What Can Families Do for Fire Safety?

Patient Presentation
A 7-year-old male came to clinic for his health maintenance examination. His mother had no concerns and the pertinent physical examination was normal. The diagnosis of a healthy male was made. While discussing some safety anticipatory guidance, the boy became very excited to talk about how his mother had used the fire extinguisher several days before to stop a kitchen grease fire. “You should have seen all the powder all over the place, it was a real mess” he almost shouted. “It got all over my school stuff and they were ruined but they didn’t catch fire,” he added. While retelling the story the mother was quite embarrassed, but the physician noted how she was prepared and used the fire extinguisher. She asked if the smoke detectors also went off. “Oh yeah,” the boys shrieked, “but mom yelled for my brother and I to go outside and we did. Afterwards we got to see the real mess.” The pediatrician praised the boy for following his mother’s instructions. “We didn’t have a real safety plan,” said the mother, “but we do now and we are going to practice it too.”

Discussion
Home fire safety is important. Prevention safeguards life and property.

In 2014, the U.S. Fire Administration reported there were 3,428 deaths caused by fires. The most common pediatric age group is 0-4 years, with decreasing risk with advancing age. In the adult age group, the rates hold steady until the 40-50’s when there starts to be an increasing risk in the older population again. Other groups at risk are those with disabilities, and people living in rural areas. Intentional fires or arson are highest obviously in urban environments.

The leading cause of fire deaths in the US is because of smoking. Other risk factors include lack of a working smoke alarm, use of a space heater and renting (versus owning) the home. Having a working smoke alarms in the home dramatically decreases fire injuries and property loss. In the US there is a 2-3x lower risk of fire death with a working smoke alarm. Having a smoker as noted also dramatically increases the risk, but this can be mitigated by consistent safety practices including only smoking outside the home.

Home fires can occur year round, but are more common in the winter months of December, January and February because of associated heating needs. Use of fireplaces and space heaters increases the risk of home fires. Home fires associated with religious and cultural celebrations also peak at these times with home candle fires peaking on Christmas, New Years Eve and New Years Day. Seasonal fire-related injuries are seen globally with the timing based on location and specific practices. Cooking is obviously associated with various methods for heating food and therefore fires. Stoves, ovens, microwave ovens, barbeques and grills, and fryers are just some of the potential fire hazards within the home. Electrical fires from improperly connected home products are also potential fire sources. Appliances washers, fryers, portable generators, portable fireplaces and portable space heaters are all potential fire risks. Gasoline and propane are hazardous fuels that must be stored and handled properly. Use of medical oxygen has increased over time and is another potential fire hazard in homes. Clutter around potential fire sources also increases the risk of fire starting and/or spreading.

Learning Point
Basic recommendations to help prevent fires in the home include:

  • Smoke alarms
    • Should be on every level of the home
    • Tested and cleaned monthly
    • Batteries changed yearly and as needed
    • Should be < 10 years old
  • Fire extinguishers
    • Should be easily available throughout the home including each floor and garage
    • Extinguishers types are:
      • A extinguishers are for combustibles such as trash, wood
      • B are for liquids/grease
      • C are for electrical fires
    • Extinguishers should be used by PASS
      • Pull the extinguisher pin
      • Aim the nozzle at the base of the fire
      • Squeeze the handles together
      • Sweep the extinguisher contents at the base of the fire
  • Carbon monoxide alarm
    • Should be one on every level of the home
    • Tested and cleaned monthly
    • Should be < 7 years old
  • Fire safety plan
    • Have a fire safety plan and practice it regularly
    • Have 2 ways to get out of every room
    • Crawl low when escaping to avoid smoke
    • Know where to meet – near front of house is usually best
    • Once out of house, stay out of house
  • Cooking
    • All cooking areas/surfaces should be kept free of flammable materials
    • Hoods are cleaned regularly and vented to the outside
    • Pots are not left unattended on stove
    • Fryers are plugged directly into electrical outlet on a non-flammable surface
    • Food should be removed promptly when cooked.
    • Microwave ovens should only have approved containers used for heating food
  • Smoking in the home
    • Try to help smokers to quit smoking
    • Smoke outside and use fire-safe cigarettes
    • Ashtrays should be large and deep. They should be emptied into fire-proof containers or the containers used directly
  • Heating
    • Furnaces and chimneys should be cleaned regularly and inspected at least yearly
    • All combustible materials are > 3 feet from the heat source
    • Fireplaces should be used under direct supervision and extinguished completely before leaving room or going to bed
    • Do not use extension cords with space heaters – they should be directly plugged into the electrical outlet
    • Any space heater should be laboratory approved and have a tip-over, shut-off mechanism
    • Fireplace and barbeque ashes should be placed into metal containers
  • Electric
    • All appliances are plugged directly into the electrical outlet
    • No frayed or cracked cords
    • No cords under rugs/blankets etc.
    • If needed, multipronged adapters are used for additional electric outlets
    • Dryer lint filters and venting systems are cleaned regularly and as needed
  • Candles, Seasonal, and Recreation
    • Candles or any other open flames should be kept in a fire proof container under direct supervision. They should be extinguished completely before leaving room or going to bed.
    • Electrical lights or decorations should be used as directed by the manufacturer. They should be inspected before use and monitored. They should be turned off before leaving the house or for bed.
    • Use of electric tools, hot glue guns, soldering irons and other home maintenace or recreational products are also potential fire sources. They should be used according to manufacturers instructions, unplugged and stored between uses.

