DOI: https://doi.org/10.25121/PNM.2018.31.1A.45 Post N Med 2018; XXXI(1A): 45-48

©Borgis

*Marta Filo-Rogulska1, Dominika Wcisło-Dziadecka2, Ligia Brzezińska-Wcisło3

Neonatal and infantile – ethiopathogenesis, clinical presentation and treatment possibilities

Trądzik noworodkowy i niemowlęcy – etiopatogeneza, obraz kliniczny oraz możliwości terapeutyczne

1Dermatology Clinic, Regional Healthcare Centre for Mother, Child and Adolescent, Częstochowa Head of Centre: Małgorzata Lemańska, MD 2Department of Skin Structural Studies, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia, Katowice Head of Department: Krzysztof Jasik, assistant professor 3Department of , School of Medicine in Katowice, Medical University of Silesia, Katowice Head of Department: Professor Ligia Brzezińska-Wcisło, MD, PhD

Keywords Summary acne vulgaris, infant and newborn diseases, dermatologic agents, Neonatal and are rare pediatric conditions. Compared to other types of acne there is a relative paucity of data on their pathogenesis and treatment. Current recommendations are mostly based on retrospective studies and case series. imbalance caused by maternal steroids in neonatal cases and endogenous secretion in Słowa kluczowe infants is believed to be the primary cause of these forms of pediatric acne. Extensive trądzik pospolity, choroby niemowląt workup for underlying endocrine causes is indicated in patients with symptoms of viriliza- i noworodków, leki dermatologiczne, tion, precocious puberty or growth disorders. izotretynoina (presenting at less than 4-6 weeks after birth) is usually a benign con- dition which resolves spontaneously and requires no treatment. However, differential di- agnoses must include other acne-mimicking diseases e.g. neonatal cephalic pustulosis. Infantile acne on the other hand may have scarring potential and may require treatment with typical anti-acne drugs. Except for tetracyclines which are strongly contraindicated in pediatric patients almost all other medications including isotretinoin have been used with good effects. This review focuses on the pathogenesis, clinical presentation and therapeutic pos- sibilities of early childhood acne.

Streszczenie

Trądzik noworodkowy i dziecięcy są stosunkowo rzadkimi chorobami wieku dzie- cięcego. W porównaniu z innymi rodzajami trądziku dysponujemy ograniczonymi danymi naukowymi dotyczącymi ich patogenezy i leczenia. Aktualne rekomendacje Conflict of interest opierają się przede wszystkim na badaniach retrospektywnych i opisach serii przy- Konflikt interesów padków. Uważa się, że przyczyną trądziku dziecięcego są zaburzenia równowagi None hormonalnj wywołane androgennymi steroidami pochodzenia matczynego u nowo- Brak konfliktu interesów rodków i wydzielanymi endogennie u niemowląt. W przypadku współwystępowania trądziku z objawami wirylizacji, przedwczesnego dojrzewania płciowego lub zabu- rzeniami wzrostu konieczna jest pilna diagnostyka w kierunku możliwych poważniej- szych zaburzeń endokrynologicznych. Address/adres: Trądzik noworodkowy (występujący w czasie krótszym niż 4-6 tygodni po urodzeniu) *Marta Filo-Rogulska przebiega zwykle łagodnie, ustępuje samoistnie i nie wymaga leczenia. Diagnoza różnico- Poradnia Dermatologii wa musi jednak obejmować inne choroby naśladujące trądzik, np. noworodkową krostko- Wojewódzki Zakład Opieki Zdrowotnej wicę głowy. Natomiast trądzik niemowlęcy może mieć ciężki przebieg, z pozostawieniem nad Matką, Dzieckiem i Młodzieżą blizn, i wymaga leczenia typowymi lekami przeciwtrądzikowymi. Z wyjątkiem tetracyklin, w Częstochowie które są przeciwwskazane u dzieci, prawie wszystkie inne leki, w tym izotretynoina, były ul. Sobieskiego 7a, 42-200 Częstochowa stosowane z dobrymi efektami. tel. +48 (34) 360-61-32 Niniejsza praca skupia się na patogenezie, objawach klinicznych i możliwościach tera- [email protected] peutycznych trądziku wczesnodziecięcego.

