The Many Faces of Pediatric Acne: A Practical Algorithm for Treatment, Maintenance Therapy, and Skincare Recommendations for Pediatric Acne Patients

June 2023 | Volume 22 | Issue 6 | 539 | Copyright © June 2023


Published online May 25, 2023

Lawrence A. Schachner MD FAAD FAAPa, Anneke Andriessen PhDb, Latanya Benjamin MD FAAD FAAPc, Madelyn Dones MD FAAPd, Leon Kircik MD FAADe, Ayleen Pinera-Llano MD FAADf, Adelaide A. Hebert MD FAADg

aDepartment of Dermatology and Cutaneous Surgery, Department of Pediatrics,
Leonard M. Miller School of Medicine, University of Miami, FL
bRadboud UMC, Nijmegen and Andriessen Consultants, Malden, The Netherlands
cDepartment of Women's and Children's Health, Florida Atlantic University, Boca Raton, FL
dBaptist Health Hospital and Nicklaus Childrens' Hospital, Miami, FL
eIcahn School of Medicine, Mount Sinai, New York, NY; Indiana University Medical Center, Indianapolis, IN;
Physicians Skin Care, PLLC, Louisville, KY; DermResearch, PLLC, Louisville, KY
fKing Bay Pediatrics and Nicklaus Children's Hospital, Miami, FL
gDepartment of Dermatology and Pediatrics, McGovern Medical School, and Children's Memorial Hermann Hospital, Houston, TX


The treatment options for comedonal acne are similar to those recommended for preadolescent acne (Figure 5). For mild-to-moderate papulopustular acne, topical retinoids (tretinoin, adapalene, tazarotene, and trifarotene) or topical antimicrobials (BPO), clindamycin, or erythromycin are prescribed.5,6,10,14,18,22  Further options comprise fixed combination treatments (BPO + adapalene, BPO + clindamycin, tretinoin + clindamycin) or azelaic acid or topical dapsone.5,6,10,14,18,22 All treatments should be combined with skin care, including gentle cleansers and moisturizers, to promote a healthy skin barrier and reduce the side effects of prescription treatments.6,10,14-18
Oral antibiotics are required for severe papulopustular acne.5,10,14,18,22  If patients do not respond to the treatment, oral isotretinoin or endocrine therapy (for females) may be given and can be combined with topical therapy.5,10,14,18,22,36,37 

For patients with mild-to-moderate nodulocystic acne, topical or oral antibiotics should be prescribed.5,10,14,18,22 If the patient is not responding to oral antibiotics (doxycycline, minocycline, or tetracycline), additional topical treatment (BPO + adapalene, tazarotene, trifarotene, adapalene, or tretinoin) is required. If the therapy is unsuccessful, oral contraceptives (females) or oral isotretinoin may be added to topical treatment.5,10,14,18,22 

Clascoterone cream 1%, an androgen receptor inhibitor, is indicated for the topical treatment of acne in males and females 12 years of age and older. 

Patients with severe nodulocystic acne should be assessed for the suitability of oral isotretinoin (Figure 6). Female patients may receive oral contraceptives or antiandrogens, which can be combined with oral tretinoin.5,10,14,18,22,36  Physicians should consider the psychosocial aspects of acne (eg, depression, mood effects of drugs such as oral contraceptives and isotretinoin) and physical aspects such as xerosis.31,35 



Once patients respond to therapy, titrate the medication down (ie, strength, frequency, number of medications). 

Acne sequelae such as discoloring and scaring are more common in acne presenting with inflammatory lesions, especially in patients with richly pigmented skin.28,27 Although the mechanism is unclear, PIH may be due to inflammation-inducing excessive melanin production or irregular pigment dispersion.28,27  In a study of 1942 acne patients with richly pigmented skin, 43% had acne-related scarring, which, in 99% of cases, originated from inflammatory acne lesions.28 Early and effective acne treatment with topical adapalene combined with BPO can reduce the risk of future scars.9,14,30-32 

The clinician should inform the patient and parents about acne-related sequelae such as PIH and scarring to avoid risk factors and promote adherence to treatment and maintenance therapy. The physician should explain that less washing and avoiding topical alcohol, abrasive scrubs, and rubbing the skin may prevent irritation and, thus, inflammation.6,10,18 

Relapse
Workup may be needed for polycystic ovary syndrome (PCOS), 17-hydroxylase deficiency, or congenital adrenal hyperplasia in patients with moderate-to-severe acne who relapse frequently.5,6 Patients should be referred to a pediatric dermatologist if the endocrinologic management is not effectively controlling acne.5,6,10,18

Maintenance Treatment
Acne maintenance therapy may comprise topical retinoids (tretinoin, adapalene, tazarotene), topical antimicrobials (BPO), topical azelaic acid, or dapsone.5,6,10,14,18,22 For maintenance, physical modalities such as photodynamic therapy (PDT) with red light or intense pulsed light, laser, or micro-needling may also be recommended.38 

LIMITATIONS

Our searches found no specific clinical publications on nonprescription pediatric acne treatment and skin care; therefore, we based recommendations on clinical experience and the opinions of panelists.

