Acne

Acne is a common skin disorder among young people, affecting up to 85% of adolescents, often causing a significant amount of distress, and, when severe, it can have long-lasting effects.

Pathophysiology

Acne vulgaris involves four processes: sebaceous hyperplasia driven by increased androgen levels; alterations of follicular growth and differentiation; colonization of follicle by Propionibacterium acnes; and immune response and inflammation.

Categorization

Categorizing acne on the basis of morphology and severity of lesions is useful. The three basic morphologies are comedonal, inflammatory, and mixed. Comedones are closed (whitehead) or open (blackhead). Closed comedones result from cell proliferation mixing with sebum and partially clogging the follicular lumen. Open comedones result when the follicle has a broader opening with visible keratin buildup that darkens. Inflammation manifests as papules, pustules, nodules, or pseudocysts and may include scarring or sinus tracts. The inflammation results from P. acne colonization, with release of inflammatory mediators. Severity is classified as mild, moderate, and severe. This assessment is subjective but should be based on number and type of lesions, amount of skin involved, scarring, and risk of dyspigmentation, which is greater in darker skin.

Age-specific considerations

The differential diagnosis and work-up of acne varies by age group. Neonatal (birth-6 weeks) acne has a prevalence of 20%, though these lesions actually may represent acneiform conditions such as self-limited neonatal cephalic pustulosis or transient neonatal pustular melanosis.

Photo courtesy of Neil Skolnik, M.D.

Infantile (6 weeks to 12 months, or uncommonly up to a few years old) acne is more common in males, usually is comedonal and inflammatory, and presents with papules, pustules, or nodules. A work-up usually is not necessary unless growth is abnormal or signs of hirsutism/virilization exist, in which case referral to endocrinology is made for a possible hormonal anomaly. Of note, true infantile acne may portend an increased risk of severe adolescent acne.

Mid-childhood (1-7 years) acne is not common since this age group does not produce significant levels of adrenal or gonadal androgens. If it does occur, a work-up by an endocrinologist is recommended.

Preadolescent (7-12 years) acne is common and may be the first sign of pubertal maturation. Such acne usually is comedonal with a "T-zone" distribution (forehead and central face), and may appear on the ears. Inflammatory lesions are sparse. No work-up beyond history and physical is needed unless there is concern for endocrinologic abnormalities (for example, PCOS), which may manifest as very severe or refractory acne.

Treatment

Goals of treatment involve addressing pathogenic factors and using the least aggressive but effective regimen, while avoiding bacterial resistance development. Additionally, side effects and expectations of results (in other words, noticeable results may take 4-8 weeks for any acne treatment) should be discussed in order to enhance compliance.

Various over-the-counter (OTC) products and prescription agents are available for the treatment of acne. OTC agents that have been tested include salicylic acid and benzoyl peroxide (BP). BP is effective, safe, and inexpensive. It can be used as monotherapy and, when used in combination with topical or systemic antibiotics, may minimize antibiotic-resistant P. acnes development.

Prescription options include topical retinoids, topical antibiotics, topical dapsone, oral antibiotics (typically tetracycline, doxycycline, or minocycline), oral isotretinoin, fixed-dose combination topical agents (BP/topical antibiotic, BP/topical retinoid, and topical retinoid/antibiotic), and hormonal therapy. The recommendations address the treatment of mild, moderate, and severe pediatric acne.

Mild acne usually presents as comedonal or mixed. Initial treatment can include BP monotherapy, topical retinoids, or combinations of topical retinoids, antibiotics, and BP. In patients of color, where there is a greater risk of scarring and dyspigmentation, initial therapy might also include a topical or oral antibiotic. In cases of inadequate response, the concentration, type, or formulation of topical retinoid can be changed or the topical combination can be modified.

Moderate acne may require an aggressive regimen of combination topical therapy that includes a retinoid and BP with or without topical dapsone, with the likely addition of an oral antibiotic. If lesions are moderate to severe inflammatory or mixed, oral antibiotics are effective, with maximal response taking 3-6 months. If an inadequate response and adherence assured, the strength, type, and formulation of topical regimens can be adjusted, although referral to a specialist may be considered.

Severe acne requires prompt initiation of treatment to avoid scarring and permanent skin changes. Treatment should include oral antibiotics with topical retinoids plus BP, with or without topical antibiotics. Strong consideration should be given to adding hormonal therapy to the treatment regimen of young menstruating women who have severe acne. In addition, for both males and females, oral isotretinoin and referral to a specialist may be considered.

Some recommend refraining from oral contraceptives until 1 year after menarche because of concerns about growth and bone density. When considering oral isotretinoin, remember it is teratogenic and that it causes questionable changes to bone health, mood, and bowel disorders, which may cause more issues in the pediatric population.

If there is an inadequate response after combination therapy with isotretinoin, physicians can try oral antibiotics with topical retinoids plus BP. If acne persists, consideration can be given to switch to a different oral antibiotic to address possible resistant organisms.

Remember that tetracyclines should not be used in ages younger than 8 years. Erythromycin, azithromycin, and trimethoprim/sulfamethoxazole are options for children younger than 8 years or those with a tetracycline allergy, as long as there is close monitoring for adverse events with any oral antibiotics in children.

Bottom line

The diagnosis, work-up, and management of pediatric acne vary depending upon age and pubertal onset. When approaching acne therapy, the best treatment is determined by assessment of type and severity of lesions. Use of topical BP, retinoids, antibiotics, and oral antibiotics are the base of therapy, with strength and combination of agents determined by type and severity of the acne.

Reference

Eichenfield, L.F., Krakowski, A.C., Piggott, C., Del Rosso, J., Baldwin, H., Friedlander, S.F., Levy, M., Lucky, A., Mancini, A.J., Orlow, S.J., Yan, A.C., Vaux, K.K., Webster, G., Zaenglein, A.L., Thiboutot, D.M. (2013). Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne. (Pediatrics 2013;131:S163 [doi:10.1542/peds.2013-0490B]).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Lee is a third-year and chief resident in the family medicine residency program at Abington Memorial Hospital.

Acne is a common skin disorder among young people, affecting up to 85% of adolescents, often causing a significant amount of distress, and, when severe, it can have long-lasting effects.

Pathophysiology

Acne vulgaris involves four processes: sebaceous hyperplasia driven by increased androgen levels; alterations of follicular growth and differentiation; colonization of follicle by Propionibacterium acnes; and immune response and inflammation.

