SAN FRANCISCO — Children can get acne at any age, but what many parents think is acne might actually be something else, Dr. Rebecca L. Smith said at a meeting sponsored by Skin Disease Education Foundation.
A good example is “neonatal acne.” That's what this imposter used to be called, until it was recognized as a pustulosis process, not acne, said Dr. Smith, a dermatologist in Fort Mill, S.C.
The condition is now known as neonatal cephalic pustulosis, a common, transient eruption that occurs in the first weeks of life and that is localized to cheeks, chin, forehead, and eyelids. Lesions may also develop on the chest, neck, and scalp.
If a parent insists on treatment, a bit of topical 2% ketoconazole cream usually clears the skin quickly, she advised.
However, “infants can get acne, and it can be very bad,” she acknowledged. It is most common on the cheeks, and more likely in boys than in girls. “You can treat these children like [most] other acne patients, with topical and oral antibiotics and even topical tretinoin at times. Extreme cases can be treated with isotretinoin.”
The situation changes after the first year, however. Dr. Smith said she refers any child between 1 year of age and puberty who has bad acne to an endocrinologist because neonatal adrenal glands produce only minimal androgen after 1 year of life, so acne in early childhood raises concern about underlying disease and hyperandrogenism.
“We're seeing children younger and younger these days” with typically midfacial acne that's often the first sign of pubertal maturation, she said. These acne-prone children secrete sebum in the midfacial area earlier than do children without acne.
When it comes to management, Dr. Smith said she tries to translate the treatment strategy into terms children can understand, targeting as many age-appropriate factors as possible.
“We're going to treat your oil, treat your plugs, treat your bugs, and then treat your redness,” she tells them. “A teenager can get that.” That corresponds with treating sebum, faulty follicular keratinization, bacteria, and inflammation.
To avoid inducing drug resistance in Propionibacterium acnes, one should use the least aggressive treatment regimen that will provide a sustained response, she advised.
“I'm not worried about P. acnes resistance. [I'm] worried about P. acnes sharing that” resistance with other bacteria, she emphasized.
Dr. Smith said that she always adds benzoyl peroxide to antibiotic therapy for acne because it increases antibiotic penetration and creates a tough environment for P. acnes. Some combination products are on the market. Patients should be told that these products can bleach clothing, pillowcases, carpet, and hair, but not skin, she said.
Retinoids are the foundation of maintenance therapy for acne. “I want everyone on retinoids eventually,” she said. Many retinoid options are available. Get to know them, and choose the one that's right for each patient, she suggested.
Dr. Smith advised against instructing children to use a pea-sized amount for the entire face, because that may not mean much to vegetable-averse children. “Tell them to use a chocolate chip-sized amount,” and show them how to dot the face and rub the retinoid in, she said.
To increase children's ability to tolerate retinoid therapy, have them wash their faces with a gentle cleanser and apply an oil-free moisturizer before applying the retinoid.
This may slightly decrease the effect of the retinoid, but increased adherence to therapy can provide better results than applying the retinoid alone, she said. Another strategy is to titrate dosing by starting applications every second or third night for the first week, and increasing frequency as tolerated.
Dr. Smith said that she has been a speaker or adviser for, or has received funding from, companies that make retinoids, antibiotics, or tretinoin products for the treatment of acne. These companies include Allergan, CollaGenex, Dermik, Galderma, Medicis, SkinMedica, Stiefel, and Warner Chilcott.
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