sign in sign up
<<
Home , Comedo, Infantile acne, Neonatal acne

FEATURE in Childhood: An Update Wendy Kim, DO; and Anthony J. Mancini, MD

cne is the most common chron- ic skin disease affecting chil- A dren and adolescents, with an 85% prevalence rate among those aged 12 to 24 years.1 However, recent data suggest a younger age of onset is com- mon and that teenagers only comprise 36.5% of patients with acne.2,3 This ar- ticle provides an overview of acne, its pathophysiology, and contemporary classification; reviews treatment op- tions; and reviews recently published algorithms for treating acne of differing levels of severity. Acne can be classified based on le- sion type (morphology) and the age All images courtesy of Anthony J. Mancini, MD. group affected.4 The contemporary Figure 1. Comedonal acne. This patient has numerous closed comedones (ie, “whiteheads”). classification of acne based on sev- eral recent reviews is addressed below. Acne lesions (see Table 1, page 419) can be divided into noninflammatory lesions (open and closed comedones, see Figure 1) and inflammatory lesions (, pustules, and nodules, see Figure 2). The comedone begins with

Wendy Kim, DO, is Assistant Professor of In- ternal Medicine and Pediatrics, Division of Der- matology, Loyola University Medical Center, Chicago. Anthony J. Mancini, MD, is Professor of Pediatrics and , Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children’s Hospital of Chi- cago. Address correspondence to: Anthony J. Man- Figure 2. Moderate mixed acne. In this patient, a combination of closed comedones, inflammatory pap- ules, and pustules can be seen. cini, MD, Division of Dermatology Box #107, Ann and Robert H. Lurie Children’s Hospital of the microcomedone, which is a micro- 3) proliferation of Propionibacterium Chicago, 225 E. Chicago Avenue, Chicago, IL scopic plug of the follicular ostia of acnes (considered the “acne organ- 60611; email: [email protected]. the pilosebaceous unit. Four process- ism”); and 4) the release of inflamma- Disclosure: Dr. Kim is an advisory board par- es are necessary for an acne lesion to tory mediators.5 The sequence of these ticipantfor Galderma. Dr. Mancini is a consul- evolve: 1) altered shedding of the ke- events remains under investigation (ie, tant, speaker, and advisory board participant for Galderma. ratinocytes that line the pilosebaceous some recent studies suggest that even doi: 10.3928/00904481-20130924-13 unit; 2) increased sebum production; comedones may be preceded by inflam-

