Tackling acne: Traditional treatments work in children

Key Points

According to Lawrence Eichenfield, M.D., professor of pediatrics and dermatology and chief of pediatric and adolescent dermatology at the University of California, San Diego, and Rady Childrens' Hospital, San Diego, 90 percent to 95 percent of pre-teens and teens will have acne at some point, making it one of the most common conditions seen in the dermatologist's office.

It's also not uncommon for infants to develop a variety of acne types before they reach age 1.

"The term 'cephalic pustulosis' has been used for non-acneiform pustular eruptions, some attributed to Malassezia species. True infantile acne usually presents with the hallmarks of acne, comedones, either open or closed; inflammatory papules or pustules; and even nodular cystic lesions," he says.

Dr. Eichenfield says most infantile acne does not present much treatment difficulty. Most can be managed with normal topical acne medicines, including benzoyl peroxide, topical antibiotics, benzoyl peroxide/ antibiotic or a retinoid/antibiotic combination.

"There are occasional infant manifestations of abnormal androgen excess or individuals with normal hormonal studies who can have significant nodules or cysts that may cause scarring.

"We have published our experience with isotretinoin for toddlers with scarring cystic acne, with excellent success and good toleration of the therapy," Dr. Eichenfield tells Dermatology Times.

Acknowledging that isotretinoin is not without controversy, even for older acne patients, Dr. Eichenfield cautions that isotretinoin in toddlers is not something every dermatologist should have need to use often, if at all.

"For very select patients who have failed both topical and systemic antibiotics, and yet have significant scarring acne, it's reasonable to consider isotretinoin even in pre-teens.

"For toddlers, the dose is 0.2 mg per kilogram per day, up to 1.5 mg per kilogram per day. You can do very low-dose therapy, using it on an every-other-day basis, as a way to keep the dosage low enough that it can be administered to young children," he says.

Dr. Eichenfield says he has an interesting way of administering partial gel caps to the youngsters.

"We did an article where we showed the administration of isotretinoin capsule in a candy bar to give it to toddlers. This is tricky, because you can't really cut a gel capsule in half, but if you freeze it first, then cut it and put it into the candy bar, it works pretty well. I call it the 'Ifudge' program."

Once children get past the first year of life, it's very uncommon for them to have acne until they hit the immediate prepubertal time period.

Dr. Eichenfield says, "When one does see significant acne in a 3-, 4-or 5-year old, we are obliged to consider a differential diagnosis, which would consider a variety of medical conditions that can present in an abnormal hormonal milieu, such as true precocious puberty, congenital adrenal hyperplasia and Cushing's syndrome.

"At the same time, a variety of acne mimics can occur in the young child that can be mistaken for acne, particularly by primary care practitioners. Those conditions can include keratosis pilaris, microcysts and demodicidosis. Each of those conditions has a variety of treatments that would differ from traditional acne therapy," he says.

Once young people reach that prepubescent or pubescent age when acne becomes much more common, Dr. Eichenfield says that first-line therapy often differs between dermatologists and pediatricians, who commonly treat teenage acne.

"Dermatologists are trained to use topical retinoid-based therapy, while many times pediatricians use benzoyl peroxide products as an alternative first line. Rather than get into a debate over which is best, it's reasonable to show that both methodologies are viable, depending upon the extent of the acne."