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The Diagnosis and Management of Mild to Moderate Pediatric Acne Vulgaris

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The Diagnosis and Management of Mild to Moderate Pediatric Acne Vulgaris The Diagnosis and Management of Mild to Moderate Pediatric Acne Vulgaris Successful management of acne vulgaris requires a comprehensive approach to patient care. By Joseph B. Bikowski, MD s a chronic, inflammatory skin disorder affect- seek treatment, males tend to have more severe pre- ing susceptible pilosebaceous units of the face, sentations. Acne typically begins between seven and Aneck, shoulders, and upper trunk, acne pres- 10 years of age and peaks between the ages of 16-19 ents unique challenges for patients and clini- years. A majority of patients clear by 20-25 years of cians. Characterized by both non-inflammatory and age, however some patients continue to have acne inflammatory lesions, three types of acne have been beyond 40 years of age. So-called “adult acne,” per- identified: neonatal acne, infantile acne, and acne sisting beyond the early-to-mid 20s, is more common vulgaris; pediatric acne vulgaris is the focus of this in women than in men. Given the hormonal media- article. Successful management of mild to moderate tors involved, acne onset correlates better with acne vulgaris requires a comprehensive approach to pubertal age than with chronological age. patient care that emphasizes 1.) education, 2.) prop- er skin care, and 3.) targeted therapy aimed at the Take-Home Tips. Successful management of mild to moderate underlying pathogenic factors that contribute to acne vulgaris requires a comprehensive approach to patient care that acne. Early initiation of effective therapy is essential emphasizes 1.) education, 2.) proper skin care, and 3.) targeted to minimize the emotional impact of acne on a therapy aimed at underlying pathogenic factors that contribute to patient, improve clinical outcomes, and prevent acne. Given the importance of topical retinoids in acne management 1,2 long-term sequelae, such as scarring. and their ability to prevent microcomedos, most patients should be Part I: Acne Vulgaris Diagnosis started on a topical retinoid. Treatment is optimized with the addition of a topical antimicrobial. Patients treated with systemic or topical Epidemiology and Pathogenesis antibiotics should always undergo concomitant topical therapy with a Acne is estimated to affect 85 percent of the popula- benzoyl peroxide-containing product, a strategy shown to reduce the tion in the US. While females are more likely to development of bacterial resistance. G 24 | Practical Dermatology for Pediatrics | May/June 2010 Mild to Moderate Pediatric Acne Vulgaris m o c . Four pathogenic fac- Types of Acne Lesions e n i l n tors contribute to acne. O d E m Elevation of dehy- r e D droepiandrosterone d n a (DHEA-S) levels associ- D M , ated with puberty is i k s w generally considered an o k i B inciting event. h p e s Increased DHEA-S pro- o J f o motes increased sebum y s e t production, which in r u o c turn encourages the o t o proliferation of h P Propionibacterium acnes, a commensal organism normally found on the skin. Concurrently, abnormal kera- ing to elucidate a causative link between diet and tinization of the follicular canal occurs with subse- acne has failed to definitively identify a relationship, quent blockage of the follicle and build-up of sebum though some evidence suggests that diet can influ- A combination of sebum and keratinocytes col- ence the course of acne. Specifically, high glycemic lects in the follicle, leading to the formation first of a load diets have been associated with exacerbation of clinically undetectable microcomedo and then of acne, and there is scant evidence implicating dairy clinically apparent open or closed comedones foods in the worsening of acne.6 (whiteheads and blackheads).3 In the case of the Acne is a chronic disease that can be character- closed comedo (whitehead), the follicle swells with ized by periods of exacerbations and remission, but keratinous and sebaceous debris, but the follicular generally it is not classified as a progressive dis- opening remains constricted and is covered over by ease.1 Left untreated, a patient with mild disease at epidermis. In the open comedo (blackhead), the fol- age 10 will likely have mild disease at age 15, licular orifice widens as the follicle swells, but a while a patient with untreated severe disease at an dark-colored mixture of keratinocytes, oxidized early age will likely have severe disease later in lipids, and melanin forms a plug in this opening. adolescence. The material that collects in the comedo also con- Though not fully elucidated, hereditary influence tains the inflammatory by-products of P. acnes, in acne has been identified; if both parents had which is shown to induce antimicrobial peptide and severe acne then the offspring has a high risk for proinflammatory cytokine/chemokine expression.4 severe acne. Studies show that a family history of However, since the material remains