418 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:10 | OCTOBER 2013 FEATURE matory events), but once the comedone TABLE 1. has formed it can proceed to become an inflammatory lesion.6 Treatment is de- Acne Lesion Nomenclature pendent upon the types and severity of Lesion Type Comment acne lesions that are present. Comedone May be closed (“whitehead”) or open (“blackhead”); believed to develop from microscopic plugs of desquamated cells from the IMPACT ON QUALITY OF LIFE follicle; early treatment of comedones may help prevent progres- Long regarded as a rite of passage sion to clinically inflammatory lesions. of adolescence, it is now clear that acne Inflammatory lesion May be a , pustule, or nodule; related to inflammatory patients suffer significant social and mediators, which increase in response to the P. acnes organism; psychological impact from the disease. nodules often result in scarring. Acne has been associated with anxiety, Post-inflammatory May be hypo- or hyperpigmentation, or erythema; changes may low self-esteem, embarrassment, social change last for months to years. withdrawal, and depression.7,8 In fact, the psychological impact of acne has Scarring A sequela of inflammatory acne; often persistent and very difficult been demonstrated to be as severe as to treat. that of patients with insulin-dependent diabetes, cystic fibrosis, cancer, epi- lepsy, and some psychiatric disorders.8 Several recent publications have ence higher rates of depression and based on the age of onset of the dis- addressed body dysmorphic disorder suicide than their peers. Cotterill and ease: occurs from birth (BDD), which is defined as a life-al- Cunliffe10 described 16 dermatology through age 4 weeks; has tering preoccupation with a minimal patients who completed suicide, and al- its onset between age 1 and 12 months; or imperceptible flaw in appearance, in most half of this cohort had acne. Gupta mid-childhood acne occurs from age 1 acne patients.7,9 It occurs in an estimat- and Gupta11 showed that active suicidal year through age 6 years; and preado- ed 2% of the general population, but it ideation was found in 5.6% of acne pa- lescent or prepubertal acne occurs from has been estimated to occur in 6.7% of tients who were screened in a dermatol- age 7 to 11 years.4 The specific type of patients in a general dermatology clinic ogy clinic setting. Acne patients had a acne, based on this classification sys- and up to 14% of patients in a cosmetic higher score on the Carroll Rating Scale tem, helps to determine whether other dermatology clinic.9 These patients are for Depression (CRSD) than patients evaluations (eg, for an underlying endo- frequently dissatisfied with medical with , atopic dermatitis, crinologic abnormality) are indicated. treatment and procedural outcomes, and psoriasis involving less than 30% which makes adherence more chal- of the body surface area, suggesting a Neonatal Acne lenging.7 A high percentage (36.7%) higher rate of depression than patients Neonatal acne may affect up to 20% of acne patients with barely percep- with other chronic skin conditions. of infants, although this figure is dif- tible or mild acne were found to meet These statistics underscore the impor- ficult to confirm because there may be subjective criteria for BDD via survey, tance of recognizing the detriment to overlap with other papulopustular con- and patients who had received therapy body image and potential self-harm that ditions (eg, erythema toxicum neonato- with were twice as likely as acne patients may experience. Such ob- rum, eosinophilic , transient controls to meet subjective criteria for servations also highlight the utility of neonatal pustular melanosis, milia, mil- BDD (15.5% of patients who had never early institution of therapy for acne. iaria). The lesions of neonatal acne may used isotretinoin vs. 31.8% of patients present from birth to age 4 weeks. Usu- who had used isotretinoin).7 Important- CONTEMPORARY ally, this type of acne is characterized ly, more than one-third of acne patients CLASSIFICATION by inflammatory lesions (papules and with barely perceptible to mild acne The term pediatric acne is used to pustules), although comedones may oc- reported severe disabling symptoms of describe acne that occurs from birth casionally be present. The latter are be- preoccupation with their acne.7 through age 11 years, with acne occur- lieved by some acne experts to be more It is important to be aware of the ring from age 12 years through adult- indicative of infantile acne than neona- potential psychosocial ramifications of hood referred to as adolescent acne. Pe- tal acne. Neonatal acne is believed to acne given that these patients experi- diatric acne can be further subdivided be caused by increased production of

PEDIATRIC ANNALS 42:10 | OCTOBER 2013 Healio.com/Pediatrics | 419 FEATURE

(DHEA), in association with a large -pro- ducing zona reticularis in the fetal adre- nal glands. There is also transplacental passage of , which stimulate sebaceous glands, as well as testicular production of androgens. From birth through age 6 to 12 months, boys also have pubertal levels of , which might explain why acne is more common in male infants than in female infants.12 Figure 3. Neonatal cephalic pustulosis. This newborn had numerous pustules over the forehead and cheeks, and improved dramatically following therapy with a topical antifungal cream. In recent years, a more pustular pre- sentation of neonatal acne has been de- scribed and termed neonatal cephalic pustulosis (see Figure 3). A relationship between this condition and increased colonization with (or hypersensitivity to) Malassezia furfur, M. sympodialis, or other species has been suggested. In a 1996 cohort of 13 neonates, - tule smears from the faces and necks were notable for M. furfur in eight pa- tients, whose skin all cleared rapidly following application of cream.13 Subsequent studies have been inconsistent in their findings, but many experts still recommend consideration of topical antifungal therapy in neo- nates with severe pustular acneiform Figure 4. Infantile acne. This infant has numerous open comedones (“blackheads”) with occasional in- eruptions.14-16 flammatory papules. Infantile Acne Infantile acne begins sometime in the first year of life, typically between ages 4 to 6 weeks and age 1 year. It is more common in boys than in girls and is more likely than neonatal acne to be predominantly comedonal (see Figure 4). Inflammatory lesions may or may not be present, but if present they may occasionally be severe. Nodules can also occur occasionally, and when in- fantile acne is moderate to severe, scar- ring may result (see Figure 5). In pa- tients with infantile acne, the physical examination should include a growth assessment as well as evaluation for any features of precocious puberty or an- Figure 5. Infantile acne. The mild scarring present in this infant highlights the importance of considering early therapy for patients with moderate or severe involvement. drogen excess, including axillary odor,

