168,000, com- possible driving force for the selection of antibiotic-resistant P.tance acnes profilesspecies. have Studies indicated looking increasing at P. acnes ratesantibiotic of antibiotic resis- articles.pliance,A recentor Although literatureconcordance search thisyielded is using a highly the a list key heterogeneous of terms moreadherence than group 168,000, com- of P. acnes species. Studies looking at P. acnes antibiotic resis- pliance, or concordance yielded a list of more than 168,000 S18 Systemicresistancetance profiles retinoid over have time. Isotretinoin indicated19 increasing rates Accutane ofA.C. antibiotic Yan et al articles,articles. some AlthoughMay key 1982 themes this is are a highly highlighted>12 years heterogeneous in these references. group of resistancetance profiles over have time.19 indicated increasing ratesAmnesteem of antibiotic articles,articles. some AlthoughNovember key themes this 2002 is are a highly highlighted>12 years heterogeneous in these references. group of resistance over time.19 Sotret articles, someDecember key themes 2002 are> highlighted12 years in these references. result in better treatment adherence. Moreover, data on an- This provides a rationale for incorporationClaravis of BP into acne SimplifyApril treatment 2003 regimens.>12Successful years adherence is in- worldwide,23 attesting to the popularity of therapeutic ritu- tibiotic resistance patterns of Propionibacterium acnes indicate Abxtherapeutic� antibiotics; regimens BP � benzoyl where peroxide. possible, either as a separate versely related to the number of agents that must be taken or als, particularly among adolescents. that the proportion of organisms resistant to doxycycline and Source:agent orDrugs@FDA as part of(http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm). a fixed combination, particularly when applied and the number of times each day that they must be minocycline are lower than with either erythromycin or tet- antibiotics are employed, as the use of BP has been associated taken or used. For patients who have difficulty with adequate Consider vehicle appropriateness. Adherence also depends racycline. Finally, photosensitivity and gastrointestinal side with a reduction in development of antibiotic resistance compliance, fixed-combination products may improve ad- on identifying patient preferences and matching vehicle se- effects tend to be somewhat lower with doxycycline and mi- among P. acnes. Likewise, use of subantimicrobial doses of herence to the prescribed regimen. Interestingly, however, lections to those preferences. For example, gels and foams are nocycline compared to tetracycline. antibiotics has shown some limited benefit for patients with one multistep, multicomponent, over-the-counter acne easier to spread on hairy areas such as the male chest. Other Alternative agents have been used when traditional tetra- comedonal and inflammatory lesions, while at the same time product has generated a reported $830 million in sales patients may prefer the tactile sensation of a cream over an cycline derivative agents have proved insufficiently effective Simplifynot demonstrating treatment a regimens. significant impactSuccessful on altering adherence native is res- in- worldwide,23 attesting to the popularity of therapeutic ritu- or in cases in which side effects preclude the use of antibiotics verselyident microbial related to flora. the number20 of agents that must be taken or als, particularly among adolescents. applied and the number of times each day that they must be in the tetracycline class. Although randomized clinical trial Pediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdef 17 data are not available for these alternative agents, case series taken or used. For patients who have difficulty with adequate Consider vehicle appropriateness. Adherence also depends have documented the efficacy and apparent tolerability of compliance,Preadolescent fixed-combination Acne products may improve ad- on identifying patient preferences and matching vehicle se- amoxicillin,3 cephalexin,4 trimethoprim and trimethoprim- herenceData are to limited the prescribed on the use regimen. of acne medications Interestingly, in the however, pread- lections to those preferences. For example, gels and foams are sulfamethoxazole,5 and azithromycin6 for patients with acne oneolescent multistep, population multicomponent, (ie, patients �7 over-the-counter to 11 years of age). acne A easier to spread on hairy areas such as the male chest. Other who were either unable to take or had previously failed ther- productnumber ofhas case generated series highlight a reported the heterogeneous $830 million groupin sales of patients may prefer the tactile sensation of a cream over an apy with more conventional therapeutic agents. medications used for children with infantile acne. Two clin- The published data on amoxicillin are scant and involve ical trials have evaluated the use of tretinoin for preadolescent assessments from retrospective chart reviews.3 One large case acne. In one open-label study involving 40 patients between series by Fenner and colleagues4 reviewed the responses of 8 and 12 years of age, tretinoin 0.04% in a microsphere gel 93 acne patients who received 98 courses of cephalexin. vehicle demonstrated good efficacy and safety, with patients These investigators reported that only 22% of patients showing both tolerability and also moderate improvement on showed no response or worsened with therapy, whereas the the Evaluator’s Global Severity Score.21 The U.S. Food and remaining patients were either somewhat improved (29%), Drug Administration granted an age indication of 10 years or much improved (45%), or cleared (4%). Trimethoprim and older for tretinoin 0.05% gel, based on the trial data submit- trimethoprim-sulfamethoxazole have seen considerable pe- ted. Otherwise, most acne medications are indicated for use diatric usage for treatment of a variety of both cutaneous and in individuals 12 years of age or older (Table 4). extracutaneous infections, but the use of these agents in acne Despite the limited data available for the use of these med- generally has been regarded as a third-line option.5,7 ications in infants and preadolescent patients, clinical judg- More extensive data are available regarding the use of azi- ment should be exercised to select appropriate therapies for thromycin for acne. A review of the available literature reveals children with acne. Topical BP, topical retinoids, and topical three randomized controlled trials8-10 and one nonrandom- antibiotics have been used with some success in younger 22 ized controlled trial11 that demonstrated noninferiority of children with acne. For those with more severe acne, sys- azithromycin to doxycycline; azithromycin also was not in- temic antibiotic therapy has included erythromycin and its ferior to minocycline in one open-label study.12 In addition, derivatives, trimethoprim, and cephalexin; these have been four open, noncontrolled studies13-16 and one retrospective used with success in cases in which tetracycline and its de- chart review17 indicated that azithromycin improved acne. rivatives are less desirable, given their propensity for dental However, there is heterogeneity in study design as well as enamel staining. Tetracycline and doxycycline are generally dosage regimens of the azithromycin and the control drug. recommended for children 8 years of age and older with Most of these studies acknowledged the long half-life of azi- severe acne; minocycline carries a recommendation for chil- thromycin and typically gave the drug as often as three to four dren 12 years of age and older with moderate-to-severe acne. times a week or as seldom as three times per month. Combination oral contraceptives may be helpful for post- menarchal adolescents and adults. However, because of con- Erythromycin, an older macrolide derivative, is used less cerns about premature epiphyseal closure, their use in pre- often now because of the emergence and establishment of menarchal patients generally is not advised except in antibiotic resistance among P. acnes organisms. There is evi- consultation with an endocrinologist. Spironolactone and its dence for significant antibiotic resistance among P. acnes, and analog, drospirenone, are sometimes used in the treatment of it is clear that erythromycin has been largely abandoned by adults and some adolescents, but these agents do not cur- both dermatologists (2.8%) and pediatricians (7.2%),2 ex- rently play a significant role in preadolescent acne. cept perhaps for use in prepubertal children or pregnant females in whom alternative agents may be less appropriate. Clinicians have become increasingly aware of the impact of Improving acne therapy on causing “ecological mischief.”18 Widespread use of antibiotics for acne has been presumed to be one Adherence in Pediatric Patients possible driving force for the selection of antibiotic-resistant A recent literature search using the key terms adherence, com- P. acnes species. Studies looking at P. acnes antibiotic resis- pliance, or concordance yielded a list of more than 168,000 tance profiles have indicated increasing rates of antibiotic articles. Although this is a highly heterogeneous group of resistance over time.19 articles, some key themes are highlighted in these references. Approach to pediatric acne treatment S19

Table 4 FDA Approvals and Pediatric Age Indications for Medications Commonly Employed for Acne Date of Earliest FDA Drug Category Active Drug Common Brand Names Approval Age Indication Topical retinoid Tretinoin Retin-A 0.025%, 0.05%, 0.1% October 1971 >12 years Avita 0.025% January 1997 >12 years Atralin 0.05% July 2007 >10 years Adapalene Differin 0.1%, 0.3% May 1996 >12 years Tazarotene Tazorac 0.05%, 0.1% June 1997 >12 years

Topical antibiotic Erythromycin Akne-Mycin, Erygel, Emgel January 1985 Indicated for pediatric use; no specific age restrictions Clindamycin Cleocin T July 1980 12 years Table 4. FDA Approvals and Pediatric> Age Indications for Medications Commonly Employed for Acne Evoclin October 2004 >12 years Drug Category Active Drug Common Brand Names Date of Earliest FDA Approval Age Indication Topical anti- Dapsone Aczone July 2005 >12 years Topical retinoid Tretinoin Retin-A 0.025%, 0.05%, 0.1% October 1971 ≥12 years inflammatory Avita 0.025% January 1997 ≥12 years Atralin 0.05% July 2007 ≥10 years Fixed combination Adapalene Differin 0.1%, 0.3% May 1996 ≥12 years product: Tazarotene Tazorac 0.05%, 0.1% June 1997 ≥12 years BP � Abx BP � erythromycin Benzamycin Topical antibioticOctober 1984 Erythromycin>12 years Akne-Mycin, Erygel, Emgel January 1985 Indicated for pediatric use; BP � clindamycin Benzaclin December 2000 >12 years no specific age restrictions Duac August 2002 Clindamycin>12 years Cleocin T July 1980 ≥12 years Acanya October 2008 >12 years Evoclin October 2004 ≥12 years BP � retinoid BP � tretinoin Epiduo December 2008 >12 years Topical antiinflammatory Dapsone Aczone July 2005 ≥12 years Retinoid � Abx Tretinoin � Ziana November 2006 >12 years clindamycin Veltin Fixed combinationJuly 2010 product >12 years Oral antibiotic Erythromycin EES, Eryped, Ery-tab BP+Abx April 1965BP+erythromycin Indicated for pediatric Benzamycin use; no October 1984 ≥12 years specific age restrictions BP+clindamycin Benzaclin December 2000 ≥12 years Tetracycline Sumycin and others September 1954 >8 years Duac August 2002 ≥12 years Doxycycline Vibramycin, Doryx and Adoxa December 1967 8 years > Acanya October 2008 ≥12 years Minocycline Dynacin, Minocin, and others August 1982 >12 years Solodyn BP+retinoidMay 2006 BP+tretinoin>12 years Epiduo December 2008 ≥12 years Trimethoprim- Bactrim, Septra Retinoid+AbxJuly 1973Tretinoin+ 2 months Ziana November 2006 ≥12 years sulfamethoxazole clindamycin Veltin July 2010 ≥12 years Amoxicillin Amoxil Oral antibioticNovember 1979Erythromycin Indicated for pediatric EES, Eryped, use; Ery-tab no April 1965 Indicated for pediatric use; specific age restrictions no specific age restrictions Cephalexin Keflex January 1971 Indicated for pediatric use; no Tetracycline Sumycin and others September 1954 ≥8 years specific age restrictions Azithromycin Zithromax November 1991 Doxycycline>6 months Vibramycin, Doryx and Adoxa December 1967 ≥8 years Minocycline Dynacin, Minocin, and others August 1982 ≥12 years S20 A.C. Yan et al Systemic retinoid Isotretinoin Accutane May 1982 >12 years Solodyn May 2006 ≥12 years Amnesteem November 2002 Trimethoprim->12 years Bactrim, Septra July 1973 2 months Sotret December 2002 sulfamethoxazole>12 years ointment. Patients with oily skin may tolerate gels or solu- Conclusion Claravis April 2003 Amoxicillin>12 years Amoxil tions, whereasNovember those 1979 with dry or combinationIndicated for skin pediatric may use; prefer A wide range of acne therapies are available for pediatric use. Abx � antibiotics; BP � benzoyl peroxide. lotions or creams. no specific age restrictions A wide range of acne therapies are available for pediatric use. lotions or creams. Although most of these are indicated for use in patients � 12 Source: Drugs@FDA (http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm). Cephalexin Keflex January 1971 Indicated for pediatric use; Although most of these are indicated for use in patients � 12 Adjust regimens for tolerability. Sideno specific effects age may restrictions arise with years of age, judicious use of these medications in an off-label fashion for children with preadolescent acne is reasonable Azithromycin Zithromax use of topicalNovember acne 1991 medications, particularly≥6 months at the start of a fashion for children with preadolescent acne is reasonable new treatment. It is possible to mitigate these side effects by until more research is available regarding use of these agents Systemic retinoid Isotretinoin Accutane May 1982 ≥12 years in the preadolescent population. Amnesteem matchingNovember the vehicle 2002 to the patient’s≥12 skin years type, as mentioned in the preadolescent population. Most children with mild acne will tolerate topical