Facing the Challenge of Acne Vulgaris in Pediatric Patients

Transcription

A CME-Certified Supplement to
Skin & Allergy News
®
Facing the Challenge
of Acne Vulgaris in
Pediatric Patients
Introduction
3
Acne Epidemiology and Pathophysiology
4
Diagnosis and Evaluation of Acne
6
Medical and Psychosocial Impact of Acne
9
Perspectives on Therapeutic Options for Acne: An Update
12
CME Post-Test and Evaluation Form
16
Faculty
Sheila F. Friedlander, MD
Chair
Lawrence F. Eichenfield, MD
Models are for illustrative purposes only.
Chief of Pediatric and
Adolescent Dermatology
Professor of Pediatrics and Medicine
(Dermatology)
Rady Children’s Hospital,
UCSD School of Medicine
San Diego, CA
Release Date: June 2010
Expiration Date of Activity for AMA PRA Credit: June 30, 2012
Estimated Time to Complete This Activity: 2.0 hour(s)
Joseph E. Fowler, Jr, MD
A continuing medical education activity held at the 34th Annual
Richard G. Fried, MD, PhD
Clinical Professor of Dermatology
University of Louisville
Louisville, KY
Private Practice
Yardley Dermatology Associates
Yardley, PA
Jointly sponsored by
Professor of Clinical Medicine,
Pediatrics and Dermatology
Rady Children’s Hospital,
UCSD School of Medicine
San Diego, CA
Moise L. Levy, MD
Specially for Children
Chief, Pediatric Dermatology
Dell Children’s Medical Center
Austin, TX
Clinical Professor, Dermatology/Pediatrics
Baylor College of Medicine
Houston, TX
Guy F. Webster, MD, PhD
Clinical Professor
Department of Dermatology
Jefferson Medical College
Philadelphia, PA
This activity is supported by an educational grant from
and
A Supplement to
Skin & Allergy News
Reprinted from
Seminars in Cutaneous
Medicine and Surgery
The manuscript was originally
published as a supplement to
Seminars in Cutaneous Medicine
and Surgery, Supplement 1, Vol. 29,
No. 2S, June 2010. It has been
reviewed and approved by the faculty
as well as the Editors of Seminars in
Cutaneous Medicine and Surgery.
This continuing medical education
(CME) supplement was developed
from a clinical roundtable held during
Skin Disease Education Foundation’s
34th Hawaii Dermatology Seminar,
CME conference, Waikoloa, Hawaii,
February 14-19, 2010.
Neither the editors of Skin & Allergy
News nor the Editorial Advisory
Board nor the reporting staff
contributed to its content. The
opinions expressed in this supplement
are those of the faculty and do not
necessarily reflect the views of
the supporter nor of the Publisher.
The faculty acknowledge the editorial
assistance of Global Academy for
Medical Education, LLC, an Elsevier
business, and Joanne Still, Medical Writer,
in the development of this supplement.
www.skinandallergynews.com
Copyright © 2010 by Elsevier Inc. and its
Licensors. All rights reserved. No part of this
publication may be reproduced or transmitted in
any form, by any means, without prior written
permission of the Publisher. Elsevier Inc. will
not assume responsibility for damages, loss, or
claims of any kind arising from or related to
the information contained in this publication,
including any claims related to the products,
drugs, or services mentioned herein.
®
Facing the Challenge of
Acne Vulgaris in Pediatric Patients
Release Date of Activity: June 2010
Target Audience
Expiration Date of Activity for AMA PRA
Credit: June 30, 2012
The target audiences for this educational
supplement are dermatologists, pediatricians, and other health care professionals
involved in the treatment of pediatric
patients with acne.
Estimated Time to Complete This Activity:
2.0 hour(s)
To get instant CME credits online, go to
http://louisville.edu/hsc/continuinged/
earn-ce-credits/acnevulgaris. (Type the
above address into your address bar in
Internet Explorer. If you are unfamiliar with
what an address bar is or how to access
yours, open Internet Explorer, then hold
down the control key and press the “O” key
on your keyboard. A dialogue box will open
– this is where you will type the above
address. After you have typed the address,
click OK to go to the evaluation.)
Upon successful completion of the online test
and evaluation form, you’ll be directed to a
webpage that will allow you to receive your
certificate of credit via e-mail. Please add
[email protected] to your e-mail “safe list.”
Once you have completed the evaluation,
you will be given a password. Please be sure
to write it down; you will then be able to
access your certificate. Please note, certificates will not be mailed, so be sure to print
a copy for your records. If you have any
questions or difficulties, please contact the
University of Louisville School of Medicine
Continuing Health Sciences Education office
at (502) 852-5329.
Joint Sponsorship
This activity has been planned and implemented in accordance with the Essential Areas
and Policies of the Accreditation Council for
Continuing Medical Education (ACCME)
through the joint sponsorship of the University
of Louisville School of Medicine Continuing
Health Sciences Education (CHSE) and Skin
Disease Education Foundation, an Elsevier
business. CHSE is accredited by the ACCME to
provide continuing education for physicians.
Designation Statement
CHSE designates this educational activity for
a maximum of 2.0 AMA PRA Category 1
Credit(s)™. Physicians should only claim
credit commensurate with the extent of their
participation in the activity.
2
Statement of Professional
Practice Gap(s)
Untreated or ineffectively managed acne vulgaris is associated with important physical
and psychosocial sequelae. The wide range
of topical and systemic treatments allows
clinicians to choose a regimen that is appropriate for each patient. Further, with
appropriate treatment, acne can be successfully managed in almost every case. The
articles in this supplement provide an update
on the epidemiology, pathophysiology, medical and psychosocial impact, and treatment
of acne vulgaris in pediatric patients. As much
of the most recent new information on acne
concerns an emerging subgroup—that is,
children between about 8 and 11 years of
age—evidence and insights about younger
patients are presented and discussed.
Clinicians who provide health care to pediatric patients with acne must have the latest
clinical data and knowledge to individualize
their patients’ care.
Learning Objectives
Upon completion of this activity, participants
will be better able to:
• Assess and classify acne vulgaris in pediatric patients.
• Describe the topical and systemic medications available and suitable for use in
pediatric patients with acne.
• Determine the type of medication and
route of delivery appropriate for individual
patients, based on age, severity of disease, and other factors.
• Counsel patients and parents regarding
the management of the disease and
review strategies for coping with acne.
Disclosure
As a sponsor accredited by the ACCME,
CHSE must ensure balance, independence,
objectivity, and scientific rigor in all its sponsored educational activities. All faculty
participating in this CME activity were asked
to disclose the following:
Volume 29, Number 2S
June 2010
Introduction
Introduction
R
ecently, a panel of experts convened during the Skin
Disease Education Foundation’s 34th Hawaii Dermatology Seminar to discuss acne vulgaris in pediatric patients.
The goal of this panel discussion was to review the medical
literature and clinical experience to provide clinicians with
an update on the epidemiology, pathophysiology, medical
and psychosocial impact, and treatment of acne vulgaris in
pediatric patients. Although new evidence and insights are
available in these areas that apply to people with acne at any
age, a great deal of the newest information refers to the condition in younger pediatric patients, those younger than the
typical “adolescent acne patient” who is between 12 and 18
years of age.
Acne is commonly observed in healthy children from 8
through 11 years of age in increasing numbers. This condition is to be distinguished from the lesions found in
neonatal acne and acne that occurs in patients with various
pathologic causes of premature adrenarche (a cause of
precocious puberty).
In these articles, the authors discuss the evidence concerning the epidemiologic trends and underlying causes for this
downward shift in acne age of onset, as well as approaches to
recognizing the severity and type of acne and treating the
condition at any age. Furthermore, in all age groups, the
treatment regimens chosen must be matched to disease se-
verity, and the effectiveness of those regimens must be monitored, assessed, and adjusted as needed.
In younger patients, in particular, careful follow-up is key
to optimal management because in many children, acne has a
tendency to worsen with pubertal maturation. Thus, in patients in the 8- to 11-year-old subgroup, changes in the effectiveness of medications over time are more likely to occur
than in older patients, whose disease is more likely to stabilize once an effective therapy has been identified (assuming
consistency of compliance with the regimen).