CONCLUSSION

Pediatric acne can be categorized by age and pubertal status and deserves more attention from healthcare providers who treat children. It is important to educate patients regarding differential diagnosis, treatment, and maintenance, as well as skin care as monotherapy or as an adjunct to prescription treatment. The presented algorithm for pediatric acne treatment and maintenance approaches using prescription and nonprescription acne products and skin care is a practical tool that supports clinicians in improving outcomes for pediatric patients with acne.

Nonprescription acne treatment and skincare products containing lipids such as ceramides play an important role in monotherapy, adjunctive, and maintenance treatment, although further research on their role in pediatric acne is recommended.

DISCLOSURES

The authors disclosed receipt of an unrestricted educational grant from CeraVe US for support with the research of this work. The authors also received consultancy fees for their work on this project.

REFERENCES

  1. Bhate K, Williams HC. Epidemiology of acne vulgaris. Br J Dermatol. 2013;168(3):474-485.
  2. Hay RJ, Johns NE, Williams HC, et al. The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. J Invest Dermatol. 2014;134(6):1527-1534.
  3. Revol O, Milliez N, Gerard D. Psychological impact of acne on 21st-century adolescents: decoding for better care. Br J Dermatol 2015;172(Suppl 1):52-58.
  4. Gordon RA, Crosnoe R, Wang X. Physical attractiveness and the accumulation of social and human capital in adolescence and young adulthood: assets and distractions. Monogr Soc Res Child Dev. 2013;78:1-137.
  5. Eichenfield LF, Krakowski AC, Piggott C, et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. American Acne and Rosacea Society. Pediatrics. 2013 May; 131 Suppl 3:S163-186. PMID: 23637225.
  6. Schachner LA, Eichenfield L, Andriessen A, et al. Consensus on neonatal through preadolescent acne. J Drugs Dermatol. 2020;19(6):1-10. doi:10.36849/ JDD.2020.5065
  7. Skroza N, Tolino E, Potenza C, et al. Adult acne versus adolescent acne. J Clin Aesthet Dermatol. 2018;11(1):21-25.
  8. Perkins AC, Maglione J, Hillebrand GG, et al. Acne vulgaris in women: prevalence across the life span. J Womens Health (Larchmt). 2012;21(2):223-230.
  9. Alexis AF, Harper JC, Stein Gold LF, et al. Treating acne in patients with skin of color. Semin Cutan Med Surg. 2018;37(Suppl 3):S71-S73.
  10. Schachner LA, Andriessen A, Benjamin L, et al. The many faces of pediatric acne: How to tailor nonprescription acne treatment and skincare using cleansers and moisturizers. J Drugs Dermatol. 2022;21(6): 602–612.
  11. Prohic A, Jovovic Sadikovic T, Krupalija-Fazlic M, et al. Malassezia species in healthy skin and in dermatological conditions. Int J Dermatol. 2016;55(5):494- 504. doi: 10.1111/ijd.13116.
  12. Tamayo CS, Janniger CK, Micali G, et al. Neonatal and infantile acne vulgaris: an update. Cutis. 2014;94(1):13-16.
  13. Piggott CDS, Eichenfield LF, Lucky AW. Acne in children. In: Shalita AR, Del Rosso JQ, Webster GF, eds. Acne Vulgaris. New York, NY: Informa Healthcare; 2011:182–197.
  14. Thiboutot DM, Dreno B, Abanmi A, et al. Practical management of acne for clinicians: an international consensus from the global alliance to improve outcomes in acne. J Am Acad Dermatol. 2018;78(2S1):S1-23.
  15. Pappas A, et al. Seasonal changes in epidermal ceramides are linked to impaired barrier function in acne patients. Experimental Dermatol. 2018;27(8):833-836.
  16. Lynde CW, Andriessen A, Barankin B, et al. Moisturizers and ceramidecontaining moisturizers may offer concomitant therapy with benefits. J Clin Aesthet Dermatol. 2014;7(3):18-26.
  17. Araviiskaia E, Dreno B. The role of dermocosmetics in acne vulgaris. J Eur Acad Dermatol Venereol. 2016; 30, 926–935. 
