Practice gaps in childhood acne treatment

It is important to choose the correct therapeutic option when treating pediatric acne.

“There are defined practice gaps among pediatricians, which I believe can be expanded to dermatologists,” says Jonette Keri, M.D., Ph.D., an associate professor of dermatology and cutaneous surgery at the University of Miami in Florida.

Dr. Keri, who gave a presentation on combating acne in children and adolescents at the 2017 South Beach Symposium in Miami Beach in February to an audience comprised of both pediatricians and dermatologists, based her guidelines for acne care from published guidelines in the journal Pediatrics in 2013 and the Journal of the American Academy of Dermatology in 2016.

A practice gap consists of a case test, for which the physician is taught about acne before treatment, immediately after treatment and then three months later, “to see if the doctor is learning to prescribe differently,” says Dr. Keri, in a post-presentation interview with Dermatology Times.

The two defined practice gaps among pediatricians were inadequate use of retinoids in the preadolescent population (ages 8 – 12) and that for severe acne, combination therapies were underused.  

Conversely, dermatologists are more likely to prescribe retinoids to preadolescents.

But dermatologists need to heed the second practice gap of combination therapies for severe acne, according to Dr. Keri.

The 2016 guidelines state that oral corticosteroids like prednisone can be used during the initiation of acne therapy in conjunction with other medications such as antibiotics and isotretinoin.

“This protocol can calm down very severe acne,” Dr. Keri observes.

Dr. Keri receives many referrals from dermatologists of children with really bad acne.

“Most of these dermatologists do not seem to consider oral steroids, and the ones who do, often do not use a large enough dose, either too small of a dose or too short of a time” she says.

Dr. Keri treats severe acne similar to acne fulminane (AF), which is explosive acne accompanied with systemic symptoms (fever, bone pain).

“The daily dose of prednisone might be 0.5 mg, even 1 mg, for every kg of body weight of the patient,” Dr. Keri says. For severe acne, a course of treatment can last 2 weeks, 4 weeks or even longer, compared to up to five months for AF.

“Acne patients need to be followed closely to ensure they are doing well on the medication,” says Dr. Keri, chief of dermatology at the Miami VA Healthcare System.

NEXT: The role of diet, cosmeceuticals

Diet and cosmeceuticals

The role of diet in acne remains controversial.

“However, there seems to be more and more evidence that a low-glycemic load diet is better for acne than those foods that provide a ‘sugar rush,’” Dr. Keri says. “But we are teasing out which patients are affected by these diets. Down the road, we are probably going to figure out the genetic variances between patients who are more sensitive to diet with regard to their acne.”

Meanwhile, cosmeceuticals can benefit mild and even moderate acne. Three agents, in particular, seem to achieve some efficacy: topical retinol, topical niacinamide and glycolic acid.

“I use all three of these products in my practice,” Dr. Keri says. “There are different protocols, though, because different companies make them.”

In general, retinol is applied once a day, and niacinamide and glycolic acid once or twice daily.

“These products may, in fact, be less expensive for some patients than prescription medications,” Dr. Keri says.

Dr. Keri notes that it is important that children with acne get treated and that their parents become educated.

“This is a condition that may not go away after the age of 12 or 13,” she says. “Acne can persist until the child is into adulthood, so you want to get a handle on it.”

On the other hand, in children between the ages of 1 and 8, “acne is very rare and is often associated with another problem, so the dermatologist should work with a pediatrician and an endocrinologist,” Dr. Keri says.

For infantile acne with scarring, isotretinoin is considered an acceptable treatment.

Disclosure: Dr. Keri reports no relevant financial disclosures.