420 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:10 | OCTOBER 2013 FEATURE

breast development, clitoromegaly, TABLE 2. presence of axillary and/or genital hair, Therapeutic Options for Neonatal, Infantile, and Mid- and increased muscle mass. If concerns Childhood Acne are present, laboratory workup and/or referral to a pediatric endocrinologist Type of Acne Therapeutic Options are recommended. Sidebar 1 (see page Neonatal No therapy; topical azole antifungal cream (ie ketoconazole) if 423) lists the recommended laboratory markedly pustular. evaluation when androgen excess is Infantile ; topical (if primarily comedonal); topical suspected.14,15,17 (if significant inflammatory component); oral non-cycline antibiotic (ie , if moderate to severe inflammatory disease); consider androgen excess when severe. Mid-Childhood Acne Acne that begins in children aged 1 Mid-childhood acne Same as above for infantile acne; evaluation for androgen excess to 7 years is termed mid-childhood acne always indicated. and is never considered normal. The neonatal continues to se- crete high levels of androgen through age 1 year, and then the zona reticularis of the adrenal gland is quiescent until TABLE 3. , around age 7 years. Late- Fixed-Dose Combination Prescription Acne Therapies onset congenital adrenal hyperplasia, true precocious puberty, and androgen- Active Ingredients Product Age Indication secreting tumors are a few of the poten- BP and BenzaClin gel (Dermik) ≥ 12 years tial underlying causes of mid-childhood Duac gel (Stiefel Labs) ≥ 12 years acne, and laboratory evaluation should Acanya gel (Medicis Pharma) ≥ 12 years be performed in all patients presenting BP and Epiduo gel (Galderma) ≥ 9 years with acne onset during this time (see Sidebar 1, page 423).16,18 Table 2 lists Clindamycin and Ziana gel (Medicis Pharma) ≥ 12 years recommended therapies for neonatal, Veltin gel (Stiefel Labs) ≥ 12 years infantile, and mid-childhood acne. BP and erythromycin Benzamycin gel (Dermik) ≥ 12 years

BP = benzoyl peroxide. Preadolescent Acne Preadolescent acne, which presents between age 7 and 11 years, is similar TABLE 4. in presentation to adolescent acne, and Topical Used for Acne Therapy* it is considered by most experts to be a common initial sign of impending pu- Retinoid Available Formulations Comment bertal maturation. Comedones tend to Adapalene Cream, gel, solution, lotion Considered the least irritating of the topical predominate (see Figure 6, page 423), retinoids; very lipophilic, so concentrates in the especially in the “T zone” (ie, across pilosebaceous unit; pregnancy category C; brand the forehead, on the nose and on the name Differin (Galderma). chin) of the face, but inflammatory le- Tretinoin Cream, gel, microsphere Considered the original topical retinoid; preg- sions may also be present. This form gel nancy category C; Atralin (tretinoin 0.05% gel) of acne is likely becoming more com- approved down to 10 years of age; brand names also include Retin A, Retin A Micro (Medicis), Avita mon, in parallel with the downward (Mylan). trend in the timing of onset of puberty Tazarotene Gel, cream, foam Also approved for treatment of psoriasis; that has been observed over the past 19-21 pregnancy category X; brand names include century. The severity of preadoles- Tazorac(Allergan), Fabior (GlaxoSmithKline). cent acne may be predictive of the fu- 22 *Unless otherwise noted, all are approved by the US Food and Drug Administration for patients aged 12 years and older. ture, as Lucky and colleagues found in a longitudinal study that adolescent

422 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:10 | OCTOBER 2013 FEATURE

SIDEBAR 1. Recommended Laboratory Evaluations for the Child with Acne and Suspected Androgen Excess • • Follicle-stimulating hormone • Dehydroepiandrosterone sulfate • 17-hydroxyprogesterone • Free and total testosterone • Prolactin • Bone age

