What Are Options for Acne Treatment?

Patient Presentation
A 14-year-old male came to clinic for his health maintenance evaluation. He was an avid athlete who had noticed an increasing amount of acne on his face. He was sporadically using an acne product but did not know what it was. He wasn’t being teased but did want some help to improve it. The past medical history was negative. The family history showed no dermatological problems. Both parents reported easily controlled acne as adolescents.

The pertinent physical exam showed a healthy male with normal vital signs. His height was 75% and his weight was 50%. He had an extensive amount of closed and open comedomes on his face along with moderate amounts of papules and pustules. He also had some closed and open comedomes on his upper back and chest. He did not have any scarring.

The diagnosis of a healthy male with moderate acne that was widespread on his face with affected areas on his trunk was made.
The pediatrician recommended he start a regimen of tretinoin and benzoyl peroxide. She said, “I want you to use tretinoin in the morning and the benzoyl peroxide at night. Each once a day but you can’t use them together because they interact. They can cause some dryness, so you can use a light moisturizer to help with that. They also can cause you to get sunburn so you should use a non-comedogenic sunscreen too everyday to help with this. Sometimes it says non-acne or something like that. Since you are an athlete and outside a lot, it is really, really important that you use the sunscreen. There are some other problems like bleaching of clothing and other fabrics with the benzoyl peroxide so I’ll go over that with you too and write everything down for you.” The pediatrician also said, “It’s going to take 2-3 months before you really see the results so don’t expect the acne to improve a lot overnight.”

Discussion
Acne vulgaris or acne is a problem of the pilosebaceous follicle. It occurs most prominently where sebaceous glands are abundant especially the face, neck, and upper back. Sebum production increases because of androgens. Keratin and sebum clog the pores of the pilosebaceous unit causing hyperkeratosis (clogged pilosebaceous unit = clogged pores = comedomes). Propionibacterium acnes, a gram-negative anaerobe, multiplies in the sebaceous unit causing an inflammatory reaction resulting in moderate or severe acne.

Skin lesions include:

  • Comedomal acne has comedomes
    • White heads = closed comedomes
    • Black heads = open comedomes
  • Inflammatory acne has papules and pustules
  • Nodulocystic acne has nodules and cysts

For each type, the density and extent of the lesions should be noted. Scarring presence or absence should be noted. Any scarring should be treated aggressively. Patients with cystic or scarring acne or who are difficult to treat should be referred to a dermatologist.

Some reasons for treatment failures include:

  • Lack of adherence is the most common reason for failure. Discussing with the patient what part(s) of the treatment regiment are not working and why can help adherence.
  • Unrealistic expectations – Need to follow the treatment for at least 2-3 months before effectiveness can be evaluated.
  • Irritation because of drying, itching, burning, etc. Check to make sure that patients are also not using other medications such as astringents, antibacterial soaps, scrubs etc. which can be drying or irritating.
    Options can include decreasing the frequency of the medications and/or adding a ceramide-containing moisturizer (such as CeraVe®) to help maintain the skin barrier.

Acne is the 8th most prevalent disease worldwide (9.4%). Peak incidence is late teens. Teen males are more likely to be affected than females and also to have more severe disease. Females are more common before and after adolescence. The mean duration is 2 years. Infantile acne, occurs in 1-12 month old infants and is usually inflammatory. Although there are no FDA approved medications for acne for children < 10 years, infants who need therapy are often treated with the same agents as moderate acne below. Mid-childhood acne occurs in 1-7 years old and is rare. A hyperandrogen state should be considered if acne is seen at this age. Preadolescent acne occurs in 7-11 year olds and is thought to be due to the onset of puberty. It is usually comedomal and is treated with the same medications as mild acne below.