Questions for Further Discussion
1. What summer safety tips do you suggest to families? For suggestions click here
2. What winter safety tips do you suggest to families? For suggestions click here

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: Fire Safety

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.

Al-Qattan MM, Al-Zahrani K. A review of burns related to traditions, social habits, religious activities, festivals and traditional medical practices. Burns. 2009 Jun;35(4):476-81.

Lehna C, Fahey E, Janes EG, Rengers S, Williams J, Scrivener D, Myers J. Home fire safety education for parents of newborns. Burns. 2015 Sep;41(6):1199-204.

Rohrer-Mirtschink S, Forster N, Giovanoli P, Guggenheim M. Major burn injuries associated with Christmas celebrations: a 41-year experience from Switzerland. Ann Burns Fire Disasters. 2015 Mar 31;28(1):71-5.

Wood RL, Teach SJ, Rucker A, Lall A, Chamberlain JM, Ryan LM. Home Fire Safety Practices and Smoke Detector Program Awareness in an Urban Pediatric Emergency Department Population. Pediatr Emerg Care. 2016 Nov;32(11):763-767.

National Fire Protection Association. Public Education. Available from the Internet at http://www.nfpa.org/public-education (cited 12/6/16).

United State Fire Administration. Fire Statistics. Available from the Internet at https://www.usfa.fema.gov/data/statistics/ (cited 12/6/16).

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

What is Black Spot Poison Ivy?

Patient Presentation
A 16-year-old female came to clinic with linear black streaks on her arms that began the day before. She had been in the woods and fields in the morning and in the afternoon noticed the black streaks. During the night she awoke because of intense itching and noticed that she now also had reddened skin with vesicles in the area around the black streaks. She denied direct exposure to any poison ivy, poison oak, etc., and said that after being in the woods she had washed her clothing and showered. She had had poison ivy in the past and thought this looked similar but it had never been black before. The pertinent physical exam showed a healthy female with normal growth parameters and vital signs. Both volar forearms and right dorsal forearm had linear black lines that were 1-3 cm in length and ~2-3 mm wide. There were 2-3 black lines in each location. Surrounding the areas were linear reddened skin with some shiny vesicles and scratch marks. The rest of her examination was negative.

The diagnosis of of black spot poison ivy was made. “This doesn’t happen very much, but you got a pretty good exposure to some poison ivy and this is why it is black. We treat it the same though. I recommend that you use some antihistamines and I’ll prescribe a steroid cream. I know you said you washed all the clothing but make sure that you wash anything else you might have contacted like garden gloves, backpack etc. because the resin can stay on those too for a long time,” the physician said.

Discussion
Poison ivy (PI, Toxicodendron radicans) is a common plant in North America that causes allergic contact dermatitis. Poison oak and sumac also cause similar problems. The rash usually appears as linear erythematous papules or vesicles occurring soon after exposure.

Patients often do not identify the exposure specifically but will say they were walking/playing in gardens, fields or woods. PI can be a small plant, vine or even a shrub. The coloring changes over the growing season. Fires may also be a source as burning the plants and being in the smoke can cause extensive lesions on the body. The plant has 3 leaves and never more. The leaf stems alternate along the growing plant and are not found directly across from each other. The leaves have smooth edges and are not saw-toothed, serrated or scalloped. There also are no thorns. Several identification guides can be found here.

PI has an oleoresin called urushiol which causes the main problem but it also contains allergens (pentadecylcatechols). The urushiol does not evaporate well and therefore stays on clothing, sports equipment etc.. for longer time periods. The allergens can contaminate clothing for years. These properties account for exposure at unexpected times of the year (i.e. in the winter children using a contaminated sleeping bag for an overnight party and getting the PI rash), or in unexpected places (e.g. PI rash presenting in the United Kingdom which has no PI after travel to the United States).

