FEATURE

Acne in Childhood: An Update

Wendy Kim, DO; and Anthony J. Mancini, MD

A
cne is the most common chron-
ic skin disease affecting chil-
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

All images courtesy of Anthony J. Mancini, MD.

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
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
(papules, 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 Dermatology, 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: amancini@northwestern.edu.
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

has formed it can proceed to become an
inflammatory lesion.6 Treatment is de-
pendent upon the types and severity of
acne lesions that are present.
IMPACT ON QUALITY OF LIFE
Long regarded as a rite of passage
of adolescence, it is now clear that acne
patients suffer significant social and
psychological impact from the disease.
Acne has been associated with anxiety,
low self-esteem, embarrassment, social
withdrawal, and depression.7,8 In fact,
the psychological impact of acne has
been demonstrated to be as severe as
TABLE 1.
Acne Lesion Nomenclature
Lesion Type Comment
Comedone May be closed (“whitehead”) or open (“blackhead”); believed to
develop from microscopic plugs of desquamated cells from the
follicle; early treatment of comedones may help prevent progres-
sion to clinically inflammatory lesions.
Inflammatory lesion May be a papule, pustule, or nodule; related to inflammatory
mediators, which increase in response to the P. acnes organism;
nodules often result in scarring.
Post-inflammatory May be hypo- or hyperpigmentation, or erythema; changes may
change last for months to years.
Scarring A sequela of inflammatory acne; often persistent and very difficult
to treat.

that of patients with insulin-dependent

diabetes, cystic fibrosis, cancer, epi-
lepsy, and some psychiatric disorders.8
Several recent publications have
addressed body dysmorphic disorder
(BDD), which is defined as a life-al-
tering preoccupation with a minimal
or imperceptible flaw in appearance, in
acne patients.7,9 It occurs in an estimat-
ed 2% of the general population, but it
has been estimated to occur in 6.7% of
patients in a general dermatology clinic
and up to 14% of patients in a cosmetic
dermatology clinic.9 These patients are
frequently dissatisfied with medical
treatment and procedural outcomes,
which makes adherence more chal-
lenging.7 A high percentage (36.7%)
of acne patients with barely percep-
tible or mild acne were found to meet
subjective criteria for BDD via survey,
and patients who had received therapy
with isotretinoin were twice as likely as
controls to meet subjective criteria for
BDD (15.5% of patients who had never
used isotretinoin vs. 31.8% of patients
who had used isotretinoin).7 Important-
ly, more than one-third of acne patients
with barely perceptible to mild acne
reported severe disabling symptoms of
preoccupation with their acne.7
It is important to be aware of the
potential psychosocial ramifications of
acne given that these patients experi-
ence higher rates of depression and
suicide than their peers. Cotterill and
Cunliffe10 described 16 dermatology
patients who completed suicide, and al-
most half of this cohort had acne. Gupta
and Gupta11 showed that active suicidal
ideation was found in 5.6% of acne pa-
tients who were screened in a dermatol-
ogy clinic setting. Acne patients had a
higher score on the Carroll Rating Scale
for Depression (CRSD) than patients
with alopecia areata, atopic dermatitis,
and psoriasis involving less than 30%
of the body surface area, suggesting a
higher rate of depression than patients
with other chronic skin conditions.
These statistics underscore the impor-
tance of recognizing the detriment to
body image and potential self-harm that
acne patients may experience. Such ob-
servations also highlight the utility of
early institution of therapy for acne.
CONTEMPORARY
CLASSIFICATION
The term pediatric acne is used to
describe acne that occurs from birth
through age 11 years, with acne occur-
ring from age 12 years through adult-
hood referred to as adolescent acne. Pe-
diatric acne can be further subdivided
based on the age of onset of the dis-
ease: neonatal acne occurs from birth
through age 4 weeks; infantile acne has
its onset between age 1 and 12 months;
mid-childhood acne occurs from age 1
year through age 6 years; and preado-
lescent or prepubertal acne occurs from
age 7 to 11 years.4 The specific type of
acne, based on this classification sys-
tem, helps to determine whether other
evaluations (eg, for an underlying endo-
crinologic abnormality) are indicated.
Neonatal Acne
Neonatal acne may affect up to 20%
of infants, although this figure is dif-
ficult to confirm because there may be
overlap with other papulopustular con-
ditions (eg, erythema toxicum neonato-
rum, eosinophilic folliculitis, transient
neonatal pustular melanosis, milia, mil-
iaria). The lesions of neonatal acne may
present from birth to age 4 weeks. Usu-
ally, this type of acne is characterized
by inflammatory lesions (papules and
pustules), although comedones may oc-
casionally be present. The latter are be-
lieved by some acne experts to be more
indicative of infantile acne than neona-
tal acne. Neonatal acne is believed to
be caused by increased production of