girls with more severe acne were more likely to have had more comedonal Figure 6. Preadolescent acne. This 9-year-old female has a combination of closed comedones and in- and inflammatory lesions as early as flammatory papules, which were limited to the “T zone” distribution on the forehead, nose, and chin. age 10 years. This cohort also was also more likely to undergo earlier men- active ingredients in these products are Topical retinoids play a paramount arche than those girls who had had often benzoyl peroxide (BP) or salicylic role in the treatment of acne. They mild preadolescent comedonal acne.22 acid. BP has been available since 1934 are vitamin A derivatives (either natu- and works by creating free radicals that rally occurring or synthetic) that bind ACNE THERAPY destroy the acne organism, P. acnes. Ad- to retinoid receptors in the skin. They The following sections apply to ado- ditionally, it reduces the release of reac- work within the nucleus to alter down- lescent acne, although preadolescent tive oxygen species from neutrophils, stream signals affecting inflammatory acne is usually treated with similar thereby reducing .24 BP pathways and proliferation.26,27 Spe- agents (albeit often in “off-label” fash- has gained favor in recent years given cifically, retinoids normalize follicular ion). An exhaustive discussion of acne its utility in acne therapy combined with keratinization and prevent the micro- therapy is beyond the scope of this ar- the lack of development of resistance to comedone from forming; therefore, ticle (for more information, the reader this agent. It has also been shown to de- they play a preventive role in the treat- is directed to recent reviews12,16,23). crease the development of resistance to ment of acne in addition to their benefi- concomitant utilized as part cial effects on the existing comedones. TOPICAL THERAPY of the acne regimen.25 BP is available It is important to educate patients on Proper skin cleansing should always in a variety of washes and “leave-on” proper use and expectations with topi- be discussed with acne patients. Al- gels, in strengths ranging from 2.5% to cal retinoids. These agents may result though the patient may be under the im- 10%. Although previously available by in some peeling, redness, and irritation, pression that scrubbing to remove dirt prescription, BP washes are now avail- primarily with initial use.28 These side and oil will improve the appearance of able exclusively on an over-the-counter effects tend to decrease after 4 weeks acne, such overmanipulation may actu- basis. However, it is also found in sev- of regular use and can be minimized ally increase inflammation and, hence, eral fixed-dose combination products by alternate-night (or every third night) should be discouraged. Cleansing once available by prescription (see Table 3, application during initiation, if needed. to twice daily with warm water and a page 422). Patients should be warned It should be reiterated that topical reti- gentle acne wash should be encour- about the potential bleaching of linens noids should be applied as a thin film at aged.16 The use of scrubbing devices and clothing by BP. Salicylic acid is a bedtime to all “fields” where the patient or abrasive sponges should be discour- keratolytic agent that may be beneficial gets acne, and not as spot therapy. Table aged for most patients. for mild comedonal acne. It is available 4 (see page 422) lists the available topi- Many over-the-counter products and in washes, pads, and other over-the- cal retinoids, along with their strengths, “systems” for acne are available. The counter products. vehicles, and proprietary names.

PEDIATRIC ANNALS 42:10 | OCTOBER 2013 Healio.com/Pediatrics | 423 FEATURE

TABLE 5. SIDEBAR 2. Common Oral Antibiotics Used for Acne Therapy General Guidelines in Oral Antibiotic Therapy for Acne Antibiotic Recommended Dose Potential Adverse Events / Comment • Continue oral antibiotics for at least 2 to 3 Doxycycline 50 mg-100 mg BID GI upset, pill esophagitis, sensitivity in the sun months to assess for response (including photo-), dental discol- • Oral antibiotic therapy should be oration (not recommended < 8 years of age), combined with a topical regimen that IBD, hepatitis, vaginal candidiasis; subantimicro- includes: bial dosing also used at 20 mg BID; available in Benzoyl peroxide (either as part of a delayed-release formulation. “leave-on” regimen or as a wash), in an Minocycline 50 mg-100 mg BID Cutaneous and mucosal hyperpigmentation, drug effort to minimize the development of hypersensitivity with hepatitis and pneumonitis, bacterial resistance; and lupus-like syndrome, Stevens Johnson syndrome, Topical retinoid, to more effectively treat vaginal candidiasis, vestibular effects, dental comedones and for their role in preven- discoloration (not recommended < 8 years of tion of the development of new acne age), IBD, photosensitivity (less than doxycycline), • Educate patients to expect a 3- to pseudotumor cerebri; available in extended- 6-month period of therapy (occasionally release formulation. longer), with the goal of discontinuing the Tetracycline 250 mg-500 mg BID GI upset, pill esophagitis, sensitivity in the sun, oral treatment as early as feasible (while hepatic dysfunction, dental discoloration (not continuing the topical maintenance recommended < 8 years of age), IBD. regimen). Erythromycin 250 mg-500 mg BID Marked GI upset, diarrhea, prolongation of QT • Discuss potential side effects and warn- interval, increasing resistance in acne; no longer ings of oral antibiotic therapy. recommended by most experts. • Routine laboratory monitoring is not Cephalexin 250 mg-500 mg BID Vaginal candidiasis, rare drug reactions; routine recommended in the absence of underly- use for acne not recommended. ing conditions that may predispose the patient to toxicities (ie hepatic or renal Trimethoprin- 80 mg/400 mg to 160 Severe drug reactions, bone marrow suppression, insufficiency) sulfamethoxa- mg/800 mg drug hypersensitivity syndrome; routine use for zole acne strongly discouraged. Adapted from Eichenfield and Mancini,12 Eichenfield et al,16 Thiboutot et al,23 Tsankov et al,33 Webster and Graber,34 Zaenglein and Thiboutot,35 and Del Rosso and Kim36

