Diagnosing and treating teenage acne requires a detailed understanding of how it manifests from infancy to pre-adolescence, as well as knowing when acne can signal other symptoms. underlying health problems such as endocrine disorders, says Raegan Hunt, MD, PhD, director of pediatric dermatology services at Texas Children’s Hospital and associate professor of dermatology and pediatrics at Baylor College of Medicine, both both in Houston, said during a Maui Derm NP + PA Fall 2021 session on childhood acne.first

Neonatal acne (0-1.5 months) without nodules or cysts and/or at risk of scarring. This common papule can clear up on its own, and gentle cleansers and topical antifungals can help clear up acne more quickly, Hunt explains.

On the other hand, infantile acne is uncommon, occurs more frequently in boys, has an onset between 1.5 and 12 months, and is more likely to result in scarring. It is also associated with a higher risk of teenage acne and the formation of nodules, inflammatory acne, cystic acne, and nodules.

Typical treatment, according to Hunt, includes topical medications such as benzoyl peroxide, retinoids and azelaic acid, or systemic medications such as erythromycin. Trimethoprim/sulfamethoxazole may be used in patients older than 3 months. For severe treatment-resistant cases, off-label isotretinoin should be considered.

Since infants (0-3 months) cannot swallow capsules, Hunt explains, if isotretinoin is prescribed for painful acne or cystic scarring in this age group, the lubricant vehicle must be removed from the capsule. by syringe and given orally, or capsules may be frozen, cut and hidden in food, if appropriate.

Infant acne is not usually associated with endocrine disease, so laboratory testing for endocrine abnormalities is often unnecessary, says Hunt. However, she advises looking for signs of rapid growth and an elevated Tanner staging and if abnormal, consider laboratory evaluation.

Follow-up question addressed: When is teenage acne most concerned? Middle-aged acne can be a sign of a much deeper problem; It’s often associated with endocrine disorders, such as tumors, Cushing’s syndrome, or early prostatitis, Hunt says. Patients in this age group need to have endocrine testing. Recommended tests include follicle-stimulating hormone, luteinizing hormone, dehydroepiandrosterone sulfate, cortisol, total and free testosterone, and 17-hydroxyprogesterone, as well as bone age X-rays.

The clinical findings of middle-aged acne include cystic acne, inflammatory papules, and nodules of onset between 1 year and 7 years of age. It carries a risk of scarring and is treated with topical retinoids, benzoyl peroxide, topical and oral antibiotics. Hunt emphasized that tetracycline derivatives should be avoided in patients younger than 8 years of age.

Juvenile acne has the same clinical findings, treatment, and risk of scarring as middle-aged acne, but onset of lesions begins between the ages of 8 and 12 and is usually is normal, not a sign of a more serious health concern. For this group of patients, no endocrine therapy is usually needed, according to Hunt.

She describes the case of an 11-year-old boy taking adalimumab for Crohn’s disease who developed multiple pustules on his nose and rare inflammatory and milia elsewhere on his face. The patient had failed treatment with topical retinoids and topical antibiotics, including doxycycline, and responded poorly to endoscopic triamcinolone injection. The patient’s gastroenterologist advises against additional oral antibiotics or isotretinoin.

For children with prominent pustules on the nose that do not go away with traditional acne treatments, the correct diagnosis may be demodicosis. She treated this patient’s case with 2 oral doses of ivermectin approximately 200 μg/kg 1 week apart and 5% permethrin topical cream once daily for 1 week.

Although the burden of Demodex infection in childhood is lower and increases with age, demodicosis can occur in pediatric patients and may be associated with disorders such as Langerhans cell leukemia, says Hunt. , leukemia, lymphoma and HIV in children. Demodicosis can aggravate perioral dermatitis in children, she adds.

Finally, she covered the topic of acne in transgender patients, and over 90% of transgender youth have problems with acne that can be either triggered by testosterone or made worse by testosterone. used in sex-affirmation therapy. Hunt explains that acne should be monitored every 3 months after starting testosterone treatment.2

Furthermore, she said that moderate to severe acne in patients taking transmasculine was associated with an increased risk of depression (adjusted odds ratio 2.4) and anxiety (adjusted odds ratio 2.4). adjusted to 2.7).3 To help treat acne that is exacerbating these mental health problems, she recommends assessing the type of acne and treating it according to severity and the type of acne it suggests.

If the patient could benefit from combined estrogen-progestin and/or isotretinoin oral contraceptives in addition to conventional first-line acne treatments with a combination of topical, topical retinoid and/or anti-inflammatory drug therapy orally, these additional options should be explored, continued Hunt. Combination oral contraceptives may also benefit patients in addition to acne by suppressing menstruation, however, clinicians should recognize that oral contraceptives for the treatment of acne may be present. declined because of its female hormone implications, she explained.

On the other hand, isotretinoin has unique risks in transgender youth, including an increased risk of hepatotoxicity if the patient is taking isotretinoin and testosterone. In addition, isotretinoin may cause depression, anxiety, or suicidal ideation in some patients, which may be more worrisome in a population already at high risk for mental health problems. this god, Hunt discussed.

Furthermore, the iPLEDGE risk assessment and risk reduction strategy for isotretinoin requires routine pregnancy screening and registration based on the assigned sex at birth, which can be distressing for transmasculine patients. She adds that long-term testosterone treatment is not considered a reliable form of birth control. Hunt concluded that these conversations should be approached with compassion and open communication.

Disclosure:

Raegan Hunt, MD, PhD undisclosed.

References:

  1. Hunt R. Acne. The session is presented at: Maui Derm NP + PA Fall 2021 conference agenda; October 1, 2021; Retrieved October 1, 2021. Asheville, North Carolina
  2. Kosche C, Mansh M, Luskus M, et al. Dermatological Care for Gender and Sexual Minority Youth / LGBTQIA, Part 2: Recognizing and managing the unique dermatological needs of SGM adolescents. Pediatric Dermatol. 2019; 36 (5): 587-593. doi: 10.1111 / pde.13898
  3. Braun H, Zhang Q, Getahun D, ​​et al. Mental health symptoms and moderate to severe acne in transmasculine users who received testosterone. JAMA Dermatology. In 2021; 157 (3): 344-346. doi: 10.1001 / jamadermatol.2020.5353

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