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

 FEATURE

dehydroepiandrosterone (DHEA), in
association with a large androgen-pro-
ducing zona reticularis in the fetal adre-
nal glands. There is also transplacental
passage of androgens, 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 testosterone,
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, pus-
tule smears from the faces and necks
were notable for M. furfur in eight pa-
tients, whose skin all cleared rapidly
following application of ketoconazole
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 Benzoyl peroxide; topical retinoid (if primarily comedonal); topical
antibiotic (if significant inflammatory component); oral non-cycline
suspected.14,15,17
antibiotic (ie erythromycin, 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 adrenal gland 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.
adrenarche, 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 clindamycin 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 adapalene Epiduo gel (Galderma) ≥ 9 years with acne onset during this time (see
Clindamycin and Ziana gel (Medicis Pharma) ≥ 12 years
Sidebar 1, page 423).16,18 Table 2 lists
tretinoin Veltin gel (Stiefel Labs) ≥ 12 years
recommended therapies for neonatal,
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 Retinoids 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
pregnancy category X; brand names include century.19-21 The severity of preadoles-
Tazorac(Allergan), Fabior (GlaxoSmithKline). cent acne may be predictive of the fu-
*Unless otherwise noted, all are approved by the US Food and Drug Administration for patients aged 12 years and older. ture, as Lucky and colleagues22 found
in a longitudinal study that adolescent

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SIDEBAR 1.
Recommended Laboratory
Evaluations for the Child
with Acne and Suspected
Androgen Excess
• Luteinizing hormone
• 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
and inflammatory lesions as early as
age 10 years. This cohort also was also
more likely to undergo earlier men-
arche than those girls who had had
mild preadolescent comedonal acne.22
ACNE THERAPY
The following sections apply to ado-
lescent acne, although preadolescent
acne is usually treated with similar
agents (albeit often in “off-label” fash-
ion). An exhaustive discussion of acne
therapy is beyond the scope of this ar-
ticle (for more information, the reader
is directed to recent reviews12,16,23).
TOPICAL THERAPY
Proper skin cleansing should always
be discussed with acne patients. Al-
though the patient may be under the im-
pression that scrubbing to remove dirt
and oil will improve the appearance of
acne, such overmanipulation may actu-
ally increase inflammation and, hence,
should be discouraged. Cleansing once
to twice daily with warm water and a
gentle acne wash should be encour-
aged.16 The use of scrubbing devices
or abrasive sponges should be discour-
aged for most patients.
Many over-the-counter products and
“systems” for acne are available. The
PEDIATRIC ANNALS 42:10 | OCTOBER 2013
FEATURE
Figure 6. Preadolescent acne. This 9-year-old female has a combination of closed comedones and in-
flammatory papules, which were limited to the “T zone” distribution on the forehead, nose, and chin.
active ingredients in these products are
often benzoyl peroxide (BP) or salicylic
acid. BP has been available since 1934
and works by creating free radicals that
destroy the acne organism, P. acnes. Ad-
ditionally, it reduces the release of reac-
tive oxygen species from neutrophils,
thereby reducing inflammation.24 BP
has gained favor in recent years given
its utility in acne therapy combined with
the lack of development of resistance to
this agent. It has also been shown to de-
crease the development of resistance to
concomitant antibiotics utilized as part
of the acne regimen.25 BP is available
in a variety of washes and “leave-on”
gels, in strengths ranging from 2.5% to
10%. Although previously available by
prescription, BP washes are now avail-
able exclusively on an over-the-counter
basis. However, it is also found in sev-
eral fixed-dose combination products
available by prescription (see Table 3,
page 422). Patients should be warned
about the potential bleaching of linens
and clothing by BP. Salicylic acid is a
keratolytic agent that may be beneficial
for mild comedonal acne. It is available
in washes, pads, and other over-the-
counter products.
Topical retinoids play a paramount
role in the treatment of acne. They
are vitamin A derivatives (either natu-
rally occurring or synthetic) that bind
to retinoid receptors in the skin. They
work within the nucleus to alter down-
stream signals affecting inflammatory
pathways and proliferation.26,27 Spe-
cifically, retinoids normalize follicular
keratinization and prevent the micro-
comedone from forming; therefore,
they play a preventive role in the treat-
ment of acne in addition to their benefi-
cial effects on the existing comedones.
It is important to educate patients on
proper use and expectations with topi-
cal retinoids. These agents may result
in some peeling, redness, and irritation,
primarily with initial use.28 These side
effects tend to decrease after 4 weeks
of regular use and can be minimized
by alternate-night (or every third night)
application during initiation, if needed.
It should be reiterated that topical reti-
noids should be applied as a thin film at
bedtime to all “fields” where the patient
gets acne, and not as spot therapy. Table
4 (see page 422) lists the available topi-
cal retinoids, along with their strengths,
vehicles, and proprietary names.
Healio.com/Pediatrics | 423

