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

What Precautions Should A Childcare Center Take For A Child with Hepatitis C Infection?

Patient Presentation
A pediatrician got a phone call from a childcare center director regarding a preschool child with Hepatitis C infection. They had recently moved to the area and the child had not previously been in childcare. The parents had disclosed this information to the director and told her that they had been told that the child could safely attend childcare and only universal precautions needed to be followed for the child’s health and the health of the other children and childcare professionals. After receiving verbal permission from the parents, the director had placed a telephone call to the state childcare regulating agency to confirm any particular regulations the center needed to follow. While awaiting a response, she also contacted the pediatrician for guidance. The pediatrician reviewed the current American Academy of Pediatrics RedBook® recommendations which confirmed that the child could safely attend the childcare center, and that universal precautions should be used. Additionally the pediatrician noted, “That you already have policies and procedures in place for using gloves and other protective equipment for minor cuts or blood spills. You and the other people just need to follow them for this child just like you would for any other child.” Later, the pediatrician heard from the director that the state regulating agency also reiterated the same advice.

Discussion
It is estimated that 180 million people worldwide are infected with Hepatitis C (HCV) which includes ~11 million children. In the United States it is estimated that there were 30,500 acute HCV cases in 2014, and 2.7-3.9 million people with chronic HCV. Many infections are not identified. It is estimated that “…only 5-15% of HCV-infected children in the United States are identified.”

Problems associated with HCV include acute hepatitis (including fever, malaise, dark-urine, abdominal pain, jaundice, appetite loss, nausea, emesis, clay-colored stools), acute fulminant hepatitis (not common in children), hepatic fibrosis, hepatic cirrhosis, and hepatocellular carcinoma.
Vertical transmission (particularly with HIV-coinfected mothers), injection drug use and iatrogenic exposures (blood, blood product or solid organ recipients, blood exposures through needlesticks, tattooing, etc.) are the most common ways children and youth are infected. International adoptees, particularly from the high prevalence areas of Africa, China, Russia, Eastern Europe, and Southeast Asia, are also at risk. Sexual transmission between heterosexual partners has not been demonstrated in prospective studies. Transmission among family contacts is uncommon.

Acute symptoms can appear from 2-12 weeks (up to 24) weeks after infection. Clearing of the HCV infection does occur especially in infants and toddlers (clearing after age 3 with vertical transmission is uncommon), but 60-80% of pediatric infections persist. Being asymptomatic is the most common symptom with chronic HCV infection. Adult patients may only be recognized when they donate blood which is screened for HCV, or have elevated transaminases on routine testing. More serious problems with chronic HCV infection can occur decades after infection.

Liver disease and other problems progress more slowly in children than adults so only 1-2% of children will have cirrhosis. Factors for progression include being immunocompromised, obese, co-infected with HIV or Hepatitis B and probably other viral factors. For adults the numbers are not as good. According to the Centers for Disease Control in the United States:
“Of every 100 persons infected with HCV, approximately

  • 75-85 will go on to develop chronic infection
  • 60-70 will go on to develop chronic liver disease
  • 5-20 will go on to develop cirrhosis over a period of 20-30 years

    1-5 will die from the consequences of chronic infection (liver cancer or cirrhosis)”

    Diagnosis is made by being seropositive for anti-HCV IgG which is confirmed by polymerase chain reaction for HCV RNA. Genotyping is also helpful to guide treatment. Genotype 1 is most common. Other biomarkers are being evaluated to also help guide treatment such as possibly Vitamin D or single nucleotide polymorphisms. Treatment by an experienced team of specialists is recommended. Currently approved treatment includes interferon and ribaviran but these drugs have side effects. There are currently new treatment for adults (HCV protease, polymerase and NS5A inhibitors) that are more effective with fewer side effects and pediatric trials are ongoing in 2016 that researchers are hopeful will show that these drugs can be used in the pediatric population. Because of the slow progression in the pediatric age group, some patients are being carefully watched and not treated while awaiting the results of these new studies.

    Unfortunately good prevention techniques for vertical transmission are not available. There is no current vaccine or immunoglobulin such is used for Hepatitis B vertical transmission. Elective caesarean section does not appear to decrease the risk of transmission, but other interventions such as no scalp monitoring or amniocentesis may.

    Learning Point
    Health considerations for children with HCV include:

    • Post exposure prophylaxis with immunoglobulin is not recommended.
    • Exclusion from childcare attendance is not recommended.
    • General household contact is recommended as HCV is not transmitted by general contact such as sharing utensils, food/water, touching, etc. Infected children should not share nail clippers, razors, and toothbrushes. Transmission in saliva is low.
    • Universal precautions are recommended for minor cuts. Fresh or dried blood should be cleaned with 1 part bleach/10 parts water solution with protective gloves.
    • Breastfeeding by a HCV-positive mother is okay, but the mother should consider abstaining if nipples have sores or cracks.
    • Routine maternal testing while pregnant is not indicated.
    • Routine immunizations are indicated.
    • Sports and school participated are indicated.
    • Healthy behaviors should be encouraged including avoidance of alcohol, drugs, self-tattooing and piercing and multiple sexual partners.

    Questions for Further Discussion
    1. Why do health care providers not worry about Hepatitis D and E as much as A, B, and C?
    2. What precautions should be taken for people with active Hepatitis A or Hepatitis B?
    3. How is Hepatitis B prevented?

    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: Hepatitis C.

    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.

    Centers for Disease Control. Hepatitis C. Available from the Internet at: http://www.cdc.gov/hepatitis/HCV/index.htm (rev. May 31, 2015, cited 11/1/2016).

