WAIKOLOA, HAWAII – New acne management recommendations from the American Acne and Rosacea Society are the first guidelines to specifically address pediatric acne.
"Acne is a common problem, and the presentations and differential diagnosis differ among the various ages of childhood and adolescence. We had a strong desire to increase recognition and improve management of pediatric and adolescent acne across the spectrum of primary and specialty care," explained Dr. Lawrence F. Eichenfield, cochair of the guideline-writing panel comprised of general pediatricians, pediatric dermatologists, and acne experts.
The comprehensive guidelines provide a simple and efficient classification scheme in which acne is categorized as comedonal, inflammatory/mixed, or nodular, and graded as globally mild, moderate, or severe. The guidelines offer detailed algorithms for the treatment of each category.
The treatment algorithms are flexible, with multiple options available based upon considerations including financial cost and treatment history.
Regimen complexity is another major consideration. Treatment adherence in pediatric and adolescent acne patients is notoriously a much bigger problem than in adults. Simple, once-daily combination products addressing multiple acne pathogenic mechanisms are advantageous.
The treatment algorithm for the adolescent with mild comedonal or inflammatory/mixed lesions begins with two broad options for initial therapy. Both are topical regimens. The first consists of monotherapy with benzoyl peroxide or a topical retinoid, which can be an inexpensive option. The second is topical fixed-dose combination therapy, which can cost far more but achieves faster clearance, Dr. Eichenfield said at the seminar sponsored by Skin Disease Education Foundation (SDEF). Recommended combinations include benzoyl peroxide with a topical antibiotic or retinoid.
Alternatively, the panel noted that topical dapsone can be used either as initial monotherapy or in place of a topical antibiotic. The panel was in agreement that a topical antibiotic should only be prescribed in conjunction with benzoyl peroxide in order to help prevent the emergence of bacterial resistance, he said.
Doxycycline and other oral antibiotics are to be reserved for treatment of moderate to severe acne, and their use should be limited to 3-6 months, according to the guidelines.
"An oral antibiotic alone is substandard care now. It needs to be accompanied by a topical retinoid, a retinoid/benzoyl peroxide, or retinoid/topical antibiotic combination to minimize resistance," Dr. Eichenfield said.
The guidelines note that it is appropriate for primary care physicians to immediately refer an adolescent who presents with severe acne to a dermatologist. Many such patients will be best-treated with oral isotretinoin, he noted.
Preadolescent acne arising in children aged 7-12 is common and considered normal. It typically begins with comedones over the forehead and midface, with truncal lesions being far less common.
Treatment follows the same algorithms as adolescent acne, with the caveat that most preadolescent therapy is off-label, since, until quite recently, nearly all treatment studies were restricted to patients aged 12 years and older. Therefore, in formulating a treatment strategy for preadolescents, the panel had to shift gears and switch from the evidence-based approach emphasized elsewhere in the guidelines to expert consensus, said Dr. Eichenfield, professor of clinical pediatrics and dermatology at the University of California, San Diego.
Infantile acne generally doesn’t show up until after the first several months of life. It is comedonal, although papules, pustules, nodules, and cysts may also be present. Infantile acne can do significant lasting damage, and treatment is warranted.
Acne developing within the first 6 weeks after birth is classified as neonatal acne. However, the erythematous papules and pustules located on the face, neck, scalp, and torso are not true acne. The skin lesions, also known as neonatal cephalic pustulosis, are associated with skin colonization by Malassezia globosa and M. sympodialis. It is a self-limited condition, although it may clear faster if treated using topical ketoconazole cream or another anti-yeast medication.
Among the other issues addressed in the report are diet and acne, the appropriate use of the various classes of medications, when and how to use oral contraceptive pills for acne, the important distinction between neonatal and infantile acne, how to prescribe the big gun – isotretinoin – in young patients, and when to refer a child with acne for a endocrinology workup, said Dr. Eichenfield.
He explained that acne arising in mid-childhood – age 1-7 years – is a red flag for an increased risk of an endocrinologic disorder. Referral to a pediatric endocrinologist is warranted if a child displays any abnormalities in height and growth, blood pressure, or displays signs of early sexual maturation. Dr. Eichenfield picks up the phone personally, he said, to talk to the pediatric endocrinologist, and to make sure the child won’t wait long for an endocrinologic evaluation.