scientist. Selected articles included guidelines, consensus papers, reviews describing current best practices in pediatric acne treatment using acne products and skin care, and clinical research studies published in English from 2010 to June 2022. Search terms used: Pediatric acne vulgaris AND pathogenesis OR quality of life OR pediatric acne guidelines OR algorithms OR consensus recommendations OR prescription treatment OR nonprescription treatment OR skincare OR retinoids OR benzoyl peroxide OR isotretinoin OR hormonal treatment OR adherence to treatment OR bacterial resistance OR efficacy, safety, tolerability, skin irritation, handling, comfort.
The results of the searches were evaluated independently by two reviewers. Based on reviewer consensus, each treatment within the publications was assigned an alphanumeric level of evidence (1 to 4 and A to C), using pre-established criteria by the American Academy of Dermatology.19 Initially, 57 articles were identified, and after excluding 19 duplications and poor-quality papers, 38 articles remained, of which only 14 were of sufficient quality to grade. The selected publications comprised 7 guidelines, algorithms, consensus papers, 22 clinical studies (15 randomized controlled trials), and 9 reviews. Notably, there were no publications specifically on nonprescription pediatric acne treatment and skin care.
Development of the Algorithm
The project used a modified Delphi process, which comprised preparing the project, conducting the literature review, and preparing a draft algorithm.20,21 The advisors convened a meeting to discuss the literature review results and the draft algorithm. During the workshop portion of the meeting, each of the three groups discussed and modified the draft algorithm. The advisors then presented the three versions to the group to fine-tune the algorithm and reach a consensus. An online process was then used to review the manuscript with the algorithm for publication.
The Algorithm
The algorithm addresses neonatal, infantile, mid-childhood, preadolescent, and adolescent acne (Figure 1). The first section addresses education on the presentation of acne, prevention, treatment, maintenance, and ongoing skin care.
The second section identifies the type of acne followed by the treatment approach according to acne presentation using a prescription, nonprescription treatment, and skincare options.
Education on Acne
Age-appropriate education on a child's acne type should be provided to patients and parents with measures on prevention and avoiding risk factors, treatment, and maintenance.6,10 The education should include why the treatment was chosen, the expected outcome, and duration.6,10 In addition, a treatment and skincare plan should be handed out during the visit, as should information about trusted websites where patients and parents can find additional information.6,10 Children with acne and their parents may hold common misconceptions about acne that need tackling before treatment begins, such as poor hygiene. Educating about the central role of inflammation in acne and measures to reduce inflammation is essential, such as how over-vigorous washing may irritate the skin, enhance inflammation, and exacerbate acne.5,6 Educating patients and parents on realistic treatment outcomes may support treatment adherence.6,10 The physician should inform the patients and parents that a slight improvement of the acne may be expected in the first month of treatment, followed by about 20% improvement per month after that. After successfully controlling the disease, the use of maintenance treatment with topical agents and skincare products incorporating gentle cleansers and moisturizers is essential.5,6,10
Skin Care With Gentle Cleansers and Moisturizers
Skincare products should be suitable for pediatric acne-prone and oily skin.5,6,10,12-18 The cleansers and moisturizers are non-comedogenic and complement acne treatments with benefits such as gentle cleansing, hydrating, and promoting a healthy skin barrier.6,10,15-18,22 Daily use of fragrance-free, non-irritating, and non-comedogenic cleansers, moisturizers, and sunscreen may reduce xerosis, erythema, and photosensitivity resulting from topical or oral acne treatments.5,6,10,15-18,22 Using the appropriate skincare products will help to minimize irritation and inflammation.5,6,10,15-18,22 Cleansers and moisturizers, such as those containing ceramides, promote a healthy skin barrier, reducing inflammation and irritation that may result from topical or systemic treatments.10,14,16-18 The skincare regimen should be included in the acne prevention, treatment, and maintenance care regimen and should be ongoing even after treatment with prescription and other nonprescription products are discontinued.
Diagnosis
The type of acne according to age used in the pediatric acne algorithm comprises neonatal acne: birth to ≤8 weeks; infantile acne: 8 weeks to <1 year; mid-childhood acne: 1 year to <7 years; preadolescent acne: ≥7 to 12 years; adolescent acne: ≤12 to 19 years or after menarche for girls.5,6,10 Other systems consider three different groups of acne patients: preadolescent (≥7 to 12 years), adolescent (≤12-25 years), and post-adolescent patients (≤25 years), which were deemed too broad and not practical for the algorithm.7,8
Effective evaluation of children with acne requires a directed medical history and physical examination.5,6,10,22 The medical history should include the age of acne onset, disease duration, growth parameters, and age of onset for any early signs of virilization.5,6,10 The physical examination should include height,