In addition, in younger patients with acne, the psychosocial impact of the condition also tends to vary over time. For
example, mild-to-moderate acne may not be especially bothersome to many 9-year-old children but may become more of
an issue when they enter middle school.
Clinicians who provide health care to children between 8
and 18 years of age—whether in dermatologic, pediatric, or
primary care settings—already are aware of the need for appropriate assessment and treatment of younger patients with
acne. The authors hope that these articles will provide information of immediate practical use, and at the same time
provide insight into future research that may yield clinically
applicable evidence over the next several years.
1.Names of proprietary entities producing
Johnson & Johnson, Quinnova, Ranbaxy,
health care goods or services—with the
Shire, Stiefel, Triax, and Valeant. He has been
exemption of nonprofit or government
a speaker for Galderma, Medicis, Ranbaxy,
organizations and non–health-related
Shire, Stiefel,UCB, and Valeant. He has
companies—with which they or their
also been an investigator for Abbott, Taro,
spouse/partner have, or have had, a releAllerderm, Allergan, Amgen, Astellas,
vant financial relationship within the past
Centocor, Coria, Dermik, Dow, Galderma,
12 months. For this purpose, we consider
Genentech, Johnson & Johnson, Medicis,
the relevant financial relationships of a
Novartis, Quinnova, Shire, Stiefel, Taisho,
spouse/partner of which they are aware to
and 3M.
be their financial relationships.
Richard G. Fried, MD, PhD, has nothing
2. Describe what they or their spouse/partto disclose.
ner received (salary, honorarium, etc).
Sheila F. Friedlander, MD, has been a con3. Describe their role.
sultant for Astellas, Barrier Therapeutics,
4. No relevant financial relationships.
Galderma, Graceway, Novartis, and sanofiLawrence F. Eichenfield, MD, has served
aventis. She has also received grant
as a speaker for Coria. He has also been an
research support from Atlanta, Amgen,
investigator and/or consultant for Johnson &
Astellas, Barrier Therapeutics, Galderma,
1085-5629/10/$-see front matter © 2010 Elsevier Inc. All rights reserved.
Johnson,
Ortho
Dermatologics,
Stiefel,
Hill Dermaceuticals, Johnson & Johnson,
doi:10.1016/j.sder.2010.04.001
Galderma, and sanofi-aventis.
LEO Pharmaceuticals, Novartis, Ortho
Dermatologics, Photocure, Pierre-Fabre,
Joseph F. Fowler, Jr, MD, has been a consultant for Galderma, Graceway, Hyland,
RegeneRx, and Dow.
Lawrence F. Eichenfield, MD
Guest Editor
Moise L. Levy, MD, has been a consultant
for GlaxoSmithKline and SkinMedica.
Sylvia Reitman, MBA, has nothing to
disclose.
Joanne Still has nothing to disclose.
Guy F. Webster, MD, PhD, has been a consultant for Allergan, Cutanea, Cipher,
Galderma,GlaxoSmithKline, Medicis, Ortho,
and Quinnova.
CHSE Committee Members have no relevant financial relationships with any
commercial interests: Carolyn Burns, MD;
Dedra DeBerry, MA; Joyce Dunagan, MA,
MSLS ; Linda H. Freeman, DNS, RN; Paul
Fultz; Terri Gipson, MSL; Ruth Greenberg,
PhD; Lucy Juett, MS; Irene Litvan, MD; Loretta
Maldaner; Mike Mansfield, DMD; Ashlee
Melendez, RN, BSN; Lisa J. Pfitzer, MD; Robert
Sexton, MD; Uldis Streips, PhD; Kathy M.
Vincent, MD; Lori Wagner, MD; Stephen
Wheeler, MD; Sharon K. Whitmer, EdD.
3
Sheila F. Friedlander, MD,* Lawrence F. Eichenfield, MD,* Joseph F. Fowler, Jr, MD,
Acne
Epidemiology and Pathophysiology
Richard G. Fried, MD, PhD, Moise L. Levy, MD, and Guy F. Webster, MD, PhD
†
‡
§
¶
Sheila F. Friedlander, MD,* Lawrence F. Eichenfield, MD,* Joseph F. Fowler, Jr, MD,†
Richard G. Fried, MD, PhD,‡ Moise L. Levy, MD,§ and Guy F. Webster, MD, PhD¶
The demographic profile of facial acne vulgaris has changed during the past several
decades; 12 years of age is no longer the low end of the “normal” range for onset of acne.
The available epidemiologic evidence raises more questions than it answers regarding the
etiology of this downward shift. More study is needed to clarify whether the trend toward
an earlier onset of puberty in the United States has influenced the clinical picture of acne.
Additional research will help advance understanding of the spectrum of pathophysiologic
changes in acne in younger pediatric patients and whether it varies from that found in
individuals in whom the onset of acne occurs at approximately 12 years of age or later.
Semin Cutan Med Surg 29:2-4 © 2010 Elsevier Inc. All rights reserved.
I
n the past several years, clinicians have noted an earlier
onset of acne—that is, the appearance of acne in patients as
young as 8 or 9 years of age. This clinical observation has
been supported by epidemiologic evidence that suggests that
the average age of the onset of puberty has decreased.
*Rady Children’s Hospital, UCSD School of Medicine, San Diego, CA.
†University of Louisville, Louisville, KY.
*Rady
Children’s Hospital, UCSD School of Medicine, San Diego, CA.
‡Yardley Dermatology
†University
of Louisville,
Louisville,
KY. PA.
Associates,
Yardley,
‡Yardley
Dermatology
Associates,
Yardley,
§Baylor College
of Medicine,
Houston,
TX. PA.
§Baylor College of Medicine, Houston, TX.
¶Jefferson Medical College, Philadelphia, PA.
¶Jefferson
Medical College, Philadelphia, PA.
Publication of this CME article was sponsored
sponsored by
by the
the University
Universityof
ofLouisville
Louisville
ContinuingHealth
HealthSciences
SciencesEducation
Education and
and Skin
Continuing
Skin Disease
Disease Education
Education
Foundation
supported
byeducational
an educational
grantOrtho
from DermaOrtho
Foundation
andand
supported
by an
grant from
Dermatologics.
tologics.
Sheila F.
F. Friedlander,
Friedlander,MD,
MD,has
has
been
a consultant
for Astellas,
Barrier
Sheila
been
a consultant
for Astellas,
Barrier
TherTherapeutics,
Galderma,
Graceway,
Novartis,
and sanofi-aventis.
apeutics,
Galderma,
Graceway,
Novartis,
and sanofi-aventis.
She hasShe
also
has alsogrant
received
grant research
from Atlanta,
received
research
support support
from Atlanta,
Amgen,Amgen,
Astellas,Astellas,
Barrier
Barrier Therapeutics,
Hill Dermaceuticals,
JohnsonLEO
&
Therapeutics,
Galderma, Galderma,
Johnson & Johnson,
Johnson, LEO Pharmaceuticals, Novartis, Ortho Dermatologics,
Pharmaceuticals, Novartis, Ortho Dermatologics, Photocure, PierrePhotocure, Pierre-Fabre, RegeneRx, and Dow.
Fabre, RegeneRx, and Dow.
Lawrence
F. Eichenfield,
Eichenfield,MD,
MD,has
hasserved
served
a speaker
Coria.
He has
Lawrence F.
asas
a speaker
forfor
Coria.
He has
also
alsobeen
an
investigator
and/or
consultant
for
Johnson
&
Johnson,
been an investigator and/or consultant for Johnson & Johnson, Ortho
Ortho Dermatologics, Stiefel, Galderma, and sanofi-aventis.
Dermatologics, Stiefel, Galderma, and sanofi-aventis.
Joseph
F. Fowler,
Joseph F.
Fowler, Jr,
Jr,MD,
MD,has
hasbeen
beenaaconsultant
consultantfor
forGalderma,
Galderma, Graceway,
Graceway,
Hyland,
Johnson
&
Johnson,
Quinnova,
Ranbaxy,
Shire, Stiefel,
Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire,
Stiefel, Triax,
Triax,
and Valeant. He has been a speaker for Galderma, Medicis, Ranbaxy,
Shire, Stiefel, UCB, and Valeant. He has also been an investigator for
Abbott, Taro, Allerderm, Allergan, Amgen, Astellas, Centocor, Coria,
Abbott,
Taro,
Allerderm,
Amgen,
Astellas,
Centocor,
Coria,
Dermik,
Dow,
Galderma,Allergan,
Genentech,
Johnson
& Johnson,
Medicis,
Dermik,
Dow,
Galderma,
Genentech,
Johnson
&
Johnson,
Medicis,
Novartis, Quinnova, Shire, Stiefel, Taisho, and 3M.