Categorization

Categorizing acne on the basis of morphology and severity of lesions is useful. The three basic morphologies are comedonal, inflammatory, and mixed. Comedones are closed (whitehead) or open (blackhead). Closed comedones result from cell proliferation mixing with sebum and partially clogging the follicular lumen. Open comedones result when the follicle has a broader opening with visible keratin buildup that darkens. Inflammation manifests as papules, pustules, nodules, or pseudocysts and may include scarring or sinus tracts. The inflammation results from P. acne colonization, with release of inflammatory mediators. Severity is classified as mild, moderate, and severe. This assessment is subjective but should be based on number and type of lesions, amount of skin involved, scarring, and risk of dyspigmentation, which is greater in darker skin.

Age-specific considerations

The differential diagnosis and work-up of acne varies by age group. Neonatal (birth-6 weeks) acne has a prevalence of 20%, though these lesions actually may represent acneiform conditions such as self-limited neonatal cephalic pustulosis or transient neonatal pustular melanosis.

Photo courtesy of Neil Skolnik, M.D.

Infantile (6 weeks to 12 months, or uncommonly up to a few years old) acne is more common in males, usually is comedonal and inflammatory, and presents with papules, pustules, or nodules. A work-up usually is not necessary unless growth is abnormal or signs of hirsutism/virilization exist, in which case referral to endocrinology is made for a possible hormonal anomaly. Of note, true infantile acne may portend an increased risk of severe adolescent acne.

Mid-childhood (1-7 years) acne is not common since this age group does not produce significant levels of adrenal or gonadal androgens. If it does occur, a work-up by an endocrinologist is recommended.

Preadolescent (7-12 years) acne is common and may be the first sign of pubertal maturation. Such acne usually is comedonal with a "T-zone" distribution (forehead and central face), and may appear on the ears. Inflammatory lesions are sparse. No work-up beyond history and physical is needed unless there is concern for endocrinologic abnormalities (for example, PCOS), which may manifest as very severe or refractory acne.

Treatment

Goals of treatment involve addressing pathogenic factors and using the least aggressive but effective regimen, while avoiding bacterial resistance development. Additionally, side effects and expectations of results (in other words, noticeable results may take 4-8 weeks for any acne treatment) should be discussed in order to enhance compliance.

Various over-the-counter (OTC) products and prescription agents are available for the treatment of acne. OTC agents that have been tested include salicylic acid and benzoyl peroxide (BP). BP is effective, safe, and inexpensive. It can be used as monotherapy and, when used in combination with topical or systemic antibiotics, may minimize antibiotic-resistant P. acnes development.

Prescription options include topical retinoids, topical antibiotics, topical dapsone, oral antibiotics (typically tetracycline, doxycycline, or minocycline), oral isotretinoin, fixed-dose combination topical agents (BP/topical antibiotic, BP/topical retinoid, and topical retinoid/antibiotic), and hormonal therapy. The recommendations address the treatment of mild, moderate, and severe pediatric acne.

Mild acne usually presents as comedonal or mixed. Initial treatment can include BP monotherapy, topical retinoids, or combinations of topical retinoids, antibiotics, and BP. In patients of color, where there is a greater risk of scarring and dyspigmentation, initial therapy might also include a topical or oral antibiotic. In cases of inadequate response, the concentration, type, or formulation of topical retinoid can be changed or the topical combination can be modified.

Moderate acne may require an aggressive regimen of combination topical therapy that includes a retinoid and BP with or without topical dapsone, with the likely addition of an oral antibiotic. If lesions are moderate to severe inflammatory or mixed, oral antibiotics are effective, with maximal response taking 3-6 months. If an inadequate response and adherence assured, the strength, type, and formulation of topical regimens can be adjusted, although referral to a specialist may be considered.

Severe acne requires prompt initiation of treatment to avoid scarring and permanent skin changes. Treatment should include oral antibiotics with topical retinoids plus BP, with or without topical antibiotics. Strong consideration should be given to adding hormonal therapy to the treatment regimen of young menstruating women who have severe acne. In addition, for both males and females, oral isotretinoin and referral to a specialist may be considered.

Some recommend refraining from oral contraceptives until 1 year after menarche because of concerns about growth and bone density. When considering oral isotretinoin, remember it is teratogenic and that it causes questionable changes to bone health, mood, and bowel disorders, which may cause more issues in the pediatric population.

If there is an inadequate response after combination therapy with isotretinoin, physicians can try oral antibiotics with topical retinoids plus BP. If acne persists, consideration can be given to switch to a different oral antibiotic to address possible resistant organisms.

Remember that tetracyclines should not be used in ages younger than 8 years. Erythromycin, azithromycin, and trimethoprim/sulfamethoxazole are options for children younger than 8 years or those with a tetracycline allergy, as long as there is close monitoring for adverse events with any oral antibiotics in children.

Bottom line

The diagnosis, work-up, and management of pediatric acne vary depending upon age and pubertal onset. When approaching acne therapy, the best treatment is determined by assessment of type and severity of lesions. Use of topical BP, retinoids, antibiotics, and oral antibiotics are the base of therapy, with strength and combination of agents determined by type and severity of the acne.

Reference

Eichenfield, L.F., Krakowski, A.C., Piggott, C., Del Rosso, J., Baldwin, H., Friedlander, S.F., Levy, M., Lucky, A., Mancini, A.J., Orlow, S.J., Yan, A.C., Vaux, K.K., Webster, G., Zaenglein, A.L., Thiboutot, D.M. (2013). Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne. (Pediatrics 2013;131:S163 [doi:10.1542/peds.2013-0490B]).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Lee is a third-year and chief resident in the family medicine residency program at Abington Memorial Hospital.

Acne is a common skin disorder among young people, affecting up to 85% of adolescents, often causing a significant amount of distress, and, when severe, it can have long-lasting effects.

Pathophysiology

Acne vulgaris involves four processes: sebaceous hyperplasia driven by increased androgen levels; alterations of follicular growth and differentiation; colonization of follicle by Propionibacterium acnes; and immune response and inflammation.