agents Sotret above. SomeDecember patients 2002 who may have≥12 more years sensitive skin may Most children with mild acne will tolerate topical agents such as BP, topical retinoids, and topical antibiotics, either as Simplify treatment regimens. Successful adherence is in- worldwide,23 attesting to the popularity of therapeuticClaravis ritu- have concernsApril 2003 about tolerating topical≥12 retinoid years therapy; these such as BP, topical retinoids, and topical antibiotics, either as single agents or in fixed combinations, especially if the dosing versely related to the number of agents that must be taken or als,Abx=antibiotics; particularly BP=benzoyl among peroxide. adolescents. Source: Drugs@FDA (http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm).individuals may benefit from gradual escalation of the reti- single agents or in fixed combinations, especially if the dosing of these agents is escalated gradually, using some of the tech- applied and the number of times each day that they must be noid, initially applying the medication every other night for 1 of these agents is escalated gradually, using some of the tech- niques discussed. Those with moderate-to-severe acne may taken or used. For patients who have difficulty with adequate Consider vehicle appropriateness. Adherence also depends to 2 weeks before advancing to every-night therapy. Alterna- niques discussed. Those with moderate-to-severe acne may require systemic therapy. Children 8 years of age and older compliance, fixed-combination products may improve ad- on identifying patient preferences and matching vehicle se- tively, some patients prefer using medication every night by require systemic therapy. Children 8 years of age and older herence to the prescribed regimen. Interestingly, however, lectionsS20 to those preferences. For example, gels and foams are using short-contact applications for 30 to 60 minutesA.C. Yan during et al should be able to tolerate tetracycline derivatives, including S20 using short-contact applications for 30 to 60 minutesA.C. Yan during et al doxycycline and minocycline, which have more favorable one multistep, multicomponent, over-the-counter acne easier to spread on hairy areas such as the male chest. Other the first 1 to 2 weeks before advancing to overnight therapy. doxycycline and minocycline, which have more favorable product has generated a reported $830 million in sales patients may prefer the tactile sensation of a cream over an Starting with lower-potency retinoids and advancing to higher- antibiotic-resistance profiles and dosing schedules than does ointment. Patients with oily skin may tolerate gels or solu- StartingConclusion with lower-potency retinoids and advancing to higher- tetracycline. When possible, BP should be incorporated into tions,ointment. whereas Patients those with with oily dry skinor combination may tolerate skin gels may or prefer solu- potencyConclusion retinoids at follow-up visits may also improve effi- tetracycline. When possible, BP should be incorporated into topical regimens in an effort to reduce the potential for “eco- lotionstions, whereas or creams. those with dry or combination skin may prefer cacyA wide while range minimizing of acne therapies irritancy. are available for pediatric use. lotions or creams. AlthoughA wide range most of of acne these therapies are indicated are available for use for in patients pediatric� use.12 logical mischief” and the risk of altering native resident mi- crobial flora. When effective, subantimicrobial doses of anti- Adjust regimens for tolerability. Side effects may arise with ProvideAlthoughyears of age, written most judicious of action these use are plans, of indicated these videos, medications for text-messaginguse in patientsin an off-label� re-12 crobial flora. When effective, subantimicrobial doses of anti- biotics are preferable to higher doses, although many patients useAdjust of topical regimens acne for medications, tolerability. particularlySide effects at may the arise start with of a minders.fashionyears ofage, forWritten children judicious action with use plans, of preadolescent these educational medications acne videos, in is an reasonable and off-label text- biotics are preferable to higher doses, although many patients fashion for children with preadolescent acne is reasonable with moderate-to-severe acne may require antimicrobial newuse of treatment. topical acne It is medications, possible to mitigate particularly these at side the effects start of by a messaginguntil more reminders research is about available using regarding prescribed use medications of these agents are with moderate-to-severe acne may require antimicrobial until more research is available regarding use of these agents doses to control their disease. matchingnew treatment. the vehicle It is possible to the patient’s to mitigate skin these type, side as mentioned effects by amongin the preadolescent the various techniques population. advocated to reinforce treat- doses to control their disease. in the preadolescent population. Ultimately, optimal outcomes require not only selection of above.matching Some the patients vehicle to who the may patient’s have moreskin type, sensitive as mentioned skin may mentMost recommendations children with mild and improve acne will adherence. tolerate topical “Cheerlead- agents Ultimately, optimal outcomes require not only selection of Most children with mild acne will tolerate topical agents appropriate pharmacotherapy, but also an understanding haveabove. concerns Some patients about tolerating who may topical have more retinoid sensitive therapy; skin these may ing”such by as the BP, clinician topical retinoids, and staff and who topical see signs antibiotics, of improvement either as appropriate pharmacotherapy, but also an understanding such as BP, topical retinoids, and topical antibiotics, either as about factors that may affect compliance with recommended individualshave concerns may about benefit tolerating from gradual topical retinoid escalation therapy; of the these reti- cansingle encourage agents or patients in fixed to combinations, continue with especially their prescribed if the dosing reg- about factors that may affect compliance with recommended single agents or in fixed combinations, especially if the dosing therapeutic regimens. noid,individuals initially may applying benefit the from medication gradual every escalation other of night the for reti- 1 imens.of these agents is escalated gradually, using some of the tech- therapeutic regimens. of these agents is escalated gradually, using some of the tech- tonoid, 2 weeks initially before applying advancing the medication to every-night every therapy. other night Alterna- for 1 niques discussed. Those with moderate-to-severe acne may 18 to 2 weeks before advancing to every-night therapy. Alterna-globalacademycme.com/sdefManagerequireniques discussed. systemic expectations. therapy. • Those PediatricIt with is Children Acne important moderate-to-severe Management: 8 years to anticipate Optimizing of age andacne Outcomes side older may ef- References tively, some patients prefer using medication every night by fectsrequire and systemic educate patients therapy. in Children advance 8 that years most of side age effectsand older do References tively, some patients prefer using medication every night by fectsshould and be educate able to patients tolerate in tetracycline advance that derivatives, most side effects including do 1. The Lewin Group. The Burden of Skin Diseases 2005. Available at: using short-contact applications for 30 to 60 minutes during notshould require be able stopping to tolerate a medication tetracycline but canderivatives, be managed including suc- 1. The Lewin Group. The Burden of Skin Diseases 2005. Available at: theusing first short-contact 1 to 2 weeks applications before advancing for 30 to 60overnight minutes therapy. during notdoxycycline require stopping and minocycline, a medication which but can have be more managed favorable suc- http://www.lewin.com/content/publications/april2005skindisease.pdf. cessfullydoxycycline with and minor minocycline, adjustments which in the have regimen. more Pediatricfavorable Accessed May 10, 2011 Startingthe first with 1 to 2lower-potency weeks before retinoids advancing and to advancing overnight to therapy. higher- cessfullyantibiotic-resistance with minor profiles adjustments and dosing in the schedules regimen. than Pediatric does Accessed May 10, 2011 Starting with lower-potency retinoids and advancing to higher- andtetracycline.antibiotic-resistance especially When adolescent possible, profiles patients and BP should dosing also benefit be schedules incorporated from than under- does into 2. Yentzer BA, Irby CE, Fleischer AB Jr, Feldman SR: Differences in acne potency retinoids at follow-up visits may also improve effi- tetracycline. When possible, BP should be incorporated into treatment prescribing patterns of pediatricians and dermatologists: An potency retinoids at follow-up visits may also improve effi- standingtopical regimens the definition in an of effort a “reasonable to reduce time the potential frame” for for seeing “eco- treatment prescribing patterns of pediatricians and dermatologists: An cacy while minimizing irritancy. topical regimens in an effort to reduce the potential for “eco- analysis of nationally representative data. Pediatr Dermatol 25:635- cacy while minimizing irritancy. signslogical of mischief” improvement. and the These risk patients of altering often native have resident unrealistic mi- 639, 2008 logical mischief” and the risk of altering native resident mi- 639, 2008 Provide written action plans, videos, text-messaging re- expectationscrobial flora. of When seeing effective, improvement subantimicrobial in hours to doses days of (often anti- 3. Turowski CB, James WD: The efficacy and safety of amoxicillin, tri- crobial flora. When effective, subantimicrobial doses of anti- 3. Turowski CB, James WD: The efficacy and safety of amoxicillin, tri- minders.Provide writtenWritten action action plans, educational videos, text-messaging videos, and text- re- reinforcedbiotics are preferableby what they to higher see in doses, advertisements although many for over-the- patients methoprim sulfamethoxazole, and spironolactone for treatment-resis- biotics are preferable to higher doses, although many patients tant acne vulgaris. Adv Dermatol 23:155-163, 2007 minders.messagingWritten reminders action about plans, using educational prescribed videos, medications and text- are counterwith moderate-to-severe products that promise acne overnight may require results), antimicrobial whereas tant acne vulgaris. Adv Dermatol 23:155-163, 2007 messaging reminders about using prescribed medications are with moderate-to-severe acne may require antimicrobial 4. Fenner JA, Wiss K, Levin NA: Oral cephalexin for acne vulgaris: Clin- among the various techniques advocated to reinforce treat- thedoses typical to control improvement their disease. is measured in weeks to months. ical experience with 93 patients. Pediatr Dermatol 25:179-183, 2008 among the various techniques advocated to reinforce treat- dosesUltimately, to control optimal their disease. outcomes require not only selection of ical experience with 93 patients. Pediatr Dermatol 25:179-183, 2008 ment recommendations and improve adherence. “Cheerlead- 5. Bhambri S, Del Rosso JQ, Desai A: Oral trimethoprim/sulfamethoxazole ment recommendations and improve adherence. “Cheerlead- MonitorappropriateUltimately, for psychological pharmacotherapy, optimal outcomes comorbidities. butrequire also notThe an only understanding psychological selection of in the treatment of acne vulgaris. Cutis 79:430-434, 2007 ing” by the clinician and staff who see signs of improvement 24 in the treatment of acne vulgaris. Cutis 79:430-434, 2007 impactappropriate of acne pharmacotherapy, can be considerable. but One also study an24 understandingaffirmed that 6. Rafiei R, Yaghoobi R. Azithromycin versus tetracycline in the treatment caning” encourage by the clinician patients and to staff continue who seewith signs their of prescribed improvement reg- impactabout factors of acne that canmay be considerable. affect compliance One study with recommendedaffirmed that 6. Rafiei R, Yaghoobi R. Azithromycin versus tetracycline in the treatment can encourage patients to continue with their prescribed reg- adolescenttherapeuticabout factors patients regimens. that may often affect have compliance psychological with and recommended especially of acne vulgaris. J Drugs Dermatol 17:217-221, 2006 imens. 