Novartis, Quinnova, Shire, Steifel, Taisho, and 3M.
Richard G. Fried, MD, PhD, has nothing to disclose.
Moise L.
L.Levy,
Levy,MD,
MD,has
hasbeen
been
a consultant
GlaxoSmithKline
and
Moise
a consultant
for for
GlaxoSmithKline
and SkinSkin-Medica.
Medica.
F. Webster,
Guy F.
Webster,MD,
MD,PhD,
PhD,has
hasbeen
beenaaconsultant
consultantfor
forAllergan,
Allergan,Cutanea,
Cutanea,
Cipher,Galderma,
Galderma,GlaxoSmithKline,
GlaxoSmithKline,Medicis,
Medicis,Ortho,
Ortho,and
andQuinnova.
Quinnova.
Cipher,
Address
Friedlander, MD,
MD, 805
805 Frost
FrostStreet,
Street,
Address reprint
reprint requests
requests to:
to: Sheila
Sheila F.
F. Friedlander,
Suite
Suite602,
602,San
SanDiego,
Diego,CA
CA92123.
92123.E-mail:
E-mail:[email protected].
[email protected].
4
2
Sørensen and colleagues1 in Denmark published the latest
data from the Copenhagen Puberty Study, in which 824 boys
were evaluated during the period 1991-1993 in a cross-sectional study, and compared with 704 boys who were evaluated in a combined cross-sectional and longitudinal study
during the period 2006-2008. The purpose of the study was
to assess trends in pubertal onset and the relationship of
those trends to body mass index in boys. The investigators
showed that the onset of puberty occurred significantly earlier during 2006-2008 (with a mean age of 11.66 years) than
in 1991-1993 (mean age, 11.92 years).
A number of articles have been published considering
whether and why sexual maturation may be occurring earlier
in the United States,2–11 but the conclusions regarding the US
data have been mixed. The National Health and Nutrition
Examination Surveys and other surveys have not clearly
demonstrated whether pubertal age is decreasing over time,
nor have they established whether socioeconomic and racial
factors may affect this. Nevertheless, epidemiologic evidence
does support the impression of many clinicians—including the
authors—that the average age of puberty has decreased.7,9
Some propose that nutrition may be one explanation for earlier onset of puberty in the United States—that is, that either
better nourishment accounts for the change, or that obesity
contributes to either a change in pubertal status or a change
in acne presentation.
Acne,Sexual
Sexual Maturation,
Acne,
and Pathophysiology
Maturation,
and Pathophysiology
A number of studies have examined the onset of acne in
relationship to sexual maturation, Propionibacterium acnes
colonization, and sebaceous gland activity. Lucky and coFacing the Challenge of Acne Vulgaris in Pediatric Patients
workers
workers were
were the
the first
first to
to demonstrate
demonstrate that
that aa surge
surge in
in dehydehydroepiandrosterone
sulfate,
a
harbinger
of
puberty,
is
associworkers
were
the
first
to
demonstrate
that
a
surge
in
dehydroepiandrosterone sulfate, a12harbinger of puberty, is associated
with
the
onset
of
acne.
Other
studies
by
Lucky
and
droepiandrosterone
harbinger
of puberty,
is associated with 13–15
the onset sulfate,
of acne.a12
Other studies
by Lucky
and
12
colleagues
showed
that
comedonal
acne
generally
ated with 13–15
the onset
of acne.
Other studies
by
Lucky preand
colleagues
showed
that
comedonal
acne
generally
pre13–15
ceded
other
external
signs
of
puberty
and
that
elevated
horcolleagues
showed
that
comedonal
acne
generally
preceded other external signs of puberty and that elevated hormone
more
acne.
ceded
other predicted
external signs
puberty
and that elevated hormone levels
levels
predicted
moreofsevere
severe
acne.
Another
interesting
line
of
study
is
the
mone
levels
predicted
more
severe
acne.
Another interesting line of study is the correlation
correlation of
of sebasebaceous
gland
activity,
P
acnes
colonization,
and
pubertal
age.
Another
interesting
line
of
study
is
the
correlation
of sebaceous gland activity, P acnes
colonization,
and
pubertal
age.
16 conducted a longitudinal study
Mourelatos
and
colleagues
ceous
gland
activity,
P
acnes
colonization,
and
pubertal
age.
Mourelatos and colleagues16
conducted
a
longitudinal
study
16 conducted
demonstrating
that,
initially,
a
small
number
of
follicles
Mourelatos
and
colleagues
a
longitudinal
study
demonstrating that, initially, a small number of follicles sesecrete
that
the
secreting
demonstrating
that,
initially,
a smallof
folliclesand
secrete sebum,
sebum, and
and
that
the number
number
ofnumber
secretingoffollicles
follicles
and
the
areas
of
the
skin
that
contain
these
follicles
increase
with
crete
sebum,
and
that
the
number
of
secreting
follicles
and
the areas of the skin that contain these follicles increase with
age
and
stage.
study
showed
that
who
the
of the skin
thatThis
contain
follicles
increase with
age areas
and pubertal
pubertal
stage.
This
studythese
showed
that children
children
who
develop
acne
have
greater
sebum
production
as
well
as
age
and
pubertal
stage.
This
study
showed
that
children
develop acne have greater sebum production as well who
as aa
greater
density
of
P
acnes
in
the
sebum-producing
areas
of
develop
acne
have
greater
sebum
production
as
well
greater density of P acnes in the sebum-producing areas ofasthe
thea
skin.
However,
P
acnes
colonization
alone,
as
demonstrated
greater
density
of
P
acnes
in
the
sebum-producing
areas
of
the
skin. However, P acnes colonization alone, as demonstrated
by
nasal
colonization
counts,
did
not
correlate
with
the
deskin.
However,
P
acnes
colonization
alone,
as
demonstrated
by nasal colonization counts, did not correlate with the development
of
colonization
did
by
nasal colonization
counts,nasal
did not
correlate with
the development
of acne,
acne, although
although
nasal
colonization
did increase
increase
with
increasing
age.
velopment
of
acne,
although
nasal
colonization
did
increase
with increasing age.
The
newest
with
age. concerning
Theincreasing
newest data
data
concerning acne
acne pathophysiology
pathophysiology demdemonstrate
that
the
relationships
between
the
of
The
newest
data
concerning
acne
onstrate that the relationships betweenpathophysiology
the development
developmentdemof P
P
acnes,
inflammation,
and
hyperkeratinization
are
more
comonstrate
that
the
relationships
between
the
development
of P
acnes, inflammation, and hyperkeratinization are more complex
previously
has
recognized.
the
past
was
acnes,
inflammation,
hyperkeratinization
plex than
than
previously and
has been
been
recognized. In
In are
the more
past it
itcomwas
believed
that,
initially,
a
keratinized
plug
develops,
then
anplex
than
previously
has
been
recognized.
In
the
past
it
believed that, initially, a keratinized plug develops, then was
androgens
cause
sebaceous
gland
activation,
P
acnes
proliferbelieved
that, initially,
a keratinized
plug develops,
androgens cause
sebaceous
gland activation,
P acnes then
proliferates,
and
the
immune
response
produces
inflammation.
drogens
cause
sebaceous
gland
activation,
P
acnes
proliferates, and the immune response produces inflammation.
However,
has
that
inflammatory
ates,
and evidence
the immune
responseshowing
produces
However,
evidence
has emerged
emerged
showing
thatinflammation.
inflammatory
events
can
precede
microcomedone
formation
and
However,
evidence
has
emerged
showing
that
events can precede microcomedone formationinflammatory
and that
that the
the
development
of
plugs
is
influenced,
to
some
degree,
by
inevents
can
precede
microcomedone
formation
and
that
the
development of plugs is influenced,
to
some
degree,
by
in17
flammation
caused
by
P
acnes.
development
of
plugs
is
influenced,
to
some
degree,
by
inflammation caused by P acnes.17
17
Theories
regarding
the
sequence
of
events
in
acne
develflammation
caused
by
P
acnes.