Categorization

Categorizing acne on the basis of morphology and severity of lesions is useful. The three basic morphologies are comedonal, inflammatory, and mixed. Comedones are closed (whitehead) or open (blackhead). Closed comedones result from cell proliferation mixing with sebum and partially clogging the follicular lumen. Open comedones result when the follicle has a broader opening with visible keratin buildup that darkens. Inflammation manifests as papules, pustules, nodules, or pseudocysts and may include scarring or sinus tracts. The inflammation results from P. acne colonization, with release of inflammatory mediators. Severity is classified as mild, moderate, and severe. This assessment is subjective but should be based on number and type of lesions, amount of skin involved, scarring, and risk of dyspigmentation, which is greater in darker skin.

Age-specific considerations

The differential diagnosis and work-up of acne varies by age group. Neonatal (birth-6 weeks) acne has a prevalence of 20%, though these lesions actually may represent acneiform conditions such as self-limited neonatal cephalic pustulosis or transient neonatal pustular melanosis.

Photo courtesy of Neil Skolnik, M.D.

Infantile (6 weeks to 12 months, or uncommonly up to a few years old) acne is more common in males, usually is comedonal and inflammatory, and presents with papules, pustules, or nodules. A work-up usually is not necessary unless growth is abnormal or signs of hirsutism/virilization exist, in which case referral to endocrinology is made for a possible hormonal anomaly. Of note, true infantile acne may portend an increased risk of severe adolescent acne.

Mid-childhood (1-7 years) acne is not common since this age group does not produce significant levels of adrenal or gonadal androgens. If it does occur, a work-up by an endocrinologist is recommended.

Preadolescent (7-12 years) acne is common and may be the first sign of pubertal maturation. Such acne usually is comedonal with a "T-zone" distribution (forehead and central face), and may appear on the ears. Inflammatory lesions are sparse. No work-up beyond history and physical is needed unless there is concern for endocrinologic abnormalities (for example, PCOS), which may manifest as very severe or refractory acne.

Treatment

Goals of treatment involve addressing pathogenic factors and using the least aggressive but effective regimen, while avoiding bacterial resistance development. Additionally, side effects and expectations of results (in other words, noticeable results may take 4-8 weeks for any acne treatment) should be discussed in order to enhance compliance.

Various over-the-counter (OTC) products and prescription agents are available for the treatment of acne. OTC agents that have been tested include salicylic acid and benzoyl peroxide (BP). BP is effective, safe, and inexpensive. It can be used as monotherapy and, when used in combination with topical or systemic antibiotics, may minimize antibiotic-resistant P. acnes development.

Prescription options include topical retinoids, topical antibiotics, topical dapsone, oral antibiotics (typically tetracycline, doxycycline, or minocycline), oral isotretinoin, fixed-dose combination topical agents (BP/topical antibiotic, BP/topical retinoid, and topical retinoid/antibiotic), and hormonal therapy. The recommendations address the treatment of mild, moderate, and severe pediatric acne.

Mild acne usually presents as comedonal or mixed. Initial treatment can include BP monotherapy, topical retinoids, or combinations of topical retinoids, antibiotics, and BP. In patients of color, where there is a greater risk of scarring and dyspigmentation, initial therapy might also include a topical or oral antibiotic. In cases of inadequate response, the concentration, type, or formulation of topical retinoid can be changed or the topical combination can be modified.

Moderate acne may require an aggressive regimen of combination topical therapy that includes a retinoid and BP with or without topical dapsone, with the likely addition of an oral antibiotic. If lesions are moderate to severe inflammatory or mixed, oral antibiotics are effective, with maximal response taking 3-6 months. If an inadequate response and adherence assured, the strength, type, and formulation of topical regimens can be adjusted, although referral to a specialist may be considered.

Severe acne requires prompt initiation of treatment to avoid scarring and permanent skin changes. Treatment should include oral antibiotics with topical retinoids plus BP, with or without topical antibiotics. Strong consideration should be given to adding hormonal therapy to the treatment regimen of young menstruating women who have severe acne. In addition, for both males and females, oral isotretinoin and referral to a specialist may be considered.

Some recommend refraining from oral contraceptives until 1 year after menarche because of concerns about growth and bone density. When considering oral isotretinoin, remember it is teratogenic and that it causes questionable changes to bone health, mood, and bowel disorders, which may cause more issues in the pediatric population.

If there is an inadequate response after combination therapy with isotretinoin, physicians can try oral antibiotics with topical retinoids plus BP. If acne persists, consideration can be given to switch to a different oral antibiotic to address possible resistant organisms.

Remember that tetracyclines should not be used in ages younger than 8 years. Erythromycin, azithromycin, and trimethoprim/sulfamethoxazole are options for children younger than 8 years or those with a tetracycline allergy, as long as there is close monitoring for adverse events with any oral antibiotics in children.

Bottom line

The diagnosis, work-up, and management of pediatric acne vary depending upon age and pubertal onset. When approaching acne therapy, the best treatment is determined by assessment of type and severity of lesions. Use of topical BP, retinoids, antibiotics, and oral antibiotics are the base of therapy, with strength and combination of agents determined by type and severity of the acne.

Reference

Eichenfield, L.F., Krakowski, A.C., Piggott, C., Del Rosso, J., Baldwin, H., Friedlander, S.F., Levy, M., Lucky, A., Mancini, A.J., Orlow, S.J., Yan, A.C., Vaux, K.K., Webster, G., Zaenglein, A.L., Thiboutot, D.M. (2013). Evidence-Based Recommendations for the Diagnosis and Treatment of Pediatric Acne. (Pediatrics 2013;131:S163 [doi:10.1542/peds.2013-0490B]).

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Lee is a third-year and chief resident in the family medicine residency program at Abington Memorial Hospital.

The truth about acne is out there, but it isn’t always on Twitter.

As the popular social-networking platform continues to grow as a forum for health information, clinicians should be aware of the acne myths, misinformation, and miscellaneous home remedies being shared, and take the opportunity to tweak their patient-education strategies in the clinic setting and online, according to information published in a research letter in JAMA Dermatology.

Health care providers who are comfortable with Twitter can use it to follow acne-related tweets and share reliable medical information and resources, Dr. Kamal Jethwani of the Center for Connected Health, Boston, and his colleagues suggested.

© Stephen Strathdee/ iStockphoto.com

During a 2-week period in June 2012, Dr. Jethwani and his colleagues identified more than 8,000 "high-impact" tweets related to acne. High-impact tweets were defined as those with one or more retweets during the study period, and contained at least one of five keywords: acne, pimple, pimples, zit, or zits.