Treatment is by antihistamines and topical or oral steroids, along with appropriate skin hygiene. Oral steroids for extensive lesions usually need to be tapered over a long time to prevent rebound symptoms. Prevention is by avoiding exposure. Use of protective clothing including areas between garments such as socks over pant legs, long-cuffed gloves that cover sleeves, and hoods or handkerchiefs to protect the neck can decrease exposure. As soon as possible, the person and all clothing and equipment should washed thoroughly to prevent the rash and further contamination of other clothing/equipment. Washing with soap and not just plain water increases prevention efficacy. Fresh jewelweed plant mash (Impatiens capensis) has been shown to decrease PI rash after exposure but not its extract or that which is added to soap. Although the author does not have scientific evidence to support the practice, the author personally recommends rubbing soap on potentially exposed areas such as wrists, ankles, neck etc.. before potential exposure and then showering immediately after exposure. In her experience, it is a low-cost, reasonably effective preventative measure.

PI plant is part of a larger family called Anacardiacaea which is a flowering, sap producing family. Mangos, cashews and pistachios are examples of this family. Other species are used for tanning and lacquers. There is global experience where first exposure to urushiol orally appears to induce tolerance to the resin and people do not react to it when it is encountered dermally; that is, they have an induced oral tolerance for the resin. People who eat mangos from an early age, children who eat chicken off of lacquerware that contains the resin (i.e. “lacquer chicken” in Korea) or Native American orally ingesting the plant are all examples of groups of people who seem to have tolerance after dermal exposure to the resin.

Learning Point
Black spot PI is an atypical variation where the initial lesions are spots or linear black streaks that are followed by the more classic presentation several hours later. The black coloring is because of high concentrations of the urushiol which oxidizes in a warm, humid environment. The black lesions cannot be washed off but they will peel away with time and do not scar. It is treated the same as regular PI.

Questions for Further Discussion
1. What PI or similar plants are in your location?
2. What skin hygiene measures do you recommend for PI?

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: Poison Ivy, Oak and Sumac

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.

Poison Ivy. Available from the Internet at http://www.poison-ivy.org. (cited 11/29/16).

Anacardiacaea. Wikipedia. Available from the Internet at https://en.wikipedia.org/wiki/Anacardiaceae. (cited 11/29/16).

Abrams Motz V, Bowers CP, Mull Young L, Kinder DH. The effectiveness of jewelweed, Impatiens capensis, the related cultivar I. balsamina and the component, lawsone in preventing post poison ivy exposure contact dermatitis. J Ethnopharmacol. 2012 Aug 30;143(1):314-8.

Pittman MA, Lane DR. Black spot poison ivy: under the cover of darkness. J Emerg Med. 2013 Apr;44(4):e331-2.

Colbeck C, Clayton TH, Goenka A. Poison ivy dermatitis. Arch Dis Child. 2013 Dec;98(12):1022.

Sinha K, Elpern DJ. A baleful weed and the king of fruits: tolerance, immunity, and the microbiome. Int J Dermatol. 2016 Jan;55(1):121-2.

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

What is in the Differential Diagnosis of Fatigue?

Patient Presentation
A 14-year-old male came to clinic for advice about seasonal allergic rhinitis. It usually was controlled with daily cetirizine but he was having more rhinorrhea, sneezing and some coughing and his mother complained that he always seemed very tired. He had some itchy eyes but denied pain or fever. The cough was non-productive but he said he would cough up clear mucous that was just like his rhinorrhea. He had just started high school where he was taking advanced courses and was in several extracurricular activities. Over the summer he had been active but had not been training before also starting running with the cross-country running team. He said that he tried to go to bed at a consistent time, but that he was only getting around 7 hours of sleep a night. He was eating a fairly good diet. He denied feeling overwhelmed and loved his classes and activities. The past medical history showed mild intermittent asthma and seasonal allergic rhinitis.

The pertinent physical exam showed a generally well-appearing male with normal vital signs. He had a 1-pound weight gain since his well adolescent visit a month previously. He had mild tearing and allergic shiners by his eyes. His nose had boggy membranes with copious clear/white rhinorrhea that was also seen in the posterior pharynx. His lungs were clear. His skin was not dry nor had any rashes. The diagnosis of seasonal allergic rhinitis and fatigue due to multiple reasons was made. The physician recommended to increase the amount of cetirizine and also beginning a nasal steroid. “You should also keep your albuterol inhaler with you and if you have more coughing, you should try it. The cough may be because of your asthma, especially if it gets worse when you are exercising. I also want you to call me, if these medicines aren’t helping in 5-7 days. I have some other medicines which may help,” she offered. The physician also discussed with the adolescent ways he could prioritize consistent sleep in his schedule. “Taking your medicine, good sleep, good eating and drinking lots of fluids, and some healthy exercise usually improves your energy,” she said.