7. Cunliffe WJ, Aldana OL, Goulden V: Oral trimethoprim: A relatively imens. moodtherapeutic issues regimens. related to their acne in a severity-dependent 7. Cunliffe WJ, Aldana OL, Goulden V: Oral trimethoprim: A relatively safe and successful third-line treatment for acne vulgaris. Br J Dermatol Manage expectations. It is important to anticipate side ef- fashion. The more severe the acne, the more severe and more 141:757-758, 1999 Manage expectations. It is important to anticipate side ef- prevalentReferences were the mood disturbances that were noted. Cli- 141:757-758, 1999 fects and educate patients in advance that most side effects do prevalentReferences were the mood disturbances that were noted. Cli- 8. Maleszka R, Turek-Urasinska K, Oremus M, Vukovic J, Barsic B: Pulsed fects and educate patients in advance that most side effects do 1. The Lewin Group. The Burden of Skin Diseases 2005. Available at: azithromycin treatment is as effective and safe as 2-week-longer daily not require stopping a medication but can be managed suc- nicians1. The who Lewin care Group. for The patients Burden with of Skin acne Diseases should 2005. remain Available alert at: azithromycin treatment is as effective and safe as 2-week-longer daily http://www.lewin.com/content/publications/april2005skindisease.pdf. doxycycline treatment of acne vulgaris: A randomized, double-blind, not require stopping a medication but can be managed suc- for thehttp://www.lewin.com/content/publications/april2005skindisease.pdf. presence of depression or other emotional or social doxycycline treatment of acne vulgaris: A randomized, double-blind, cessfully with minor adjustments in the regimen. Pediatric for theAccessed presence May 10, of 2011 depression or other emotional or social noninferiority study. Skinmed 9:86-94, 2011 cessfully with minor adjustments in the regimen. Pediatric Accessed May 10, 2011 noninferiority study. Skinmed 9:86-94, 2011 and especially adolescent patients also benefit from under- issues,2. Yentzer and BA, may Irby provide CE, Fleischer encouragement AB Jr, Feldman for SR: the Differences patient in and acne 9. Parsad D, Pandhi R, Nagpal R, Negi KS: Azithromycin monthly pulse vs daily 2. Yentzer BA, Irby CE, Fleischer AB Jr, Feldman SR: Differences in acne 9. Parsad D, Pandhi R, Nagpal R, Negi KS: Azithromycin monthly pulse vs daily and especially adolescent patients also benefit from under- familytreatment to seek prescribing counseling patterns or other of pediatricians therapy, and as dermatologists: appropriate. An doxycycline in the treatment of acne vulgaris. J Dermatol 28:1-4, 2001 standing the definition of a “reasonable time frame” for seeing familytreatment to seek prescribing counseling patterns or other of pediatricians therapy, and as dermatologists: appropriate. An doxycycline in the treatment of acne vulgaris. J Dermatol 28:1-4, 2001 standing the definition of a “reasonable time frame” for seeing analysis of nationally representative data. Pediatr Dermatol 25:635- 10. Kus S, Yucelten D, Aytug A: Comparison of efficacy of azithromycin vs. signs of improvement. These patients often have unrealistic analysis of nationally representative data. Pediatr Dermatol 25:635- 10. Kus S, Yucelten D, Aytug A: Comparison of efficacy of azithromycin vs. Consider639, 2008 cost issues. Medication costs can have a substan- doxycycline in the treatment of acne vulgaris. Clin Exp Dermatol 30: signs of improvement. These patients often have unrealistic Consider639, 2008 cost issues. Medication costs can have a substan- doxycycline in the treatment of acne vulgaris. Clin Exp Dermatol 30: expectations of seeing improvement in hours to days (often 3. Turowski CB, James WD: The efficacy and safety of amoxicillin, tri- 215-220, 2005 expectations of seeing improvement in hours to days (often tial3. impact Turowski on CB, whether James WD: a prescription The efficacy andis filled safety and of amoxicillin, on whether tri- 215-220, 2005 reinforced by what they see in advertisements for over-the- methoprim sulfamethoxazole, and spironolactone for treatment-resis- 11. Singhi MK, Ghiya BC, Dhabhai RK: Comparison of oral azithromycin a patientmethoprim who sulfamethoxazole, begins using a and medication spironolactone remains for treatment-resis- adherent 11. Singhi MK, Ghiya BC, Dhabhai RK: Comparison of oral azithromycin counterreinforced products by what that they promise see in advertisements overnight results), for over-the- whereas a patienttant acne who vulgaris. begins Adv using Dermatol a medication 23:155-163, 2007 remains adherent pulse with daily doxycycline in the treatment of acne vulgaris. Indian J withtant the acne recommended vulgaris. Adv Dermatol regimen 23:155-163, in the long 2007 term. Cost con- pulse with daily doxycycline in the treatment of acne vulgaris. Indian J counter products that promise overnight results), whereas with4. Fenner the recommended JA, Wiss K, Levin regimen NA: Oral in cephalexin the long for term. acne vulgaris: Cost con- Clin- Dermatol Venereol Leprol 69:274-276, 2003 the typical improvement is measured in weeks to months. 4. Fenner JA, Wiss K, Levin NA: Oral cephalexin for acne vulgaris: Clin- Dermatol Venereol Leprol 69:274-276, 2003 siderationsical experience should with be 93 taken patients. into Pediatr account Dermatol when 25:179-183, selecting 2008 ap- 12. Gruber F, Grubisic´-Greblo H, Kastelan M, Brajac I, Lenkovic´ M, Za- the typical improvement is measured in weeks to months. siderationsical experience should with be 93 taken patients. into Pediatr account Dermatol when 25:179-183, selecting 2008 ap- 12. Gruber F, Grubisic´-Greblo H, Kastelan M, Brajac I, Lenkovic´ M, Za- propriate5. Bhambri medications. S, Del Rosso JQ, Desai A: Oral trimethoprim/sulfamethoxazole molo G: Azithromycin compared with minocycline in the treatment of Monitor for psychological comorbidities. The psychological propriate5. Bhambri medications. S, Del Rosso JQ, Desai A: Oral trimethoprim/sulfamethoxazole molo G: Azithromycin compared with minocycline in the treatment of Monitor for psychological comorbidities. The psychological in the treatment of acne vulgaris. Cutis 79:430-434, 2007 impact of acne can be considerable. One study24 affirmed that 6. Rafieiin the R, treatment Yaghoobi of R. acne Azithromycin vulgaris. Cutis versus 79:430-434, tetracycline 2007 in the treatment 24 impactadolescent of acne patients can be often considerable. have psychological One study andaffirmed especially that 6.of Rafiei acne R, vulgaris. Yaghoobi J DrugsR. Azithromycin Dermatol 17:217-221, versus tetracycline 2006 in the treatment of acne vulgaris. J Drugs Dermatol 17:217-221, 2006 moodadolescent issues patients related often to their have acne psychological in a severity-dependent and especially 7. Cunliffe WJ, Aldana OL, Goulden V: Oral trimethoprim: A relatively mood issues related to their acne in a severity-dependent 7.safe Cunliffe and successful WJ, Aldana third-line OL, Goulden treatment V: Oral for acne trimethoprim: vulgaris. Br A J Dermatol relatively fashion. The more severe the acne, the more severe and more safe and successful third-line treatment for acne vulgaris. Br J Dermatol fashion. The more severe the acne, the more severe and more 141:757-758, 1999 prevalent were the mood disturbances that were noted. Cli- 8. Maleszka141:757-758, R, Turek-Urasinska 1999 K, Oremus M, Vukovic J, Barsic B: Pulsed niciansprevalent who were care the for mood patients disturbances with acne that should were remain noted. alert Cli- 8.azithromycin Maleszka R, Turek-Urasinska treatment is as effectiveK, Oremus and M, safe Vukovic as 2-week-longer J, Barsic B: Pulsed daily fornicians the presencewho care of for depression patients with or other acne should emotional remain or social alert doxycyclineazithromycin treatment treatment of is acne as effective vulgaris: and A saferandomized, as 2-week-longer double-blind, daily for the presence of depression or other emotional or social noninferioritydoxycycline treatment study. Skinmed of acne 9:86-94, vulgaris: 2011 A randomized, double-blind, issues, and may provide encouragement for the patient and noninferiority study. Skinmed 9:86-94, 2011 issues, and may provide encouragement for the patient and 9. Parsad D, Pandhi R, Nagpal R, Negi KS: Azithromycin monthly pulse vs daily family to seek counseling or other therapy, as appropriate. 9.doxycycline Parsad D, Pandhi in the R, treatment Nagpal R, of Negi acne KS: vulgaris. Azithromycin J Dermatol monthly 28:1-4, pulse 2001 vs daily family to seek counseling or other therapy, as appropriate. 10.doxycycline Kus S, Yucelten in the D, treatment Aytug A: of Comparison acne vulgaris. of J Dermatol efficacy of 28:1-4, azithromycin 2001 vs. Consider cost issues. Medication costs can have a substan- 10.doxycycline Kus S, Yucelten in the D, Aytug treatment A: Comparison of acne vulgaris. of efficacy Clin of Exp azithromycin Dermatol 30: vs. tialConsider impact cost on whether issues. Medication a prescription costs is filled can haveand on a substan- whether 215-220,doxycycline 2005 in the treatment of acne vulgaris. Clin Exp Dermatol 30: atial patient impact who on whether begins using a prescription a medication is filled remains and on adherent whether 11. Singhi215-220, MK, 2005 Ghiya BC, Dhabhai RK: Comparison of oral azithromycin 11. Singhi MK, Ghiya BC, Dhabhai RK: Comparison of oral azithromycin witha patient the recommended who begins using regimen a medication in the long remains term. Cost adherent con- pulse with daily doxycycline in the treatment of acne vulgaris. Indian J with the recommended regimen in the long term. Cost con- Dermatolpulse with Venereol daily doxycycline Leprol 69:274-276, in the treatment 2003 of acne vulgaris. Indian J siderations should be taken into account when selecting ap- 12. GruberDermatol F, Venereol Grubisic´-Greblo Leprol 69:274-276, H, Kastelan 2003 M, Brajac I, Lenkovic´ M, Za- propriatesiderations medications. should be taken into account when selecting ap- 12.molo Gruber G: F, Azithromycin Grubisic´-Greblo compared H, Kastelan with minocycline M, Brajac I, in Lenkovic´ the treatment M, Za- of propriate medications. molo G: Azithromycin compared with minocycline in the treatment of S20 A.C. Yan et al S20 A.C. Yan et al ointment. Patients with oily skin may tolerate gels or solu- ointment. Patients with oily skin may tolerate gels or solu- Conclusion tions,ointment. whereas Patients those with with oily dry skinor combination may tolerate skin gels may or prefer solu- Conclusion tions, whereas those with dry or combination skin may prefer A wide range of acne therapies are available for pediatric use. lotions or creams. A wide range of acne therapies are available for pediatric use. lotions or creams. AlthoughA wide range most of of acne these therapies are indicated are available for use for in patients pediatric� use.12 lotions or creams. Although most of these are indicated for use in patients � 12 Adjust regimens for tolerability. Side effects may arise with Althoughyears of age, most judicious of these use are of indicated these medications for use in patientsin an off-label� 12 Adjust regimens for tolerability. Side effects may arise with years of age, judicious use of these medications in an off-label useAdjust of topical regimens acne for medications, tolerability. particularlySide effects at may the arise start with of a fashionyears ofage, for children judicious with use of preadolescent these medications acne in is an reasonable off-label use of topical acne medications, particularly at the start of a fashion for children with preadolescent acne is reasonable newuse of treatment. topical acne It is medications, possible to mitigate particularly these at side the effects start of by a untilfashion more for research children is with available preadolescent regarding acneuse of is these reasonable agents new treatment. It is possible to mitigate these side effects by until more research is available regarding use of these agents new treatment. It is possible to mitigate these side effects by inuntil the more preadolescent research is population. available regarding use of these agents matching the vehicle to the patient’s skin type, as mentioned in the preadolescent population. matching the vehicle to the patient’s skin type, as mentioned inMost the preadolescent children with population. mild acne will tolerate topical agents above. Some patients who may have more sensitive skin may Most children with mild acne will tolerate topical agents above. Some patients who may have more sensitive skin may suchMost as BP, children topical with retinoids, mild acne and topical will tolerate antibiotics, topical either agents as have concerns about tolerating topical retinoid therapy; these such as BP, topical retinoids, and topical antibiotics, either as have concerns about tolerating topical retinoid therapy; these singlesuch as agents BP, topical or in fixed retinoids, combinations, and topical especially antibiotics, if the either dosing as individuals may benefit from gradual escalation of the reti- single agents or in fixed combinations, especially if the dosing individuals may benefit from gradual escalation of the reti- ofsingle these agents agents or is in escalated fixed combinations, gradually, using especially some if of the the dosing tech- noid, initially applying the medication every other night for 1 of these agents is escalated gradually, using some of the tech- noid, initially applying the medication every other night for 1 niquesof these discussed. agents is escalated Those with gradually, moderate-to-severe using some of acne the tech- may to 2 weeks before advancing to every-night therapy. Alterna- niques discussed. Those with moderate-to-severe acne may to 2 weeks before advancing to every-night therapy. Alterna- requireniques discussed. systemic therapy. Those with Children moderate-to-severe 8 years of age andacne older may tively, some patients prefer using medication every night by require systemic therapy. Children 8 years of age and older tively, some patients prefer using medication every night by shouldrequire be systemic able to therapy. tolerate Childrentetracycline 8 years derivatives, of age andincluding older usingtively, short-contact some patients applications prefer using for medication 30 to 60 minutes every night during by should be able to tolerate tetracycline derivatives, including using short-contact applications for 30 to 60 minutes during doxycyclineshould be able and to minocycline, tolerate tetracycline which derivatives, have more including favorable theusing first short-contact 1 to 2 weeks applications before advancing for 30 to 60overnight minutes therapy. during doxycycline and minocycline, which have more favorable the first 1 to 2 weeks before advancing to overnight therapy. antibiotic-resistancedoxycycline and minocycline, profiles and which dosing have schedules more than favorable does Startingthe first with 1 to 2lower-potency weeks before retinoids advancing and to advancing overnight to therapy. higher- antibiotic-resistance profiles and dosing schedules than does Starting with lower-potency retinoids and advancing to higher- tetracycline.antibiotic-resistance When possible, profiles and BP should dosing be schedules incorporated than does into potencyStarting with retinoids lower-potency at follow-up retinoids visits and may advancing also improve to higher- effi- tetracycline. When possible, BP should be incorporated into potency retinoids at follow-up visits may also improve