They used the Twitter Streaming Application Programming Interface to determine how Twitter users share information (and misinformation) about acne.

The researchers sorted the tweets into four categories: personal, celebrity (because stars like Jessica Simpson get acne, too), education, and irrelevant/excluded.

Overall, the researchers examined 8,192 English-language high-impact tweets. Of these, 43% were personal, 20% were about celebrities (the researchers didn’t mention any names), 27% were educational, and 9% were excluded or irrelevant. Of the education tweets, 17% were related to disease information and 9% were treatment-related.

Approximately two-thirds of the disease tweets were variations on the theme of "Why does acne exist?" Not surprisingly, the most often tweeted treatment-related question was a variation of "How do I get rid of my acne?"

"There were a large variety of acne home remedies suggested, including topical food-based remedies ranging from eggs to herbs to fruit," the researchers noted. In addition, 3% of tweeters recommended the topical use of over-the-counter products including baking soda, aloe vera gel, and crushed aspirin (for salicylic acid).

The researchers then compared the word frequency of the selected tweets to the word choices on the American Academy of Dermatology website. Tweeters were more likely to use nonmedical terms such as pimple or pimples vs. terms like pores, skin, or cells used on the AAD website.

"In addition, the AAD website did not address topics that are commonly discussed on Twitter, like makeup, stress, and the efficacy of diet, toothpaste, or other home remedies on acne," the researchers noted.

So, doctors who tweet, you have 140 characters to say whether toothpaste works on zits.

One of the study coauthors, Dr. Joseph Kvedar, reported serving as a consultant for and holding stock in Healthrageous. The other researchers had no financial conflicts to disclose.

hsplete@frontlinemedcom.com

The truth about acne is out there, but it isn’t always on Twitter.

As the popular social-networking platform continues to grow as a forum for health information, clinicians should be aware of the acne myths, misinformation, and miscellaneous home remedies being shared, and take the opportunity to tweak their patient-education strategies in the clinic setting and online, according to information published in a research letter in JAMA Dermatology.

Health care providers who are comfortable with Twitter can use it to follow acne-related tweets and share reliable medical information and resources, Dr. Kamal Jethwani of the Center for Connected Health, Boston, and his colleagues suggested.

© Stephen Strathdee/ iStockphoto.com

During a 2-week period in June 2012, Dr. Jethwani and his colleagues identified more than 8,000 "high-impact" tweets related to acne. High-impact tweets were defined as those with one or more retweets during the study period, and contained at least one of five keywords: acne, pimple, pimples, zit, or zits.

They used the Twitter Streaming Application Programming Interface to determine how Twitter users share information (and misinformation) about acne.

The researchers sorted the tweets into four categories: personal, celebrity (because stars like Jessica Simpson get acne, too), education, and irrelevant/excluded.

Overall, the researchers examined 8,192 English-language high-impact tweets. Of these, 43% were personal, 20% were about celebrities (the researchers didn’t mention any names), 27% were educational, and 9% were excluded or irrelevant. Of the education tweets, 17% were related to disease information and 9% were treatment-related.

Approximately two-thirds of the disease tweets were variations on the theme of "Why does acne exist?" Not surprisingly, the most often tweeted treatment-related question was a variation of "How do I get rid of my acne?"

"There were a large variety of acne home remedies suggested, including topical food-based remedies ranging from eggs to herbs to fruit," the researchers noted. In addition, 3% of tweeters recommended the topical use of over-the-counter products including baking soda, aloe vera gel, and crushed aspirin (for salicylic acid).

The researchers then compared the word frequency of the selected tweets to the word choices on the American Academy of Dermatology website. Tweeters were more likely to use nonmedical terms such as pimple or pimples vs. terms like pores, skin, or cells used on the AAD website.

"In addition, the AAD website did not address topics that are commonly discussed on Twitter, like makeup, stress, and the efficacy of diet, toothpaste, or other home remedies on acne," the researchers noted.

So, doctors who tweet, you have 140 characters to say whether toothpaste works on zits.

One of the study coauthors, Dr. Joseph Kvedar, reported serving as a consultant for and holding stock in Healthrageous. The other researchers had no financial conflicts to disclose.

hsplete@frontlinemedcom.com

The truth about acne is out there, but it isn’t always on Twitter.

As the popular social-networking platform continues to grow as a forum for health information, clinicians should be aware of the acne myths, misinformation, and miscellaneous home remedies being shared, and take the opportunity to tweak their patient-education strategies in the clinic setting and online, according to information published in a research letter in JAMA Dermatology.

Health care providers who are comfortable with Twitter can use it to follow acne-related tweets and share reliable medical information and resources, Dr. Kamal Jethwani of the Center for Connected Health, Boston, and his colleagues suggested.

© Stephen Strathdee/ iStockphoto.com

During a 2-week period in June 2012, Dr. Jethwani and his colleagues identified more than 8,000 "high-impact" tweets related to acne. High-impact tweets were defined as those with one or more retweets during the study period, and contained at least one of five keywords: acne, pimple, pimples, zit, or zits.

They used the Twitter Streaming Application Programming Interface to determine how Twitter users share information (and misinformation) about acne.

The researchers sorted the tweets into four categories: personal, celebrity (because stars like Jessica Simpson get acne, too), education, and irrelevant/excluded.

Overall, the researchers examined 8,192 English-language high-impact tweets. Of these, 43% were personal, 20% were about celebrities (the researchers didn’t mention any names), 27% were educational, and 9% were excluded or irrelevant. Of the education tweets, 17% were related to disease information and 9% were treatment-related.

Approximately two-thirds of the disease tweets were variations on the theme of "Why does acne exist?" Not surprisingly, the most often tweeted treatment-related question was a variation of "How do I get rid of my acne?"

"There were a large variety of acne home remedies suggested, including topical food-based remedies ranging from eggs to herbs to fruit," the researchers noted. In addition, 3% of tweeters recommended the topical use of over-the-counter products including baking soda, aloe vera gel, and crushed aspirin (for salicylic acid).

The researchers then compared the word frequency of the selected tweets to the word choices on the American Academy of Dermatology website. Tweeters were more likely to use nonmedical terms such as pimple or pimples vs. terms like pores, skin, or cells used on the AAD website.

