|Year : 2015 | Volume
| Issue : 1 | Page : 1-4
Acne in childhood: Clinical presentation, evaluation and treatment
Akshay Kumar Jain, Manjaree Morgaonkar
Department of Dermatology, Venereology and Leprosy, Government Medical College, Kota, Rajasthan, India
|Date of Web Publication||16-Jan-2015|
Akshay Kumar Jain
B 302, Indra Vihaar, Kota - 324 005, Rajasthan
Source of Support: None, Conflict of Interest: None
Acne can be classified into neonatal acne, infantile acne, mid-childhood acne and prepubertal acne depending on the age of onset. There is limited literature available on acne in pediatric age group. This article provides an overview of clinical presentation and pathogenesis of acne in children and proposes therapeutic guidelines.
Keywords: Acne, children, dehydroepiandrosterone
|How to cite this article:|
Jain AK, Morgaonkar M. Acne in childhood: Clinical presentation, evaluation and treatment. Indian J Paediatr Dermatol 2015;16:1-4
|How to cite this URL:|
Jain AK, Morgaonkar M. Acne in childhood: Clinical presentation, evaluation and treatment. Indian J Paediatr Dermatol [serial online] 2015 [cited 2019 Dec 10];16:1-4. Available from: http://www.ijpd.in/text.asp?2015/16/1/1/149399
| Introduction|| |
Acne is a disease of pilosebaceous units.  It is predominantly a dermatological problem in adolescents, but neonates, infants, and young children may also be affected.  Lesions of acne are polymorphic and consist of comedones, papules, pustules, nodules and sometimes scarring can also be present.  There is not much literature available on childhood acne, besides, its polymorphic nature and contraindication of some drugs in children make the evaluation and treatment of childhood acne more difficult. This article presents pathogenesis, evaluation and treatment of acne in children.
| Neonatal acne|| |
Neonatal acne may be hormonally mediated because newborns with neonatal acne present transient increase in circulating androgens. Meanwhile in the neonatal period, sebaceous glands are hyperplastic and increased androgenic activity of the glands may be responsible of neonatal acne development.
Now the term neonatal cephalic pustulosis (NCP) is used for neonatal acne. Up to 20% of newborns can be affected by this condition in first few weeks of life. , In this condition, erythematous papules or pustules appear mainly over the cheeks, chin, eyelids, neck but rarely upper chest, scalp and back may be involved [Figure 1]. Usually, comedones are not seen , but early onset androgen driven acne can present with comedones. The condition is thought to occur due to the poral or follicular colonization by Malassezia sympodialis and Malassezia globosa. ,,
|Figure 1: Neonatal cephalic pustulosis: Multiple erythematous papules and pustules over cheeks, comedones are absent|
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Many neonatal dermatoses can mimic NCP. Possibility of Infections including bacterial, viral, or fungal should be kept in mind. Milia, miliaria, sebaceous gland hyperplasia, Transient neonatal pustular melanosis, erythema toxicum neonatorum are noninfectious conditions simulating NCP. Always exclude acneiform eruption in neonate due to use of topical steroids, ointments (acne venenata), maternal medications during pregnancy (lithium, phenytoin, steroids). Although rare but one should rule out congenital adrenal hyperplasia (CAH) or other endocrinopathies also.
Course of NCP is benign and does not require any treatment except assurance to parents. Lesions resolve spontaneously without scarring. 2% ketoconazole cream is effective. ,
| Infantile acne|| |
Infantile acne appears from the age of 6 months up to16 months. , Occurrence is less than that of neonatal acne. It is more common in boys. Exact pathogenesis is still not known but it is thought to occur due to high level of production of dehydroepiandrosterone (DHEA) by fetal adrenal glands and this additional androgen production in boys further stimulates the sebaceous glands. High level of DHEA stimulates sebaceous gland up to 1-year of age then disappears and reappears at adrenarche. , Lesions of Infantile acne include closed and open comedones, papules, and pustules occasionally cysts and scar formation. Lesions generally resolve itself by 4-5 years of age. Infants with infantile acne are more prone to develop severe acne in their adolescence. 
Differential diagnosis should include acneiform eruptions, chloracne, and persistent neonatal acne. If the acne is severe and persistent, hyperandrogenemia should be suspected. In such cases, proper evaluation of weight, height, signs of precocious puberty (enlarged clitoris/penis) and serum level of testosterone (free and total), dehydroepiandrosterone sulfate (DHEAS), luteinizing hormone (LH) and follicle-stimulating hormone (FSH) measurement becomes mandatory.
For infantile acne, therapeutic approach is same as that for acne in other age groups. , Comedonal lesions and mild cases are managed by topical agents like retinoids (tretinoin, adapalene), benzoyl peroxide and topical antibiotics such as erythromycin. When oral antibiotics are needed, erythromycin in doses of 125-250 mg twice daily is given. In patients with documented Propionibacterium acnes resistant to erythromycin, trimethoprim/sulfamethoxazole 100 mg orally twice daily can be used.  Tetracyclines are contraindicated in children below 8 years of age because they can cause Permanent discoloration of the teeth and abnormal skeletal development.
Intralesional injections of triamcinolone acetonide in low concentration (2.5 mg/kg) can be given for nodules and cysts.  Isotretinoin is Food and Drug Administration (FDA) approved drug for treatment of nodulocystic acne only in children of 12 years or older, , but there are published reports suggesting successful role of isotretinoin in younger children. Dose of isotretinoin for infantile acne is not known but dose range of 0.2-2.0 mg/kg/day divided in two daily doses for 4-14 months in children up to 5 years of age can be used. ,,,,, As isotretinoin is available in capsules, it is problematic to administer in children. The problem can be overcome by opening the capsule in dim light and mixing the contents with soft food like cheese and butter.  The capsule should never be opened in light as isotretinoin is very labile to light and heat. Another way of administration of the capsule is to freeze it till it becomes solid and then cut the capsule up to desired dose and mix it with palatable food. Liver function tests, serum lipid profile, complete blood count and skeletal growth should be monitored regularly while patient is on isotretinoin. Adverse effects of isotretinoin in infants are mild and include dermatitis, reversible mood changes, umbilical granulation tissue, elevation of liver enzymes, periosteal thickening, and cortical hyperostosis. Premature epiphyseal closure is unlikely to occur at such low doses used in the treatment of acne.
| MID-CHILDHOOD ACNE|| |
Acne in age group of 1-7 years is called as mid-childhood acne. Acne in this age is of very rare occurrence as production of androgen by fetal adrenal gland is maximum up to 1-year of age and then stops but recurs at adrenarche. So presence of acne in mid-childhood almost always points toward hyperandrogenism. 
Differential diagnosis includes CAH, gonadal/adrenal tumors, precocious puberty or underlying endocrinopathy (Cushing's syndrome) and keratosis pilaris. Careful examination and lab tests should be performed to reach the cause of mid-childhood acne. Physical examination for precocious puberty, bone age measurements, growth chart maintenance and serum FSH, LH, testosterone, DHEA, prolactin, cortisol, and 17 a-hydroxyprogesterone level are recommended. If there is any abnormality in these parameters, patient should be referred to an endocrinologist. Treatment is same as that for infantile acne.
| Prepubertal acne|| |
Prepubertal acne is the appearance of acne before true puberty that is due to maturation of ovary and testis. During adrenarche, there is an increase in secretion of DHEA and DHEAS by adrenal glands leading to activation of sebaceous gland. Age of adrenarche is 6-7 years in females and 7-8 years in males. DHEAS is secreted from the adrenal gland. Raised Serum level of DHEAS is associated with increased sebum production in prepubartal age, so the causative factor for prepubertal acne, can be attributed to adrenal androgens.  In this age, there is little adrenal production by gonads and their maturation takes place 3-4 years after adrenarche. Excess androgen by ovary in this age can be due to benign or malignant tumor or more commonly due to polycystic ovary disease (PCOD).
Lesions of prepubertal acne mainly consist of comedones, with or without inflammatory lesions. Central area of the face (mid-forehead, nose, and chin) is mainly affected  [Figure 2]. Lesions may appear before any other signs of pubertal development. Acne can be the first sign of pubertal maturation in girls and may present before pubic hair and areolar development. 
Differential diagnosis is similar to mid-childhood acne and include precocious puberty, millia, lupus miliaris disseminatus faciei, childhood granulomatous rosacea, childhood granulomatous periorificial dermatitis and acneiform eruption due to certain drugs like phenytoin, steroids or isoniazide etc.
Severe acne in prepubertal age raises the possibility of hormonal abnormality. In girls with severe prepubertal acne, ultrasonography of the pelvis should be performed to rule out the possibility of PCOD or less commonly, benign or malignant tumor of the ovary. Lab investigations should include serum levels of free or total testosterone, DHEAS and a ratio of LH to FSH.
Treatment depends on grading of acne. Mild cases can be managed by topical therapy alone including tretinoin, benzoyl peroxide, and azelaic acid. Topical retinoids should be started gradually, and gentle cleansing of the face is recommended to remove surface sebum and keratin. For inflammatory lesions use of topical antibiotics (erythromycin, azithromycin) is recommended. If lesions are severely inflamed, oral antibiotics (erythromycin, tetracycline, azithromycin, sulfamethoxazole) can be administered. Tetracycline should never be given if the child is less than 8 years of age. Monotherapy should be avoided as this can lead to the development of resistance. Therefore, it is recommended to use antibiotics along with benzoyl peroxide or tretinoin. If there is nodulocystic acne, use of oral isotretinoin may be necessary.
Hormonal therapy is considered when etiology of acne is CAH or polycystic ovary syndrome. Oral contraceptives or antiandrogen can be prescribed in case of polycystic ovary syndrome.For CAH, low doses of oral corticosteroids are given.  If benign or malignant tumor of the ovary is the underlying cause of acne then, gynecological reference is recommended.
| Conclusion|| |
Acne has varied manifestations according to age. Many other dermatoses can be confused with acne especially in children. Neonatal acne is self-limiting and rarely needs any treatment. Infantile acne can be a predictor of more severe acne in adolescence. In the treatment of childhood acne, contraindication of oral tetracyclines should be considered. Use of oral isotretinoin has proven to be successful in infantile and mid-childhood acne but currently it is FDA approved only for children above 12 years of age. Further studies are needed to prove its safety in children in doses used for adult acne. Severe acne in children of any age warrants careful evaluation to rule out endocrinal abnormalities.
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[Figure 1], [Figure 2]