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 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.
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:
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.
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.
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).
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 such as clindamycin and erythromycin can be used but should be combined with benzoyl peroxide to prevent bacterial resistance.
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.
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:
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.
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.
Listeners will explain the basic pathophysiology, diagnosis, and management of acne.
After listening to this episode listeners will be able to…
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.
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.
Producer, Writer, Infographic: Clara Mao MD
Executive Producer: Max Cruz MD
Showrunner: Sam Masur
Cover Art: Chris Chiu MD
Hosts: Chris Chiu MD, Rebecca Raymond-Kolker MD, Clara Mao MD
Editor: Clair Morgan of nodderly.com
Guest: Brandi Kenner-Bell MD
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