Maui, Hawaii — Guidelines for the diagnosis and treatment of pediatric acne developed by the American Acne Rosacea Society (AARS) and endorsed by the American Academy of Pediatrics (AAP) provide the AAP with its first-ever evidence-based guidelines for the management of this very common pediatric condition.
Released in May 2013, the guidelines present an age-based categorization of acne and a set of severity-based treatment algorithms, says Lawrence F. Eichenfield, M.D. He is president of the AARS and co-chaired the panel that developed the guidelines. He spoke to the impetus for the project and highlighted some of the key recommendations at the MauiDerm 2014 meeting.
“The onset of acne is occurring earlier now than in the past, and one goal of the guidelines was to get physicians to recognize that early significant acne is a predictor of worse acne over time. In addition, numerous articles have identified a huge gap, essentially a chasm, between the way dermatologists and pediatricians manage children and teens with acne,” says Dr. Eichenfield, professor of pediatrics and dermatology, University of California, San Diego, and Rady Children’s Hospital.
“The new guidelines are also helpful for dermatologists in terms of what they should be doing in their own practice and when speaking to primary care providers,” he says. “We truly believe that the new guidelines will improve acne patient care.”
The age-based categorization divides acne type into neonatal, infantile, mid-childhood, preadolescent and adolescent acne. Dr. Eichenfield points out that neonatal acne usually represents some non-acne pustular eruption whereas acne in infants tends to be a true acneiform condition. Acne during the mid-childhood years, ages 1 to <7 years, is a condition that should raise concern about an underlying endocrinologic cause.
“Acne in a child this age, even when it appears mild, is worrisome because it may be a sign of hyperandrogenism associated with Cushing syndrome, premature adrenarche, congenital adrenal hyperplasia, or adrenal tumors,” Dr. Eichenfield says.
“The guidelines recommend that children with mid-childhood acne be referred for evaluation by a pediatric endocrinologist.”
Preadolescent acne, with onset between ages 7 and 12 or prior to menarche in girls, is now very common, and unless there are other findings to suggest an endocrine-related or other systemic problem, there is no need for these children to undergo work-up beyond history and physical.
“Acne can precede other signs of pubertal maturization, and we know that the average age of puberty is now about one year younger than it was a decade ago for both males and females,” Dr. Eichenfield says.
Optimized regimens of care
Severity-based treatment algorithms represent the crux of the guidelines. Adherence to the recommendations should eliminate important practice gaps that include low retinoid prescribing rates with over-reliance on antibiotics as monotherapy.
“One goal is to be able to successfully maintain patients on topical treatment with a retinoid alone or in combination with a topical antimicrobial, even in moderate patients who may use oral antibiotic for a few months. Therefore, one should not be treating acne using an oral antibiotic alone,” Dr. Eichenfield says.
He notes the guidelines also emphasize the use of a topical retinoid alone or in combination for all severities of acne in pediatric patients of all ages, even though per the prescribing information for individual products, use in children younger than ages 9 or 12 years is off-label. In addition, they make benzoyl peroxide a priority in regimens of care.
“Benzoyl peroxide should be prescribed whenever using a topical or oral antibiotic to decrease the development of bacterial resistance,” he says.
Highlighting some of the key points within the individual algorithms, Dr. Eichenfield notes that as a departure from prior acne guidelines, the AARS guideline recommends that benzoyl peroxide may be considered as initial monotherapy for mild acne. Other options for initial treatment include a topical retinoid alone or topical combinations including benzoyl peroxide with an antibiotic and/or retinoid. Topical dapsone is also identified as a monotherapy option or to be used in place of a topical antibiotic, although topical antibiotics are not recommended as monotherapy.
Moderate acne therapies
Treatment for moderate acne is initiated with a combination regimen that should always include a topical retinoid and benzoyl peroxide with an oral or topical antibiotic. Again, topical dapsone can be substituted for a topical antibiotic.
“Oral antibiotics are reasonable for treating moderate or worse inflammatory acne at any age, and the guidelines note that second generation tetracyclines are sometimes preferred based on absorption and dosing frequency. However, tetracyclines should not be used in children younger than 8 years of age,” Dr. Eichenfield says.
The treatment regimen can be modified for inadequate responders by altering the topical components or substituting an oral antibiotic for a topical agent. If there is still insufficient control, the guidelines recommend considering hormonal therapy for females or oral isotretinoin along with dermatology referral. Consideration of referral to a dermatologist is also recommended for any patient with severe acne.
Dr. Eichenfield notes there is controversy on the appropriate age for initiating hormonal therapy. The group’s consensus recommendation was that a combined oral contraceptive (OC) can be used as second-line therapy for pubertal females with moderate-to-severe acne and note the need to assess tobacco use and family history of thrombotic events. It is also noted that due to concerns about potential effects on bone, some experts recommend withholding OCs to treat acne in girls until they are at least one year past onset of menstruation.
Disclosures: Dr. Eichenfield is a clinical investigator for and past consultant to companies that market products for treatment of acne.