BID = twice daily; GI = gastrointestinal; IBD = inflammatory bowel disease. cetamide in acne products to mask its odor. Sodium sulfacetamide is available as a solution or lotion. Topical antibiotics, including eryth- combination product, is highly recom- Several topical, fixed-dose combina- romycin and clindamycin, are used in mended when topical antibiotics are tion therapies have been approved for the treatment of inflammatory acne and used. Dapsone 5% gel (Aczone, Aller- the treatment of mild-to-moderate acne are aimed at the reduction of P. acnes. gan) was recently approved for acne. It vulgaris (see Table 3, page 422). The These agents are typically applied once has been shown to reduce inflammatory advantages of these therapies include daily. Clindamycin is available as a lesions in as early as 2 weeks, with the the improved adherence they offer (via 1% gel, solution, lotion, and foam, and safety of twice-daily use being demon- simplification of the treatment regimen) erythromycin is available as a 5% gel strated for up to 1 year in patients aged and the complementary mechanisms of and solution. Monotherapy with topi- 12 to 15 years.29,30 Hemolytic anemia action of the individual components. cal antibiotics is not recommended be- can occur in patients with glucose- The fixed-dose combination products cause of their prolonged onset of action 6-phosphate dehydrogenase (G6PD) currently available include products and the likelihood of bacterial resis- deficiency when treated with oral dap- containing BP and clindamycin, BP tance.25 Since the 1970s, the resistance sone, but this effect seems very unlikely and adapalene, BP and erythromycin, of P. acnes to erythromycin as well as in G6PD-deficient patients treated with and tretinoin and clindamycin. These clindamycin has increased dramati- topical dapsone.31 Sulfur exhibits anti- agents are typically applied once to cally.25 Concomitant use of BP, either bacterial and keratolytic properties, and twice daily. To obtain US Food and as a wash or as part of a fixed-dose it is often combined with sodium sulfa- Drug Administration (FDA) approval

