weight, types, locations of acne, and signs of puberty (body odor, axillary and pubic hair, breast buds, enlarged phallus, testis, or clitoris).5,6,10 A workup may be indicated for patients with other signs of virilization.5,6,10 A hand and wrist X-ray for bone age is a simple, practical initial examination.5,6,10
A referral to a pediatric endocrinologist and a workup is warranted for mid-childhood acne (ages 1 to < 7 years), which is very uncommon, and patients need a referral, especially if displaying secondary sexual characteristics.5,6,10 Physicians should collect a history of the patient’s diet and consider any potential contributing factors related to acne (eg, milk consumption).22
Neonatal and Infantile Acne
Neonatal acne occurring at 0 to 8 weeks of life is estimated to affect 20% of newborns, more frequently boys than girls, and usually presents small erythematous papules and pustules on the face, rarely with comedones (Figure 2).5,6,10,22 Neonatal acne is mostly self-limited, benign, and typically resolves over a few months without scarring.5,6,10 Eruptions due to infections need to be excluded, such as bacterial folliculitis, secondary syphilis, herpes simplex virus, and varicella-zoster virus.5,11,12 Other conditions to be excluded comprise transient neonatal pustular melanosis, erythema toxicum neonatorum, eosinophilic pustular folliculitis, sebaceous gland hyperplasia, and congenital adrenal hyperplasia.5,6,10-12 Neonatal cephalic pustulosis due to colonization of Malassezia yeasts present monomorphic red papules or pustules on the face and neck without comedones.5,6,10-12 Maternal medications may also cause neonatal or infantile eruptions and should be checked; for instance, lithium, phenytoin, and corticosteroids.5,6,10-12
When, in rare cases, significant neonatal acne presents with signs of sexual precocity, virilization, or growth abnormalities, an underlying endocrinologic disease, tumor, or other gonadal/ovarian pathology needs to be ruled out by a pediatric endocrinologist.5,6,10 Most cases benefit from skincare products, such as those containing ceramides, and off-label topical therapies, which may be considered for more complicated neonatal and infantile acne cases.5,6,10,12,13,18,22
