Conference Coverage

Childhood acne: When to worry



WAILEA, HAWAII – Acne arising in a 1- to 7-year-old means "it’s time to worry," according to Dr. Lawrence F. Eichenfield.

Acne originating in this midchildhood age range is very uncommon. It signals the need for a detailed endocrinologic work-up. Possible underlying causes include precocious adrenarche, congenital adrenal hyperplasia, Cushing’s syndrome, precocious puberty, and a gonadal or adrenal tumor, he noted at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

Dr. Lawrence F. Eichenfield

"If you want to take it on yourself you can, but the standard is going to be an evaluation that includes a growth chart, a bone age assessment, Tanner staging, and measurement of total and free testosterone, LH [luteinizing hormone], FSH [follicle-stimulating hormone], prolactin, DHEAS [dehydroepiandrosterone sulfate], andrestenedione, and 17-hydroxyprogesterone. Generally we say refer to a pediatric endocrinologist," said Dr. Eichenfield, professor of clinical pediatrics and medicine (dermatology) at the University of California, San Diego.

He noted that acne occurring at age 1-7 is prominently identified as a red flag in guidelines for the management of pediatric acne developed by the American Acne and Rosacea Society and subsequently approved by the American Academy of Pediatrics. Dr. Eichenfield was cochair of the expert panel that crafted the guidelines.

The comprehensive guidelines – the first ever to specifically address acne in the pediatric age range – include a general acne categorization scheme based upon age. While acne in a 1- to 7-year-old is characterized as a cause for concern, acne arising in a seemingly healthy slightly older preadolescent – roughly age 7-12 – is not.

"Acne in a child in this age group who otherwise looks well and has no signs or history that would make you suspicious of an underlying endocrinopathy is essentially a normal variant we now call preadolescent acne. You do not need to refer that patient for further evaluation," the pediatric dermatologist explained.

Nonworrisome preadolescent acne presents as comedone-predominant disease typically concentrated on the forehead and midface, with truncal involvement much less frequent. The acne may precede other signs of puberty. There is solid evidence that the more pronounced the expression of early preadolescent acne – that is, the greater the number of facial comedones present – the more severe the acne will be in adolescence. Indeed, severe preadolescent acne is often a harbinger of the later need for isotretinoin.

Acne developing within the first 6 weeks of life is most often an erythematous papulopustular eruption categorized in the guidelines as neonatal acne, also known as neonatal cephalic pustulosis. It is not true acne, but rather a self-limited condition associated with Malassezia globosa and M. sympodialis.

In contrast, infantile acne is true acne, mainly comedonal, which typically doesn’t show up until a baby is several months old and lasts for up to about a year.

The guidelines put forth detailed treatment algorithms featuring multiple options available for each acne age category and degree of severity. Of note, benzoyl peroxide is listed as a first-line treatment across the board, either as monotherapy or in combination with an antibiotic or topical retinoid.

"There is a theme that whenever one is using an antibiotic – whether a systemic drug or a topical product like clindamycin – benzoyl peroxide is advised in the regimen of care because of the feeling that if you use an unopposed antibiotic, you can have the development of bacterial resistance," Dr. Eichenfield noted.

He reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

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