effi- topicaltetracycline. regimens When in possible,an effort to BP reduce should the be potential incorporated for “eco- into cacypotency while retinoids minimizing at follow-up irritancy. visits may also improve effi- topical regimens in an effort to reduce the potential for “eco- cacy while minimizing irritancy. logicaltopical mischief”regimens in and an the effort risk to of reduce altering the native potential resident for “eco- mi- cacy while minimizing irritancy. logical mischief” and the risk of altering native resident mi- crobiallogical mischief” flora. When and effective, the risk subantimicrobial of altering native doses resident of anti- mi- Provide written action plans, videos, text-messaging re- crobial flora. When effective, subantimicrobial doses of anti- Provide written action plans, videos, text-messaging re- bioticscrobial are flora. preferable When effective, to higher subantimicrobial doses, although many doses patients of anti- minders. Written action plans, educational videos, and text- biotics are preferable to higher doses, although many patients minders. Written action plans, educational videos, and text- withbiotics moderate-to-severe are preferable to higher acne doses, may although require many antimicrobial patients messaging reminders about using prescribed medications are with moderate-to-severe acne may require antimicrobial messaging reminders about using prescribed medications are doseswith moderate-to-severe to control their disease. acne may require antimicrobial among the various techniques advocated to reinforce treat- doses to control their disease. among the various techniques advocated to reinforce treat- dosesUltimately, to control optimal their disease. outcomes require not only selection of ment recommendations and improve adherence. “Cheerlead- Ultimately, optimal outcomes require not only selection of ment recommendations and improve adherence. “Cheerlead- appropriateUltimately, pharmacotherapy, optimal outcomes butrequire also not an only understanding selection of ing” by the clinician and staff who see signs of improvement appropriate pharmacotherapy, but also an understanding ing” by the clinician and staff who see signs of improvement aboutappropriate factors pharmacotherapy, that may affect compliance but also with an understandingrecommended caning” encourage by the clinician patients and to staff continue who seewith signs their of prescribed improvement reg- about factors that may affect compliance with recommended can encourage patients to continue with their prescribed reg- therapeuticabout factors regimens. that may affect compliance with recommended imens.can encourage patients to continue with their prescribed reg- therapeutic regimens. imens. therapeutic regimens. Manage expectations. It is important to anticipate side ef- Manage expectations. It is important to anticipate side ef- References fectsManage and expectations.educate patientsIt in is advance important that to most anticipate side effects side ef-do ReferencesReferences fects and educate patients in advance that most side effects do References1. The Lewin Group. The Burden of Skin Diseases 2005. Available at: fects and educate patients in advance that most side effects do 1. The Lewin Group. The Burden of Skin Diseases 2005. Available at: not require stopping a medication but can be managed suc- 1.http://www.lewin.com/content/publications/april2005skindisease.pdf. The Lewin Group. The Burden of Skin Diseases 2005. Available at: not require stopping a medication but can be managed suc- http://www.lewin.com/content/publications/april2005skindisease.pdf. cessfullynot require with stopping minor a adjustments medication inbut the can regimen. be managed Pediatric suc- Accessedhttp://www.lewin.com/content/publications/april2005skindisease.pdf. May 10, 2011 cessfully with minor adjustments in the regimen. Pediatric Accessed May 10, 2011 cessfully with minor adjustments in the regimen. Pediatric 2. YentzerAccessed BA, May Irby 10, CE, 2011 Fleischer AB Jr, Feldman SR: Differences in acne and especially adolescent patients also benefit from under- 2. Yentzer BA, Irby CE, Fleischer AB Jr, Feldman SR: Differences in acne and especially adolescent patients also benefit from under- 2.treatment Yentzer BA, prescribing Irby CE, Fleischer patterns ofAB pediatricians Jr, Feldman andSR:Differences dermatologists: in acne An standingand especially the definition adolescent of a patients “reasonable also time benefit frame” from for under- seeing treatment prescribing patterns of pediatricians and dermatologists: An standing the definition of a “reasonable time frame” for seeing analysistreatment of prescribing nationally patterns representative of pediatricians data. Pediatr and dermatologists: Dermatol 25:635- An standing the definition of a “reasonable time frame” for seeing analysis of nationally representative data. Pediatr Dermatol 25:635- signs of improvement. These patients often have unrealistic 639,analysis 2008 of nationally representative data. Pediatr Dermatol 25:635- signs of improvement. These patients often have unrealistic 639, 2008 expectations of seeing improvement in hours to days (often 3. Turowski639, 2008 CB, James WD: The efficacy and safety of amoxicillin, tri- expectations of seeing improvement in hours to days (often 3. Turowski CB, James WD: The efficacy and safety of amoxicillin, tri- expectations of seeing improvement in hours to days (often 3.methoprim Turowski CB, sulfamethoxazole, James WD: The and efficacy spironolactone and safety for of amoxicillin,treatment-resis- tri- reinforced by what they see in advertisements for over-the- methoprim sulfamethoxazole, and spironolactone for treatment-resis- reinforced by what they see in advertisements for over-the- tantmethoprim acne vulgaris. sulfamethoxazole, Adv Dermatol and 23:155-163, spironolactone 2007 for treatment-resis- counter products that promise overnight results), whereas tant acne vulgaris. Adv Dermatol 23:155-163, 2007 counter products that promise overnight results), whereas 4. Fennertant acne JA, vulgaris. Wiss K, Adv Levin Dermatol NA: Oral 23:155-163, cephalexin 2007 for acne vulgaris: Clin- counter products that promise overnight results), whereas 4. Fenner JA, Wiss K, Levin NA: Oral cephalexin for acne vulgaris: Clin- the typical improvement is measured in weeks to months. 4.ical Fenner experience JA, Wiss with K, Levin 93 patients. NA: Oral Pediatr cephalexin Dermatol foracne 25:179-183, vulgaris: 2008 Clin- the typical improvement is measured in weeks to months. ical experience with 93 patients. Pediatr Dermatol 25:179-183, 2008 the typical improvement is measured in weeks to months. 5. Bhambriical experience S, Del Rosso with 93 JQ, patients. Desai A: Pediatr Oral trimethoprim/sulfamethoxazole Dermatol 25:179-183, 2008 Monitor for psychological comorbidities. The psychological 5. Bhambri S, Del Rosso JQ, Desai A: Oral trimethoprim/sulfamethoxazole Monitor for psychological comorbidities. The psychological 5.in Bhambri the treatment S, Del Rosso of acne JQ, vulgaris. Desai A: OralCutis trimethoprim/sulfamethoxazole 79:430-434, 2007 Monitor for psychological comorbidities. The24 psychological in the treatment of acne vulgaris. Cutis 79:430-434, 2007 impact of acne can be considerable. One study24 affirmed that 6. Rafieiin the R, treatment Yaghoobi of R. acne Azithromycin vulgaris. Cutis versus 79:430-434, tetracycline 2007 in the treatment impact of acne can be considerable. One study24 affirmed that 6. Rafiei R, Yaghoobi R. Azithromycin versus tetracycline in the treatment impactadolescent of acne patients can be often considerable. have psychological One study andaffirmed especially that 6.of Rafiei acne R, vulgaris. Yaghoobi J DrugsR. Azithromycin Dermatol 17:217-221, versus tetracycline 2006 in the treatment adolescent patients often have psychological and especially of acne vulgaris. J Drugs Dermatol 17:217-221, 2006 adolescent patients often have psychological and especially 7. Cunliffeof acne vulgaris. WJ, Aldana J Drugs OL, Dermatol Goulden 17:217-221, V: Oral trimethoprim: 2006 A relatively mood issues related to their acne in a severity-dependent 7. Cunliffe WJ, Aldana OL, Goulden V: Oral trimethoprim: A relatively mood issues related to their acne in a severity-dependent 7.safe Cunliffe and successful WJ, Aldana third-line OL, Goulden treatment V: Oral for acne trimethoprim: vulgaris. Br A J Dermatol relatively mood issues related to their acne in a severity-dependent safe and successful third-line treatment for acne vulgaris. Br J Dermatol fashion. The more severe the acne, the more severe and more 141:757-758,safe and successful 1999 third-line treatment for acne vulgaris. Br J Dermatol fashion. The more severe the acne, the more severe and more 141:757-758, 1999 prevalent were the mood disturbances that were noted. Cli- 8. Maleszka141:757-758, R, Turek-Urasinska 1999 K, Oremus M, Vukovic J, Barsic B: Pulsed prevalent were the mood disturbances that were noted. Cli- 8. Maleszka R, Turek-Urasinska K, Oremus M, Vukovic J, Barsic B: Pulsed niciansprevalent who were care the for mood patients disturbances with acne that should were remain noted. alert Cli- 8.azithromycin Maleszka R, Turek-Urasinska treatment is as effectiveK, Oremus and M, safe Vukovic as 2-week-longer J, Barsic B: Pulsed daily nicians who care for patients with acne should remain alert azithromycin treatment is as effective and safe as 2-week-longer daily nicians who care for patients with acne should remain alert doxycyclineazithromycin treatment treatment of is acne as effective vulgaris: and A saferandomized, as 2-week-longer double-blind, daily for the presence of depression or other emotional or social doxycycline treatment of acne vulgaris: A randomized, double-blind, for the presence of depression or other emotional or social noninferioritydoxycycline treatment study. Skinmed of acne 9:86-94, vulgaris: 2011 A randomized, double-blind, for the presence of depression or other emotional or social noninferiority study. Skinmed 9:86-94, 2011 issues, and may provide encouragement for the patient and 9. Parsadnoninferiority D, Pandhi study. R, Nagpal Skinmed R, Negi 9:86-94, KS: Azithromycin 2011 monthly pulse vs daily issues, and may provide encouragement for the patient and 9. Parsad D, Pandhi R, Nagpal R, Negi KS: Azithromycin monthly pulse vs daily family to seek counseling or other therapy, as appropriate. 9.doxycycline Parsad D, Pandhi in the R, treatment Nagpal R, of Negi acne KS: vulgaris. Azithromycin J Dermatol monthly 28:1-4, pulse 2001 vs daily family to seek counseling or other therapy, as appropriate. doxycycline in the treatment of acne vulgaris. J Dermatol 28:1-4, 2001 family to seek counseling or other therapy, as appropriate. 10.doxycycline Kus S, Yucelten in the D, treatment Aytug A: of Comparison acne vulgaris. of J Dermatol efficacy of 28:1-4, azithromycin 2001 vs. 10. Kus S, Yucelten D, Aytug A: Comparison of efficacy of azithromycin vs. Consider cost issues. Medication costs can have a substan- 10.doxycycline Kus S, Yucelten in the D, Aytug treatment A: Comparison of acne vulgaris. of efficacy Clin of Exp azithromycin Dermatol 30: vs. Consider cost issues. Medication costs can have a substan- doxycycline in the treatment of acne vulgaris. Clin Exp Dermatol 30: tialConsider impact cost on whether issues. Medication a prescription costs is filled can haveand on a substan- whether 215-220,doxycycline 2005 in the treatment of acne vulgaris. Clin Exp Dermatol 30: tial impact on whether a prescription is filled and on whether 215-220, 2005 tial impact on whether a prescription is filled and on whether 11. Singhi215-220, MK, 2005 Ghiya BC, Dhabhai RK: Comparison of oral azithromycin a patient who begins using a medication remains adherent 11. Singhi MK, Ghiya BC, Dhabhai RK: Comparison of oral azithromycin a patient who begins using a medication remains adherent 11.pulse Singhi with MK, daily Ghiya doxycycline BC, Dhabhai in the RK: treatment Comparison of acne of oral vulgaris. azithromycin Indian J witha patient the recommended who begins using regimen a medication in the long remains term. Cost adherent con- pulse with daily doxycycline in the treatment of acne vulgaris. Indian J with the recommended regimen in the long term. Cost con- Dermatolpulse with Venereol daily doxycycline Leprol 69:274-276, in the treatment 2003 of acne vulgaris. Indian J with the recommended regimen in the long term. Cost con- ApproachDermatol to pediatric Venereol Leprol acne treatment 69:274-276, 2003 S21 siderations should be taken into account when selecting ap- 12. GruberDermatol F, Venereol Grubisic´-Greblo Leprol 69:274-276, H, Kastelan 2003 M, Brajac I, Lenkovic´ M, Za- siderations should be taken into account when selecting ap- 12. Gruber F, Grubisic´-Greblo H, Kastelan M, Brajac I, Lenkovic´ M, Za- S20 propriate medications. A.C. Yan et al 12.molo Gruber G: F, Azithromycin Grubisic´-Greblo compared H, Kastelan with minocycline M, Brajac I, in Lenkovic´ the treatment M, Za- of propriate medications. moloacne G:comedonica Azithromycin and compared papulo-pustulosa. with minocycline J Chemother in the 10:469-473,treatment of 19. Eady AE, Cove JH, Layton AM: Is antibiotic resistance in cutaneous 1998 propionibacteria clinically relevant? Implications of resistance for acne ointment. Patients with oily skin may tolerate gels or solu- Conclusion 13. Antonio JR, Pegas JR, Cestari TF, DoNascimento LV: Azithromycin patients and prescribers. Am J Clin Dermatol 4:813-831, 2003 tions, whereas those with dry or combination skin may prefer pulses in the treatment of inflammatory and pustular acne: Efficacy, 20. Skidmore R, Kovach R, Walker C, et al: Effects of subantimicrobial- A wide range of acne therapies are available for pediatric use. tolerability, and safety. J Dermatolog Treat 19:210-215, 2008 dose doxycycline in the treatment of moderate acne. Arch Dermatol lotions or creams. 