424 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:10 | OCTOBER 2013 FEATURE for these products, manufacturers need to show that the combination product TABLE 6. demonstrates increased efficacy com- Treatment Recommendations Based on Acne Severity pared with the individual components (the “monads”) and the vehicle. Type of Acne Initial Therapy Inadequate Response Mild BP or topical retinoid or topical com- Add BP or retinoid if not already Oral Therapy bination therapy (ie, BP/antibiotic using, or change topical retinoid Although only two oral antibiot- combination, retinoid/BP combina- concentration/type/formulation, ics (minocycline extended-release for tion, or retinoid/antibiotic combina- or change topical combination moderate and severe acne and doxycy- tion plus BP) therapy. cline delayed-release for severe acne) Moderate Topical combination therapy (ie, Change topical retinoid concentra- are FDA-approved for the treatment retinoid/BP combination, BP/anti- tion/type/formulation, or change of acne, the use of oral antibiotics has biotic combination plus a retinoid, topical combination therapy; or or retinoid/antibiotic combination add/change oral antibiotic; or con- been common practice for decades. The plus BP) or oral antibiotic + topical sider hormonal therapy for female goal of antibiotic therapy is to reduce retinoid/BP combination patients; or consider isotretinoin the P. acnes count and therefore the referral. inflammatory stimulus. Oral antibiot- Severe Combination therapy (oral antibiotic Consider changing oral antibiotic ics are typically viewed as “anti-in- plus topical retinoid plus BP, with or and consider oral isotretinoin; con- flammatory” treatment for acne, rather without topical antibiotic) sider hormonal therapy for female than treatment for a true infection.32,33 patients. By reducing the overall P. acnes load, BP = benzoyl peroxide. Adapted from Eichenfield et al16 bacterial lipases (and therefore triglyc- erides and subsequent free fatty acids) are reduced as well. Oral antibiotics are typically recommended when there is a Hormonal therapies, including spi- program is to reduce fetal exposure to suboptimal response to a topical thera- ronolactone and combined oral contra- isotretinoin by requiring monthly preg- peutic regimen, when there is wide- ceptive pills, are potentially effective nancy tests in females of childbearing spread disease (ie, extensive truncal therapies in some patients with ado- age. Unfortunately, a recent retrospec- disease) for which topical therapy alone lescent or young adult acne. Patients tive study of pregnancies occurring may not be feasible, and when there is most likely to respond include females during isotretinoin use revealed that greater overall severity that seem un- of childbearing age with acne accentu- iPLEDGE has not made a significant likely to respond to topical treatments ated on the neck and in the mandibular impact in this regard.37 Isotretinoin is alone.16,23,34 regions, those with perimenstrual flares most appropriately prescribed by der- Chlortetracycline, the first antibiotic in their acne, those with or matologists (or other clinicians familiar in the cycline class, was introduced other features of androgen excess, and with its use); further discussion of this in 1948.33 Antibiotics in this class are those with a poor response to conven- topic is beyond the scope of this article. still first-line therapy for patients older tional treatments. than 8 years with moderate-to-severe Oral isotretinoin is an extremely ef- DESIGNING A TREATMENT inflammatory acne. Tetracycline, how- fective treatment for nodulocystic acne, REGIMEN ever, has become less desirable in the and it was approved for use in 1982. Table 6 is a summary of recently era of newer-generation cyclines, such It should be considered in patients published acne-treatment algorithms, as minocycline and doxycycline, given with severe or resistant acne vulgaris with suggestions for initial therapy its limitations related to dosing on an in whom the likelihood for scarring is and subsequent treatment modifica- empty stomach and gastrointestinal considered significant. Isotretinoin is a tions based on acne severity. When intolerance. Table 5 (see page 424) known teratogen, a fact that led to the developing a treatment plan for acne summarizes the oral antibiotics most development of the iPLEDGE program. patients, one must evaluate the type commonly used for acne therapy. Some iPLEDGE is an FDA-mandated regis- and severity of lesions as well as the general guidelines in oral antibiotic tration program for prospective patients potential psychosocial impact. It is therapy for acne are listed in Sidebar 2 as well as prescribing physicians and important to take into account the pa- (see page 424). dispensing pharmacies. The goal of the tient’s perspective on their acne, as