  18. Schachner LA, Andriessen A, Benjamin L, et al. The many faces of pediatric acne: clinical cases. J Drugs Dermatol. 2022; in print.
  19. Smith Begolka W, et al. American Academy of Dermatology evidencebased guideline development process: responding to new challenges and establishing transparency. J Am Acad Dermatol. 2011;64(6):e105-12. doi: 10.1016/j.jaad.2010.10.029. 
  20. Trevelyan EG, Robinson N. Delphi methodology for health research; how to do it? Eur J Integrative Med. 2015;7(4):423-428. 
  21. Brouwers M, Kho ME, Browman GP, et al. AGREE next steps consortium AGREE II: advancing guideline development, reporting and evaluation in healthcare. Can Med Association J. 2010;182:E839-842.
  22. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945-973.e33. http://dx.doi.org/10.1016/j. jaad.2015.12.037
  23. Parikh SA, Davis SA, Krowchuck DP, et al. Common use of prescription off-label acne therapy in children younger than 12 years old. Ped Derm. 2014;31(5):551- 555.
  24. Karciauskiene J, Valiukeviciene S, Gollnick H, et al. The prevalence and risk factors of adolescent acne among schoolchildren in Lithuania: a cross-sectional study. J Eur Acad Dermatol Venereol. 2014;28:733-740.
  25. Bree AF, Siegfried EC. Acne vulgaris in preadolescent children: recommendations for evaluation. Pediatr Dermatol. 2014;31:27-32.
  26. Eun DH, Kim JY, Jang YH, et al. Clinical investigation on preadolescent acne. Korean Dermatol Association and Korean Society for Invest Dermatol. 2019;31(2):249-251. https://doi.org/10.5021/ad.2019.31.2.249
  27. Abad-Casintahan F, Chow SK, Goh CL, et al. Frequency and characteristics of acne-related post‐inflammatory hyperpigmentation. J Dermatol. 2016; 43(7): 826-828.
  28. Tan J, Kang S, Leyden J. Prevalence and risk factors of acne scarring among patients consulting dermatologists in the United States. J Drugs Dermatol. 2017;16(2):97-102.
  29. Dreno B, Bissonnete R, Tan J, et al. Prevention and reduction of atrophic acne scars with adapalene 0.3%/benzoyl peroxide 2.5% gel in subjects with moderate or severe facial acne: Results of a 6-month randomized, vehicle-controlled trial using intra-individual comparison. Am J Clin Dermatol. 2018;19:275-286. https://doi.org/10.1007/s40257-018-0352-y
  30. Lovaszi M, Szegedi A, Zouboulis CC, et al. Sebaceous-immunobiology is orchestrated by sebum lipids. Dermatoendocrinol. 2017;9(1):e1375636.
  31. Halvorsen JA, Stern RS, Dalgard F, et al. Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study. J Invest Dermatol. 2011;131(2):363-370.
  32. Sundström A, Alfredsson L, Sjölin-Forsberg G, et al. Association of suicide attempts with acne and treatment with isotretinoin: retrospective Swedish cohort study. Br Med J. 2010;341:c5812.
  33. Magin P, Adams J, Heading G, et al. "Perfect skin", the media and patients with skin disease; a qualitative study of patients with acne, psoriasis and atopic eczema. Aust J Prim Health. 2011;17;181-185.
  34. Serefican B, Tuman TC, Tuman BA, et al. Type D personality, anxiety sensitivity, social anxiety and disability in patients with acne: a cross-sectional controlled study. Postepy Dermatol Alergol. 2019;36:51-57.
  35. Maron SE, Miranda-Sivelo A, Tomas-Aragones I, et al. Body dysmorphic disorder in patients with acne: a multicentre study. J Eur Acad Dermatol Venerol. 2020;34:370-376
  36. Elsaie ML. Hormonal treatment of acne vulgaris: an update. Clin Cosmet Investig Dermatol. 2016;9:241-248.
  37. Del Rosso JQ. Clinical relevance of skin barrier changes associated with the use of oral isotretinoin: the importance of barrier repair therapy in patient management. J Drugs Dermatol. 2013;12(6):626-631.
  38. Boen M, Brownell J, Patel P, et al. The role of photodynamic therapy in acne: An evidence-based review. Am J Clin Dermatol. 2017;18(3):311-321.

AUTHOR CORRESPONDENCE

Anneke Andriessen PhD anneke.a@tiscali.nl
Close Menu