"In addition, the AAD website did not address topics that are commonly discussed on Twitter, like makeup, stress, and the efficacy of diet, toothpaste, or other home remedies on acne," the researchers noted.

So, doctors who tweet, you have 140 characters to say whether toothpaste works on zits.

One of the study coauthors, Dr. Joseph Kvedar, reported serving as a consultant for and holding stock in Healthrageous. The other researchers had no financial conflicts to disclose.

hsplete@frontlinemedcom.com

In the April 2013 issue of the Journal of Drugs in Dermatology (2013;12:428-431), Clark et al retrospectively reviewed 115 laser sessions with the 1550-nm erbium-doped fractional nonablative laser (Fraxel Re:Store SR 1550, Solta Medical) in 45 patients with Fitzpatrick skin types IV to VI to assess the rate of postinflammatory hyperpigmentation and the associated laser parameters. The fluence, treatment level, and number of passes were all reviewed, as well as any posttreatment complications (ie, erythema, blistering, edema, bruising, pain) and long-term (1 month) complications (ie, hypopigmentation, hyperpigmentation). All patients were pretreated with hydroquinone cream 4% 2 weeks before, stopping 7 days before treatment and then continuing 4 weeks thereafter. Also, continuous forced-air cooling was used during treatment as well as posttreatment ice packs. Fifty-eight percent (26/45) of treatments were performed in patients with Fitzpatrick skin type IV, 24% (11/45) with type V, and 18% (8/45) with type VI. Laser parameters ranged from 4 to 70 mJ, treatment level 2 to 9, and 4 to 8 passes. Of 115 sessions, 5 (4%) were associated with postinflammatory hyperpigmentation; 2 of these instances occurred in 1 patient. The occurrence of postinflammatory hyperpigmentation was found to be statistically significant (P=.05), correlating with higher mean energy levels compared to those without hyperpigmentation (60.8 vs 44.7 mJ). Only 1 episode of postinflammatory hyperpigmentation lasted longer than 1 month, and 2 of 5 cases had only transient (<7 days) hyperpigmentation. All 5 cases resolved.

What’s the issue?

The 1550-nm erbium-doped fractional nonablative laser is being used for many skin conditions and has a low incidence of adverse effects when appropriate laser parameters are chosen. When treating darker skin phototypes with this technology, the concern for postinflammatory pigmentary alteration is more concerning. Higher treatment densities used in darker phototypes have been associated with a greater risk for postinflammatory hyperpigmentation. In their review, the authors showed that higher energy levels were associated with their cases of postinflammatory hyperpigmentation, with the caveat that they were careful not to use higher density or treatment levels than they would have used in lighter phototypes. Importantly, all 5 cases of hyperpigmentation did resolve and only 1 lasted longer than 1 month (2 months in total). This analysis reinforces that the 1550-nm erbium-doped fractional nonablative laser is quite safe in Fitzpatrick skin types IV to VI when appropriate parameters are utilized, as well as methodical pretreatment and posttreatment with hydroquinone, concomitant cooling, and strict posttreatment sun protection. With the right parameters, the treatment is quite safe; however, what are the optimal treatment parameters to provide efficacious and lasting results?

We want to know your views! Tell us what you think.

In the April 2013 issue of the Journal of Drugs in Dermatology (2013;12:428-431), Clark et al retrospectively reviewed 115 laser sessions with the 1550-nm erbium-doped fractional nonablative laser (Fraxel Re:Store SR 1550, Solta Medical) in 45 patients with Fitzpatrick skin types IV to VI to assess the rate of postinflammatory hyperpigmentation and the associated laser parameters. The fluence, treatment level, and number of passes were all reviewed, as well as any posttreatment complications (ie, erythema, blistering, edema, bruising, pain) and long-term (1 month) complications (ie, hypopigmentation, hyperpigmentation). All patients were pretreated with hydroquinone cream 4% 2 weeks before, stopping 7 days before treatment and then continuing 4 weeks thereafter. Also, continuous forced-air cooling was used during treatment as well as posttreatment ice packs. Fifty-eight percent (26/45) of treatments were performed in patients with Fitzpatrick skin type IV, 24% (11/45) with type V, and 18% (8/45) with type VI. Laser parameters ranged from 4 to 70 mJ, treatment level 2 to 9, and 4 to 8 passes. Of 115 sessions, 5 (4%) were associated with postinflammatory hyperpigmentation; 2 of these instances occurred in 1 patient. The occurrence of postinflammatory hyperpigmentation was found to be statistically significant (P=.05), correlating with higher mean energy levels compared to those without hyperpigmentation (60.8 vs 44.7 mJ). Only 1 episode of postinflammatory hyperpigmentation lasted longer than 1 month, and 2 of 5 cases had only transient (<7 days) hyperpigmentation. All 5 cases resolved.

What’s the issue?

The 1550-nm erbium-doped fractional nonablative laser is being used for many skin conditions and has a low incidence of adverse effects when appropriate laser parameters are chosen. When treating darker skin phototypes with this technology, the concern for postinflammatory pigmentary alteration is more concerning. Higher treatment densities used in darker phototypes have been associated with a greater risk for postinflammatory hyperpigmentation. In their review, the authors showed that higher energy levels were associated with their cases of postinflammatory hyperpigmentation, with the caveat that they were careful not to use higher density or treatment levels than they would have used in lighter phototypes. Importantly, all 5 cases of hyperpigmentation did resolve and only 1 lasted longer than 1 month (2 months in total). This analysis reinforces that the 1550-nm erbium-doped fractional nonablative laser is quite safe in Fitzpatrick skin types IV to VI when appropriate parameters are utilized, as well as methodical pretreatment and posttreatment with hydroquinone, concomitant cooling, and strict posttreatment sun protection. With the right parameters, the treatment is quite safe; however, what are the optimal treatment parameters to provide efficacious and lasting results?

We want to know your views! Tell us what you think.