14. Innocenzi D, Skroza N, Ruggiero A, Concetta Potenza M, Proietti I: Although most of these are indicated for use in patients � 12 139:459-464, 2003 Moderate acne vulgaris: Efficacy, tolerance and compliance of oral azi- 21. Eichenfield L, Matiz C, Funk A, Dill SW: Study of the efficacy and Adjust regimens for tolerability. Side effects may arise with years of age, judicious use of these medications in an off-label thromycin thrice weekly. Acta Dermatovenerol Croat 16:13-18, 2008 tolerability of 0.04% tretinoin microsphere gel for preadolescent acne. 15. Kapadia N, Talib A: Acne treated successfully with azithromycin. Int J use of topical acne medications, particularly at the start of a fashion for children with preadolescent acne is reasonable Pediatrics 125:1316-1323, 2010 Dermatol 43:766-767, 2004 new treatment. It is possible to mitigate these side effects by until more research is available regarding use of these agents 22. Cunliffe WJ, Baron SE, Coulson IH: A clinical and therapeutic study of in the preadolescent population. 16. Gruber F, Grubisic-Greblo H, Kastelan M, Brajac I, Lenkovic M, Zamolo G: matching the vehicle to the patient’s skin type, as mentioned Azithromycin compared with minocycline in the treatment of acne come- 29 patients with infantile acne. Br J Dermatol 145:463-466, 2001 above. Some patients who may have more sensitive skin may Most children with mild acne will tolerate topical agents donica and papulo-pustulosa. J Chemother 10:469-473, 1998 23. Katz S: Online exclusive: Proactive reformulates packaging. Available at: have concerns about tolerating topical retinoid therapy; these such as BP, topical retinoids, and topical antibiotics, either as 17. Fernandez-Obregon AC: Azithromycin for the treatment of acne. Int J http://www.beautypackaging.com/articles/2010/01/online-exclusive- proactiv-reformulates-packaging. Accessed July 19, 2011. individuals may benefit from gradual escalation of the reti- single agents or in fixed combinations, especially if the dosing Dermatol 39:45-50, 2000 Approachof these agents to pediatric is escalated acne treatment gradually, using some of the tech- 18. Leyden JJ, Del Rosso JQ, Webster GF: Clinical considerations inS21 the 24. Dalgard F, Gieler U, Holm JO, Bjertness E, Hauser S: Self-esteem and noid, initially applying the medication every other night for 1 treatment of acne vulgaris and other inflammatory skin disorders: A body satisfaction among late adolescdents with acne: Results from a to 2 weeks before advancing to every-night therapy. Alterna- niques discussed. Those with moderate-to-severe acne may status report. Dermatol Clin 27:1-15, 2009 population survey. J Am Acad Dermatol 59:46-51, 2008 tively, some patients prefer using medication every night by requireacne systemic comedonica therapy. and papulo-pustulosa. Children 8 years J Chemother of age 10:469-473, and older 19. Eady AE, Cove JH, Layton AM: Is antibiotic resistance in cutaneous 1998 using short-contact applications for 30 to 60 minutes during should be able to tolerate tetracycline derivatives, including propionibacteria clinically relevant? Implications of resistance for acne 13.doxycycline Antonio JR, and Pegas minocycline, JR, Cestari TF, which DoNascimento have more LV: Azithromycin favorable patients and prescribers. Am J Clin Dermatol 4:813-831, 2003 the first 1 to 2 weeks before advancing to overnight therapy. pulses in the treatment of inflammatory and pustular acne: Efficacy, antibiotic-resistance profiles and dosing schedules than does 20. Skidmore R, Kovach R, Walker C, et al: Effects of subantimicrobial- Starting with lower-potency retinoids and advancing to higher- tolerability, and safety. J Dermatolog Treat 19:210-215, 2008 dose doxycycline in the treatment of moderate acne. Arch Dermatol tetracycline. When possible, BP should be incorporated into potency retinoids at follow-up visits may also improve effi- 14. Innocenzi D, Skroza N, Ruggiero A, Concetta Potenza M, Proietti I: 139:459-464, 2003 topicalModerate regimens acne vulgaris: in an effort Efficacy, to tolerance reduce andthe compliance potential offor oral “eco- azi- 21. Eichenfield L, Matiz C, Funk A, Dill SW: Study of the efficacy and cacy while minimizing irritancy. thromycin thrice weekly. Acta Dermatovenerol Croat 16:13-18, 2008 logical mischief” and the risk of altering native resident mi- tolerability of 0.04% tretinoin microsphere gel for preadolescent acne. 15. Kapadia N, Talib A: Acne treated successfully with azithromycin. Int J crobial flora. When effective, subantimicrobial doses of anti- Pediatrics 125:1316-1323, 2010 Provide written action plans, videos, text-messaging re- Dermatol 43:766-767, 2004 22. Cunliffe WJ, Baron SE, Coulson IH: A clinical and therapeutic study of minders. Written action plans, educational videos, and text- 16.biotics Gruber are F, preferable Grubisic-Greblo to higher H, Kastelan doses, M, Brajac although I, Lenkovic many M, Zamolo patients G: 29 patients with infantile acne. Br J Dermatol 145:463-466, 2001 messaging reminders about using prescribed medications are withAzithromycin moderate-to-severe compared with acne minocycline may in require the treatment antimicrobial of acne come- dosesdonica to control and papulo-pustulosa. their disease. J Chemother 10:469-473, 1998 23. Katz S: Online exclusive: Proactive reformulates packaging. Available at: among the various techniques advocated to reinforce treat- http://www.beautypackaging.com/articles/2010/01/online-exclusive- 17.Ultimately, Fernandez-Obregon optimal AC: outcomes Azithromycin require for the not treatment only selection of acne. Int of J ment recommendations and improve adherence. “Cheerlead- Dermatol 39:45-50, 2000 proactiv-reformulates-packaging. Accessed July 19, 2011. ing” by the clinician and staff who see signs of improvement 18.appropriate Leyden JJ, pharmacotherapy,Del Rosso JQ, Webster butGF: Clinical also an considerations understanding in the 24. Dalgard F, Gieler U, Holm JO, Bjertness E, Hauser S: Self-esteem and can encourage patients to continue with their prescribed reg- abouttreatment factors of that acne may vulgaris affect and compliance other inflammatory with recommended skin disorders: A body satisfaction among late adolescdents with acne: Results from a imens. therapeuticstatus report. regimens. Dermatol Clin 27:1-15, 2009 population survey. J Am Acad Dermatol 59:46-51, 2008 Pediatric Acne Management: Optimizing Outcomes • globalacademycme.com/sdef 19 Manage expectations. It is important to anticipate side ef- References fects and educate patients in advance that most side effects do 1. The Lewin Group. The Burden of Skin Diseases 2005. Available at: not require stopping a medication but can be managed suc- http://www.lewin.com/content/publications/april2005skindisease.pdf. cessfully with minor adjustments in the regimen. Pediatric Accessed May 10, 2011 and especially adolescent patients also benefit from under- 2. Yentzer BA, Irby CE, Fleischer AB Jr, Feldman SR: Differences in acne standing the definition of a “reasonable time frame” for seeing treatment prescribing patterns of pediatricians and dermatologists: An analysis of nationally representative data. Pediatr Dermatol 25:635- signs of improvement. These patients often have unrealistic 639, 2008 expectations of seeing improvement in hours to days (often 3. Turowski CB, James WD: The efficacy and safety of amoxicillin, tri- reinforced by what they see in advertisements for over-the- methoprim sulfamethoxazole, and spironolactone for treatment-resis- counter products that promise overnight results), whereas tant acne vulgaris. Adv Dermatol 23:155-163, 2007 4. Fenner JA, Wiss K, Levin NA: Oral cephalexin for acne vulgaris: Clin- the typical improvement is measured in weeks to months. ical experience with 93 patients. Pediatr Dermatol 25:179-183, 2008 5. Bhambri S, Del Rosso JQ, Desai A: Oral trimethoprim/sulfamethoxazole Monitor for psychological comorbidities. The psychological in the treatment of acne vulgaris. Cutis 79:430-434, 2007 impact of acne can be considerable. One study24 affirmed that 6. Rafiei R, Yaghoobi R. Azithromycin versus tetracycline in the treatment adolescent patients often have psychological and especially of acne vulgaris. J Drugs Dermatol 17:217-221, 2006 mood issues related to their acne in a severity-dependent 7. Cunliffe WJ, Aldana OL, Goulden V: Oral trimethoprim: A relatively safe and successful third-line treatment for acne vulgaris. Br J Dermatol fashion. The more severe the acne, the more severe and more 141:757-758, 1999 prevalent were the mood disturbances that were noted. Cli- 8. Maleszka R, Turek-Urasinska K, Oremus M, Vukovic J, Barsic B: Pulsed nicians who care for patients with acne should remain alert azithromycin treatment is as effective and safe as 2-week-longer daily for the presence of depression or other emotional or social doxycycline treatment of acne vulgaris: A randomized, double-blind, noninferiority study. Skinmed 9:86-94, 2011 issues, and may provide encouragement for the patient and 9. Parsad D, Pandhi R, Nagpal R, Negi KS: Azithromycin monthly pulse vs daily family to seek counseling or other therapy, as appropriate. doxycycline in the treatment of acne vulgaris. J Dermatol 28:1-4, 2001 10. Kus S, Yucelten D, Aytug A: Comparison of efficacy of azithromycin vs. Consider cost issues. Medication costs can have a substan- doxycycline in the treatment of acne vulgaris. Clin Exp Dermatol 30: tial impact on whether a prescription is filled and on whether 215-220, 2005 a patient who begins using a medication remains adherent 11. Singhi MK, Ghiya BC, Dhabhai RK: Comparison of oral azithromycin with the recommended regimen in the long term. Cost con- pulse with daily doxycycline in the treatment of acne vulgaris. Indian J Dermatol Venereol Leprol 69:274-276, 2003 siderations should be taken into account when selecting ap- 12. Gruber F, Grubisic´-Greblo H, Kastelan M, Brajac I, Lenkovic´ M, Za- propriate medications. molo G: Azithromycin compared with minocycline in the treatment of Parents as Partners in Pediatric Acne Management Volume 30, Number 3S September 2011 Parents As Partners in Pediatric Acne Management

ooperation and communication between parents or over-the-counter (OTC) topical products for mild acne (such Cother caregivers and a child’s clinicians are essential to as those containing benzoyl peroxide) are unlikely to cause providing the highest quality of medical treatment, regardless parental concerns; however, a child with moderate-to-severe of the health issue at hand. The provision of written materials acne may require more aggressive therapy with prescription hasThe acnelong continuum been recognized as a valuable means of enhancing products that are FDA-indicated for pages 12 years of age andS11 the parents’ knowledge about the child’s condition, diagnos- older. The authors have experienced resistance from some tic tests, therapeutic procedures, and medications. Written parents who hesitate to allow their children to be treated with materialsble 4. Bone also age can should be effective also be evaluated. tools for reinforcing In addition, informa- if Cush- “adult”present medications. with mild, usually This is a comedonal particular issue disease, when which oral med- most tioning’s and syndrome instructions is suspected, provided adrenocorticotropic directly to the patient hormone and icationoften is is a normal an appropriate physiologic option—even occurrence. including, in rare parentsstimulation in clinical testing encounters. can be considered. cases,Treatment isotretinoin. at any age depends on the type and severity of Some clinicians recommend initial therapy with a benzoyl involvement. Comedonal disease responds best to topical The treatment of acne in preadolescent patients is some- The average age of onset of puberty has decreased over the peroxide wash for patients with very mild comedonal acne, pastbenzoyl 50 years, peroxide and and the presentation topical retinoid of preadolescent products; inflamma- acne is times a challenge for clinicians, for two main reasons. First, but all of the topical medications that are used for acne in notory longer disease either usually unusual benefits or a from cause the for addition concern. of Many topical clini- or when a child between 7 and 11 years of age presents with patients 12 years of age or older also are appropriate for use in cianssystemic who antibiotics. treat children Severe now disease are aware may of thiswarrant phenomenon, treatment facial acne lesions, parents usually require reassurance about preadolescents. The efficacy and safety data on these younger aswith well systemic as its implications, isotretinoin, whereas regardless most of age. parents Families are not. should the accuracy of the diagnosis and the fact that acne is normal patients are limited: tretinoin has been tested in children as alwaysThe authors be counseled collaborated regarding in developing the risks and a parent benefits education of any in children in this age group. Acne generally is thought of as young as 8 years of age,11 and a benzoyl peroxide/adapalene handouttherapeutic that option. is designed to help bridge this information gap. a “teenager’s disease” and is usually associated with the onset combination topical agent has been tested in children as It includes background information on acne, reinforces the of puberty. The appearance of lesions in a child who may not young as 10 years of age. Based on the large body of efficacy messageReferences regarding the normalcy of preadolescent acne, dis- have any external signs of puberty may cause parents to The acne continuum and safety data from older pediatric patients (ie, those fromS11 cusses1. Tom appropriate WL, Friedlander skin SF: care, Acne through and addresses the ages: Case-based acne treatment observa- worry12 through that the 17 years child of has age)—and, some underlying as extensive disease, clinical such expe- as optionstions and through their childhood appropriate and adolescence. use. Clin Pediatr (Phila) 47:639- hormonal imbalance. 