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Colleen Cotton, MD, Explains Conditions Often Mistaken For Pediatric Acne


In a Q&A, she shares pearls from her personal experiences treating pediatric acne and other underlying conditions that may require a multidisciplinary plan.

Colleen Cotton, MD, is a board-certified dermatologist and pediatrician at Children's National Hospital and assistant professor of dermatology and pediatrics at George Washington School of Medicine in Washington, DC. She spoke with Dermatology Times® to share pearls about pediatric acne and hidradenitis suppurativa (HS), how they are sometimes mistaken, and her armamentarium to treat both. She is presenting in 2 sessions at Maui Derm NP+PA Fall 2023 in Asheville, North Carolina from September 27-30. Attendees will gain her insight on both pediatric acne and pediatric atopic dermatitis.

Dermatology Times: Which pediatric conditions are often mistaken for acne?

Cotton: When we're talking about acne, usually we're talking about acne vulgaris, which is the type of acne that comes on in those preteen/teenage years, maybe a little bit after. But there are other conditions, some which are true acne and some which are not that can carry that acne name with them. So neonatal acne is one that I see a lot as a pediatric dermatologist, and most people know kind of what it looks like there are these little papules and pustules, sometimes some yellow crusting that typically occurs on the face, scalp, upper chest, upper back of infants, usually starting around 4 to 6 weeks of age, and usually fading out by the time they're several months old. And it's not true acne. There are no actual comedones that come up with neonatal acne. It's just sort of named because it looks a little bit like acne, but it's really more of a sort of hypersensitivity reaction to yeast that normally lives on the skin like Malassezia, or things like that. And it's a very normal part of infancy. So we see it quite a bit.

Infantile acne is actual acne and does appear generally around the time of maybe 6 months to 1 year of age. So when they're still in that first year of life, those can have comedones, they can have nodule of cystic lesions, Very rarely, [do] we have to treat those patients with things like isotretinoin or oral antibiotics. But a lot of times we use the same topical medications that we'll use for our older acne patients, just in lower concentrations, or less frequently, to try to prevent scarring, which that can do.

Then, you can see true acne in kids ages 1 to 6. But that's really the time where if you're seeing true acne, there's something wrong going on there, that's almost always going to be pathologic, secondary to lead something else going on in the body.

Dermatology Times: What else could be going on in a patient's body if they are experiencing acne below the age of 6?

Cotton: Usually, that's secondary to something systemic going on in the body. That could be a tumor producing hormones. It could be what we call premature puberty, or premature adrenarche, which are signs of puberty without the actual acceleration or change in growth. There's lots of different reasons that that could happen. And so it's never something at that age that you kind of want to look at and say, "Oh, weird, you're just getting early acne." You really want to do a full comprehensive skin exam to look for other signs of puberty, and have that patient consider a workup with endocrinology. So lots of different ways that we can see acne present in the pediatric age group.

Dermatology Times: What treatment considerations should be made for acne treatment in pediatric and adolecent patients?

Cotton: A lot of the topicals that we have are FDA-approved down to either 9 or 11, or 12. So generally speaking, we have a lot of the same tools in our toolbox that we have for adults. For younger children under the age of 9, in terms of oral antibiotics, doxycycline or other tetracyclines are things that we might want to avoid because of a potential risk of tooth staining. So we might use different antibiotics. Some people will use amoxicillin. Some people will use sulfamethoxazole/trimethoprim. So there's different options that we have there. And then we do use isotretinoin in young children as well. There's not really an age cut off that we have for that particular medication. We know from using it in children with ichthyosis that we can use it, even down to infants, so the toolbox is the same, just with a couple of different considerations.

Dermatology Times: Tell us about challenges that can come with treating preteens and how to overcome them.