TABLE 5.
Common Oral Antibiotics Used for Acne Therapy
Antibiotic Recommended Dose
Doxycycline 50 mg-100 mg BID
Minocycline 50 mg-100 mg BID
Tetracycline 250 mg-500 mg BID
Erythromycin 250 mg-500 mg BID
Cephalexin 250 mg-500 mg BID
Trimethoprin- 80 mg/400 mg to 160
sulfamethoxa- mg/800 mg
zole
BID = twice daily; GI = gastrointestinal; IBD = inflammatory bowel disease.
Topical antibiotics, including eryth-
romycin and clindamycin, are used in
the treatment of inflammatory acne and
are aimed at the reduction of P. acnes.
These agents are typically applied once
daily. Clindamycin is available as a
1% gel, solution, lotion, and foam, and
erythromycin is available as a 5% gel
and solution. Monotherapy with topi-
cal antibiotics is not recommended be-
cause of their prolonged onset of action
and the likelihood of bacterial resis-
tance.25 Since the 1970s, the resistance
of P. acnes to erythromycin as well as
clindamycin has increased dramati-
cally.25 Concomitant use of BP, either
as a wash or as part of a fixed-dose
424 | Healio.com/Pediatrics
FEATURE
Potential Adverse Events / Comment
GI upset, pill esophagitis, sensitivity in the sun
(including photo-onycholysis), dental discol-
oration (not recommended < 8 years of age),
IBD, hepatitis, vaginal candidiasis; subantimicro-
bial dosing also used at 20 mg BID; available in
delayed-release formulation.
Cutaneous and mucosal hyperpigmentation, drug
hypersensitivity with hepatitis and pneumonitis,
lupus-like syndrome, Stevens Johnson syndrome,
vaginal candidiasis, vestibular effects, dental
discoloration (not recommended < 8 years of
age), IBD, photosensitivity (less than doxycycline),
pseudotumor cerebri; available in extended-
release formulation.
GI upset, pill esophagitis, sensitivity in the sun,
hepatic dysfunction, dental discoloration (not
recommended < 8 years of age), IBD.
Marked GI upset, diarrhea, prolongation of QT
interval, increasing resistance in acne; no longer
recommended by most experts.
Vaginal candidiasis, rare drug reactions; routine
use for acne not recommended.
Severe drug reactions, bone marrow suppression,
drug hypersensitivity syndrome; routine use for
acne strongly discouraged.
combination product, is highly recom-
mended when topical antibiotics are
used. Dapsone 5% gel (Aczone, Aller-
gan) was recently approved for acne. It
has been shown to reduce inflammatory
lesions in as early as 2 weeks, with the
safety of twice-daily use being demon-
strated for up to 1 year in patients aged
12 to 15 years.29,30 Hemolytic anemia
can occur in patients with glucose-
6-phosphate dehydrogenase (G6PD)
deficiency when treated with oral dap-
sone, but this effect seems very unlikely
in G6PD-deficient patients treated with
topical dapsone.31 Sulfur exhibits anti-
bacterial and keratolytic properties, and
it is often combined with sodium sulfa-
SIDEBAR 2.
General Guidelines in Oral
Antibiotic Therapy for Acne
• Continue oral antibiotics for at least 2 to 3
months to assess for response
• Oral antibiotic therapy should be
combined with a topical regimen that
includes:
B
 enzoyl peroxide (either as part of a
“leave-on” regimen or as a wash), in an
effort to minimize the development of
bacterial resistance; and
Topical retinoid, to more effectively treat
comedones and for their role in preven-
tion of the development of new acne
• Educate patients to expect a 3- to
6-month period of therapy (occasionally
longer), with the goal of discontinuing the
oral treatment as early as feasible (while
continuing the topical maintenance
regimen).
• Discuss potential side effects and warn-
ings of oral antibiotic therapy.
• Routine laboratory monitoring is not
recommended in the absence of underly-
ing conditions that may predispose the
patient to toxicities (ie hepatic or renal
insufficiency)
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
cetamide in acne products to mask its
odor. Sodium sulfacetamide is available
as a solution or lotion.
Several topical, fixed-dose combina-
tion therapies have been approved for
the treatment of mild-to-moderate acne
vulgaris (see Table 3, page 422). The
advantages of these therapies include
the improved adherence they offer (via
simplification of the treatment regimen)
and the complementary mechanisms of
action of the individual components.
The fixed-dose combination products
currently available include products
containing BP and clindamycin, BP
and adapalene, BP and erythromycin,
and tretinoin and clindamycin. These
agents are typically applied once to
twice daily. To obtain US Food and
Drug Administration (FDA) approval
PEDIATRIC ANNALS 42:10 | OCTOBER 2013