45 Marta Filo-Rogulska, Dominika Wcisło-Dziadecka, Ligia Brzezińska-Wcisło

INTRODUCTION case, skin lesions are acne-like without the presence Acne vulgaris occurs in 79-95% of adolescents and of comedones. It is most likely caused by Malas- young adults (1). Often, however, it develops in infants sezia yeasts colonizing the skin (11). In most cases, and children before adolescence. Under certain cir- treatment is not required (12). In patients with severe cumstances, especially when the symptoms of pre- changes, 2% creams (13) can be used. mature puberty or virilization coexist, it must induce INFANTILE ACNE diagnostic work-up towards underlying endocrine dis- orders (2). Treatment of acne in neonates and infants Infantile acne occurs primarily between 6 weeks and should be adjusted to the severity of acne. Beside tet- 12 months of age and similarly to neonatal acne male racyclines, which are absolutely contraindicated in this predominance is observed. Skin changes such as age group, medications used should be adapted to the comedones and inflammatory lesions (, pus- type of acne lesions. Most anti-acne drugs are not reg- tules, ) are located mainly on the cheeks. How- istered in children under 12 years of age. According to ever, the lesions may have more severe character and pediatric acne treatment consensus they can be used may be more numerous in comparison with acne in in infants, but with extreme caution. newborns (14). Neonatal and infantile acne are part of the spectrum In most children acne remits before 4-5 years of age of pediatric acne. Table 1 presents the current distinc- and only rarely persists until adolescence (15). Con- tion between the five types of pediatric acne (3). This trary to the neonatal acne, this form of acne can leave division is based on the child’s age at the development scars, which prompts early treatment, especially in of the first acne lesions. more severe cases (14). Conglobate acne character- ized by burrowing and interconnecting abscesses and Tab. 1. Division of pediatric acne according to age at onset irregular scars (both keloidal and atrophic) has been Neonatal acne During first 6 weeks of life described in this age group but is very rare (16). Infantile acne Between 6 weeks and 12 months As with the neonatal acne, it is believed that the infan- tile acne is induced by secreted by the ad- Mid-childhood acne Between 1 and 6 years renal cortex in both sexes (7). Elevated values of DHEA Between 7 and 12 years or until first men- Prepubertal acne struation in girls secreted by the adrenal cortex are observed up to Juvenile acne Between 12 and 19 years 12 months of age. After this period there is a decrease in the secretion of DHEA, which results in a gradual remission of skin lesions (8). Higher prevalence of in- NEONATAL ACNE fantile acne in boys can also be explained by the in- Neonatal acne occurs in the first 6 weeks of life and creased secretion of LH which stimulates testicular an- affects about 20% of newborns (4). It usually manifests drogen synthesis. This process is probably a result of with small, closed comedones located on the fore- the immaturity of the hormonal feedback mechanism head, nose and cheeks with frequently co-existing se- between the gonads and the pituitary gland (14, 17). baceous gland hyperplasia (5). Propionibacterium acnes (18) also plays an im- The pathomechanism of acne formation in this age portant role in the etiopathogenesis of acne. These group has not been fully explained. It is believed that are commensal gram-positive, lipophilic, anaerobic it is caused by the increased production of sebum in microbes, colonizing seborrhoeic areas of the skin. enlarged sebaceous glands under the influence of ma- The composition of seborrhoeic microbiome is subject ternal androgens delivered through placenta and beta- to significant changes during human life. Infant skin is hydroxysteroids produced in excess by the newborn’s dominated by Firmicutes phylum and their number is adrenal cortex ( – DHEA, de- significantly higher than Actinobacteria, which include hydroepiandrosterone sulfate – DHEA-S). Additionally, Propionibacterium genus (19). During puberty the se- some of the affected male newborns may have elevat- baceous gland microbiome shifts towards dominance ed levels of testicular androgens, produced under the of Propionibacterium and Corynobacterium (20). influence of (LH), levels of which in Increased seborrhoea is closely followed by the in- these children may reach puberty values (7). LH stimu- crease in the quantity of Propionibacterium acnes. lates the synthesis of which leads to in- It has been demonstrated that in children with acne creased seborrhoea. This phenomenon may explain the process of skin colonization by Propionibacterium increased incidence of neonatal acne in boys (7, 8). acnes is much faster than in children without acne (21). Neonatal acne subsides spontaneously within 1 to It is believed that these bacteria contribute to the devel- 3 months and does not require pharmacological treat- opment of acne (comedones, inflammatory lesions) by ment (9). stimulating proliferation and the synthesis Differential diagnosis should include viral, bacterial of proinflammatory factors such as interleukin 8 (22). and fungal infections, neonatal milia, Infantile acne rarely coexists with endocrine disor- hyperplasia, neonatal pustular melanosis and neonatal ders and only in the presence of clear symptoms of toxic erythema (10). Particularly frequently observed is virilization or premature puberty does require extensive the occurrence of neonatal cephalic pustulosis. In this diagnostics. Detailed physical examination is essential