Discussion
Fatigue is a subjective feeling of decreased energy, tiredness or feeling of exhaustion. Lethargy is often used synonymously, but lethargy is a state of being drowsiness or sleepy, and implies mental status changes. Both can cause the person to be apathetic or less active.

Fatigue is a common state that almost everyone experiences multiple times in his or her lifetime. For most people it is a relatively acute or short-term chronic problem, often with a relatively easily identifiable problem cause, such as inadequate sleep, acute illness, or overexertion. For some, it can be less readily identifiable such as depression, anemia, or hypothyroidism or because of a chronic illness with its waxing and waning natural history or being under- or over-treated. Chronic fatigue and cause decreased quality of life, school or work problems, and depression.

It seems to many health care providers that adolescents and their parents complain about fatigue. This is not surprising as adolescents often do not get enough sleep, may be either overexerting themselves with activities or conversely be deconditioned because of little activity, be worried about school and other life issues, or not eat or drink consistently or are dieting. They may also be taking medications or drugs, have a chronic disease or are pregnant.

The keys to the evaluation of fatigue often lie in a detailed history and review of systems that can then guide laboratory evaluation and treatment. Laboratory testing can include a complete blood count, complete metabolic panel, thyroid function testing, erythrocyte sedimentation rate, and urinalysis. Other simple tests to consider include pregnancy test, Epstein Barr titers or monospot, rheumatoid factor, tuberculosis testing, and chest radiograph. Many other tests can also be ordered based on history and previous testing.

Other PediatricEducation.org cases of interest:

  • Health problems caused by inadequate sleep, found here.
  • Obesity, activity, and weight loss, found here and here.
  • Growth and pubertal development, found here.

Learning Point
The differential diagnosis of fatigue is enormous. Below are only some of the potential causes given as a framework when considering the individual patient’s story.

  • Overexertion
  • Deconditioning
  • Puberty
  • Sleep
    • Insufficient/deficit
    • Sleep disorders
      • Insomnia
      • Narcolepsy
      • Obstructive sleep apnea
  • Psychological/psychiatric
    • Boredom
    • Depression
    • Anxiety/stress/insecurity – worrier, bullying, self-esteem issues
    • School phobia
    • Normal quiet personality
  • Infections
    • Obvious – upper respiratory infection, streptococcal pharyngitis, pneumonia, gastroenteritis, etc..
    • Surreptitious – urinary tract infection, abscess, osteomyelitis, HIV, tuberculosis, parasites
    • Acute viral illnesses
      • Adenovirus
      • Epstein-Barr virus
      • Influenza
      • Lyme disease
      • Parvovirus
  • Medications and illicit drugs
    • Alcohol
    • Antidepressants
    • Antihistamines
  • Metabolic
    • Anemia
    • Abnormal diet or malnutrition
    • Hypoglycemia
    • Hyperammonemia
  • Obesity
  • Pregnancy
  • Chronic illnesses
    • Cardiovascular
      • Congenital heart disease
      • Acquired heart disease, e.g. endocarditis
    • Endocrine
      • Diabetes
      • Hypothyroidism
      • Hyperthyroidism
      • Addison disease
      • Cushing’s syndrome
    • Gastrointestinal
      • Crohn’s disease
      • Ulcerative colitis
      • Hepatitis or liver failure
    • Renal – renal insult or failure
    • Neurological/Genetic
      • Myasthenia gravis
      • Muscle weakness
      • Many other neurological or genetic problems
    • Miscellaneous
      • Chronic fatigue syndrome
      • Heavy metal intoxication
      • Pain, e.g. Fibromyalgia
    • Oncologic – malignancy
    • Respiratory
      • Allergies
      • Asthma – unrecognized or uncontrolled
      • Cystic fibrosis
    • Rheumatologic
      • Juvenile idiopathic arthritis
      • Dermatomyositis
      • Systemic lupus erythematosus

Questions for Further Discussion
1. How much cetirizine can be used for seasonal allergic rhinitis? To learn more click, here.
2. What is the definition of chronic fatigue syndrome?
3. What are indications for referral for a sleep study or sleep medicine specialist?

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: Fatigue.

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.

Illingworth RS. Common Symptoms of Disease in Children. Blackwell Scientific Publications: Oxford. 1988:42-45.

Fisher M. Fatigue in adolescents. J Pediatr Adolesc Gynecol. 2013 Oct;26(5):252-6.

Crichton A, Knight S, Oakley E, Babl FE, Anderson V. Fatigue in child chronic health conditions: a systematic review of assessment instruments. Pediatrics. 2015 Apr;135(4):e1015-31.

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

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