PEDIATRIC ANNALS 42:10 | OCTOBER 2013 Healio.com/Pediatrics | 425 FEATURE some with even mild acne may be ex- ated and less drying than their prior ing of acne lesions indicate that most in- periencing serious psychosocial com- formulations. flammatory lesions arise from - nes and de novo. J Am Acad Dermatol. promise. Patients and their parents 2008;58(4):603-608. should be warned if they are likely to CONCLUSION 7. Bowe WP, Leyden JJ, Crerand CE, Sar- have permanent scarring. The pathogenesis of acne is com- wer DB, Margolis DJ. Body dysmor- phic disorder symptoms among patients Before utilizing a treatment algo- plex and multifactorial, and our un- with acne vulgaris. J Am Acad Dermatol. rithm, the patient’s acne should be derstanding of it continues to evolve. 2007;57(2):222-230. categorized as mild (predominantly Acne may be associated with signifi- 8. Pawin H, Chivot M, Beylot C, et al. Living with acne: a study of adolescents’personal ex- comedonal or mixed comedonal and cant psychosocial compromise and periences. Dermatology. 2007;215(4):308- mildly inflammatory acne), moder- BDD, highlighting the importance 314. ate (more inflammatory lesions with of early therapy. Acne presenting in 9. Conrado LA, Hounie AG, Diniz JB, et a substantial comedonal component younger children may have other ram- al. Body dysmorphic disorder among dermatologic patients: prevalence and as well), or severe (even greater num- ifications, and it can be categorized by clinical features. J Am Acad Dermatol. bers of inflammatory lesions and often the age of onset. In preadolescents and 2010;63(2):435-443. comedones as well as nodules, and adolescents with acne, there are a vari- 10. Cotterill JA, Cunliffe WJ. Suicide in der- matological patients. Br J Dermatol. greater risk for scarring). Proper use ety of traditional and newer treatment 1997;137(2):246-250. and application of the treatment regi- options. Use of a published treatment 11. Gupta MA, Gupta AK. Depression and sui- men should be discussed, including a algorithm is helpful in guiding initial cidal ideation in patients with acne, alope- cia areata, atopic dermatitis and psoriasis. discussion of expected side effects of and subsequent therapeutic agents and Br J Dermatol. 1998;139(5):846-850. the medications. Written action plans combinations. Benzoyl peroxide is 12. Eichenfield LF, Mancini AJ. PedAcne Re- are very beneficial and may increase desirable as a component of any acne source Guide: A Comprehensive Overview adherence, which should be assessed regimen, given its ability to help di- of Pediatric Acne & Companion to the On- line Self-Assessment Exam. New York, NY: at every visit, and the patient should be minish the development of resistance. Education Testing & Assessment Systems; offered positive reinforcement when Topical retinoids play an important 2013. improvement is noted. It is also impor- role in acne therapy, both for their ef- 13. Rapelanoro R, Mortureux P, Couprie B, Maleville J, Taieb A. Neonatal Malas- tant to highlight changes that may not fects on established lesions as well as sezia furfur pustulosis. Arch Dermatol. be clear to the patient, such as post- their role in long-term maintenance. 1996;132(2):190-193. inflammatory hyperpigmentation as a Adherence to an acne-treatment plan 14. Tom WL, Friedlander SF. Acne through the ages: case-based observations through sign of treatment response. can be increased by appropriate edu- childhood and adolescence. Clin Pediatr. Adherence to therapy is a major is- cation, anticipatory guidance, written 2008;47(7):639-651. sue in acne treatment in adolescents. action protocols, frequent follow-up, 15. Friedlander SF, Baldwin HE, Mancini AJ, Nonconfrontational but directed ques- and simplification of the regimen, as Yan AC, Eichenfield LF. The acne continu- um: age based approach to therapy. Semin tions such as “How many times per feasible. Cutan Med Surg. 2011;30(3 Suppl):S6-S11. week do you forget to use your medi- 16. Eichenfield LF, Krakowski AC, Piggott C, cation?” rather than “Are you using et al. Evidence based recommendations REFERENCES for the diagnosis and treatment of pediatric your medication as directed?” may 1. Bhate K, Williams HC. Epidemiol- acne. Pediatrics. 2013;131(Suppl 3):S163- lead to more truthful answers. Other ogy of acne vulgaris. Br J Dermatol. S186. suggestions for increasing adherence 2013;168(3):474-485. 17. Mann MW, Ellis SS, Mallory SB. Infantile 2. Friedlander SF, Eichenfield LF, Fowler RF, acne as the initial sign of an adrenocorti- with acne regimens include simplify- Fried RG, Levy ML, Webster GF. Acne cal tumor. J Am Acad Dermatol. 2007;56(2 ing the number of medications pre- epidemiology and pathophysiology. Semin Suppl):S15-S18. scribed (when feasible), setting re- Cutan Med Surg. 2010;29(2 Suppl 1):2-4. 18. Cantatore Francis JL, Glick SA. Childhood alistic expectations, and reinforcing 3. Yentzer BA, Hick J, Reese EL, Uhas A, acne: evaluation and management. Derma- Feldman SR, Balkrishnan R. Acne vulgaris tol Ther. 2006;19(4)202-209. maintenance therapy once clinical im- in the United States: a descriptive epidemi- 19. Golub MS, Collman GW, Foster PM, et al. provement is noted.12 Ease of use and ology. Cutis. 2010;86(2):94-99. Public health implications of altered pu- choice of vehicle for topical medica- 4. Mancini AJ, Baldwin HE, Eichenfield LF, berty timing. Pediatrics. 2008;121(Suppl Friedlander SF, Yan AC. Acne life cycle: 3):S218-S230. tions should be considered. For exam- the spectrum of pediatric disease. Semin 20. Toppari J, Juul A. Trends in puberty timing ple, gels are traditionally more drying Cutan Med Surg. 2011;30(3 Suppl):S2-S5. in human and environmental modifiers. Mol than creams, but may be appropriate 5. Williams HC, Dellevealle RP, Garner S. Acne Cell Endocrinol. 2010;324(1-2):39-44. vulgaris. Lancet. 2012;379(9813):361-372. 21. Euling SY, Herman-Giddens ME, Lee PA, for patients with oily skin. In addition, 6. Do TT, Zarkhin S, Orringer JS, et al. et al. Examination of US puberty-timing newer gel technologies are well toler- Computer assisted alignment and track- data from 1940 to 1994 for secular trends:

426 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:10 | OCTOBER 2013 FEATURE