46 Neonatal and infantile acne – ethiopathogenesis, clinical presentation and treatment possibilities with particular attention to the assessment of devel- must be adapted to the morphology of skin lesions and opmental parameters such as height, weight, growth the severity of acne. curve, testicles, mammary glands, presence of pubic Guidelines for treating acne in children up to hair, , clitoral hypertrophy or increased mus- 12 years of age were published in 2013 in “Pediat- cle mass. In the case of any abnormalities bone age ics”. They point out that, in the case of infants, topical assessment and initial hormonal tests (FSH, LH, tes- medications such as , , anti- tosterone, dehydroepiandrosterone sulphate) should biotics and combined preparations are not contraindi- be obtained followed by a prompt referral to a pediatric cated and can be safely used (3). In infants as well as endocrinologist (3). in older children, the use of in monotherapy Harde et al. have described the case of a 23-month-old should be avoided due to the increasing re- boy with acne since the early infancy. They found ex- sistance (27). cessive growth (99.6 percentile) corresponding to Side effects which are most often present in the form a child twice the age and enlarged genitals with pubic of local skin irritations should be managed by decreas- hair. The development of acne preceded these symp- ing the frequency of application and by moistening the toms by several months. After detailed examination, skin with non-comedogenic preparations (17). he was diagnosed with congential adrenal hyperplasia Local treatment may be insufficitent in severe cas- caused by 11-beta-hydroxylase deficiency. It caused es of acne during infancy presenting with numerous a decrease in the synthesis of and an inflammatory lesions including purulent cysts. Con- overproduction of androgens due to the constant stim- sideration should be given to the employment of sys- ulation of the adrenal cortex via pituitary ACTH (23). temic therapy. Tetracyclines, widely used in adults and Androgen-secreting tumors have also been report- children over 12 years of age, are contraindicated in ed as a causative factor in infantile acne. Mann et al. infants because they interfere with the development have described a case of a boy with androgen-secret- of teeth (28). is an effective therapeutic ing adrenal tumor. Importantly, beside acne the child option at the dose of 125 mg twice daily orally (17). also demonstrated features of virilization and excessive Among other antibiotics that can be used in infants growth, which underlines the importance of a thorough with severe inflammatory acne are amoxicillin, cefalex- physical examination in children with acne. It should in, trimetoprin-sulfometaxazole and azithromycin (29). be noted, however, that such tumors are very rare and These antibiotics are also used in many infectious dis- account for only 0.02% of childhood cancers (24). eases and due to the increasing antibiotic resistance Unfortunately, infantile acne predisposes to the de- and possible side effects should only be used as sec- velopment of severe forms of acne in later life (7). For ond line drugs. this reason effective acne treatment should be quickly If there is no improvement after oral antibiotics or implemented in adolescent patients with a personal the acne is very severe with scarring oral isotretinoin history of infantile acne in order to prevent the occur- can be used with due caution (4). During the treatment rence of severe, scarring forms of the disease. with isotretinoin, the child requires constant medical Between 1 and 7 years of age acne is extremely rare. supervision and monitoring of laboratory parameters, The adrenal cortex produces very small quantities of i.e. blood count with smear, lipidogram with particular androgens during early prepubertal period. It is only emphasis on triglycerides and hepatic enzymes, renal around the age of 7 that the reticular layer of this organ function and glucose (7). One should begin with a dose begins to produce gradually increasing amounts of of 0.5 mg/kg per day to prevent an exacerbation at the sex steroids (25). The appearance of acne between 1 beginning of therapy. The dose can then be titrated up and 7 years of age, especially with concurrent signs of to 1 mg/kg (3). In the case of a typical dosage used in premature puberty must prompt the exclusion of ovar- the treatment of acne there is no increased risk of bone ian and testicular pathology, congenital adrenal hyper- demineralization or fractures (30, 31). Few cases of plasia, Cushing’s syndrome and rare but possibly life- the premature closure of lower extremity growth plates threatening androgen-secreting tumors. caused by isotretinoin and other vitamin A analogues were reported in the literature (32). TREATMENT Long term treatment with high-dose vitamin A ana- The treatment of acne in infants is a significant problem logues, commonly administered in keratinisation dis- for dermatologists, as topical and general medications are orders, increases the risk of extraspinal hyperostosis. not registered for use in this age group. In addition, due This phenomenon, however, with relatively low dosage to the polymorphism of acne lesions (comedones, inflam- of retinoids and short therapy is very rarely observed matory lesions) and sometimes the occurrence of severe in acne (33). forms of acne several drugs should be used simultane- Many cases of the effective treatment of severe ously for treatment to be effective. This raises concerns forms of acne in infants using isotretinoin have been about the risk of drug interactions, local or systemic com- described in the literature. Torrelo et al. have reported plications, or developmental disorders. the case of a 10-month-old boy with a severe scarring For infants, the simplest formulas with the lowest on his face. After ineffective treatment with erythromy- possible side effects should be used. However, they cin, oral treatment with isotretinoin 1 mg/kg resulted