In the April 2013 issue of the Journal of Drugs in Dermatology (2013;12:428-431), Clark et al retrospectively reviewed 115 laser sessions with the 1550-nm erbium-doped fractional nonablative laser (Fraxel Re:Store SR 1550, Solta Medical) in 45 patients with Fitzpatrick skin types IV to VI to assess the rate of postinflammatory hyperpigmentation and the associated laser parameters. The fluence, treatment level, and number of passes were all reviewed, as well as any posttreatment complications (ie, erythema, blistering, edema, bruising, pain) and long-term (1 month) complications (ie, hypopigmentation, hyperpigmentation). All patients were pretreated with hydroquinone cream 4% 2 weeks before, stopping 7 days before treatment and then continuing 4 weeks thereafter. Also, continuous forced-air cooling was used during treatment as well as posttreatment ice packs. Fifty-eight percent (26/45) of treatments were performed in patients with Fitzpatrick skin type IV, 24% (11/45) with type V, and 18% (8/45) with type VI. Laser parameters ranged from 4 to 70 mJ, treatment level 2 to 9, and 4 to 8 passes. Of 115 sessions, 5 (4%) were associated with postinflammatory hyperpigmentation; 2 of these instances occurred in 1 patient. The occurrence of postinflammatory hyperpigmentation was found to be statistically significant (P=.05), correlating with higher mean energy levels compared to those without hyperpigmentation (60.8 vs 44.7 mJ). Only 1 episode of postinflammatory hyperpigmentation lasted longer than 1 month, and 2 of 5 cases had only transient (<7 days) hyperpigmentation. All 5 cases resolved.

What’s the issue?

The 1550-nm erbium-doped fractional nonablative laser is being used for many skin conditions and has a low incidence of adverse effects when appropriate laser parameters are chosen. When treating darker skin phototypes with this technology, the concern for postinflammatory pigmentary alteration is more concerning. Higher treatment densities used in darker phototypes have been associated with a greater risk for postinflammatory hyperpigmentation. In their review, the authors showed that higher energy levels were associated with their cases of postinflammatory hyperpigmentation, with the caveat that they were careful not to use higher density or treatment levels than they would have used in lighter phototypes. Importantly, all 5 cases of hyperpigmentation did resolve and only 1 lasted longer than 1 month (2 months in total). This analysis reinforces that the 1550-nm erbium-doped fractional nonablative laser is quite safe in Fitzpatrick skin types IV to VI when appropriate parameters are utilized, as well as methodical pretreatment and posttreatment with hydroquinone, concomitant cooling, and strict posttreatment sun protection. With the right parameters, the treatment is quite safe; however, what are the optimal treatment parameters to provide efficacious and lasting results?

We want to know your views! Tell us what you think.

MAUI, HAWAII – The relationship between diet and acne risk has grown more intriguing as a consequence of a recent Italian study linking milk consumption to an increased risk, while eating fish had a protective effect.

"This was a well-done, very large, multicenter case-control study," said Dr. Lawrence F. Eichenfield, who presented highlights of the Italian investigation at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Courtesy Lynda Banzi

A diet-acne link has been an endless topic of debate for many years among dermatologists and dieticians, with the public looking on attentively. Conventional wisdom formerly held that chocolate and greasy foods exacerbated acne, a notion that later was dispelled. A recent literature review of 27 published studies implicated high-glycemic-index foods and milk (J. Acad. Nutr. Diet. 2013;113:416-30).

The Italian study Dr. Eichenfield spotlighted included 205 consecutive patients aged 10-24 years who were newly diagnosed with moderate to severe acne. The control group consisted of 358 patients with no or only mild acne who consulted a dermatologist for a concern other than acne. Investigators inquired about family history, diet, personal habits, and menstrual history.

Family history of acne emerged as a strong risk factor. A history of acne in a first-degree relative was associated with a 3.4-fold increased risk of moderate to severe acne.

Drinking milk more than three times per week was associated with a 1.8-fold increased risk of significant acne. The risk was more pronounced in skim-milk drinkers than whole-milk drinkers, with consumption of more than three servings per week of nonfat milk being associated with a 2.2-fold increased risk of moderate to severe acne (J. Am. Acad. Dermatol. 2012;67:1129-35).

In contrast, regular consumption of fish was associated with a 32% reduction in the likelihood of having moderate to severe acne.

Body mass index was *directly associated with acne: Adolescents and young adults with a BMI greater than 18.5 kg/m² were at 1.9-fold greater risk of significant acne than those with a smaller BMI. This protective effect of a low BMI was stronger in male than female subjects.

Neither menstrual factors nor smoking showed any relationship with acne risk in the Italian study, noted Dr. Eichenfield, professor of clinical pediatrics and medicine at the University of California, San Diego.

"How do I take this new information and use it in the clinic? The answer is, I don’t, because I really don’t know what the impact will be of dietary changes in my actual care of individuals with acne who come to me. But this whole issue of diet and acne is a really fascinating one," the pediatric dermatologist commented.

SDEF and this news organization are owned by the same parent company.

Dr. Eichenfield reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

bjancin@frontlinemedcom.com

*Correction (04/09/13): A previous version of this story mischaracterized the association between BMI and acne in one instance. This story has been updated. 

MAUI, HAWAII – The relationship between diet and acne risk has grown more intriguing as a consequence of a recent Italian study linking milk consumption to an increased risk, while eating fish had a protective effect.

"This was a well-done, very large, multicenter case-control study," said Dr. Lawrence F. Eichenfield, who presented highlights of the Italian investigation at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Courtesy Lynda Banzi

A diet-acne link has been an endless topic of debate for many years among dermatologists and dieticians, with the public looking on attentively. Conventional wisdom formerly held that chocolate and greasy foods exacerbated acne, a notion that later was dispelled. A recent literature review of 27 published studies implicated high-glycemic-index foods and milk (J. Acad. Nutr. Diet. 2013;113:416-30).

The Italian study Dr. Eichenfield spotlighted included 205 consecutive patients aged 10-24 years who were newly diagnosed with moderate to severe acne. The control group consisted of 358 patients with no or only mild acne who consulted a dermatologist for a concern other than acne. Investigators inquired about family history, diet, personal habits, and menstrual history.

Family history of acne emerged as a strong risk factor. A history of acne in a first-degree relative was associated with a 3.4-fold increased risk of moderate to severe acne.

Drinking milk more than three times per week was associated with a 1.8-fold increased risk of significant acne. The risk was more pronounced in skim-milk drinkers than whole-milk drinkers, with consumption of more than three servings per week of nonfat milk being associated with a 2.2-fold increased risk of moderate to severe acne (J. Am. Acad. Dermatol. 2012;67:1129-35).

In contrast, regular consumption of fish was associated with a 32% reduction in the likelihood of having moderate to severe acne.

