#95: Acne – Don’t Break Out!

October 11, 2023 | By Sam Masur

Audio

Summary:

Don’t “break out” from the stress of treating acne! In this episode, pediatric dermatologist Dr. Brandi Kenner-Bell teaches us about the age distribution of acne,  practical lifestyle tips to give patients, and how to step up therapy like a pro.

Acne Pearls

1. Acne is related to inflammation of the hair follicle and sebaceous glands.
2. Mid-childhood acne (age 1 or 2 to 7 years old) requires a further endocrine work-up that may include bone age, LH, FSH, free/total testosterone, and DHEA-S.
3. Retinoids are the base of any acne regimen and pair well with benzoyl peroxide.
4. Oral antibiotics should be used for no longer than 3 months to prevent antibiotic resistance.
5. Potential side effects of isotretinoin include teratogenicity, dryness, hepatotoxicity, elevated triglycerides, idiopathic intracranial hypertension, and bone issues.

Acne Notes

Definition 

Acne is an inflammatory process of the pilosebaceous unit (hair follicle + sebaceous gland). Cutibacterium acnes is a bacteria in the skin flora that has been implicated in the pathogenesis of acne through triggering inflammation rather than true infection.

Classification

Acne should be classified based on the age at which it began.

Neonatal acne occurs from birth to <6 weeks and is related to maternal hormones. Differential diagnosis includes:

• Neonatal cephalic pustulosis (papules and pustules but no comedones)
• Transient neonatal pustulosis (more common in darker-skinned babies)
• Erythema toxicum

Infantile acne occurs from 6 weeks to <1 year and usually does not require further workup unless physical exam or growth abnormalities are noted. Red flags would include severe acne which is uncommon at this age. Differential diagnosis includes folliculitis, impetigo, HSV.

Mid-childhood acne occurs from 1 year to <7 years and SHOULD trigger a further endocrine workup because children at this age normally have minimal hormonal activity. This can include bone age, LH, FSH, free/total testosterone and DHEA-S.

• Expert Opinion: Dr. Kenner-Bell generally does not pursue a work-up until age 2 unless the acne is significant.
• Expert Opinion: If the child has no abnormal findings on physical exam (ex. breast buds, pubic hair, clitoromegaly), can consider starting with just the bone age and deferring labs unless bone age is abnormal.

Pre-adolescent acne occurs from >7 years to <12 years and is related to normal pubertal development. 

Adolescent acne occurs after 12 years and occurs in 80-90% of all teens.

Management

Dr. Kenner-Bell reminds us that acne is a disease that deserves to be treated because it can lead to significant scarring on skin as well as mental health impacts. It is important to be aware of racial and socioeconomic disparities in the undertreatment of acne including decreased rates of prescriptions for oral antibiotics, spironolactone, and isotretinoin in Black patients (Barbieri et al, 2020). 

OTC Treatments

At baseline, patients should wash their face twice daily with a gentle cleanser. They can start with salicylic acid and step up to benzoyl peroxide which is a more effective OTC therapy that also has antibacterial properties. Pair this with a retinoid which is an excellent base for any acne regimen. Retinoids include adapalene, tretinoin, and tazarotene and should be used at night to prevent UV light inactivation. Start retinoids 1-2x weekly and then build up to build up tolerance. Because acne treatments can be drying, patients should moisturize with non-comedogenic products. 

Topical Antibiotics

Topical antibiotics such as clindamycin and erythromycin can be used but should be combined with benzoyl peroxide to prevent bacterial resistance.

Oral Antibiotics

Consider oral antibiotics for any patients who are not responding to topical therapy, patients who have primarily truncal acne, or patients who already have scarring from acne. For older children and teenagers, doxycycline and minocycline are commonly used. For children under 8, use alternatives such as erythromycin. Should only be used for <3 months at a time.

