Know the risk factors for the different types of acne, how to manage, diagnose, and treat
Know the risk factors for the different types of acne, how to manage, diagnose, and treat: Excerpt from Avoiding Common Pediatric Errors
Author:
Elizabeth Wells, MD
What to Do - Gather Appropriate Data,
Interpret the Data, Make a Decision,
Take Action
Acne vulgaris the most common dermatologic disorder treated by physicians, affecting 80% of persons aged 11 to 30 years old. Because acne usually
presentsinearlyadolescence,pediatriciansmustbefamiliarwithcurrentrecommendations about acne management. Appropriate management depends
on a number of factors, including the types and numbers of lesions present,
the patient's experiences with medications, and personal preferences. Growing knowledge about the multifactorial etiology of acne has led to new recommendations in favor of combination therapy and against monotherapy
with antibiotics.
The microcomedo is now known to be the precursor of all acne lesions,
inflammatoryandnoninflammatory.Itdevelopsfromthepilosebaceousunit,
which consists of the hair follicle, the hair shaft, and the sebaceous gland.
The four primary factors contributing to the development of acne lesions are
abnormal desquamation of keratinocytes within the pilosebaceous unit, increased sebum production, proliferation of Propionibacterium acnes (a gram-
positive anaerobe that resides in the pilosebaceous unit), and inflammation.
The two main types of acne lesions are comedonal and inflammatory,
and their etiology depends on the relative contribution of the preceding
factors. Noninflammatory acne lesions are comedones. They may be open
(i.e., blackheads) or closed (i.e., whiteheads). Closed comedones are small
white papules with no surrounding erythema, containing only a microscopic
opening to the skin surface. P. acnes is associated with inflammatory lesions (i.e., pimples). Inflammatory lesions are characterized by erythema.
They may be papules and pustules (<5 mm in diameter) or nodules, which
measure >5 mm and involve more than one follicle. The severity of inflammatory/pustular acne depends on the level of antibody, complement, and
cell-mediated immune responses to the bacterium, rather than an infectious
etiology. Large deep lesions that coalesce may form cysts. Scars may develop as inflammatory lesions resolve. Facial scars may appear as small pits,
whereas truncal scars tend to be small hypopigmented spots. Scars may be
irreversible and their presence may lead clinicians to be more aggressive in
selecting anti-inflammatory therapeutic agents.
When evaluating a patient with acne, a pediatrician should record the
number of open comedones, closed comedones, and inflammatory lesions
in each region of the face. A rating of mild means that about one fourth of
the face is involved, and there may be few-to-several papules or pustules
but no nodules or scarring. In moderate acne, about one half of the face
is involved, and there are several-to-many papules or pustules and a few-
to-several nodules and a few scars. Severe acne involves three quarters of
the face and is characterized by many papules, pustules, and nodules, with
scarring often present.
The distribution and severity of acne lesions correlates with pubertal/hormonal stage. Blackheads and whiteheads distributed in the midface
occur early in puberty, while inflammatory lesions are more prevalent later,
affecting the lateral cheeks, lower jaw, back, and chest. Premenstrual acne in
girls is thought to be due to the effects of progesterone, which is dominant
during the second half of the menstrual cycle and leads to increased production of sebum. Some birth control hormones improve acne, whereas others
with a higher level of progesterone, such as Depo-Provera, worsen acne.
Thereisnoevidencethatchocolateorotherfoodscauseacne,norismost
acne caused by dirt or poor hygiene. Acne may be worsened, however, by
certain behaviors, such as wearing tight-fitting sports protection (e.g., chin
straps,shoulderpads),touchingthefacealot,orusingskinandhairproducts
that contain oily and harsh substances. Certain medications, such as lithium,
rifampin, or corticosteroids, can also worsen acne. Familial tendency seems
to play a role, although no one has quantified the genetic contribution.
TheAmericanAcademyofPediatricsExpertCommitteeforAcneManagementandtheGlobal AlliancetoImproveOutcomes inAcnerecommends
combination therapy to target as many pathogenic factors as possible. Topical retinoids (e.g., tretinoin, adapalene, tazarotene) are now recommended as
the foundation for most acne treatment. Retinoids target the microcomedo,
are comedolytic, and have anti-inflammatory effects. Oral antibiotics, no
longer recommended as single-drug therapy for acne, should be used only
in moderate-to-severe acne, in combination with another agent, and for a
maximum length of treatment of 8 to 12 weeks.
Algorithmsfortreating acne are availableinthe literature(seecitations).
They break down the treatment of acne by severity and type of lesion. For
mild comedonal acne, a topical retinoid alone is recommended, with salicylic acid as an alternative. For mild inflammatory acne, a topical retinoid
and a benzoyl peroxide (BPO), or a BPO and a topical antibiotic, is recommended. Moderate acne requires a topical retinoid, an oral antibiotic (such
as doxycycline or tetracycline), and a BPO or a BPO with a topical antibiotic. If the moderate acne is also nodular, the addition of oral isotretinoin is
recommended. The recommendation for severe nodular acne is similar to
that for moderate nodular acne. Female patients have the added option of
trying hormonal therapy. Maintenance therapy is recommended for all types
of acne and includes a topical retinoid with or without BPO and a topical
antibiotic.
Oral isotretinoin (Accutane) is a powerful medication sometimes indicated for patients with severe acne or acne that has not responded to conventional therapy with a topical retinoid, benzoyl peroxide, and oral antibiotic.
The U.S. Food and Drug Administration warns that isotretinoin may also
cause depression, psychosis, and rarely suicidal thoughts or suicide. There
is not enough scientific evidence to prove or disprove a causal link between
psychiatric morbidity and the use of retinoids. Patients should be warned
about these side effects, along with the more common side effects of dry
mucous membranes and increased sensitivity to light, as well as an increase
in cholesterol, and muscle or joint pain.
Pediatricians should prepare patients for the fact that acne treatment
takes 6 to 8 weeks to cause significant results. Follow-up visits are important
for addressing compliance, treatment response, adverse effects, and the effectiveness of therapy. Physicians should also be aware that in some states
prescription topical acne medications are not approved for Medicaid reimbursement. Although acne cannot be cured, proper management can impact
theemotionalwell-beingoftheadolescentandlimitthepotentialforphysical
scarring.
Suggested Readings
Krowchuk DP. Managing adolescent acne: a guide for pediatricians. Pediatr Rev. 2005;26(7):
250–261.
Strahan JE, Raimer S. Isotretinoin and the controversy of psychiatric adverse effects. Int
J Dermatol. 2006;45(7):789–799.
Zaenglein AL, Thiboutot DM. Expert committee recommendations for acne management.
Pediatrics. 2006;118(3):1188–1199.
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Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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» Next page: Acne (The 5-Minute Pediatric Consult)
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