    Red Book® Online. Hepatitis C. American Academy of Pediatric Committee on Infectious Diseases. Kimberlin, DW, Brady MT, Jackson MA, Long SS. eds. 2015. Available from the Internet at http://redbook.solutions.aap.org/chapter.aspx?sectionid=88187160&bookid=1484 (cited 11/1/16).

    Pawlowska M, Domagalski K, Pniewska A, Smok B, Halota W, Tretyn A. What’s new in hepatitis C virus infections in children? World J Gastroenterol. 2015 Oct 14;21(38):10783-9.

    Lee CK, Jonas MM. Hepatitis C: Issues in Children. Gastroenterol Clin North Am. 2015 Dec;44(4):901-9.

    Ohmer S, Honegger J. New prospects for the treatment and prevention of hepatitis C in children. Curr Opin Pediatr. 2016 Feb;28(1):93-100.

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

  • What Medical Problems Do Laundry Pods Cause?

    Patient Presentation
    A 2-year-old female came to clinic for her 2 year health maintenance examination. Her mother said that she was a typical 2-year-old but was more adventurous. She seemed to be more active and would get into more things than her other 2 siblings. Recently her mother had found her trying to get into the laundry detergent. “Luckily I have safety locks on the cabinet but she was still trying to get into the container. I bought some of the new laundry pods because I thought they would be less messy, but I worry that she might have tried to eat them if I hadn’t found her. I’ve already put a second latch on the cabinet, ” her mother said.

    The pertinent physical exam showed a healthy female with normal vital signs and growth parameters in the 25-50%. Her examination was normal. The diagnosis of a healthy female was made. “I’m really glad you already had a safety latch on the door and I know you try to keep a close eye on her. Laundry pods have become a bigger problem because the kids want to eat them. We actually recommend that parents of small children use regular liquid or powered detergent instead. So you could give the pods away or throw them out. If you keep them I would put the laundry pod detergent container high up in another cabinet if possible so the kids can’t get into them,” the pediatrician recommended. “I’ll write the poison control center number down for you to keep by your phone too just in case something happens.”

    Discussion
    Laundry detergent capsules are small, single-use pod, liquidtab or sachets with concentrated cleaning product encased in a water dissolvable membrane. They are brightly colored and promote use by being conveniently single-use. They are used mainly for laundry and dishwashers, and look similar to candy or toys which encourages ingestion by children. They were first used in Europe in 2001, and then were marketed in the U.S. in 2010. Not long afterwards, there was an increase in Poison Control Center calls regarding exposure to the products particularly by small children. An analysis from 2012-2013 found the number of exposures increased 645%. Exposure was approximately equal for both genders, and highest in the 1- and 2-yea- old age groups. Almost all cases were in children < 6 years old.

    The pods contain anionic and non-anionic detergents and cationic surfactant. Some products also contact alkaline substances. All products contain irritants. It is not really known at this time why laundry pods have more toxic effects than liquid detergent but it does not appear to be simply a chemical concentration issue. Specific chemicals and alkalinity of the products are possible causes.

    A review of common toxidromes can be found here.

    Learning Point
    Patients have primarily 3 types of health problems because of laundry pod exposure (data is from the 2014 study listed below, and is similar to other studies):

    • Ingestion – most common exposure at ~80%, types of clinical effects include emesis, nausea, oral or throat irritation, diarrhea and abdominal pain
    • Multiple routes ~10%
    • Ocular ~7% effects include pain/irritation, red eye/conjunctivitis, lacrimation, abrasion, burns and photophobia
    • Dermal ~1% effects include erythema, edema, irritation/pain, and rash

    The most common clinical problems for all types of laundry pod exposures were emesis (48%), coughing/choking (13.3%), ocular irritation (10.9%), lethargy/drowsiness (7.0%) and red eye/conjunctivitis (6.7%).

    Most children exposed to laundry pods were not treated in a health care facility (53.5%), 35.4% were treated and released from a health care facility, 2.4% were admitted to a critical care unit, and 2% were admitted to a non-critical care unit. Most children fortunately had a minor effect (50.3%), 17.6% had no effect, 0.6% had a major effect. Other children were not followed for various reasons (31.5%). Major effects include coma, seizure, pulmonary edema and respiratory arrest. Two children died. Endotracheal intubation was required by 102 children.

    Although companies have made changes to their packaging including making containers opaque to be less attractive and being harder to open, it is recommended that households with small children use liquid or powdered cleaning products and not laundry pods. As with any household cleaner and other similar products, keeping them out of reach, in locked cabinets is the best way to decrease unintentional exposure with the products.

    Questions for Further Discussion
    1. Describe your treatment/management strategy if you had a child with a laundry pod exposure come to your practice?
    2. What anticipatory guidance do you routinely provide to 2 year old children?
    3. What anticipatory guidance do you routinely provide regarding poisoning?

    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: Poisoning.

    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.

    American Association of Poison Control Centers. AAPCS Position Statement on Single-Load Liquid Laundry Packets. Available from the Internet at: https://aapcc.s3.amazonaws.com/files/library/AAPCC_Laundry_Packet_Position_Statement.pdf (cited 10/25/16)

    Valdez AL, Casavant MJ, Spiller HA, Chounthirath T, Xiang H, Smith GA. Pediatric exposure to laundry detergent pods. Pediatrics. 2014 Dec;134(6):1127-35.

    Fontane E. Ingestion of Concentrated Laundry Detergent Pods. J Emerg Med. 2015 Jul;49(1):e37-8.

    Sjogren PP, Skarda DE, Park AH. Upper aerodigestive injuries from detergent ingestion in children. Laryngoscope. 2016 Jul 28.

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