Theories regarding the sequence of events in acne development
have
evolved
years.
is
that
acnes
Theories
therecent
sequence
in acne
opment
haveregarding
evolved in
in
recent
years.ofIt
It events
is known
known
that P
Pdevelacnes
contributes
to
inflammation
through
activation
of
the
innate
opment
havetoevolved
in recent
years. It
is knownofthat
acnes
contributes
inflammation
through
activation
thePinnate
immune
system,
including
complement
and
toll-like
recepcontributes
to
inflammation
through
activation
of
the
innate
immune system, including complement and toll-like receptors,
that
proliferator-activated
receptors
immune
including complement
and toll-like
receptors, and
andsystem,
that peroxisome
peroxisome
receptors
17 Second, andropartially
regulate
the
production
of
sebum.
tors,
and
that
peroxisome
receptors
17
partially regulate the production of sebum.17 Second, androgens
are
known
follicular
corneocytes—that
is,
partially
theinfluence
production
of sebum.
Second, androgens
are regulate
known to
to
influence
follicular
corneocytes—that
is,
androgens
do
not
just
mediate
acne
through
sebaceous
gland
gens
are
known
to
influence
follicular
corneocytes—that
is,
androgens do not just mediate acne through sebaceous
gland
17 Third,
activity,
they
also
have
an
impact
on
keratinization.
androgens
do
not
just
mediate
acne
through
sebaceous
gland
activity, they also have an impact on keratinization.17
Third,
17 Third,
oxidized
lipids
in
stimulate
inflammatory
activity,
also
have ancan
impact
on keratinization.
oxidizedthey
lipids
in sebum
sebum
can
stimulate
inflammatory mediamediators,
and
it
that
can
oxidized
in sebum
can stimulate proteins
inflammatory
mediators, 17
and lipids
it is
is clear
clear
that inflammatory
inflammatory
proteins
can mediate
mediate
acne.
These
mediators
include
certain
matrix
metalloprotors,
and
it
is
clear
that
inflammatory
proteins
can
mediate
17
acne.17 These mediators include certain matrix metalloproteinases,
which
are
in
it
been
shown
acne. These
include
certain
matrix
teinases,
whichmediators
are present
present
in sebum;
sebum;
it has
has
beenmetalloproshown that
that
the
production
of
these
matrix
metalloproteinases
decreases
teinases,
which
are
present
in
sebum;
it
has
been
that
the production of these matrix metalloproteinasesshown
decreases
17,18
after
the
resolution
of
acne
lesions
with
treatment.
the
production
of
these
matrix
metalloproteinases
decreases
after the resolution of acne lesions with treatment.17,18
17,18 sebaFourth,
and
it
has
that
after
the resolution
of acne
lesions
withshown
treatment.
Fourth,
and finally,
finally,
it also
also
has been
been
shown
that the
the sebaceous
gland
is
part
of
a
neuroendocrine
organ;
it
is
yet
Fourth,
and
finally,
it
also
has
been
shown
that
sebaceous gland is part of a neuroendocrine organ; it isthenot
not
yet
known
how
activity
be
ceous
is part of agland
neuroendocrine
organ;
it is not usyet
knowngland
how sebaceous
sebaceous
gland
activity might
might
be mediated
mediated
using
the
neuroendocrine
inflammatory
apparatus,
but
this
known
how
sebaceous
gland
activity
might
be
mediated
using the neuroendocrine inflammatory apparatus, but
this
17
represents
an
research
in
ing
the neuroendocrine
inflammatory
but
17 this
represents
an area
area for
for potential
potential
research apparatus,
in the
the future.
future.
17
Another
intriguing
of
concerns
possibility
represents
area forline
potential
research
in thethe
future.
Another an
intriguing
line
of research
research
concerns
the
possibility
19
of
preventing
acne.
and
developed
an
intriguing
line of research
concerns
possibility
19 the
of Another
preventing
acne. Nakatsuji
Nakatsuji
and colleagues
colleagues
developed
an
19with
experimental
vaccine
by
inactivating
P
acnes
heat
and
of
preventing
acne.
Nakatsuji
and
colleagues
developed
an
experimental vaccine by inactivating P acnes with heat and
administered
it
intranasally
to
mice.
The
investigators
reexperimental
vaccine
by
inactivating
P
acnes
with
heat
and
administered it intranasally to mice. The investigators reported
in
protective
immunity
administered
it intranasallyresulted
to mice.
investigators
reported that
that immunization
immunization
resulted
in The
protective
immunity
against
P
acnes
in
vivo
and
that
the
immunized
mice
also
ported
that
immunization
resulted
in
protective
immunity
against P acnes in vivo and that the immunized mice also
developed
antibodies
to
P
their
producagainst
P acnes
in vivo
thatand
thedecreased
immunized
also
developed
antibodies
to and
P acnes
acnes
and
decreased
theirmice
production
of
interleukin-8,
a
protein
important
in
the
development
developed
antibodies
to
P
acnes
and
decreased
their
production of interleukin-8, a protein important in the development
tion of interleukin-8, a protein important in the development
of
of human
human sebocytes.
sebocytes. It
It is
is not
not known
known whether
whether immunization
immunization
would
mediate
the
development
of
acne
in
humans.
of
human
sebocytes.
It
is
not
known
whether
immunization
would mediate the development of acne in humans.
would mediate the development of acne in humans.
Notes
on
Notes
ononAcne
Acne
Notes
Acne
Notes
on Acne
Pathophysiology
Pathophysiology
Pathophysiology
Pathophysiology
in
Younger
Patients
in in
Younger
Patients
Younger
Patients
in
Younger Patients
The presentation of acne in younger pediatric patients typiThe presentation of acne in younger pediatric patients typically
differs
observed
in
with
aa later
The
of acne
in younger
pediatric
typicallypresentation
differs from
from that
that
observed
in patients
patients
withpatients
later onset
onset
of
The
presentation
in
patients
to
cally
differs
that observed
in patients
with atends
later onset
of acne.
acne.
Thefrom
presentation
in younger
younger
patients
tends
to be
be
characterized
by
noninflammatory,
comedonal
lesions.
of
acne.
The
presentation
in
younger
patients
tends
be
characterized by noninflammatory, comedonal lesions.toThe
The
explanation
for
this
difference
is
determined
on
the
basis
characterized
by
noninflammatory,
comedonal
lesions.
The
explanation for this difference is determined on the basis of
of
the
aforementioned
evidence.
It
is
clear
that
sebum
in
necesexplanation
for
this
difference
is
determined
on
the
basis
of
the aforementioned evidence. It is clear that sebum in necessary
for
skin,
along
with
imisthe
the
evidence.of
is clear
sebum
necessaryaforementioned
for P
P acnes
acnes colonization
colonization
ofIt the
the
skin,that
along
within
the
immune
response
that
results
in
the
development
of
inflammasary
for
P
acnes
colonization
of
the
skin,
along
with
the
immune response that results in the development of inflammatory
papules,
pustules,
and
nodules.
Younger
patients
mune
response
that
results
in
the
development
of
inflammatory papules, pustules, and nodules. Younger patients do
do
develop
follicular
plugs
comedones,
they
tory
papules,
pustules,
andvisible
nodules.
Youngerbut
patients
do
develop
follicular
plugs and
and
visible
comedones,
but
they have
have
not
yet
begun
to
produce
sufficient
sebum
to
support
large
develop
follicular
plugs
and
visible
comedones,
but
they
have
not yet begun to produce sufficient sebum to support large
numbers
of
bacteria.
not
yet begun
to produce
sufficient sebum to support large
numbers
of P
P acnes
acnes
bacteria.
numbers of P acnes bacteria.
Conclusions
Conclusions
Conclusions
Conclusions
Epidemiologic evidence from US studies has supported the clin-
Epidemiologic evidence from US studies has supported the clinical
of
practitioners
regarding
an
of
Epidemiologic
US studies
has supported
theage
clinical impression
impressionevidence
of7,9many
many from
practitioners
regarding
an earlier
earlier
age
of
Further
investigations
are
needed
to
clarify
onset
of
puberty.
ical
impression
of
many
practitioners
regarding
an
earlier
age
of
7,9
onset of puberty.7,9 Further investigations are needed to clarify
the
that
be
with
The
investigations
are shift.
needed
to earlier
clarify
onset
of puberty.
the factors
factors
that may
mayFurther
be associated
associated
with this
this
shift.