for these products, manufacturers need
to show that the combination product
demonstrates increased efficacy com-
pared with the individual components
(the “monads”) and the vehicle.
Oral Therapy
Although only two oral antibiot-
ics (minocycline extended-release for
moderate and severe acne and doxycy-
cline delayed-release for severe acne)
are FDA-approved for the treatment
of acne, the use of oral antibiotics has
been common practice for decades. The
goal of antibiotic therapy is to reduce
the P. acnes count and therefore the
inflammatory stimulus. Oral antibiot-
ics are typically viewed as “anti-in-
flammatory” treatment for acne, rather
than treatment for a true infection.32,33
By reducing the overall P. acnes load,
bacterial lipases (and therefore triglyc-
erides and subsequent free fatty acids)
are reduced as well. Oral antibiotics are
typically recommended when there is a
suboptimal response to a topical thera-
peutic regimen, when there is wide-
spread disease (ie, extensive truncal
disease) for which topical therapy alone
may not be feasible, and when there is
greater overall severity that seem un-
likely to respond to topical treatments
alone.16,23,34
Chlortetracycline, the first antibiotic
in the cycline class, was introduced
in 1948.33 Antibiotics in this class are
still first-line therapy for patients older
than 8 years with moderate-to-severe
inflammatory acne. Tetracycline, how-
ever, has become less desirable in the
era of newer-generation cyclines, such
as minocycline and doxycycline, given
its limitations related to dosing on an
empty stomach and gastrointestinal
intolerance. Table 5 (see page 424)
summarizes the oral antibiotics most
commonly used for acne therapy. Some
general guidelines in oral antibiotic
therapy for acne are listed in Sidebar 2
(see page 424).
PEDIATRIC ANNALS 42:10 | OCTOBER 2013
FEATURE
TABLE 6.
Treatment Recommendations Based on Acne Severity
Type of Acne Initial Therapy Inadequate Response
Mild BP or topical retinoid or topical com- Add BP or retinoid if not already
bination therapy (ie, BP/antibiotic using, or change topical retinoid
combination, retinoid/BP combina- concentration/type/formulation,
tion, or retinoid/antibiotic combina- or change topical combination
tion plus BP) therapy.
Moderate Topical combination therapy (ie, Change topical retinoid concentra-
retinoid/BP combination, BP/anti- tion/type/formulation, or change
biotic combination plus a retinoid, topical combination therapy; or
or retinoid/antibiotic combination add/change oral antibiotic; or con-
plus BP) or oral antibiotic + topical sider hormonal therapy for female
retinoid/BP combination patients; or consider isotretinoin
referral.
Severe Combination therapy (oral antibiotic Consider changing oral antibiotic
plus topical retinoid plus BP, with or and consider oral isotretinoin; con-
without topical antibiotic) sider hormonal therapy for female
patients.
BP = benzoyl peroxide.
Adapted from Eichenfield et al16
Hormonal therapies, including spi- program is to reduce fetal exposure to
ronolactone and combined oral contra- isotretinoin by requiring monthly preg-
ceptive pills, are potentially effective nancy tests in females of childbearing
therapies in some patients with ado- age. Unfortunately, a recent retrospec-
lescent or young adult acne. Patients tive study of pregnancies occurring
most likely to respond include females during isotretinoin use revealed that
of childbearing age with acne accentu- iPLEDGE has not made a significant
ated on the neck and in the mandibular impact in this regard.37 Isotretinoin is
regions, those with perimenstrual flares most appropriately prescribed by der-
in their acne, those with hirsutism or matologists (or other clinicians familiar
other features of androgen excess, and with its use); further discussion of this
those with a poor response to conven- topic is beyond the scope of this article.
tional treatments.
Oral isotretinoin is an extremely ef- DESIGNING A TREATMENT
fective treatment for nodulocystic acne, REGIMEN
and it was approved for use in 1982. Table 6 is a summary of recently
It should be considered in patients published acne-treatment algorithms,
with severe or resistant acne vulgaris with suggestions for initial therapy
in whom the likelihood for scarring is and subsequent treatment modifica-
considered significant. Isotretinoin is a tions based on acne severity. When
known teratogen, a fact that led to the developing a treatment plan for acne
development of the iPLEDGE program. patients, one must evaluate the type
iPLEDGE is an FDA-mandated regis- and severity of lesions as well as the
tration program for prospective patients potential psychosocial impact. It is
as well as prescribing physicians and important to take into account the pa-
dispensing pharmacies. The goal of the tient’s perspective on their acne, as
Healio.com/Pediatrics | 425