Cotton: Preteens are still developmentally kind of coming into their own. There can be a really wide variety of maturity level and ability to form your own skincare routine. At that age, I have some 9-year olds who are like, "This is my 5-step routine," when they come in to see me and I have some 11-year olds who are like, "I wash my face sometimes." So it's everywhere in between, and developmentally speaking, preteens are still at that age where they do need help and support from their parents to remember to do some type of medication. So it's really important to make sure parents understand that because a lot of times they'll come back and they'll be very frustrated and they're like, "She's not doing it," and I'm like, "I get it but developmentally speaking, she can't necessarily take that on so you do need to be the one to help her and remind her." If the parents are not necessarily on board with that, then maybe certain treatments aren't necessarily a good option for those patients, either. It can also be really helpful to figure out what is post inflammatory hyperpigmentation, and what is true scarring so that if the patient is not really bothered by the acne, it's really just their parent, you can kind of work together to say, you know, this is the plan we're going to do. But it's okay if they're not, you know, going after their acne, because as of right now, I don't see any evidence of permanent scarring. Likewise, if you are seeing permanent scarring, that is a time where I really tried to explain to the kid I'm like, "Even if your acne doesn't bother you now, I want to prevent it from bothering you 2 to 5 to 10 years down the road."

Dermatology Times: Patients and their families sometimes mistake hidradenitis suppurativa for acne. What do you tell them?

Cotton: When I see a patient who has HS or who I think might have HS, I always try to make sure that I explain to them what it is and what it isn't. It's not an infection. It's not because of something that they did or didn't do. It's not because they're not cleaning well enough. And I make the point of saying that to everyone because I never know what they've been told before or what they've assumed themselves. So it never for me goes without saying that, "This isn't your fault." They may assume that it is or have been told that it is by another healthcare provider. And then I tell them, what it is is really complicated and that we don't fully have an understanding of it in-depth, but we do know that it has to do with the hair follicle and an over reactive immune response to some irritation or insult in that area. And it's a chronic condition that tends to progress over time. Even if at the beginning, there may be sort of episodes with nothing in between, gradually over time that does start to become more of a chronic condition with periods of sort of acute exacerbation.

Dermatology Times: How do you help pediatric patients manage HS with only 1 FDA-approved treatment for adults?

Cotton: As of right now, we have 1 FDA approved treatment for HS and that is adalimumab. Biosimilars have just started coming out now with that, which is an interesting opportunity. We don't have any evidence to suggest that those biosimilars are not as effective as the original brand name drug. But it is a new situation that we really haven't had to deal with before, in that these injectables look different and the mechanism of delivery may act differently. So it is something that we need to be talking with our patients about in terms of the treatment options that are available to them and to reassure them, even if it looks different, that doesn't necessarily mean this isn't going to continue to work for you.

But what do you do with the patient who has failed adalimumab? Either it never worked to begin with, or they have had efficacy and it's waned over time? That's where I think the tools that are coming in our toolbox are really exciting. I don't know exactly when they're gonna get there for adolescents. But for adults, there are several different IL-17 inhibitors that are on the horizon. With approval for HS, hopefully within the next year, bimekizumab and secukinumab being kind of the 2 big ones. But there are lots of other treatments that we can use before we get to a biologic, even if they're not necessarily FDA-approved for the treatment of HS.

Some of those things are similar to what we have in our toolbox for acne. So benzoyl peroxide washes, oral antibiotics, but then other things that we use for acne don't really work as well for HS like isotretinoin not really as effective for HS as it is for acne. And I often have patients who have both where it clears their nodular cystic acne very well, but their HS remains active and we still have to do some things to manage that.

So thinking about what their comorbidities are, what other medications they're currently taking, can help determine do we need hormonal therapies? Do we need therapies targeted at insulin resistance? Do we need zinc or other non-medicated supplementary types of medications? Is a procedure needed? Are there sinus tracts or scarring that need actual surgery or do roofing procedures in order to get them out of that constant cycle of just a biofilm with re aggravated inflammation? So there's lots of different treatments and a lot of it is trying to get a sense of your patient, how much they're able to do, and where you can get the biggest bang for your buck.

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