Pediatric Acne: Clinical Presentations, Evaluation, and Management
June 2007 | Volume 6 | Issue 6 | Original Article | 589 | Copyright © 2007
Andrew C. Krakowski MD,a Lawrence F. Eichenfield, MDb
a. Pediatric Fellow, Division of Pediatric and Adolescent Dermatology, Rady Children’s Hospital, San Diego, CA
b. Chief of Pediatric and Adolescent Dermatology, Rady Children’s Hospital, San Diego, CA;
Professor of Pediatrics and Medicine at the University of California, San Diego, CA
Acne vulgaris can be easy to diagnose yet difficult to evaluate and manage, especially when it presents in infancy and childhood. The differential diagnosis of acne varies by age and, in some cases, may warrant a work-up in order to rule out underlying systemic abnormalities. Likewise, treatment strategies can be influenced by the patient’s age. In this article, we present an overview of the clinical presentations of acne by age, an approach to patient evaluation, and a general strategy for management of this common and important disease.
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While part of its name, vulgaris, reflects the very fact that it is common, acne vulgaris is much less common in babies, toddlers, or preadolescents. In most individuals at a variety of ages acne vulgaris is not subtle, and a preteen or teen presenting with comedones, pustules, and inflammatory papules on his or her face is considered to have acne until proven otherwise. There is a good understanding of the basic pathophysiology of acne, and multiple algorithms have been developed to help assist practitioners in composing successful treatment regimens. The pharmaceutical, cosmetics, and cosmeceutical industries have recognized acne as an important consumer concern, supporting the development of a myriad of treatment products from which to choose a therapeutic strategy for individual patients.
However, especially when presenting in infancy and childhood, acne may not be straightforward and can be of great consequence. It may cause serious sequelae including severe scarring and emotional distress1,2 (in both the child and parents), and its treatment has fueled concerns about contributing to the public health threat of increased antibacterial resistance.3 It can present much earlier than expected, and it can resemble a number of other inflammatory and noninflammatory dermatoses (Figure 1).4 The myths and conjectures that circulate regarding cause and exacerbators of acne have been a source of consternation for patients, families, and practitioners alike.5 The young pediatric acne patient shows that some of our knowledge regarding pathogenesis is limited. Similarly, treating acne is not always as easy as mail order companies make it seem with 3-step products. Conscientious healthcare providers run into the daily problem of choosing acne weapons that are highly effective with the least amount of collateral ill effects.
Acne vulgaris is near universal in adolescents and young adults in the western world, with an incidence of greater than 80% in people aged 11 to 30 years.6 It has been estimated that newborns are affected with up to 20% prevalence in the first few weeks of life, though it is uncertain if the reported eruptions eruptions are all true acne.7 The next and much less commonly affected population is infants, generally between 6 and 16 months of age.8 Mid-childhood acne, seen in those children between 1 and 7 years of age, is rare though few scattered comedones are occasionally observed in this age group.9,10 The incidence of acne vulgaris rises in the next subset of patients with prepubertal acne, which can have age of onset around 8 years old.11