47 Marta Filo-Rogulska, Dominika Wcisło-Dziadecka, Ligia Brzezińska-Wcisło in a complete remission of skin lesions. During the such as halides or aromatic hydrocarbons may also treatment, no side effects were observed. Laboratory cause severe forms of acne in children. parameters were also within normal range (34). Mill- er et al. in their retrospective study described cases of CONCLUSIONS 6 boys with severe acne and high risk of scarring effec- 1. Neonatal acne in most cases resolves sponta- tively and safely treated with oral isotretinoin. The av- neously without leaving scars and does not re- erage age of children was 6.2 months. No significant quire treatment. It is important to differentiate it adverse reactions have occurred, neither during the from other skin diseases that occur during this treatment nor in the follow-up (35). period of life, especially neonatal pustulosis. We should also mention the importance of proper 2. Infantile acne poses the risk of scarring and education of parents. This is very important in terms may require treatment, which in most cases is of the adherence to medical advice, knowledge of similar to that of adolescent acne. possible complications and avoidance of substances 3. Extensive endocrinological testing should be that may induce the so-called cosmetic acne in infants. performed in cases of acne coexisting with In this case, parents should beware of cosmetics in the other symptoms suggesting endocrine disor- form of essential oils or greasy ointments. Additonally, ders such as virilization symptoms, premature it should be reminded that exposure to toxic agents puberty or growth disorders.

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received/otrzymano: 6.02.2018 accepted/zaakceptowano: 27.02.2018

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