651, 2008 ble 4. Bone age should also be evaluated. In addition, if Cush- presentrience has with shown—it mild, usually is reasonable comedonal to presume disease, which similar most effi- Second, once the parents are comfortable with the diagno- 2. Antoniou C, Dessinioti C, StratigosLawrence AJ, Katsambas F. Eichenfield, AD: Clinical MD and ing’s syndrome is suspected, adrenocorticotropic hormone oftencacy and is a safetynormal in physiologic younger children. occurrence. However, because pre- therapeutic approach to childhood acne: An update. Pediatr Dermatol sis, the issue of treatment options must be addressed. With Anthony J. Mancini, MD stimulation testing can be considered. adolescentTreatment patients at any tend age depends to produce on less the sebum type and than severity do older of 26:373-380, 2009 few exceptions, standard acne therapy is approved by the Some clinicians recommend initial therapy with a benzoyl involvement.patients, their Comedonal skin tends to disease be more responds sensitive. best To to improve topical 3. Rapelanoro R, Mortureux P, Couprie B, MalevilleAlbert J, Taieb C. A: Yan, Neonatal MD U.S. Food and Drug Administration (FDA) for patients as peroxide wash for patients with very mild comedonal acne, benzoyltolerance, peroxide it is often and helpful topical to initiate retinoid therapy products; with inflamma- decreased Malassezia furfur pustulosis. ArchSheila Dermatol Fallon 132:190-193, Friedlander, 1996 MD youngfrequency as 12 of applicationyears of age. (for The example, recommendations twice weekly for or use every of 4. Niamba P, Weill FX, Sarlangue J, LabrèzeHilary C, Couprie E. Baldwin, B, Taïeh MDA: Is but all of the topical medications that are used for acne in tory disease usually benefits from the addition of topical or common neonatal cephalic pustulosis (neonatal acne) triggered by patients 12 years of age or older also are appropriate for use in systemicother day), antibiotics. and application Severe of disease smaller may amounts warrant of treatmentthe medi- Malassezia sympodialis? Arch Dermatol 134:995-998, 1998 preadolescents. The efficacy and safety data on these younger withcation. systemic In addition, isotretinoin, the daily regardless application of age. of Families a noncomedo- should 5. Bernier V, Weill FX, Hirigoyen V, et al. Skin colonization by Malassezia patients are limited: tretinoin has been tested in children as alwaysgenic moisturizer be counseled may regarding be useful. the risks and benefits of any species in neonates: A prospective study and relationship with neonatal young as 8 years of age,11 and a benzoyl peroxide/adapalene therapeuticWhen necessary option. for the treatment of severe, nodulocystic cephalic pustulosis. Arch Dermatol 138:215-218, 2002 Theacne Acne in preadolescent Continuum: patients, An systemic Age-Based agents—including Approach to Therapy6. Ayhan M, Sancak B, Karaduman A, Arikancontinued S, Sahin S: from Colonization page 11 of combination topical agent has been tested in children as neonate skin by Malassezia species: Relationship with neonatal cephalic young as 10 years of age. Based on the large body of efficacy Referencesoral isotretinoin—should be considered. pustulosis. J Am Acad Dermatol 57:1012-1018, 2007 and safety data from older pediatric patients (ie, those from 1. Tom WL, Friedlander SF: Acne through the ages: Case-based observa- 7. Chew EW, Bingham A, Burrows D: Incidence of acne vulgaris in pa- 12 through 17 years of age)—and, as extensive clinical expe- Summarytions through childhood and adolescence. Clin Pediatr (Phila) 47:639- tients with infantile acne. Clin Exp Dermatol 15:376-377, 1990 rience has shown—it is reasonable to presume similar effi- 651, 2008 8. Lucky AW, Biro FM, Huster GA, Morrison JA, Elder N: Acne vulgaris in Acne2. Antoniou can occur C, Dessinioti at any time C, Stratigos in life; AJ, cause Katsambas for concern AD: Clinical differs and early adolescent boys. Correlations with pubertal maturation and age. cacy and safety in younger children. However, because pre- therapeutic approach to childhood acne: An update. Pediatr Dermatol Arch Dermatol 127:210-216, 1991 adolescent patients tend to produce less sebum than do older depending26:373-380, on 2009 age of presentation. Neonatal disease is often 9. Lucky AW, Biro FM, Huster GA, Leach AD, Morrison JA, Ratterman J: patients, their skin tends to be more sensitive. To improve transient3. Rapelanoro and R, may Mortureux be related P, Couprie to pityrosporum B, Maleville J, Taieb disease. A: Neonatal Acne Acne vulgaris in premenarchal girls: An early sign of puberty associated tolerance, it is often helpful to initiate therapy with decreased thatMalassezia presents furfur in thepustulosis. postneonatal Arch Dermatol period 132:190-193, but before 1996 1 year of with rising levels of dehydroepiandrosterone. Arch Dermatol 130:308- frequency of application (for example, twice weekly or every age4. isNiamba usually P, Weill defined FX, Sarlangueas infantile J, Labrèze disease C, and Couprie generally B, Taïeh is A: not Is 314, 1994 associatedcommon with neonatal underlying cephalic pustulosis pathology. (neonatal In contrast, acne) triggered disease by 10. Krakowski AC, Eichenfield LF: Pediatric acne: Clinical presentations, other day), and application of smaller amounts of the medi- Malassezia sympodialis? Arch Dermatol 134:995-998, 1998 evaluation, and management. J Drugs Dermatol 6:589-593, 2007 cation. In addition, the daily application of a noncomedo- that5. Bernier presents V, Weill between FX, Hirigoyen 1 and 7 V, years et al. Skin of life colonization is of more by concern,Malassezia 11. Eichenfield LF, Matiz C, Funk A, Dill SW: Study of the efficacy and genic moisturizer may be useful. andspecies a full in evaluation neonates: A prospective for possible study underlying and relationship hormonal with neonatal pa- tolerability of 0.4% tretinoin microsphere gel for preadolescent acne. When necessary for the treatment of severe, nodulocystic thologycephalic is warranted. pustulosis. Arch Children Dermatol as 138:215-218, young as 7 2002 years of age can Pediatrics 125:e1316-e1323, 2010 acne in preadolescent patients, systemic agents—including 1085-5629/11/$-see6. Ayhan M, Sancak front B, Karaduman matter © 2011 A, Arikan Elsevier S, Inc.Sahin All S: rights Colonization reserved. of doi:10.1016/j.sder.2011.08.006neonate skin by Malassezia species: Relationship with neonatal cephalic oral isotretinoin—should be considered. pustulosis. J Am Acad Dermatol 57:1012-1018, 2007 7. Chew EW, Bingham A, Burrows D: Incidence of acne vulgaris in pa- 20 tients with infantile acne. Clin Exp Dermatol 15:376-377, 1990 globalacademycme.com/sdef • Pediatric Acne Management: Optimizing Outcomes Summary 8. Lucky AW, Biro FM, Huster GA, Morrison JA, Elder N: Acne vulgaris in Acne can occur at any time in life; cause for concern differs early adolescent boys. Correlations with pubertal maturation and age. Arch Dermatol 127:210-216, 1991 depending on age of presentation. Neonatal disease is often 9. Lucky AW, Biro FM, Huster GA, Leach AD, Morrison JA, Ratterman J: transient and may be related to pityrosporum disease. Acne Acne vulgaris in premenarchal girls: An early sign of puberty associated that presents in the postneonatal period but before 1 year of with rising levels of dehydroepiandrosterone. Arch Dermatol 130:308- age is usually defined as infantile disease and generally is not 314, 1994 associated with underlying pathology. In contrast, disease 10. Krakowski AC, Eichenfield LF: Pediatric acne: Clinical presentations, evaluation, and management. J Drugs Dermatol 6:589-593, 2007 that presents between 1 and 7 years of life is of more concern, 11. Eichenfield LF, Matiz C, Funk A, Dill SW: Study of the efficacy and and a full evaluation for possible underlying hormonal pa- tolerability of 0.4% tretinoin microsphere gel for preadolescent acne. thology is warranted. 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However, treatments these also treat- have Acne most commonly affects teenagers, but it is not just a condition of i E.ute Baldwin, copies of MD this is educational provided as material a service to patients from Elsevier, and their Inc. parents. may—free of mentsbeen used have safely been andfully effectively tested in adolescents for many years and youngin preadolescents. adults and have adolescence. Acne is often seen in children as young as 7 years old. In Shouldcharge and My without Child’s requesting Acne further permission—reproduce Be Treated by and distrib- been found to be safe and effective. These same treatments also have This two-page handout developed by Lawrence F. Eichenfield, MD, Anthony J. Mancini, MD, Albert C. Yan, MD, Sheila Fallon Friedlander, MD, and Hilary E.i many preadolescent children, acne is the first sign of puberty (sexual ute copies of this educational material to patients and their parents. been used safely and effectively for many years in preadolescents. i development). For example, in a girl, acne may be seen before the Baldwin,a Doctor? MD is provided as a service from Elsevier, Inc. may—free of charge and without requesting further permission—reproduce and distribute copies of this educational material to patients and their parents. i development of breasts, pubic and underarm hair, and first menstrua- There are a number of conditions that can look like acne, so your tion (period). In a boy, acne can occur before the testicles and penis child should be examined and diagnosed by a health care practi- i enlarge, pubic and underarm hair appear, or the voice deepens. Pediatrictioner. Acne If a child Management: has mild Optimizing acne (comedones Outcomes that• globalacademycme.com/sdef are not inflamed or 21 i Occasionally, acne can even develop in babies or very young too numerous) and if the condition is not bothersome to your child, children. When this occurs, it is particularly important that the good skin care may be all that is needed at this point. condition be evaluated by a health care provider. However, your child’s health care provider will advise you whether your child needs to use an over-the-counter (OTC) or prescription What Causes Acne? medication applied to the skin (topical medication), to use an oral medication (taken by mouth), or both. There are several factors to be There are four contributors to acne—the body’s natural oil (sebum), considered when making the decision about whether a preadolescent child clogged pores, bacteria (with the scientific name Propionibacterium needs one or more prescription medications. Certain findings would acnes, or P. acnes), and the body’s reaction to the above (inflamma- make it more appropriate to start treatment. They include the following: tion). Here’s what happens: 1) Acne is more than mild (there is inflammation, or there are 1) Sebum is produced in glands in the deeper layers of the skin many comedones, whether they are inflamed or not). and reaches the surface through the skin’s pores. An increase 2) There is some sign that acne scars have developed. Scarring is in certain hormones occurs around the time of puberty, and most common when acne is severe, but it can happen even in these hormones trigger the oil glands to produce increased children with mild acne. amounts of sebum. 3) The child is having emotional problems because of the acne or 2) Pores with excess oil tend to become clogged more easily. is experiencing negative comments from other children. 3) At the same time, P. acnes—one of the many types of bacteria that normally live on everyone’s skin—thrives in the excess oil How Should the Face Be Washed? and creates a skin reaction (inflammation). 4) If a pore is clogged close to the surface, there is little inflammation. Everyone with acne should wash twice a day—once in the morning The result is the formation of whiteheads (closed comedones) or and once in the evening. It’s also important to wash the face as soon blackheads (open comedones) at the surface of the skin. as possible after playing sports or other activities that cause a lot of 5) A plug that extends to or forms a little deeper in the pore, or one sweating (such as bike riding). that enlarges or ruptures, causes more inflammation. The result Acne does not come from “dirt,” and scrubbing is not necessary to is red bumps (papules) and pus-filled pimples (pustules). get the skin clean. Dryness and irritation make it harder for the 6) If plugging happens in the deepest skin layer, the inflammation is patient to tolerate acne medications and should be avoided. Use a more severe, resulting in the formation of nodules or cysts. gentle touch when washing, and use a mild soap (such as those that are labeled “for sensitive skin”), unless the health care provider advises otherwise. Avoid using deodorant soaps as well. Does Acne Look Different in Many preadolescents seem to have skin that tends to become irri- Preadolescents Than in Older Children? tated or dry, so it’s important to be aware of this when using a nonpre- In most preadolescents, acne is a milder condition. Typically, chil- scription acne “wash.” Some of these over-the-counter (OTC) products dren in this age group have whiteheads and blackheads (come- contain ingredients such as salicylic acid and benzoyl peroxide that can dones) and sometimes red pimples (papules) in the T zone of the be very helpful in reducing skin bacteria and clearing surface oil from face—across the forehead, on and along the nose, and on the chin. the skin, but they may also cause irritation and dryness. Are Acne Treatments Safe for Preadolescents? This two-page handout developed by Lawrence F. Eichenfield, MD, Anthony J. Most acne treatments have not been formally tested in clinical trials in Mancini, MD, Albert C. Yan, MD, Sheila Fallon Friedlander, MD, and Hilary pediatric patients younger than 12 years old. However, these treat- E. Baldwin, MD is provided as a service from Elsevier, Inc. may—free of ments have been fully tested in adolescents and young adults and have charge and without requesting further permission—reproduce and distrib- been found to be safe and effective. These same treatments also have ute copies of this educational material to patients and their parents. been used safely and effectively for many years in preadolescents.