Panel findings. Pediatrics. 2008;121(Suppl 25. Humphrey S. Antibiotic resistance in acne efficacy and safety of dapsone gel, 5% for 3):S172-S191. treatment. Skin Therapy Lett. 2012;17(9):1-3. the treatment of acne vulgaris. J Am Acad 22. Lucky AW, Biro FM, Sumbarti LA, Morrison 26. Zaenglein AL. Topical retinoids in the treat- Dermatol. 2007;56(3):439. JA, Sorg NW. Predictors of severity of acne ment of acne vulgaris. Semin Cutan Med 30. Lucky AW, Maloney JM, Roberts J, et al. vulgaris in young adolescent girls: results Surg. 2008;27(3):177-182. Dapsone gel 5% for the treatment of acne of a five year longitudinal study. J Pedatr. 27. Kligman AM, Fulton JE, Plewig G. Topical vulgaris: safety and efficacy of long-term 1997;130(1):30-39. vitamin A acid in acne vulgaris. Arch Der- (1 year) treatment. J Drug Dermatol. 23. Thiboutot D, Gollnick H, Bettoli V, et al. matol. 1969;99(4):469-476. 2007;6(10):981-987. New insights into the management of acne: 28. Cunliffe WJ, Danby FW, Dunlap F, Gold 31. Piette WW, Taylor S, Pariser D, Jarratt M, an update from the Global Alliance to Im- MH, Gratton D, Greenspan A. Randomised, Sheth P, Wilson D. Hematologic safety prove Outdomes in Acne group. J Am Acad controlled trial of the efficacy and safety of dapsone gel, 5%, for topical treat- Dermatol. 2009;60(5 Suppl):S1-S50. of adapalene gel 0.1% and tretinoin cream ment of acne vulgaris. Arch Dermatol. 24. Worret WI, Fluhr JW. Acne therapy with 0.05% in patients with acne vulgaris. Eur J 2008;144(12):1564-1570. topical benzoyl peroxide, antibiotics, Dermatol. 2002;12(4):350-354. 32. Esterly NB, Koransky JS, Furey NL, Trev- and . J Dtsch Dermatol Ges. 29. Draelos ZD, Carter E, Maloney M, et al. isan M. Neutrophil chemotaxis in patients 2006;4(4):293-300. Two randomized studies demonstrate the with acne receiving oral tetracycline ther- apy. Arch Dermatol. 1984;120(10):1308- 1313. 33. Tsankov N, Broshtilova V, Kazandjieva J. AD INDEX Tetracyclines in dermatology. Clin Derma- tol. 2003;21(1):33-39. ASSOCIATION AND MEETING SOLUTIONS, LLC 34. Webster GF, Graber EM. Antibiotic treat- 6900 Grove Road, Thorofare, NJ 08086 ment for acne vulgaris. Semin Cutan Med Infectious Diseases in Children® 2013 Symposium...... C2-385 Surg. 2008;27(3):183-187. 35. Zaenglein AL, Thiboutot DM. Expert com- PFIZER INC mittee recommendations for acne manage- 235 East 42nd Street, New York, NY 10017 ment. Pediatrics. 2006;118(3):1189-1199. Children’s Advil...... C4 36. Del Rosso JQ, Kim G. Optimizing the use of SALIX PHARMACEUTICALS INC. oral antibiotics in acne vulgaris. Dermatol 8510 Colonnade Center Drive, Raleigh, NC 27615 Clin. 2009;27(1):33-42. Vesicoureteral Reflux...... 392A-D 37. Shin J, Cheetham TC, Wong L, et al. The impact of the iPLEDGE program on SLACK INCORPORATED isotretinoin fetal exposure in an integrated 6900 Grove Road, Thorofare, NJ 08086 health care system. J Am Acad Dermatol. Curbside Pediatrics...... 395 2011;65(6):1117-1125. Healio Experience...... C3 Healio iPad Sweepstakes...... 405 Infectious Diseases in Children® Education Lab...... 421

While every precaution is taken to ensure accuracy, Pediatric Annals cannot guarantee against occasional changes or omissions in the preparation of this index.

Erratum: At the request of the authors, the online article by Linda Van Horn, PHD, RD and Eileen Vincent, MS, RD, “The CHILD 1 and DASH Diets: Rationale and Translational Application” (September 2013) contains updated nutritional infor- mation in the Tables that differs from the print version. It can be seen at Healio. com/Pediatrics. Search the authors’ names to view those revisions.

PEDIATRIC ANNALS 42:10 | OCTOBER 2013 Healio.com/Pediatrics | 427