The
earlier
onset
of
acne
now
is
seen
more
frequently
in
patients
between
the
factors
that
may
be
associated
with
this
shift.
The
earlier
onset of acne now is seen more frequently in patients between 8
8
and
age.
evidence
regarding
acne
onset
acne of
now
seen more
frequently
in patients
between 8
and 11
11ofyears
years
of
age.isRecent
Recent
evidence
regarding
acne pathophyspathophysiology
explain
the
presentation
of
and
11helps
years of
age. Recent
evidence in
regarding
acne pathophysiology
helps
explain
the difference
difference
in
presentation
of acne
acne in
in
younger
versus
older
children
and
teenagers.
iology
helps
explain
the
difference
in
presentation
of
acne
in
younger versus older children and teenagers.
younger versus older children and teenagers.
References
References
1. Sørensen K, Aksglaede L, Petersen JH, et al: Recent changes in pubertal
References
1. Sørensen K, Aksglaede L, Petersen JH, et al: Recent changes in pubertal
timing in K,
healthy
Danish
boys: Associations
withchanges
body mass
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1. Sørensen
Aksglaede
L, Petersen
JH, et al: Recent
in pubertal
timing in healthy
Danish
boys: Associations
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Jtiming
Clin Endocrinol
Metab
95:263-270,
2010
in healthy Metab
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J Clin Endocrinol
2010 with body mass index.
2. Biro
Lucky AW,
Huster
GA, et al: Pubertal
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J ClinFM,
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2. Biro
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Lucky AW,
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GA, et al: Pubertal
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2. Biro
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Lucky
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Huster
GA,
et
al:
Pubertal
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3. Euling
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ME, Lee PA, et al: Examination of US
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3. Euling
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ME, Lee PA, et al: Examination of US
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Lee PA,
et al: Examination
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2008
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puberty-timing
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secular
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Panel
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4. Foster
TA, Voors
AW, Webber
LS,(suppl)
et al: Anthropometric and matings. Pediatrics
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2008
4. Foster
TA, Voors
AW, Webber
LS, et al: Anthropometric and maturation
measurements
of
children,
ages
to 14 years, in aand
biracial
4. Foster
Voors AW, Webber
LS, et
al: 5
maturationTA,
measurements
of children,
ages
5Anthropometric
to 14 years, in a biracial
community—The
Bogalusa
Heart Study.
Am
J Clin
Nutr
30:582uration
measurements
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children,
ages
5
to
14
years,
in
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biracial
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1977
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5. Harlan
WR, Grillo GP, Cornoni-Huntley J, et al: Secondary sex charac591, 1977
5. Harlan
WR, Grillo GP, Cornoni-Huntley J, et al: Secondary sex characteristicsWR,
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5. Harlan
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J, et U.S.
al: Secondary
sex characteristics of boys
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17 years of age: The
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Survey. JofPediatr
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1979
teristics
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12
to
17
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The
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6. Herman-Giddens
ME, Wang 1979
L, Koch G: Secondary sexual characSurvey. J Pediatr 95:293-297,
6. Herman-Giddens
ME, Wang L, Koch G: Secondary sexual characteristics in boys: Estimates
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the National
Health sexual
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6. Herman-Giddens
ME,
Wang
L, Koch
G: Secondary
characteristics in boys: Estimates from
the National
Health and Nutrition
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III, 1988-94.
Arch
Pediatr
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Med
155:
teristics
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boys:
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from
the
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and
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Examination Survey III, 1988-94. Arch Pediatr Adolesc Med 155:
1022-1028,
2001
Examination
Survey
III,
1988-94.
Arch
Pediatr
Adolesc
Med
155:
1022-1028, 2001
7. Herman-Giddens
Recent data on pubertal milestones in United
1022-1028, 2001ME:
7. Herman-Giddens
ME: Recent data on pubertal milestones in United
States children: The
earliermilestones
development.
Int J
7. Herman-Giddens
ME:secular
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States children: The
secular
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PB, Oberfield
SE: Reexamination of the age limit for defining
Androl 29:241-246,
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8. Kaplowitz
PB, Oberfield
SE: Reexamination of the age limit for defining
when puberty
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8. Kaplowitz
PB, Oberfield
SE: Reexamination
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limitImplications
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States:
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the
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States:
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andLawson
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DrugPediatric
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atrics 104:936-941, 1999
atrics 104:936-941, 1999
continued on page 15
5
Lawrence F. Eichenfield,
MD,* Joseph F. Fowler,
Jr, MD, Sheila F. Friedlander, MD,*
Diagnosis
and
Evaluation
of
Acne
Moise L. Levy, MD, and Guy F. Webster, MD, PhD
†
‡
§
Lawrence F. Eichenfield, MD,* Joseph F. Fowler, Jr, MD,† Sheila F. Friedlander, MD,*
Moise L. Levy, MD,‡ and Guy F. Webster, MD, PhD§
The diagnosis of acne usually can be made on the basis of a history and physical
examination. The differential diagnosis includes a variety of possible causes and differs
according to age group (mid-childhood, 1-7 years of age; pre-, peri-, and early pubertal,
8-11 years of age; pubertal/postpubertal, >12 years of age). The presentation of acne in
adolescents tends to include both noninflammatory and inflammatory lesions, whereas in
younger patients noninflammatory comedones are typical. Keratosis pilaris affecting the
cheeks sometimes may be confused with early acne vulgaris. Screening tests, particularly
bone age, may be considered to support the clinical diagnosis in younger children. Further
testing usually is not indicated unless patients show signs of virilization.
T
he presentation of acne vulgaris differs according to the
age at onset. The signs and symptoms of acne vulgaris in
patients 12 years of age and older has been thoroughly and
well described and in most cases are readily recognized. Often these patients have both noninflammatory lesions (comedones) and inflammatory lesions (papules, pustules, and/or
cystic lesions).
*Rady
Children’s
Hospital,
UCSD School
†University
of Louisville,
Louisville,
KY. of Medicine, San Diego, CA.
†University
of Louisville, Louisville, KY.
‡Baylor College of Medicine, Houston, TX.
‡Baylor College of Medicine, Houston, TX.
§Jefferson Medical College, Philadelphia, PA.
§Jefferson
Publication of
of this
this CME
Publication
CME article
article was
was sponsored
sponsored by
by the
theUniversity
Universityof
ofLouisville
Louisville
Continuing
Health
Sciences
Education
Disease
Education
Continuing
Health
Sciences
Education
and and
Skin Skin
Disease
Education
FounFoundation
and supported
by an educational
grant
from Ortho
dation
and supported
by an educational
grant from Ortho
Dermatologics.
Dermatologics.
Lawrence F. Eichenfield, MD, has served as a speaker for Coria. He has also
Lawrence
F. Eichenfield,
hasconsultant
served as afor
speaker
for Coria.
He hasOrtho
also
been an
investigator MD,
and/or
Johnson
& Johnson,
Joseph F. Fowler, Jr, MD, has been a consultant for Galderma, Graceway,
Joseph
F. Fowler,
Jr, MD,
has been
a consultant
for Galderma,
Graceway,
Hyland,
Johnson
& Johnson,
Quinnova,
Ranbaxy,
Shire, Stiefel,
Triax,
Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Stiefel, Triax,
Shire,
been an
an investigator
investigator for
for
Shire,Stiefel,
Stiefel,UCB,
UCB,and
andValeant.
Valeant. He
He has
has also
also been
Abbott,
Astellas, Centocor,
Centocor, Coria,
Coria,
Abbott,Taro,
Taro,Allerderm,
Allerderm,Allergan,
Allergan, Amgen,
Amgen, Astellas,
Dermik,
& Johnson,
Johnson, Medicis,
Medicis,
Dermik,Dow,
Dow,Galderma,
Galderma, Genentech,
Genentech, Johnson
Johnson &
Novartis,
Novartis,Quinnova,
Quinnova,Shire,
Shire,Steifel,
Stiefel,Taisho,
Taisho, and 3M.
