Guidelines for managing acne in children promote more consistent care

Miami Beach, Fla. - With acne presenting in increasingly younger patients, new guidelines developed by the American Acne and Rosacea Society (AARS) promote more consistent care for pediatric patients, according to an expert.

“Acne is increasingly common in preadolescents, as well as adolescents,” says Lawrence F. Eichenfield, M.D., chief of pediatric and adolescent dermatology at Rady Children’s Hospital and professor of pediatrics and medicine (dermatology) at the University of California, San Diego. He spoke at the annual meeting of the American Academy of Dermatology.

Simultaneously, “We know that there is a younger onset of puberty in both girls and boys. This means that a younger set of patients can present for evaluation of their acne.”

Moreover, “We know that there are tremendous variations - especially among pediatricians, primary care practitioners and dermatologists - in how people manage acne.” Such variations involve the appropriate use of retinoids in managing all types of acne, and of systemic antibiotics in moderate-to-severe acne, he says.

Guidelines by age

Fortunately, Dr. Eichenfield says, “We believe that the guidelines for pediatric acne will increase health practitioners’ knowledge about pediatric acne and improve care for these patients (Eichenfield LF, Krakowski AC, Piggott C, et al. Pediatrics. 2013;131 Suppl 3:S163-S186).” The American Academy of Pediatrics also endorses the guidelines.

Central to the guidelines is classifying acne by age. In this regard, the lesions of neonatal acne (ages 0 to 6 weeks) are more acneiform than true acne, Dr. Eichenfield says.

“Many pustular eruptions have traditionally been called neonatal acne, though they may not be true acne. One such variation is neonatal cephalic pustulosis, which has been associated with Malassezia species (M. sympodialis and M. globosa).”

Infantile acne can present from a few months to one year of age. “It’s true acne, with comedones usually present. In addition, patients can have inflammatory papules, pustules, nodules and cyst-like lesions.”

Mid-childhood acne (ages 1 to less than 7 years) is the most worrisome form of pediatric acne, Dr. Eichenfield says. Fortunately, “It’s very uncommon in an otherwise well child. Sebaceous glands usually are not active, or relatively inactive, in this age group.” However, he adds, the presence of acne in mid-childhood should warrant a workup for an underlying systemic cause (the guidelines also suggest a referral to a pediatric endocrinologist). Systemic causes can include premature adrenarche, Cushing’s syndrome, congenital adrenal hyperplasia, gonadal adrenal tumors or precocious puberty, he says.

Preadolescent acne (ages 7 to 12 years) is much more common, and generally not associated with underlying endocrinopathy, Dr. Eichenfield says.

“It often presents with early comedones of the forehead and midface,” he says. “It’s been shown that early significant acne can correlate with advanced pubertal maturation” and signal a higher risk for severe acne over time.”

Additional factors

Acne type, extent and severity also drive treatment choices. In the former area, the guidelines specify that pediatric acne can be comedonal, mixed (comedonal/inflammatory) or nodular/cystic. As for severity, the guidelines recommend considering the presence of acne scarring and the impact of acne on a child’s psychological health and development.

Addressing each of the foregoing parameters, the guidelines include an algorithm that covers initial acne treatment, along with additional strategies to consider if patients don’t respond adequately to these options.

“For instance, for mild acne (comedonal or inflammatory/mixed), the general approach is a topical regimen. The initial treatment can be benzoyl peroxide, or a topical retinoid, as monotherapy,” Dr. Eichenfield says. “Alternatively, one can prescribe topical combination therapy, which can include benzoyl peroxide, antibiotics, retinoids or combination products.” If initial treatment fails, he adds, dermatologists already prescribing topical retinoids can consider changing the retinoid type, concentration and/or formulation.

For moderate acne, “Initial treatment can include topical combination therapies, including a retinoid and an antimicrobial. Alternatively, one can initiate therapy with an oral antibiotic and a topical retinoid, with benzoyl peroxide advised to minimize the emergence of bacterial resistance.”

Additionally, Dr. Eichenfield says that evidence-based guidelines offer specific recommendations by therapeutic class.

Antibiotic caution

“Topical antibiotics (clindamycin, erythromycin) are not recommended as monotherapy. And if they are to be used for more than a few weeks, topical benzoyl peroxide should be added, or utilized in combination products,” he says.

Likewise, he adds, dermatologists can prescribe fixed-dose combination topical products for all types and severities of acne. In this regard, a recent study of a benzoyl peroxide-adapalene combination (Eichenfield LF, Herbert AA, Lucky AW, et al. J Am Acad Dermatol. 2013; Abstract P6243. 68(4): Suppl 1, AB19. In press, J Drugs Dermatol.) resulted in a Food and Drug Administration indication for use in children as young as age 9.

Somewhat similarly, “Oral antibiotics are appropriate for moderate-to-severe inflammatory acne at any age, as long as one avoids the cycline-based products in patients under age 8” because these drugs can permanently stain teeth. The guidelines also recommend isotretinoin for severe acne scarring or refractory acne in adolescents. “We may utilize it in younger patients as well - with extensive, appropriate counseling regarding potential side effects and the need to avoid pregnancy.”

Disclosures: Dr. Eichenfield co-chaired the AARS guideline committee with Diane Thiboutot, M.D. His adapalene/benzoyl peroxide study was supported by Galderma.