some with even mild acne may be ex-
periencing serious psychosocial com-
promise. Patients and their parents
should be warned if they are likely to
have permanent scarring.
Before utilizing a treatment algo-
rithm, the patient’s acne should be
categorized as mild (predominantly
comedonal or mixed comedonal and
mildly inflammatory acne), moder-
ate (more inflammatory lesions with
a substantial comedonal component
as well), or severe (even greater num-
bers of inflammatory lesions and often
comedones as well as nodules, and
greater risk for scarring). Proper use
and application of the treatment regi-
men should be discussed, including a
discussion of expected side effects of
the medications. Written action plans
are very beneficial and may increase
adherence, which should be assessed
at every visit, and the patient should be
offered positive reinforcement when
improvement is noted. It is also impor-
tant to highlight changes that may not
be clear to the patient, such as post-
inflammatory hyperpigmentation as a
sign of treatment response.
Adherence to therapy is a major is-
sue in acne treatment in adolescents.
Nonconfrontational but directed ques-
tions such as “How many times per
week do you forget to use your medi-
cation?” rather than “Are you using
your medication as directed?” may
lead to more truthful answers. Other
suggestions for increasing adherence
with acne regimens include simplify-
ing the number of medications pre-
scribed (when feasible), setting re-
alistic expectations, and reinforcing
maintenance therapy once clinical im-
provement is noted.12 Ease of use and
choice of vehicle for topical medica-
tions should be considered. For exam-
ple, gels are traditionally more drying
than creams, but may be appropriate
for patients with oily skin. In addition,
newer gel technologies are well toler-
426 | Healio.com/Pediatrics
FEATURE
ated and less drying than their prior
formulations.
CONCLUSION
The pathogenesis of acne is com-
plex and multifactorial, and our un-
derstanding of it continues to evolve.
Acne may be associated with signifi-
cant psychosocial compromise and
BDD, highlighting the importance
of early therapy. Acne presenting in
younger children may have other ram-
ifications, and it can be categorized by
the age of onset. In preadolescents and
adolescents with acne, there are a vari-
ety of traditional and newer treatment
options. Use of a published treatment
algorithm is helpful in guiding initial
and subsequent therapeutic agents and
combinations. Benzoyl peroxide is
desirable as a component of any acne
regimen, given its ability to help di-
minish the development of resistance.
Topical retinoids play an important
role in acne therapy, both for their ef-
fects on established lesions as well as
their role in long-term maintenance.
Adherence to an acne-treatment plan
can be increased by appropriate edu-
cation, anticipatory guidance, written
action protocols, frequent follow-up,
and simplification of the regimen, as
feasible.
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PFIZER INC
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235 East 42nd Street, New York, NY 10017
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6900 Grove Road, Thorofare, NJ 08086 health care system. J Am Acad Dermatol.
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While every precaution is taken to ensure accuracy, Pediatric Annals cannot guarantee against occasional
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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.

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