Though acne is one of the most common skin conditions in children and adolescents, with prevalence reported in up to 95% of teens, there are challenges related to the treatment of preadolescent patients. Since only few studies have been conducted in patients under 12 years of age, there is limited evidence about the safety and efficacy of many acne medications in pediatric patients.
Four factors are involved in the pathogenesis of acne: increased androgen levels influencing sebaceous hyperplasia; alterations in follicular growth and differentiation; colonization of the follicle by Propionibacterium acnes; and the consequential immune response and inflammation. The age of pubertal maturation is an important milestone in relation to acne, due to the hormonal changes that can be a trigger, and today, the lower end of the range for acne onset is under 12 years of age, likely because of the trend toward earlier onset of adrenarche and menarche.
Acne can present as comedonal with closed and open comedones ("whiteheads" and "blackheads"); inflammatory, with erythematous papules, nodules, or cyst-like nodular lesions; or as mixed. Depending on the amount and type of lesions present, and on how much skin is involved, the degree and severity of acne may be classified clinically as mild, moderate, or severe. When diagnosing pediatric acne, the age and the form of presentation are always taken into consideration. Neonatal acne may appear from birth to ≤6 weeks of age, infantile from 6 weeks to ≤1 year, mid-childhood from 1 to <7 years, preadolescent from ≥7 to ≤12 years (or menarche in girls), and adolescent from ≥12 to ≤19 years (or after menarche in girls).
Treatment of pediatric acne involves assessment of its severity as a function of the number, type, and severity of skin lesions. It is also necessary to assess the potential psychological impact, as scarring and/or dyspigmentation are commonly detrimental for patients and therefore treatment that is more aggressive is usually warranted. Depending on the type of acne or severity, multiple medications may be needed, which can add further complexity to treatment of pediatric patients because of potential interaction between medications. Systemic side effects and the impact of medications on growth and development can also be concerns.
Evidence-based treatment recommendations for pediatric acne include the use of OTC products, topical benzoyl peroxide, topical retinoids, topical antibiotics, oral antibiotics, hormonal therapy, and isotretinoin.
- Mild acne, which typically presents as predominantly comedonal or as mixed comedonal and inflammatory disease, is initially treated with OTC products such as benzoyl peroxide as a single agent, topical retinoids, or combinations of topical retinoids, antibiotics, and benzoyl peroxide as individual agents or fixed-dose combinations.
- Moderate acne is initially treated with topical combinations including a retinoid and benzoyl peroxide and/or antibiotics, or with oral antibiotics in addition to a topical retinoid and benzoyl peroxide and/or topical antibiotics.
- Severe acne should be treated with oral antibiotics and topical retinoids with benzoyl peroxide, with or without topical antibiotics, and hormonal therapy in pubertal females, oral isotretinoin, and dermatology referral should be considered.
For detail on pharmacotherapy for acne, see PDR's Acne Management table (content revised in January 2015 using FDA-approved labeling and included as part of the 2016 PDR Nurse's Drug Handbook).
While selecting acne treatments for pediatric patients, additional considerations need to be taken into account. It is prudent to understand previous treatment history, have awareness of the cost of medications, have perspective regarding ease of use and regimen complexity and its impact on adherence, and be aware of vehicle selection, active scarring, and psychosocial impact of the acne on the individual. Additionally, consideration regarding the influence of diet on acne should be taken, as it is an area of evolving understanding.
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Salvatore Volpe, MD, FAAP, FACP, CHCQM
Chief Medical Officer