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CME ARTICLE
Year : 2015  |  Volume : 16  |  Issue : 1  |  Page : 1-4

Acne in childhood: Clinical presentation, evaluation and treatment


Department of Dermatology, Venereology and Leprosy, Government Medical College, Kota, Rajasthan, India

Date of Web Publication16-Jan-2015

Correspondence Address:
Akshay Kumar Jain
B 302, Indra Vihaar, Kota - 324 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.149399

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  Abstract 

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 Top


Acne is a disease of pilosebaceous units. [1] It is predominantly a dermatological problem in adolescents, but neonates, infants, and young children may also be affected. [2] Lesions of acne are polymorphic and consist of comedones, papules, pustules, nodules and sometimes scarring can also be present. [3] 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 Top


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. [4],[5] 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 [6],[7] 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. [7],[8],[9]
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.

Management

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. [10],[11]


  Infantile acne Top


Infantile acne appears from the age of 6 months up to16 months. [12],[13] 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. [2],[14] 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. [15]

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.

Management

For infantile acne, therapeutic approach is same as that for acne in other age groups. [6],[16] 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. [17] 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. [6] Isotretinoin is Food and Drug Administration (FDA) approved drug for treatment of nodulocystic acne only in children of 12 years or older, [12],[18] 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. [12],[13],[19],[20],[21],[22] 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. [22] 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 Top


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. [23]

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 Top


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. [24] 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 [17] [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. [25]
Figure 2: Prepubartal acne: Comedones over mid-forehead

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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.

Management

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. [25] If benign or malignant tumor of the ovary is the underlying cause of acne then, gynecological reference is recommended.


  Conclusion Top


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.

 
  References Top

1.
Layton AM. Disorders of the sebaceous glands. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Text Book of Dermatology. 8 th ed. West Sussex: Wiley-Blackwell; 2010. p. 42, 1-89.  Back to cited text no. 1
    
2.
Jansen T, Burgdorf WH, Plewig G. Pathogenesis and treatment of acne in childhood. Pediatr Dermatol 1997;14:17-21.  Back to cited text no. 2
    
3.
Simpson NB, Cunliffe WJ. Disorders of sebaceous gland. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 7 th ed. Oxford: Blackwell Publishing; 2004. p. 43, 1-75.  Back to cited text no. 3
    
4.
Marcoux D, McCuaig CC, Powell J. Prepubertal acne: Clinical presentation, evaluation, and treatment. J Cutan Med Surg 1998;2 Suppl 3:2-6.  Back to cited text no. 4
    
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Smolinski KN, Yan AC. Acne update: 2004. Curr Opin Pediatr 2004;16:385-91.  Back to cited text no. 5
    
6.
Cantatore-Francis JL, Glick SA. Childhood acne: Evaluation and management. Dermatol Ther 2006;19:202-9.  Back to cited text no. 6
    
7.
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8.
Bernier V, Weill FX, Hirigoyen V, Elleau C, Feyler A, Labrèze C, et al. Skin colonization by Malassezia species in neonates: A prospective study and relationship with neonatal cephalic pustulosis. Arch Dermatol 2002;138:215-8.  Back to cited text no. 8
    
9.
Bergman JN, Eichenfield LF. Neonatal acne and cephalic pustulosis: Is Malassezia the whole story? Arch Dermatol 2002;138:255-7.  Back to cited text no. 9
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10.
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11.
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13.
Cunliffe WJ, Baron SE, Coulson IH. A clinical and therapeutic study of 29 patients with infantile acne. Br J Dermatol 2001;145:463-6.  Back to cited text no. 13
    
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Lucky AW. A review of infantile and pediatric acne. Dermatology 1998;196:95-7.  Back to cited text no. 14
    
15.
Chew EW, Bingham A, Burrows D. Incidence of acne vulgaris in patients with infantile acne. Clin Exp Dermatol 1990;15:376-7.  Back to cited text no. 15
    
16.
Antoniou C, Dessinioti C, Stratigos AJ, Katsambas AD. Clinical and therapeutic approach to childhood acne: An update. Pediatr Dermatol 2009;26:373-80.  Back to cited text no. 16
    
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18.
Brecher AR, Orlow SJ. Oral retinoid therapy for dermatologic conditions in children and adolescents. J Am Acad Dermatol 2003;49:171-82.  Back to cited text no. 18
    
19.
Arbegast KD, Braddock SW, Lamberty LF, Sawka AR. Treatment of infantile cystic acne with oral isotretinoin: A case report. Pediatr Dermatol 1991;8:166-8.  Back to cited text no. 19
    
20.
Horne HL, Carmichael AJ. Juvenile nodulocystic acne responding to systemic isotretinoin. Br J Dermatol 1997;136:796-7.  Back to cited text no. 20
[PUBMED]    
21.
Sarazin F, Dompmartin A, Nivot S, Letessier D, Leroy D. Treatment of an infantile acne with oral isotretinoin. Eur J Dermatol 2004;14:71-2.  Back to cited text no. 21
    
22.
Torrelo A, Pastor MA, Zambrano A. Severe acne infantum successfully treated with isotretinoin. Pediatr Dermatol 2005;22:357-9.  Back to cited text no. 22
    
23.
Lucky AW. Hormonal correlates of acne and hirsutism. Am J Med 1995;98:89S-94.  Back to cited text no. 23
    
24.
Stewart ME, Downing DT, Cook JS, Hansen JR, Strauss JS. Sebaceous gland activity and serum dehydroepiandrosterone sulfate levels in boys and girls. Arch Dermatol 1992;128:1345-8.  Back to cited text no. 24
    
25.
Lucky AW, Biro FM, Huster GA, Leach AD, Morrison JA, Ratterman J. Acne vulgaris in premenarchal girls. An early sign of puberty associated with rising levels of dehydroepiandrosterone. Arch Dermatol 1994;130:308-14.  Back to cited text no. 25
    


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  In this article
Abstract
Introduction
Neonatal acne
Infantile acne
MID-CHILDHOOD ACNE
Prepubertal acne
Conclusion
References
Article Figures

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