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creased levels of dihydrotestosterone also may stimulate its 2. Cantatore-Francis JL, Glick SA: Childhood acne: Evaluation and man- production. agement. Dermatol Ther 19:202-209, 2006 3. Niamba P, Weill FX, Sarlangue J, Labreze C, Couprie B, Tiaeh A: Is Microbial Flora common neonatal cephalic pustolosis (neonatal acne) triggered by Microbial Flora Malassezia sympodialis? Arch Dermatol 134:995-998, 1998 The significance of P. acnes is still somewhat controversial, 4. Sancak B, Ayhan M, Karaduman A, Arikan S: In vitro activity of keto- with some arguing against its role in pathogenesis because conazole, itraconazole and terbinafine against Malassezia strains iso- the organism is part of the resident microflora. However, it lated from neonates [in Turkish]. Microbiyol Bul 39:301-308, 2005 has been shown that P. acnes can induce expression of anti- 5. Bergman J, Eichenfield LF: Neonatal acne and cephalic pustulosis: Is has been shown that P. acnes can induce expression of anti- Malassezia the whole story? Arch Dermatol 138:255-257, 2002 microbial peptides and proinflammatory cytokines and has Malassezia the whole story? Arch Dermatol 138:255-257, 2002 microbial peptides and proinflammatory cytokines and has 6. Tom WL, Friedlander SF: Acne through the ages: Case-based observa- Acnean effect life cycleon toll-like receptor 2, leading to increased synthesis 6. Tom WL, Friedlander SF: Acne through the ages: Case-based observa-S5 an effect on toll-like receptor 2, leading to increased synthesis tions through childhood and adolescence. Clin Pediatr (Phila) 47:639- of cytokines. 651, 2008 creased levels of dihydrotestosterone also may stimulate its 2.7. Cantatore-FrancisNational Campaign JL, to Glick Control SA: Acne: Childhood Secaucus acne: (NJ): Evaluation Thomson and Profes- man- production.Immunoinflammatory Mechanisms agement.sional Postgraduate Dermatol Ther Services. 19:202-209, 2003 2006 A great deal of research has focused on immunoinflammatory 3.8. NiambaGolub MS, P, Collman Weill FX, GW, Sarlangue Foster PM, J, Labreze et al: Public C, Couprie health implications B, Tiaeh A: ofIs A great deal of research has focused on immunoinflammatory commonaltered puberty neonatal timing. cephalic Pediatrics pustolosis 121:S218-S230, (neonatal acne)2008 (suppl triggered 3) by Microbialpathways of acne Flora pathogenesis, including demonstration of altered puberty timing. Pediatrics 121:S218-S230, 2008 (suppl 3) pathways of acne pathogenesis, including demonstration of 9.Malassezia Toppari J, Juul sympodialis? A: Trends Arch in puberty Dermatol timing 134:995-998, in human and 1998 environmen- Thethe upregulation significance of ofP. multiple acnes is cytokines still somewhat in the controversial, presence of 4. Sancaktal modifiers. B, Ayhan Mol M, Cell Karaduman Endocrinol A, 324:39-44, Arikan S: In 2010 vitro activity of keto- withboth P. some acnes arguing, as previously against its mentioned, role in pathogenesis and lipopolysaccha- because 10.conazole, Euling SY, itraconazole Herman-Giddens and terbinafine ME, Lee againstPA, et al: Malassezia Examination strains of iso- US therides. organism Here again, is part toll-like of the resident receptors microflora. have been However, innately it latedpuberty-timing from neonates data [in from Turkish]. 1940 to Microbiyol 1994 for secular Bul 39:301-308, trends: Panel 2005 find- haslinked been toshown acne inflammation. that P. acnes Incan addition, induce expression it has been of shown anti- 5. Bergmanings. Pediatrics J, Eichenfield 121:S172-S191, LF: Neonatal 2008 acne (suppl and 3) cephalic pustulosis: Is 11.Malassezia Mouritsen A,the Aksglaede whole story? L, Sørensen Arch Dermatol K, et al: 138:255-257, Hypothesis: Exposure2002 to microbialthat patients peptides with acne and proinflammatorytend to have reduced cytokines expression and has of 11. Mouritsen A, Aksglaede L, Sørensen K, et al: Hypothesis: Exposure to 6. Tomendocrine-disrupting WL, Friedlander chemicals SF: Acne through may interfere the ages: with Case-based puberty timing. observa- Int ananti-inflammatoryAcne effect Life on toll-like Cycle: cytokines, receptor The Spectrum 2, such leading as IL-10. to increasedof Pediatric synthesis Disease continued from page 6 anti-inflammatory cytokines, such as IL-10. tionsJ Androl through 33:346-359, childhood 2010 and adolescence. Clin Pediatr (Phila) 47:639- of cytokines. 12.651, Lucky 2008 AW, Biro FM, Huster GA, Morrison JA, Elder N: Acne vulgaris in Conclusion 7. Nationalearly adolescent Campaign boys: to CorrelationsControl Acne: with Secaucus pubertal (NJ): maturation Thomson and Profes- age. ImmunoinflammatoryConclusion Mechanisms sionalArch Dermatol Postgraduate 127:210-216, Services. 2003 1991 13. Lucky AW, Biro FM, Simbart LA, Morrison JA, Sorg NW: Predictors of AThe great epidemiology, deal of research demographics, has focused on and immunoinflammatory pathophysiology of 13.8. GolubLucky MS,AW, Collman Biro FM, GW, Simbart Foster LA, PM, Morrison et al: Public JA, Sorg health NW: implications Predictors of alteredseverity puberty of acne vulgaristiming. Pediatrics in young adolescent 121:S218-S230, girls: Results 2008 (suppl of a five-year 3) pathwaysacne in adolescents of acne pathogenesis, have been well including described demonstration in the literature. of severity of acne vulgaris in young adolescent girls: Results of a five-year Fewer studies have focused on acne and acneiform condi- 9. Topparilongitudinal J, Juul study. A: Trends J Pediatr in puberty 130:30-39, timing 1997 in human and environmen- theFewer upregulation studies have of focused multiple on cytokines acne and in acneiform the presence condi- of 14.tal Chen modifiers. GY, Cheng Mol Cell YW, Endocrinol Wang CY, 324:39-44, et al: Prevalence 2010 of skin diseases tions in pediatric patients less than 12 years of age. True acne 14. Chen GY, Cheng YW, Wang CY, et al: Prevalence of skin diseases bothtionsP. inacnes pediatric, as previously patients less mentioned, than 12 years and of lipopolysaccha- age. True acne 10. Eulingamong SY, schoolchildren Herman-Giddens in Magong, ME, Lee Penghu, PA, et Taiwan: al: Examination A community- of US rides.is rarely Here seen again, in patients toll-like less thanreceptors about have 6 or 7been years innately of age, puberty-timingbased clinical survey. data from J Formos 1940 Medto 1994 Assoc for 107:21-29, secular trends: 2008 Panel find- linkedbut it is to important acne inflammation. to note—and In addition, to educate it has parents—that been shown 15.ings. Bhambri Pediatrics S, Del 121:S172-S191, Rosso JQ, Bhambri 2008 A: (suppl Pathogenesis 3) of acne vulgaris: thatacne patients may be the with first acne sign tend of onset to have of puberty reduced in preadolescent expression of 11. MouritsenRecent advances. A, Aksglaede J Drugs L, Dermatol Sørensen 8:615-618, K, et al: Hypothesis: 2009 Exposure to children (ie, those from 7 through 11 years of age). Ongoing 16.endocrine-disrupting Caillon F, O’ConnellM, chemicals Eady EA, may et interfere al: Interleukin-10 with puberty secretion timing. from Int anti-inflammatory cytokines, such as IL-10. JCD14 Androl� peripheral 33:346-359, blood 2010 mononuclear cells is downregulated in pa- research continues to elucidate and expand on the etiologic CD14� peripheral blood mononuclear cells is downregulated in pa- 12. Luckytients with AW, acne Biro FM, vulgaris. Huster Br GA, J Dermatol Morrison 162:296-303, JA, Elder N:Acne 2010 vulgaris in factors involved in the development of acne. Conclusion 17.early Degitz adolescent K, Placzek boys: M, Borelli Correlations C, Plewig with G: pubertal Pathophysiology maturation of and acne. age. J ArchDtsch Dermatol Dermatol 127:210-216, Ges 5:316-323, 1991 2007 References Dtsch Dermatol Ges 5:316-323, 2007 Acne life cycle TheReferences epidemiology, demographics, and pathophysiology ofS5 13.18. LuckyKurokawa AW, I, Biro Danby FM, FW, Simbart Ju Q, LA, et Morrisonal: New developments JA, Sorg NW: in Predictors our under- of acne1. Friedlander in adolescents SF, Eichenfield have been LF, wellFowler described JF Jr, et al: in Acne the epidemiology literature. severitystanding of of acne acne vulgaris pathogenesis in young and adolescent treatment. girls: Exp Results Dermatol of a five-year 18:821- and pathophysiology. Semin Cutan Med Surg 29:2-4, 2010 832, 2009 Fewerand studies pathophysiology. have focused Semin Cutan on acne Med Surg and 29:2-4, acneiform 2010 condi- longitudinal832, 2009 study. J Pediatr 130:30-39, 1997 2. Cantatore-Francis JL, Glick SA: Childhood acne: Evaluation and man- 14. Chen GY, Cheng YW, Wang CY, et al: Prevalence of skin diseases creased levels of dihydrotestosterone also may stimulate its tions in pediatric patients less than 12 years of age. True acne production. agement. Dermatol Ther 19:202-209, 2006 among schoolchildren in Magong, Penghu, Taiwan: A community- is3. rarely Niamba seen P, Weill in patients FX, Sarlangue less than J, Labreze about C, 6 Couprie or 7 years B, Tiaeh of age, A: Is based clinical survey. J Formos Med Assoc 107:21-29, 2008 but it is important to note—and to educate parents—that 15. Bhambri S, Del Rosso JQ, Bhambri A: Pathogenesis of acne vulgaris: Microbial Flora common neonatal cephalic pustolosis (neonatal acne) triggered by acneMalassezia may be the sympodialis? first sign Arch of onset Dermatol of puberty 134:995-998, in preadolescent 1998 Recent advances. J Drugs Dermatol 8:615-618, 2009 The significance of P. acnes is still somewhat controversial, childrenEffects4. Sancak of (ie, nonclinical B, Ayhanthose M, from issues Karaduman 7 throughon acne A, Arikan treatment 11 years S: In vitroof age). activity Ongoing of keto- 16. Caillon F, O’Connell M, Eady EA, et al: Interleukin-10 secretion fromS15 with some arguing against its role in pathogenesis because researchconazole, continues itraconazole to elucidate and terbinafine and against expand Malassezia on the strains etiologic iso- CD14� peripheral blood mononuclear cells is downregulated in pa- lated from neonates [in Turkish]. Microbiyol Bul 39:301-308, 2005 tients with acne vulgaris. Br J Dermatol 162:296-303, 2010 the organism is part of the resident microflora. However, it factors involved in the development of acne. 6. Shah SK, Alexis AF: Acne in skin of color. J Dermatol Treat 21:206-211, bothersome5. Bergman J, to Eichenfield patients LF: than Neonatal are the acne acne and lesions cephalic that pustulosis: caused Is 17. Degitz K, Placzek M, Borelli C, Plewig G: Pathophysiology of acne. J has been shown that P. acnes can induce expression of anti- 2010 the dyschromia.Malassezia the whole In skin story? of color,Arch Dermatol PIH can 138:255-257, occur secondary 2002 to Dtsch Dermatol Ges 5:316-323, 2007 microbial peptides and proinflammatory cytokines and has 7. Taylor SC, Cook-Bolden F, Rahman Z, Strachan D: Acne vulgaris in Referencesany6. Tom acne WL, lesion, Friedlander even SF: comedonal Acne through lesions the ages: with Case-based no clinical observa- 18. Kurokawa I, Danby FW, Ju Q, et al: New developments in our under- an effect on toll-like receptor 2, leading to increased synthesis skin of color. J Am Acad Dermatol 46:S98-S106, 2002 (2 suppl) appearance1. Friedlandertions through of SF, inflammation. childhood Eichenfield and LF, adolescence. Fowler JFJr, Clin et Pediatr al: Acne (Phila) epidemiology 47:639- standing of acne pathogenesis and treatment. Exp Dermatol 18:821- of cytokines. 8. Roberts WE. Chemical peeling in ethnic/dark skin. Dermatol Ther 17: EffectsEarlyand651, of pathophysiology. 2008and nonclinical effective issues Semintherapy, on Cutan acne tailored Med treatment Surg not 29:2-4, only 2010 to the acne 832,196-205, 2009 2004 S15 7. National Campaign to Control Acne: Secaucus (NJ): Thomson Profes- severity but also to the level of psychological distress, is ex- 9. Terrell S, Aires D, Schweiger ES: Treatment of acne vulgaris using blue Immunoinflammatory Mechanisms sional Postgraduate Services. 