Sheila
been
a consultant
for Astellas,
Barrier
TherSheila F.F. Friedlander,
Friedlander,MD,
MD,has
has
been
a consultant
for Astellas,
Barrier
apeutics,
Galderma,
Graceway,
Novartis,
and sanofi-aventis.
She hasShe
also
Therapeutics,
Galderma,
Graceway,
Novartis,
and sanofi-aventis.
received
research
from Atlanta,
Amgen,Amgen,
Astellas,Astellas,
Barrier
has alsogrant
received
grant support
research support
from Atlanta,
JohnsonLEO
&
Therapeutics,
Galderma, Galderma,
Johnson & Johnson,
Johnson, LEO Pharmaceuticals,
Novartis, OrthoNeutrogena,
Photocure,
Pharmaceuticals,
Novartis, OrthoNeutrogena,
Photocure, Pierre-Fabre,
Pierre-Fabre,
and Dow.
RegeneRx,
and RegeneRx,
Dow.
Moise L.
L.Levy,
Levy,MD,
MD,has
hasbeen
beena consultant
a consultant
GlaxoSmithKline
and
Moise
for for
GlaxoSmithKline
and SkinSkin-Medica.
Medica.
Guy F.
Webster,MD,
MD,PhD,
PhD,has
hasbeen
beenaaconsultant
consultantfor
forAllergan,
Allergan,Cutanea,
Cutanea,
F. Webster,
Cipher,Galderma,
Galderma,GlaxoSmithKline,
GlaxoSmithKline,Medicis,
Medicis, Ortho,
Ortho, and Quinnova.
Cipher,
Address reprint requests to Lawrence F
F.. Eichenfield,
Eichenfield,MD,
MD,8010
8010Frost
FrostStreet,
Street,
Suite602,
602,San
SanDiego,
Diego,CA
CA92123.
92123.E-mail:
E-mail:[email protected].
[email protected].
Suite
6
In contrast, acne in younger patients typically is noninflammatory, characterized by comedones on the nose, midface, and forehead (Fig. 1). The number of lesions ranges
from just a few to 100 or more. In a study of a topical medication, Eichenfield and colleagues1 found that the median
number of lesions in 8- to 11-year-old children enrolled in
their clinical trial was between 50 and 60. In more than one
half of these patients, the lesions were located on the forehead
or forehead plus other facial areas; approximately 4 in 10
children had comedonal lesions on the nose or nose plus
other facial areas.
Figure 1 Mild acne in a prepubertal boy. Acne in pediatric patients
between approximately 8 and 11 years of age typically presents as
mild comedonal disease on the nose, midface, and forehead. Photograph courtesy of Moise L. Levy, MD.
5
L.F. Eichenfield et al
6
Table 1 Differential Diagnosis of Acne in Younger Pediatric
Table
Differential
Diagnosis of
Younger
Pediatric
and
Adolescent
Patients
Table
1 1Differential
Diagnosis
ofAcne
Acneinin
Younger
Pediatric
and
Adolescent
Patients
and Adolescent Patients
Pubertal/postpubertal (�12-18 years of age)
Pubertal/postpubertal
(≈12-18
yearsyears
of age)
Corticosteroid-induced
acne
Pubertal/postpubertal
(�12-18
of age)
acne acne
Demodex folliculitis
Demodex
folliculitis
Gram-negative
folliculitis
Demodex
folliculitis
Gram-negative
folliculitis
Keratosis
pilaris
Gram-negative
folliculitis
Keratosis
pilaris
Malassezia
(pityrosporum) folliculitis
Keratosis
pilaris
Papular
sarcoidosis
Malassezia
(Pityrosporum)
folliculitis
Malassezia
(pityrosporum
) folliculitis
Perioral
dermatitis
Papular
sarcoidosis
Papular
sarcoidosis
Pseudofolliculitis
Perioral
dermatitisbarbae
Perioral
dermatitis
Tinea faciei barbae
Pseudofolliculitis
barbae
Pseudofolliculitis
Prepubertal/peripubertal
(�8-11 years of age)
Tinea
faciei
Tinea
faciei
Acne venenata or pomade
acne
(from
the
use of
(�8-11
of age)
(≈8-11
yearsyears
of age)
topical
oil-based
products)
Acne
venenata
or pomade
Acne
venenata
or pomade
acneacne (from the use of
or adenoma
sebaceum
topical
oil-based
products)
Angiofibromas
(from
the use
of topical
oil-based
products)
acnesebaceum
Angiofibromas
or adenoma
Angiofibromas
or adenoma
sebaceum
Flat
warts
acne acne
Keratosis
Flat
warts pilaris
Flat warts
Milia
Keratosis
pilaris
Keratosis
pilaris
Molluscum
contagiosum
Milia
Milia
Perioral
dermatitis
Molluscum
contagiosum
Molluscum contagiosum
Syringomas
Perioral
dermatitis
Perioral dermatitis
Mid-childhood/prepubertal
(1-7 years of age)
Syringomas
Syringomas
Adrenal
tumors
Mid-childhood/prepubertal
(1-7
years
of age)
Mid-childhood/prepubertal (1-7
years
of age)
Congenital
adrenal
hyperplasia
Adrenal
tumors
Adrenal tumors
Cushing’s
syndrome
Congenital
adrenal
hyperplasia
Congenital
adrenal
hyperplasia
Gonadal
tumors
Cushing’s
syndrome
Cushing’s syndrome
Ovarian
Gonadal tumors
tumors
Gonadal
tumors
Polycystic
ovary syndrome
Ovarian tumors
Ovarian tumors
Premature
adrenarche
Polycystic ovary
syndrome
Polycystic ovary syndrome
True
precocious
puberty
Premature
adrenarche
Premature adrenarche
Any
ageprecocious puberty
True
True precocious puberty
Acne
Any
agevenenata or pomade acne (from the use of
Any age
topical
oil-based
products)
Acne
venenata
or pomade
acne (from the use of
Acne
venenata or pomade
acne
Bilateral
comedonicus
topicalnevus
oil-based
products)
Chlorinated
(from the use aromatic
of topical
oil-based
products)
hydrocarbons
(chloracne)
Bilateral nevus
comedonicus
Bilateral
nevus
comedonicus
Corticosteroids
(topical,
inhaled, oral)
Chlorinated aromatic
hydrocarbons
(chloracne)
Chlorinated
aromatic(topical,
hydrocarbons
(chloracne)
Demodicidosis
Corticosteroids
inhaled,
oral)
Corticosteroids
(topical, inhaled,
oral) sclerosis)
Facial
angiofibromas
(tuberous
Demodicidosis
Demodicidosis
Flat
warts
Facial
angiofibromas (tuberous sclerosis)
Facial
(tuberous
Infections
viral,sclerosis)
fungal)
Flat angiofibromas
warts (bacterial,
Flat
warts pilaris
Keratosis
Infections
(bacterial, viral, fungal)
Infections
(bacterial,
fungal) steroids, dactinomycin,
Medication-induced
(anabolic
Keratosis
pilaris viral,
Keratosis
pilaris
gold, isoniazid, lithium,
progestins)
Medication-induced
(anabolicphenytoin,
steroids, dactinomycin,
Medication-induced
(anabolic
dactinomycin,
Milia
gold, isoniazid,
lithium,steroids,
phenytoin,
progestins)
gold,Miliaria
isoniazid, lithium, phenytoin, progestins)
Milia
Milia
Molluscum
contagiosum
Miliaria
Miliaria
Periorificial
dermatitis
Molluscum contagiosum
Molluscum
contagiosum
Rosacea
Periorificial
dermatitis
Periorificial
dermatitis
Rosacea
Reprinted with permission.2,4
Rosacea
Reprinted with permission.2,4
Adapted with permission.2,4
As previously discussed (see “Acne Epidemiology and
As previously discussed
(seeearliest
“Acnepresentation
Epidemiology
and
Pathophysiology,”
page 42), the
of acne
Pathophysiology,”
page 2), thebecause
earliestsebum
presentation
of acne
tends
to be noninflammatory
production
in
tends to be
noninflammatory
because
sebum
production
in
younger
patients
usually is not
sufficiently
high
to support
younger
patients
usually
is
not
sufficiently
high
to
support
high numbers of Propionibacterium acnes bacteria. High P
high
Propionibacterium
acnescutaneous
bacteria.immune
High P
acnes numbers
counts, inofturn,
prompt a vigorous
acnes counts,
in turn, prompt
a vigorous
cutaneous immune
response
in susceptible
patients,
and inflammatory
papules
response in susceptible patients, and inflammatory papules
appear.
appear.