Body mass index was *directly associated with acne: Adolescents and young adults with a BMI greater than 18.5 kg/m² were at 1.9-fold greater risk of significant acne than those with a smaller BMI. This protective effect of a low BMI was stronger in male than female subjects.

Neither menstrual factors nor smoking showed any relationship with acne risk in the Italian study, noted Dr. Eichenfield, professor of clinical pediatrics and medicine at the University of California, San Diego.

"How do I take this new information and use it in the clinic? The answer is, I don’t, because I really don’t know what the impact will be of dietary changes in my actual care of individuals with acne who come to me. But this whole issue of diet and acne is a really fascinating one," the pediatric dermatologist commented.

SDEF and this news organization are owned by the same parent company.

Dr. Eichenfield reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

bjancin@frontlinemedcom.com

*Correction (04/09/13): A previous version of this story mischaracterized the association between BMI and acne in one instance. This story has been updated. 

MAUI, HAWAII – The relationship between diet and acne risk has grown more intriguing as a consequence of a recent Italian study linking milk consumption to an increased risk, while eating fish had a protective effect.

"This was a well-done, very large, multicenter case-control study," said Dr. Lawrence F. Eichenfield, who presented highlights of the Italian investigation at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Courtesy Lynda Banzi

A diet-acne link has been an endless topic of debate for many years among dermatologists and dieticians, with the public looking on attentively. Conventional wisdom formerly held that chocolate and greasy foods exacerbated acne, a notion that later was dispelled. A recent literature review of 27 published studies implicated high-glycemic-index foods and milk (J. Acad. Nutr. Diet. 2013;113:416-30).

The Italian study Dr. Eichenfield spotlighted included 205 consecutive patients aged 10-24 years who were newly diagnosed with moderate to severe acne. The control group consisted of 358 patients with no or only mild acne who consulted a dermatologist for a concern other than acne. Investigators inquired about family history, diet, personal habits, and menstrual history.

Family history of acne emerged as a strong risk factor. A history of acne in a first-degree relative was associated with a 3.4-fold increased risk of moderate to severe acne.

Drinking milk more than three times per week was associated with a 1.8-fold increased risk of significant acne. The risk was more pronounced in skim-milk drinkers than whole-milk drinkers, with consumption of more than three servings per week of nonfat milk being associated with a 2.2-fold increased risk of moderate to severe acne (J. Am. Acad. Dermatol. 2012;67:1129-35).

In contrast, regular consumption of fish was associated with a 32% reduction in the likelihood of having moderate to severe acne.

Body mass index was *directly associated with acne: Adolescents and young adults with a BMI greater than 18.5 kg/m² were at 1.9-fold greater risk of significant acne than those with a smaller BMI. This protective effect of a low BMI was stronger in male than female subjects.

Neither menstrual factors nor smoking showed any relationship with acne risk in the Italian study, noted Dr. Eichenfield, professor of clinical pediatrics and medicine at the University of California, San Diego.

"How do I take this new information and use it in the clinic? The answer is, I don’t, because I really don’t know what the impact will be of dietary changes in my actual care of individuals with acne who come to me. But this whole issue of diet and acne is a really fascinating one," the pediatric dermatologist commented.

SDEF and this news organization are owned by the same parent company.

Dr. Eichenfield reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

bjancin@frontlinemedcom.com

*Correction (04/09/13): A previous version of this story mischaracterized the association between BMI and acne in one instance. This story has been updated. 

WAILEA, HAWAII – Acne arising in a 1- to 7-year-old means "it’s time to worry," according to Dr. Lawrence F. Eichenfield.

Acne originating in this midchildhood age range is very uncommon. It signals the need for a detailed endocrinologic work-up. Possible underlying causes include precocious adrenarche, congenital adrenal hyperplasia, Cushing’s syndrome, precocious puberty, and a gonadal or adrenal tumor, he noted at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

"If you want to take it on yourself you can, but the standard is going to be an evaluation that includes a growth chart, a bone age assessment, Tanner staging, and measurement of total and free testosterone, LH [luteinizing hormone], FSH [follicle-stimulating hormone], prolactin, DHEAS [dehydroepiandrosterone sulfate], andrestenedione, and 17-hydroxyprogesterone. Generally we say refer to a pediatric endocrinologist," said Dr. Eichenfield, professor of clinical pediatrics and medicine (dermatology) at the University of California, San Diego.

He noted that acne occurring at age 1-7 is prominently identified as a red flag in guidelines for the management of pediatric acne developed by the American Acne and Rosacea Society and subsequently approved by the American Academy of Pediatrics. Dr. Eichenfield was cochair of the expert panel that crafted the guidelines.

The comprehensive guidelines – the first ever to specifically address acne in the pediatric age range – include a general acne categorization scheme based upon age. While acne in a 1- to 7-year-old is characterized as a cause for concern, acne arising in a seemingly healthy slightly older preadolescent – roughly age 7-12 – is not.

"Acne in a child in this age group who otherwise looks well and has no signs or history that would make you suspicious of an underlying endocrinopathy is essentially a normal variant we now call preadolescent acne. You do not need to refer that patient for further evaluation," the pediatric dermatologist explained.

Nonworrisome preadolescent acne presents as comedone-predominant disease typically concentrated on the forehead and midface, with truncal involvement much less frequent. The acne may precede other signs of puberty. There is solid evidence that the more pronounced the expression of early preadolescent acne – that is, the greater the number of facial comedones present – the more severe the acne will be in adolescence. Indeed, severe preadolescent acne is often a harbinger of the later need for isotretinoin.

Acne developing within the first 6 weeks of life is most often an erythematous papulopustular eruption categorized in the guidelines as neonatal acne, also known as neonatal cephalic pustulosis. It is not true acne, but rather a self-limited condition associated with Malassezia globosa and M. sympodialis.

In contrast, infantile acne is true acne, mainly comedonal, which typically doesn’t show up until a baby is several months old and lasts for up to about a year.

The guidelines put forth detailed treatment algorithms featuring multiple options available for each acne age category and degree of severity. Of note, benzoyl peroxide is listed as a first-line treatment across the board, either as monotherapy or in combination with an antibiotic or topical retinoid.