2003 light photodynamic therapy in an African-American patient. J Drugs tremely important. 6. Shah SK, Alexis AF: Acne in skin of color. J Dermatol Treat 21:206-211, bothersome8. Golub MS, to Collman patients GW, than Foster are PM, the et al: acne Public lesions health implications that caused of Dermatol 8:669-671, 2009 A great deal of research has focused on immunoinflammatory 2010 theIn dyschromia.altered determining puberty In timing. treatment skin Pediatrics of color, regimens, 121:S218-S230, PIH can clinicians occur 2008 secondary (suppl must 3) take to 10. Manias E, Williams A: Medication adherence in people of culturally and 7. Taylor SC, Cook-Bolden F, Rahman Z, Strachan D: Acne vulgaris in pathways of acne pathogenesis, including demonstration of into9. Toppari consideration J, Juul A: Trends the widely in puberty varying timing in differences human and environmen- that exist linguistically diverse backgrounds: A meta-analysis. Ann Pharmacother any acne lesion, even comedonal lesions with no clinical skin of color. J Am Acad Dermatol 46:S98-S106, 2002 (2 suppl) the upregulation of multiple cytokines in the presence of tal modifiers. Mol Cell Endocrinol 324:39-44, 2010 44:964-982, 2010 amongappearance patients of inflammation. of different ages and of different ethnic and 8. Roberts WE. Chemical peeling in ethnic/dark skin. Dermatol Ther 17: both P. acnes, as previously mentioned, and lipopolysaccha- The10. Euling Effects SY, Herman-Giddens of Culture, ME, Skin Lee PA,Color, et al: Examination and Other of US 11. Layton AM, Seukeran D, Cunliffe WJ: Scarred for life? Dermatology culturalEarly backgrounds.and effective therapy, tailored not only to the acne 196-205, 2004 puberty-timing data from 1940 to 1994 for secular trends: Panel find- 195:15-21, 1997 (suppl 1) rides. Here again, toll-like receptors have been innately Nonclinical Issues on Acne Treatment 9. Terrell S, Aires D, Schweiger ES: Treatmentcontinued of acne vulgaris from usingpage blue14 severityings.but Pediatrics also 121:S172-S191, to the level of 2008 psychological (suppl 3) distress, is ex- 12. Dalgard F, Gieler U, Holm JØ, Bjertness E, Hauser S: Self-esteem linked to acne inflammation. In addition, it has been shown light photodynamic therapy in an African-American patient. J Drugs tremely important. and body satisfaction among late adolescents with acne: Results References11. Mouritsen A, Aksglaede L, Sørensen K, et al: Hypothesis: Exposure to Dermatol 8:669-671, 2009 that patients with acne tend to have reduced expression of from a population survey. J Am Acad Dermatol 59:746-751, 2008 Inendocrine-disrupting determining treatment chemicals regimens, may interfere clinicians with puberty must timing. take Int 10. Manias E, Williams A: Medication adherence in people of culturally and anti-inflammatory cytokines, such as IL-10. 1. Perkins A, Cheng C, Hillebrand G, Miyamoto K, Kimball A: Compari- 13. Krakowski AC, Stendardo S, Eichenfield LF: Practical considerations in intoJ consideration Androl 33:346-359, the 2010 widely varying differences that exist linguistically diverse backgrounds: A meta-analysis. Ann Pharmacother son of the epidemiology of acne vulgaris among Caucasian, Asian, acne treatment and the clinical impact of topical combination therapy. 12. Lucky AW, Biro FM, Huster GA, Morrison JA, Elder N: Acne vulgaris in 44:964-982, 2010 amongContinental patients Indian, of different and African ages American and of women. different J Eur ethnicAcad Derma- and Pediatr Dermatol 25:1-14, 2008 (suppl 1) early adolescent boys: Correlations with pubertal maturation and age. 11. Layton AM, Seukeran D, Cunliffe WJ: Scarred for life? Dermatology Conclusion culturaltol Venereol backgrounds. November 25, 2010 [Epub ahead of print] 14. Gollnick H, Cunliffe W, Berson D, et al: Management of acne: A report Arch Dermatol 127:210-216, 1991 195:15-21, 1997 (suppl 1) 2. Lucky AW: A review of infantile and pediatric acne. Dermatology 196: from a Global Alliance to improve outcomes in acne. J Am Acad Der- 13. Lucky AW, Biro FM, Simbart LA, Morrison JA, Sorg NW: Predictors of 12. Dalgard F, Gieler U, Holm JØ, Bjertness E, Hauser S: Self-esteem The epidemiology, demographics, and pathophysiology of 95-97, 1998 matol 49:S1-S38, 2003 severity of acne vulgaris in young adolescent girls: Results of a five-year and body satisfaction among late adolescents with acne: Results acne in adolescents have been well described in the literature. References3. Halder RM, Brooks HL, Callender VD: Acne in ethnic skin. Dermatol 15. Layton AM: Optimal management of acne to prevent scarring and psy- from a population survey. J Am Acad Dermatol 59:746-751, 2008 Clinlongitudinal 21:609-615, study. 2003 J Pediatr 130:30-39, 1997 chological sequelae. Am J Clin Dermatol 2:135-141, 2001 Fewer studies have focused on acne and acneiform condi- 1. Perkins A, Cheng C, Hillebrand G, Miyamoto K, Kimball A: Compari- 13. Krakowski AC, Stendardo S, Eichenfield LF: Practical considerations in 14.4. HalderChen GY, RM, Cheng Holmes YW, YC, Wang Bridgeman-Shah CY, et al: Prevalence S, Kligman of AM: skin A diseases clinico- 16. Halvorsen JA, Stern RS, Dalgard F, Thoresen M, Bjertness E, Lien L: tions in pediatric patients less than 12 years of age. True acne son of the epidemiology of acne vulgaris among Caucasian, Asian, acne treatment and the clinical impact of topical combination therapy. pathologicalamong schoolchildren study of acne in vulgaris Magong, in Penghu, black females Taiwan: [abstract]. A community- J Invest Suicidal ideation, mental health problems, and social impairment are Continental Indian, and African American women. J Eur Acad Derma- Pediatr Dermatol 25:1-14, 2008 (suppl 1) is rarely seen in patients less than about 6 or 7 years of age, Dermatolbased clinical 106:888, survey. 1996 J Formos Med Assoc 107:21-29, 2008 increased in adolescents with acne: A population-based study. J Invest tol Venereol November 25, 2010 [Epub ahead of print] 14. Gollnick H, Cunliffe W, Berson D, et al: Management of acne: A report but it is important to note—and to educate parents—that 15.5. DavisBhambri EC, S, Callender Del Rosso VD: JQ, A review Bhambri of acneA: Pathogenesis in ethnic skin: of acnePathogenesis, vulgaris: Dermatol 131:363-370, 2011 Effects of nonclinical issues on acne treatment 2. Lucky AW: A review of infantile and pediatric acne. Dermatology 196:S15 from a Global Alliance to improve outcomes in acne. J Am Acad Der- acne may be the first sign of onset of puberty in preadolescent clinicalRecent advances.manifestations, J Drugs and Dermatol management 8:615-618, strategies. 2009 J Clin Aesthet Der- 17. Misery L: Consequences of psychological distress in adolescents with 95-97, 1998 matol 49:S1-S38, 2003 16.matol Caillon 3:24-38, F, O’Connell 2010 M, Eady EA, et al: Interleukin-10 secretion from acne [editorial]. J Invest Dermatol 131:290-292, 2011 children (ie, those from 7 through 11 years of age). Ongoing 3. Halder RM, Brooks HL, Callender VD: Acne in ethnic skin. Dermatol 15. Layton AM: Optimal management of acne to prevent scarring and psy- 6. ShahCD14 SK,� peripheral Alexis AF: Acne blood in mononuclear skin of color. Jcells Dermatol is downregulated Treat 21:206-211, in pa- bothersomeresearch continues to patients to elucidate than are and the acne expand lesions on the that etiologic caused Clin 21:609-615, 2003 chological sequelae. Am J Clin Dermatol 2:135-141, 2001 2010tients with acne vulgaris. Br J Dermatol 162:296-303, 2010 the dyschromia. In skin of color, PIH can occur secondary to 4. Halder RM, Holmes YC, Bridgeman-Shah S, Kligman AM: A clinico- 16. Halvorsen JA, Stern RS, Dalgard F, Thoresen M, Bjertness E, Lien L: factors involved in the development of acne. 17.7. Taylor Degitz SC,K, Placzek Cook-Bolden M, Borelli F, Rahman C, Plewig Z, G: Strachan Pathophysiology D: Acne vulgaris of acne. in J pathological study of acne vulgaris in black females [abstract]. J Invest Suicidal ideation, mental health problems, and social impairment are any acne lesion, even comedonal lesions with no clinical skin of color. J Am Acad Dermatol 46:S98-S106, 2002 (2 suppl) DermatolDtsch Dermatol 106:888, Ges 1996 5:316-323, 2007 increased in adolescents with acne: A population-based study. J Invest appearance of inflammation. 8. Roberts WE. Chemical peeling in ethnic/dark skin. Dermatol Ther 17: References 18.5. DavisKurokawa EC, Callender I, Danby FW,VD: A Ju review Q, et al: of acneNew indevelopments ethnic skin: Pathogenesis,in our under- Dermatol 131:363-370, 2011 196-205, 2004 1.Early Friedlander and effective SF, Eichenfield therapy, LF, Fowler tailored JF Jr, not et al: only Acne to epidemiology the acne clinicalstanding manifestations, of acne pathogenesis and management and treatment. strategies. Exp J Dermatol Clin Aesthet 18:821- Der- 17. Misery L: Consequences of psychological distress in adolescents with 9. Terrell S, Aires D, Schweiger ES: Treatment of acne vulgaris using blue severityand pathophysiology. but also to the Semin level Cutan of psychological Med Surg 29:2-4, distress, 2010 is ex- matol832, 2009 3:24-38, 2010 acne [editorial]. J Invest Dermatol 131:290-292, 2011 tremely important. light photodynamic therapy in an African-American patient. J Drugs Dermatol 8:669-671, 2009 In determining treatment regimens, clinicians must take 10. Manias E, Williams A: Medication adherence in people of culturally and into consideration the widely varying differences that exist Pediatriclinguistically Acne Management: diverse backgrounds: Optimizing AOutcomes meta-analysis. • globalacademycme.com/sdef Ann Pharmacother 23 among patients of different ages and of different ethnic and 44:964-982, 2010 cultural backgrounds. 11. Layton AM, Seukeran D, Cunliffe WJ: Scarred for life? Dermatology 195:15-21, 1997 (suppl 1) 12. Dalgard F, Gieler U, Holm JØ, Bjertness E, Hauser S: Self-esteem References and body satisfaction among late adolescents with acne: Results from a population survey. J Am Acad Dermatol 59:746-751, 2008 1. Perkins A, Cheng C, Hillebrand G, Miyamoto K, Kimball A: Compari- 13. Krakowski AC, Stendardo S, Eichenfield LF: Practical considerations in son of the epidemiology of acne vulgaris among Caucasian, Asian, acne treatment and the clinical impact of topical combination therapy. Continental Indian, and African American women. J Eur Acad Derma- Pediatr Dermatol 25:1-14, 2008 (suppl 1) tol Venereol November 25, 2010 [Epub ahead of print] 14. Gollnick H, Cunliffe W, Berson D, et al: Management of acne: A report 2. Lucky AW: A review of infantile and pediatric acne. Dermatology 196: from a Global Alliance to improve outcomes in acne. J Am Acad Der- 95-97, 1998 matol 49:S1-S38, 2003 3. Halder RM, Brooks HL, Callender VD: Acne in ethnic skin. Dermatol 15. Layton AM: Optimal management of acne to prevent scarring and psy- Clin 21:609-615, 2003 chological sequelae. Am J Clin Dermatol 2:135-141, 2001 4. Halder RM, Holmes YC, Bridgeman-Shah S, Kligman AM: A clinico- 16. Halvorsen JA, Stern RS, Dalgard F, Thoresen M, Bjertness E, Lien L: pathological study of acne vulgaris in black females [abstract]. J Invest Suicidal ideation, mental health problems, and social impairment are Dermatol 106:888, 1996 increased in adolescents with acne: A population-based study. J Invest 5. Davis EC, Callender VD: A review of acne in ethnic skin: Pathogenesis, Dermatol 131:363-370, 2011 clinical manifestations, and management strategies. J Clin Aesthet Der- 17. Misery L: Consequences of psychological distress in adolescents with matol 3:24-38, 2010 acne [editorial]. J Invest Dermatol 131:290-292, 2011