Differential Diagnosis
Differential2Diagnosis
Diagnosis
Differential
Tom and Friedlander published a case-illustrated review of
2 published a case-illustrated review of
Tom conditions
and Friedlander
acne
that mimic
acne through childhood and adacne conditions
that mimic to
acne
childhood
and age
adolescence.
The conditions
be through
considered
in various
olescence.
conditions
considered inbetween
variousacne
age
groups
are The
shown
in Table to
1. be
Distinguishing
groups
are shown
in Tablecondition
1. Distinguishing
between
acne
and
another
dermatologic
or disease
typically
is
and another
condition
or disease acne
typically
is
easier
in very dermatologic
young patients:
True inflammatory
is rare
easier
in
very
young
patients:
True
inflammatory
acne
is
rare
in children between 1 and 8 years of age.
in However,
children between
1 and
8 years
of age.of adrenal androgens
an increase
in the
production
3 andandrogens
However, an
the production
adrenal
(adrenarche)
canincrease
begin asinearly
as 7 years ofofage,
acne may
and acne may
(adrenarche)
can sign
beginofaspuberty,
early aseven
7 years
of age,
occur
as an early
before
the3 appearance
of
occur as
aninearly
of and
puberty,
before
the appearance
of
pubic
hair
bothsign
boys
girls,even
areolar
development
in girls,
pubic
hair in both
boys and
development
in girls,
and
testicular
enlargement
ingirls,
boys areolar
(Table 2).
Dermatologic
conand testicular
enlargement
boys
2).and
Dermatologic
conditions
that should
be ruledinout
via(Table
history
physical examditions
that
should
be
ruled
out
via
history
and
physical
examination include keratosis pilaris, milia and microcysts, rosacea
ination
include keratosis
pilaris,
milia causes,
and microcysts,
rosacea
from corticosteroid
exposure
or other
periorificial
der4,5
from corticosteroid
exposure or other causes, periorificial dermatitis,
and demodicidosis.
matitis,
and
If there
is demodicidosis.
no evidence to 4,5
suggest any of these other causes—
no evidence
to suggest
any of these
andIf there
unlessis signs
of hormonal
pathology
are other
notedcauses—
on the
and unless
signs of hormonal
pathology
are can
noted
on the
physical
examination—acne
in this
age group
be considphysical
examination—acne
this ageclinical
group can
be considered
as normal,
requiring noin further
workup.
The
ered as normal,
requiring
no further
clinical
indications
for further
diagnostic
testing
in workup.
younger The
and
indications
for
further
diagnostic
testing
in
younger
and
older pediatric patients with acne are summarized in Table
3.
older pediatric patients with acne are summarized in Table 3.
Evaluation of Severity
Evaluationof
ofSeverity
Severity
Evaluation
In clinical research studies, lesion counts— quantifying the
In clinical
research
studies,
lesion counts—
quantifying
the
number
and
types of
lesions—and
investigator
and patient
number and types of lesions—and
investigator
patient
severity/improvement
scores are used
to evaluateand
disease
seseverity/improvement
scores
are
used
to
evaluate
disease
severity and assess treatment efficacy. However, no standardveritymethod
and assess
treatment
efficacy.
However,
no standardized
has been
widely
accepted
for the assessment
of
ized method
hasclinical
been widely
accepted
for the assessment
of
acne
in routine
practice,
and a qualitative
evaluation
acne
routine clinical
practice,
anddoa agree
qualitative
evaluation
is,
byin
definition,
subjective.
Experts
generally
on the
is, by definition,
subjective.
Experts
agree generally
on the
factors
that should
be considered.
A do
qualitative
assessment
of
factorsseverity
that should
be considered.
qualitative
of
acne
is useful
in helpingAthe
clinicianassessment
decide how
acne severity
is treatment
useful in helping
the clinician
decide how
aggressive
early
efforts should
be.
aggressive
treatment
efforts
shouldmay
be. not be practical
Althoughearly
counting
lesions
obviously
Although
counting
lesions
obviously
may
be practical
or reasonable outside of a research setting, annot
overall
impresor reasonable
outside
of a research
overall impression
of whether
a patient
has just setting,
a few, aan
moderately
large
sion of whether
patientcan
hasbe
just
a few,
a moderately
large
number,
or manya lesions
made
(Figs.
2-4). Generally,
number,
or many
lesions of
caninflammatory
be made (Figs.
2-4). Generally,
the
greater
the number
lesions,
the more
the greater
the number
of inflammatory
lesions,
the more
severe
the disease.
In addition,
any evidence
of scarring
or
severe the disease.should
In addition,
any evidence
scarring or
dyspigmentation
be considered
as anofindicator
of
dyspigmentation should be considered as an indicator of
Table 2 Screening Tests for Androgen Excess
Bone age (physiological assessment of androgenicity)
Bone
age
(physiological
assessment
of androgenicity)
Laboratory
tests
Bone
age
(physiological
assessment
of androgenicity)
Laboratory
tests
DHEA/DHEA-S
Laboratory
tests
DHEA/DHEA-S
Follicle-stimulating
hormone
DHEA/DHEA-S
Free
testosterone
(or
total testosterone)
hormone
hormone
Luteinizing
hormone
Free
testosterone
(or testosterone)
total testosterone)
Free
testosterone
(or total
Prolactin
Luteinizing
hormone
Luteinizing
hormone
SeventeenProlactin �-hydroxyprogesterone
Prolactin
Seventeen�-hydroxyprogesterone
4
Reprinted
with permission.
Seventeen-α-hydroxyprogesterone
DHEA,
dehydroepiandrosterone;
DHEA-S, dehydroepiandrosterone
Reprinted
with permission.4
Reprinted with permission.4
sulfate.
DHEA,
dehydroepiandrosterone;
DHEA-S, dehydroepiandrosterone
DHEA, dehydroepiandrosterone; DHEA-S, dehydroepiandrosterone
sulfate.
sulfate.