contained in acne is associated with earlier onset of acne and the follicular unit, an inflammatory host response is recalcitrance.7 not initiated. If the contents spill out of the follicle into the surrounding tissues of the dermis, an Acne Assessment inflammatory response is initiated, leading to the While several different acne grading scales have formation of inflammatory papules and pustules. In been used in clinical trials, no standard method for severe acne, nodules may form. acne grading has been adopted into practice. The Acne is not caused by dirt, grease, grime, oil on Basic Acne Severity Index is a proposed method for the skin, chocolate, soft drinks, nuts, pizza or any assessing acne severity based upon lesion type, num- other dietary components.5 Recent research attempt- ber, and location.11 May/June 2010 | Practical Dermatology for Pediatrics | 25 Mild to Moderate Pediatric Acne Vulgaris Type of lesion. The lesion type is designated by a Acne Impact and Sequelae grade. Since there are four primary lesion types, Acne vulgaris can have a strong psychosocial impact there are four grades from I to IV. Importantly, these on affected patients,12 with one studying showing grades simply describe a lesion morphology and are that mental health scores among affected adults not intended to represent a qualitative severity were worse than those for patients with asthma, “ranking.” For example, a Grade I lesion is no more epilepsy, diabetes, back pain, arthritis, and coronary or less severe than a Grade IV lesion. artery disease.13 In surveys of affected teens and Grade I - comedo adults acne has been shown to lead to decreased dat- Grade II - papule ing, sports, and eating out, impaired academic per- Grade III - pustule formance, and increased unemployment rates.14 Grade IV - nodulo-cyst Post inflammatory hyperpigmentation (PIH) or Number of lesions. One to 10 lesions constitutes persistent darkening of the skin in areas of healed mild acne. Moderate acne is 11 to 20 lesions. More acne lesions can occur in patients of all skin types, than 20 lesions is severe. though it is more common in patients of color.15-17 Location of lesions. Typical anatomic sites of PIH results from the deposition of melanin at the involvement include: site of previous inflammation and may persist indefi- Head nitely without treatment. Post-inflammatory erythe- • Face ma, by contrast, is reddening at the site of involve- - Forehead ment that resolves over time. - Cheeks – Right or Left - Nose Differential Diagnosis for Adolescent Acne - Chin • Ears The differential diagnosis of acne vulgaris includes several Neck “red face” diseases. Rosacea. Rosacea (sometimes called “acne rosacea,” though Torso • Shoulders this technically inaccurate term has fallen out of widespread use) • Chest typically affects adults, with earliest onset usually reported in the • Back early-to-mid 20s. Open and closed comedones are not seen in rosacea, although papules/pustules may be seen. Perioral dermatitis. More common in women than men, the When Laboratory Testing and Referral Are Indicated pathogenesis of perioral dermatitis is not well understood. In fact, perioral dermatitis is often used as an imprecise descriptor for While elevated androgen levels are implicated in the pathogen- any eruption of unknown origin affecting the perioral area. esis of acne vulgaris, in relatively rare instances androgen excess Allergic contact dermatitis may be implicated, as may misuse of associated with systemic diseases may contribute to atypical acne topical corticosteroids. presentations: early onset, severe presentation,8 or treatment Drug-induced Folliculitis. A manifestation of a systemic drug resistance. Simple laboratory tests aid diagnosis, though compre- reaction, monomorphic lesions can form on the head, upper trunk hensive specialist evaluation is indicated. Clinicians should be and proximal upper extremities. Commonly implicated drugs aware of these potential diagnoses that may manifest with severe include: corticosteroids, androgens, ACTH, lithium, isoniazid or treatment resistant acne: (INH), phenytoin. 1. Delayed onset congenital adrenal hyperplasia.9 2. Adrenal or ovarian tumor.10 Pseudofolliculitis barbae (PFB). As a result of shaving, hair 3. Cushing’s disease.10 shafts may perforate below the skin surface and become trapped, 4. Polycystic ovary syndrome.10 leading to the formation of inflammatory papules. 26 | Practical Dermatology for Pediatrics | May/June 2010 Mild to Moderate Pediatric Acne Vulgaris Scarring is a common sequelae of m o c 18,19 . acne, and the risk may be increased e n i l n among patients who “pick” and “pop” O d E lesions, causing trauma to the follicular unit m r e D and surrounding structures. d n a Early initiation of therapy is expected to D M , minimize the development of damaging i k 1,2 s w sequelae. Of note, particular therapeutic o k i B agents, such as topical retinoids (discussed h p e below) can be useful to treat acne vulgaris s o J f o as well as post-inflammatory hyperpigmen- y s 15-17 e t tation.
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