"There is a theme that whenever one is using an antibiotic – whether a systemic drug or a topical product like clindamycin – benzoyl peroxide is advised in the regimen of care because of the feeling that if you use an unopposed antibiotic, you can have the development of bacterial resistance," Dr. Eichenfield noted.

He reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAILEA, HAWAII – Acne arising in a 1- to 7-year-old means "it’s time to worry," according to Dr. Lawrence F. Eichenfield.

Acne originating in this midchildhood age range is very uncommon. It signals the need for a detailed endocrinologic work-up. Possible underlying causes include precocious adrenarche, congenital adrenal hyperplasia, Cushing’s syndrome, precocious puberty, and a gonadal or adrenal tumor, he noted at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

"If you want to take it on yourself you can, but the standard is going to be an evaluation that includes a growth chart, a bone age assessment, Tanner staging, and measurement of total and free testosterone, LH [luteinizing hormone], FSH [follicle-stimulating hormone], prolactin, DHEAS [dehydroepiandrosterone sulfate], andrestenedione, and 17-hydroxyprogesterone. Generally we say refer to a pediatric endocrinologist," said Dr. Eichenfield, professor of clinical pediatrics and medicine (dermatology) at the University of California, San Diego.

He noted that acne occurring at age 1-7 is prominently identified as a red flag in guidelines for the management of pediatric acne developed by the American Acne and Rosacea Society and subsequently approved by the American Academy of Pediatrics. Dr. Eichenfield was cochair of the expert panel that crafted the guidelines.

The comprehensive guidelines – the first ever to specifically address acne in the pediatric age range – include a general acne categorization scheme based upon age. While acne in a 1- to 7-year-old is characterized as a cause for concern, acne arising in a seemingly healthy slightly older preadolescent – roughly age 7-12 – is not.

"Acne in a child in this age group who otherwise looks well and has no signs or history that would make you suspicious of an underlying endocrinopathy is essentially a normal variant we now call preadolescent acne. You do not need to refer that patient for further evaluation," the pediatric dermatologist explained.

Nonworrisome preadolescent acne presents as comedone-predominant disease typically concentrated on the forehead and midface, with truncal involvement much less frequent. The acne may precede other signs of puberty. There is solid evidence that the more pronounced the expression of early preadolescent acne – that is, the greater the number of facial comedones present – the more severe the acne will be in adolescence. Indeed, severe preadolescent acne is often a harbinger of the later need for isotretinoin.

Acne developing within the first 6 weeks of life is most often an erythematous papulopustular eruption categorized in the guidelines as neonatal acne, also known as neonatal cephalic pustulosis. It is not true acne, but rather a self-limited condition associated with Malassezia globosa and M. sympodialis.

In contrast, infantile acne is true acne, mainly comedonal, which typically doesn’t show up until a baby is several months old and lasts for up to about a year.

The guidelines put forth detailed treatment algorithms featuring multiple options available for each acne age category and degree of severity. Of note, benzoyl peroxide is listed as a first-line treatment across the board, either as monotherapy or in combination with an antibiotic or topical retinoid.

"There is a theme that whenever one is using an antibiotic – whether a systemic drug or a topical product like clindamycin – benzoyl peroxide is advised in the regimen of care because of the feeling that if you use an unopposed antibiotic, you can have the development of bacterial resistance," Dr. Eichenfield noted.

He reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAILEA, HAWAII – Acne arising in a 1- to 7-year-old means "it’s time to worry," according to Dr. Lawrence F. Eichenfield.

Acne originating in this midchildhood age range is very uncommon. It signals the need for a detailed endocrinologic work-up. Possible underlying causes include precocious adrenarche, congenital adrenal hyperplasia, Cushing’s syndrome, precocious puberty, and a gonadal or adrenal tumor, he noted at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

"If you want to take it on yourself you can, but the standard is going to be an evaluation that includes a growth chart, a bone age assessment, Tanner staging, and measurement of total and free testosterone, LH [luteinizing hormone], FSH [follicle-stimulating hormone], prolactin, DHEAS [dehydroepiandrosterone sulfate], andrestenedione, and 17-hydroxyprogesterone. Generally we say refer to a pediatric endocrinologist," said Dr. Eichenfield, professor of clinical pediatrics and medicine (dermatology) at the University of California, San Diego.

He noted that acne occurring at age 1-7 is prominently identified as a red flag in guidelines for the management of pediatric acne developed by the American Acne and Rosacea Society and subsequently approved by the American Academy of Pediatrics. Dr. Eichenfield was cochair of the expert panel that crafted the guidelines.

The comprehensive guidelines – the first ever to specifically address acne in the pediatric age range – include a general acne categorization scheme based upon age. While acne in a 1- to 7-year-old is characterized as a cause for concern, acne arising in a seemingly healthy slightly older preadolescent – roughly age 7-12 – is not.

"Acne in a child in this age group who otherwise looks well and has no signs or history that would make you suspicious of an underlying endocrinopathy is essentially a normal variant we now call preadolescent acne. You do not need to refer that patient for further evaluation," the pediatric dermatologist explained.

Nonworrisome preadolescent acne presents as comedone-predominant disease typically concentrated on the forehead and midface, with truncal involvement much less frequent. The acne may precede other signs of puberty. There is solid evidence that the more pronounced the expression of early preadolescent acne – that is, the greater the number of facial comedones present – the more severe the acne will be in adolescence. Indeed, severe preadolescent acne is often a harbinger of the later need for isotretinoin.

Acne developing within the first 6 weeks of life is most often an erythematous papulopustular eruption categorized in the guidelines as neonatal acne, also known as neonatal cephalic pustulosis. It is not true acne, but rather a self-limited condition associated with Malassezia globosa and M. sympodialis.

In contrast, infantile acne is true acne, mainly comedonal, which typically doesn’t show up until a baby is several months old and lasts for up to about a year.

The guidelines put forth detailed treatment algorithms featuring multiple options available for each acne age category and degree of severity. Of note, benzoyl peroxide is listed as a first-line treatment across the board, either as monotherapy or in combination with an antibiotic or topical retinoid.

"There is a theme that whenever one is using an antibiotic – whether a systemic drug or a topical product like clindamycin – benzoyl peroxide is advised in the regimen of care because of the feeling that if you use an unopposed antibiotic, you can have the development of bacterial resistance," Dr. Eichenfield noted.

He reported receiving research grants for clinical investigations from half a dozen pharmaceutical companies.

SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com