Isotretinoin

In patients with severe acne who are refractory to other treatments or have scarring, isotretinoin is an excellent option. Only providers registered in the iPLEDGE REMS system can prescribe the medication due to its high risk of teratogenicity (requires monthly negative pregnancy tests). Other side effects to counsel patients on include:

• Dryness – eyes, nose, lips
• Blurry vision
• Risk of idiopathic intracranial hypertension – need to STOP oral tetracyclines before starting isotretinoin
• Hepatotoxicity – monitor LFTs
• Elevated serum triglycerides – monitor lipids
• Bone issues
• Theoretical association with IBD although evidence is mixed 
• Theoretical association with mood disorders although this is primarily anecdotal and many patients have improved mental health with improvement of their acne

Hormonal Therapy

Hormonal therapy, including OCPs and spironolactone ,are good second-line options for pubertal females, especially if acne tends to follow a hormonal pattern (ex. flare with menses or distributed along lower face and neck). Counsel patients that they may take several months to take effect.

Recommendations for Dry Skin Care

Please note: these are expert recommendations by Dr. Brandi Kenner Bell. The Cribsiders does not have any association with any of the brands listed below.

1. Bathing:

• A daily bath with lukewarm water is suggested – avoid HOT or COLD water. Do NOT vigorously scrub skin with a washcloth, sponge, or brush.  Use your hands to wash your child. Do not use bubble bath or other fragranced soaps or washes.  When eczema is flaring, twice daily bathing may be needed.
• Recommended Cleansers – There are many choices on the market; here are a few of our top recommendations:
• Bar Soaps: Cetaphil Gentle Cleansing Bar, Dove Sensitive Skin Bar, Oilatum Cleansing Bar (unscented)  
• Liquid Soaps: Cetaphil Gentle Skin Cleanser, Cetaphil Restoraderm Skin Restoring Body Wash, CeraVe Hydrating Cleanser, Dove Sensitive Skin Nourishing Body Wash (unscented), Aquanil Cleanser
• REDUCE bathing time to 5-10 minutes. Apply a moisturizer afterwards.  To dry your child, pat him/her dry with a towel and apply prescription creams/ointments to affected areas of dermatitis.

2. Recommended Moisturizers:

• Moisturizers are applied to the entire body within a few minutes of the bath for the best effect.  If moisturizers are applied at the same time as prescriptions ointments or creams, always apply the prescription medication first.
• Creams:  CeraVe Moisturizing Cream, Cetaphil Moisturizing Cream, Eucerin Original Soothing Repair Cream, Vanicream Moisturizing Skin Cream
• Lotions: CeraVe Moisturizing Lotion, Cetaphil Moisturizing Lotion, Cetaphil Restoraderm Skin Moisturizer, Eucerin Soothing Repair Lotion, Lubriderm Moisture Lotion for Sensitive Skin, Nutraderm Advanced Formula Therapeutic Lotion
• Ointments:  Aquaphor Healing Ointment, Vaseline (brand name or generic petrolatum)

3. Recommended Shampoos for Sensitive Skin:

• Aquaphor Baby Gentle Wash & Shampoo, DHS Zinc Shampoo, DHS Clear Shampoo, Free & Clear Shampoo

4. Do NOT use colognes, perfumes, sprays, powders etc. on your skin or your child’s skin.  Your child’s skin may be irritated by your use of these products.
5. If able, use a small amount of unscented laundry products such as Cheer Free & Gentle, All Free & Clear, Tide Free, Dreft, or Purex Free & Clear.  Double rinse clothes if possible after washing.  Try to avoid the use of dryer sheets.
6. Do not wear tight or rough clothing.  Wool clothes and new clothes can be irritating.
7. For extreme dryness, a humidifier or vaporizer may help.  Remember to keep it clean or mold may spread throughout the humidified area.  Keep the power cord safely out of the reach of children.

Goal

Listeners will explain the basic pathophysiology, diagnosis, and management of acne.

Learning Objectives

After listening to this episode listeners will be able to…  

1. Describe the age distribution of acne.
2. Identify cases of acne that require a further endocrine workup.
3. Counsel patients on lifestyle modifications and over-the-counter treatments for acne.
4. Recognize indications for stepping up therapy and/or referral to a pediatric dermatologist.

Disclosures

Dr. Kenner-Bell discloses that she serves on the advisory board at Verrica Pharmaceuticals for which she has received honoraria. The Cribsiders report no relevant financial disclosures. 

Citation

Mao C, Kenner-Bell B, Cruz M, Raymond-Kolker R, Masur S, Chiu C, Berk J. “95: Acne – Don’t Break Out!”. The Cribsiders Pediatric Podcast. https://www.thecribsiders.com/ October 11, 2023.