Learning Point
Acne treatment for adolescent and adult patients is based on subtype, according to the American Academy of Dermatology. Check all dosing before prescribing. There are some other options that dermatologist also consider:

  • Mild acne, comedomal acne with few inflammatory lesions
    • Initial treatment:
      • Topical retinoid or benzoyl peroxide (BP)
        • Topical retinoid (also includes Adapalene, Tazarotene)
          • Tretinoin
            • Cream, gel, lotion, solution
            • Apply a thin film to affected area daily (at night) where lesions occur. Keep away from eyes, mouth, nasal creases and mucous membranes
            • Problems: dry skin, peeling, burning, erythema, pain, photosensitivity
            • Ultraviolet light and environmental exposure can increase irritation
            • Do not use at same time as BP as BP oxidizes tretinoin. Use one medication in am and one in pm.
            • Use sunscreen
        • Benzoyl peroxide
          • Dosing 2.5%, 5% or 10% gel, wash or cream
          • Applied 1-2x/day
          • Problems: hypersensitivity, erythema, peeling, bleaches clothing and fabric
    • Alternative:
      • Combination BP and topical retinoid
      • Combination BP and topical antibiotic
        • Erythromycin, topical
          • 2% solution, gel or ointment
          • Apply a thin film to affected area 1-2x/day
          • Problems: Do not use as monotherapy because of bacterial resistance, use with other agents, can cause irritation or drying
          • If using commercially precombined BP and Erythromycin, apply twice daily
        • Clindamycin, topical
          • 1% gel, lotion, solution, foam
          • Apply a thin film to area where acnes develops daily
          • If using commercially precombined BP and Clindamycin, apply daily at night
          • Problems: colitis, dermatitis, photosensitivity, redness, dry skin and peeling
      • Combination BP and topical retinoid and topical antibiotic

  • Moderate acne – comedomal acne with many inflammatory lesions
    • Initial treatment:
      • Combination BP and topical retinoid
      • Combination BP and topical antibiotic
      • Combination BP and topical retinoid and topical antibiotic
    • Inadequate response:
      • Consider dermatology referral
      • Combination BP and topical retinoid and topical antibiotic
      • Consider for females oral contraceptives
        • Oral contraceptive
          • Makes sure the patient also meets criteria for usage for contraception
          • Yaz®, Ortho Tri-Cyclen® and Estrostep® are FDA approved for acne
          • Problems include weight gain, nausea, emesis, headache, breast tenderness, increased risk of thromboembolic events

  • Severe acne – extensive inflammatory lesions with scarring
    • Initial treatment:
      • Consider dermatology referral
      • Combination with oral antibiotic and BP and topical retinoid
        • Oral antibiotics should not be used as monotherapy because of risk of resistance
        • Tetracycline, oral
          • > 8 year old: 25-50 mg/kg daily in 4 divided doses
          • Adults: 1 gram in divided doses until improvement 1-2 weeks later then decrease slowly to maintenance dosage of 125-500 mg daily
          • Problems: permanent discoloration of teeth in children < 8 years, gastrointestinal, renal, and hematological problems, rashes, photosensitivity
          • Sunscreen is recommended
        • Minocycline, oral
          • > 8 year old: 4 mg/kg initially followed by 2 mg/kg every 12 hours
          • Adults: 50 mg 1-3x/day
          • Problems: vertigo, dizziness and hyperpigmentation can occur along with other gastrointestinal, respiratory, renal, musculoskeletal, hematological, central nervous system problems, rashes, photosensitivity
        • Doxycycline, oral
          • > 8 years of age and < 100 pounds: 2 mg/pound of body weight divided into 2 doses on first day, followed by 1 mg/pound of body weight given as a single daily dose or divided into 2 doses on subsequent days
          • Adults and children > 100 pounds, 200 mg on first day (given as 100 mg every 12 hours x 2 doses), then 100 mg/day
          • Problems: gastrointestinal, renal and hematologic problems, rashes and photosensitivity
      • Combination with oral antibiotic and BP and topical retinoid and topical antibiotic
    • Inadequate response:
      • Consider dermatology referral
      • Consider isotretinoin
        • Isotretinoin
        • This is usually prescribed by a dermatologist
        • Is a known teratogen
      • Consider for females oral contraceptives

Questions for Further Discussion
1. What evaluation can be considered for a potential hyperandrogen state?
2. What are some of the mental health risks for a patient with scarring acne?
3. What else is in the differential diagnosis of acne?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Acne

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Admani S, Barrio VR. Evaluation and treatment of acne from infancy to preadolescence. Dermatol Ther. 2013 Nov-Dec;26(6):462-6.

Tan JK, Bhate K. A global perspective on the epidemiology of acne. Br J Dermatol. 2015 Jul;172 Suppl 1:3-12

Zaenglein AL, Pathy AL, Schlosser BJ, et. al.. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73.e33.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital