Pediatric Acne: What Signs are Concerning?

Is neonatal acne or infantile acne more worrisome? This question and more were brought up during the Acne and Rosacea Update session at Maui Derm NP+PA Fall 2021.

Pediatric acne was discussed in a presentation at Maui Derm NP+PA Fall 2021 by Raegan Hunt, MD, PhD, service chief of pediatric dermatology at Texas Children’s Hospitals and assistant professor of dermatology and pediatrics at the Baylor College of Medicine, both in Houston Texas.1

Her objective was to explain how to diagnose and treat acne in pre-adolescent children and recognize when early onset acne may indicate a need to rule out underlying endocrinologic abnormalities.

Her first question was on whether neonatal acne or infantile acne is more worrisome. The answer was infantile acne. While neonatal acne (benign cephalic pustulosis) can develop in neonates (0-1.5 months of age), there are no comedones, cysts, or acne scarring for the physician to think about.This common papulopustular eruption is self-resolving, and gentle cleansers and topical antifungal medications can help the skin clear more rapidly, Hunt explained.

On the other hand, infantile acne is uncommon, appearing more frequently in male patients with an onset between 1.5 to 12 months with a risk of scarring. It is also associated with a higher risk of adolescent acne and does have comedones, inflammatory papules, acne cysts and nodules.

Typical treatment, according to Hunt, would be topical medications like benzoyl peroxide, retinoids, and azelaic acid or systemic medications like erythromycin or trimethoprim/sulfamethoxazole (TMX-SMX—not in patients younger than 3 months of age). For severe treatment resistant cases, off-label use of isotretinoin should be considered.

As young babies cannot swallow capsules, Hunt explained, when isotretinoin is prescribed for painful or cystic scarring acne in this age group, the oily medication vehicle must be removed from the capsule with a syringe and given by mouth or the capsules can be frozen and cut to be hidden in food as appropriate.

She said that a laboratory work up for endocrinologic abnormality is not usually needed, as infantile acne is typically not associated with an endocrinopathy, but advised to look for signs of accelerated growth and advanced tanner staging and consider laboratory evaluation if abnormal.

What about mid-childhood acne vs pre-adolescent acne? Which one is raises more concern?

Hunt said that mid-childhood acne, which develops between ages 1-7 years, can be a sign of a much deeper issues, as it is often associated with endocrinologic disorders, such as a tumor, Cushing syndrome, or premature adrenarche. For this, an endocrine laboratory work up is needed. Recommended tests include follicle-stimulating hormone (FSH), luteinizing hormone (LH), dehydroepiandrosterone sulfate (DHEAS), cortisol, free and total testosterone, 17-OH progesterone, and a bone age x-ray.

The clinical findings of mid-childhood acne are comedones, inflammatory papules, and nodules with an onset between 1 and 7 years old. It does have a risk of scarring and treatment includes topical retinoids, benzoyl peroxide, and topical and oral antibiotics. Hunt emphasized that tetracycline derivatives should be avoided in pediatric patients less than 8 years old for acne treatment.

Pre-adolescent acne has the same clinical findings, treatment, and risk of scarring as mid-childhood acne, but the onset of acne lesions begins between 8 to 12 years old. For this patient group, an endocrine work up is not typically needed, according to Hunt.

She went on to explain a previous case of an 11-year-old patient on adalimumab for Crohn’s Disease with numerous pustules on the nose and only rare inflammatory papules and comedones elsewhere on the face that had failed treatment from topical retinoids, topical antibiotics, doxycycline, and had a poor response to intralesional triamcinolone injection. The patient was advised against additional oral antibiotics or isotretinoin by his gastroenterologist.

Hunt diagnosed him with demodicosis, which she treated with 2 doses of about 200 mcg/kg oral ivermectin 1 week apart and topical permethrin 5% cream once daily for 1 week. When there are prominent pustules on the nose in children that are not clearing with regular acne treatment, demodicosis may be the correct diagnosis, she explained.

While demodex colonization burden is lower in childhood and increases with age, Hunt said, demodicosis can be associated with disorders like Langerhans cell histiocytosis, leukemia, lymphoma, and HIV in children. She mentioned that it may also secondarily exacerbate pediatric periorificial dermatitis.

Lastly, she touched on the subject of acne in transgender patients and how more than 90% of transmasculine youth experience issues with acne which may be triggered or made worse by testosterone that is used in gender affirming therapy. Hunt explained that it is recommended that acne is monitored every 3 months after the start of testosterone therapy.2

Furthermore, she said that moderate to severe acne in transmasculine patients is associated with an increased risk of depression (adjusted odds ratio of 2.4) and anxiety (adjusted odds ratio of 2.7).3 To help treat the acne that is exacerbating these mental health issues, she recommended assessing the acne type and treating as the severity and acne type indicates.

If the patient would likely benefit from a combination estrogen-progestin oral contraceptive pill and/or isotretinoin beyond standard first-line acne treatments with a combination of topical retinoid, topical and/or oral antibiotic therapy, these additional options should be offered, Hunt continued. The combination oral contraceptive pills may also benefit the patient beyond acne by suppressing menstruation, however, the clinician should recognize that oral contraceptive pills for acne therapy may be rejected by the patient because of its female hormone connotation she explained.

On the other hand, isotretinoin has its own risks in trans youth, including an increased risk of hepatotoxicity if the patient is taking isotretinoin and testosterone. Additionally, isotretinoin may cause depression, anxiety or suicidal ideation in some patients which could be more worrisome in a population already at high risk for these mental health issues, Hunt discussed.

Further, the iPLEDGE risk evaluation and mitigation strategy for isotretinoin requires registration and regular pregnancy tests based on sex assigned at birth, which may cause emotional distress for transmasculine patients. She added that long-term testosterone treatment is not considered a reliable form of birth control. These conversations should be approached with compassion and open communication, Hunt concluded.


Raegan Hunt, MD, PhD had no disclosures.


  1. Hunt R. Pediatric Acne. Session presented at: Maui Derm NP+PA Fall 2021 conference Program; October 1, 2021; Accessed October 1, 2021. Asheville, North Carolina
  2. Kosche C, Mansh M, Luskus M, et al. Dermatologic care of sexual and gender minority/LGBTQIA youth, Part 2: Recognition and management of the unique dermatologic needs of SGM adolescents. Pediatr Dermatol. 2019;36(5):587-593. doi:10.1111/pde.13898
  3. Braun H, Zhang Q, Getahun D, et al. Moderate-to-severe acne and mental health symptoms in transmasculine persons who have received testosterone. JAMA Dermatology. 2021;157(3):344-346. doi:10.1001/jamadermatol.2020.5353