7
With
Children
between
and 11 years
of ageTesting
with acne
Table
3Acne
Indications
for8 Further
Diagnostic
in Patients
should be referred for further workup by a
With
Acne
Table
3
Indications
for
Further
Diagnostic
Testing
in
Children
between
8
and
11
years
of
age
with
acne
Table 3 Indications
for Further Diagnostic
Testing in Patients
Patients
pediatric endocrinologist
if:
Table
3
Indications
for
Further
Diagnostic
Testing
inaPatients
With
Acne
should
be
referred
for
further
workup
by
With
Acne
Children
between
8
and
11
years
of
age
with
acne
is recalcitrant despite appropriate therapy,
WithAcne
Acne
pediatric
if: workup by a
should
beendocrinologist
referred
for further
and/or
Children
between
88 and
11
of
Children
between
and despite
11 years
yearsappropriate
of age
age with
with acne
acne
Acne
is
recalcitrant
therapy,
pediatric
endocrinologist
Children
between
8referred
and
years
ofif:
age
with
acne
Screening
tests
are11performed
and
yield
abnormal
should
be
for
further
workup
by
aa
should
be
referred
for
further
workup
by
and/or
Acne
is
recalcitrant
despite
appropriate
therapy,
should be
referred
for
further
workup
by
a
pediatric
results,
and/or
pediatric
endocrinologist
if:
pediatric
endocrinologist
if: and yield abnormal
Screening
tests
are performed
endocrinologist
if:
The and/or
patient
has signs despite
of virilization
(androgen
excess):
Acne
is
recalcitrant
appropriate
therapy,
Acne
is
recalcitrant
despite
appropriate
therapy,
results,
and/or
tests
are
performed
and therapy,
yield abnormal
• Screening
Acne
is
recalcitrant
despite
appropriate
Accelerated
growth
and/or
and/or
The
patient has
signs of virilization (androgen excess):
results,
and/or
and/or
Advanced
bone
age
Screening
tests
are
performed
Screening
tests
are
performed and
and yield
yield abnormal
abnormal
Accelerated
growth
patient
hasare
signs
of virilization
(androgen
• The
Screening
tests
performed
and yield
abnormal excess):
Body
odor
results,
and/or
results,
and/or
Advanced
bone
age
Accelerated
growth
results,
and/or
Genital
maturation
The
patient
has
The
patient
has signs
signs of
of virilization
virilization (androgen
(androgen excess):
excess):
Body
odor
Advanced
bone
age
• The
patient
signs
of virilization (androgen excess):
Pubic
orhas
axillary
hair
Accelerated
growth
Accelerated
growth
Genital
maturation
Body
odor
–Advanced
Accelerated
growth
Pediatric
patients
ages
12 and older require further
bone
age
Advanced
bone
age
Pubic ormaturation
axillary
hair
Genital
–Body
Advanced
bone
age
diagnostic
workup
and/or referral if:
odor
Bodypatients
odor
Pediatric
ages
12 and older require further
Pubic
ormaturation
axillary
hair
–Genital
Body
odor
Screening
tests
are
performed
and yield abnormal
Genital
maturation
diagnostic
workup
and/or
referral
if: further
Pediatric
patients
ages
12
and older
require
results,
and/or
or
axillary
hair
–Pubic
Genital
maturation
Pubic or tests
axillary
Screening
arehair
performed
and yield
diagnostic
workup
and/or
referral
if: abnormal
Signs
including:
Pediatric
12
and
require
– Pubicofpatients
orvirilization
axillaryages
hairare
Pediatric
patients
ages
12present,
and older
older
require further
further
results,
and/or
Screening
tests
are performed
and yield
abnormal
Acanthosis
nigricans
diagnostic
workup
and/or
referral
if:
diagnostic
workup
and/or
referral
if:
Pediatric
patients
ages 12are
or older
require
further
Signs
of virilization
present,
including:
results,
and/or
Alopecia
(male
or performed
female
pattern)
Screening
tests
are
and
Screening
tests
are
performed
and yield
yield abnormal
abnormal
diagnostic
workup
and/or
referral
if:
Acanthosis
nigricans
Signs
of virilization
are present, including:
Hirsutism
results,
and/or
results,
and/or
• Screening
tests
are performed
yield abnormal
Alopecia
(male
or female and
pattern)
Acanthosis
nigricans
Infertility
Signs
of
virilization
Signs
ofand/or
virilization are
are present,
present, including:
including:
results,
Hirsutism
Alopecia
(male
or
female
pattern)
Infrequent
menses
Acanthosis
nigricans
Acanthosis
nigricans
• Signs
of virilization are present, including:
Infertility
Hirsutism
Polycystic(male
ovaries
Alopecia
or
or female
female pattern)
pattern)
– Alopecia
Acanthosis(male
nigricans
Infrequent
menses
Infertility
Truncal
obesity
Hirsutism
Hirsutism
ovaries
– Polycystic
Alopecia
(male
or
female
pattern)
Infrequent menses
Infertility
4
Reprinted
with permission.
Truncal
obesity
– Infertility
Hirsutism
Polycystic
ovaries
Infrequent
menses
Infrequent
menses
– Truncal
Infertility
4
obesity
Reprinted
with permission.
Polycystic
ovaries
Polycystic
ovaries
–Truncal
Infrequent
menses
obesity
Reprinted
with permission.
Truncal
obesity 4
– Polycystic ovaries
44
Reprinted
with
permission.
Reprinted
withdisease,
permission.
Truncal
obesityas should
more–
severe
the presence of hyperpigmen-
Reprintedin
with
permission.4
tation
darker-skinned
patients.
more severe
disease, as should
the presence of hyperpigmenIn
a
classic,
5-year,
longitudinal
study, Lucky and coltation
in
darker-skinned
patients.
more severe
disease, as should the presence of hyperpigmen6 showed
leagues
that
the
early
development
of severe
comeIn severe
ainclassic,
5-year,
longitudinal
study,ofLucky
and
coltation
darker-skinned
patients.
more
disease,
as should
the
presence
hyperpigmendonal
acne
in
prepubertal
girls
was
a
strong
predictor
of
later,
6 showed that the early development of severe comeleagues
In ainclassic,
5-year, longitudinal
study, Lucky and coltation
darker-skinned
patients.
inflammatory
acne. Although
scarring
is usually
thought
of as
6 showed
donal
acne
in
prepubertal
girls
was
a
strong
predictor
ofcomelater,
leagues
that
the
early
development
of severe
In
a
classic,
5-year,
longitudinal
study,
Lucky
and
colainflammatory
potential consequence
of inflammatory
lesions,thought
it is imporacne.
Although
is usually
of as
66 showed
donal acne
in prepubertal
girlsscarring
was
a strong
predictor
ofcomelater,
leagues
that
the
early
development
of
severe
tant
to noteconsequence
that scarringofalso
may be associated
with
diffuse
a potential
inflammatory
lesions,
it isofimporinflammatory
acne. Although
scarring
is usually
thought
of as
donal
acne inacne.
prepubertal
girls
was a strong
predictor
later,
comedonal
tant
to
note
that
scarring
also
may
be
associated
with
diffuse
a
potential
consequence
of
inflammatory
lesions,
it
is
imporinflammatory acne. Although scarring is usually thought of as
acne.
tant
to noteconsequence
that scarringofalso
may be associated
diffuse
acomedonal
potential
inflammatory
lesions,with
it is imporcomedonal
tant
to note acne.
that scarring also may be associated with diffuse
comedonal acne.
Figure 3 Moderate pediatric acne in a 10-year-old girl. This photo
demonstrates the typical distribution of moderate acne, which is
Figure 3 Moderate pediatric acne in a 10-year-old girl. This photo
more prominent on the forehead, nose, and chin and is less promdemonstrates
the typical
distribution
of moderategirl.
acne,
which is
Figure
3 Moderate
pediatric
in a 10-year-old
This
inent on
the cheeks.
Photo acne
courtesy
of Catalina Matiz,
MD,photo
and
more
prominent
on
the
forehead,
nose,
and
chin
and
is
less
promdemonstrates
the typical
distribution
of moderategirl.
acne,
which
is
Lawrence
F. Eichenfield,
MD.
Figure
33 Moderate
pediatric
acne
in
aa 10-year-old
This
photo
Figure
Moderate
pediatric
acne
in
10-year-old
girl.
This
photo
inent prominent
on the cheeks.
Photo
courtesy
Catalina
Matiz,
MD,
and
more
on
the
forehead,
nose,of
and
chin and
is less
promdemonstrates
the
typical
distribution
of
moderate
acne,
which
is
demonstrates
the typical MD.
distribution of moderate acne, which is
Lawrence
F. Eichenfield,
inent
on the
cheeks.thePhoto
courtesy ofand
Catalinaand
Matiz,less
MD, and
more
more prominent
prominent on
on the forehead,
forehead, nose,
nose, and chin
chin and is
is less prompromLawrence
F.
Eichenfield,
MD.
inent
the
Photo
courtesy
of
Matiz,
inent
on
the cheeks.
cheeks.
Photo
courtesyqualitative
of Catalina
Catalina evaluation,
Matiz, MD,
MD, and
and
In on
addition
to the
clinician’s
the
Lawrence
F.
MD.
Lawrence
F. Eichenfield,
Eichenfield,
MD. should include the patient’s selfassessment
of acne severity
In addition to the clinician’s qualitative evaluation, the
assessment
and
the severity
parents’ should
impressions.
Identifying
anyselfexassessment
of acne
include
the
patient’s
In addition
to the
clinician’s qualitative
evaluation,
the
isting
discord
between
the
clinician’s
assessment
and
that
of
assessment
and
parents’
impressions.
Identifying
anyselfexof acne
severity
should
include
the
patient’s
Inpatient
addition
tothethe
clinician’s
qualitative
evaluation,
the
the
and/or
the
parents
will
be
helpful
in
guiding
isting
discord
between
the clinician’s
assessment
andany
that
of
assessment
and
theseverity
parents’
impressions.
Identifying
exassessment
of
acne
should
include
the patient’s
selfchoices
of treatment,
aggressiveness
of
treatment
approach,
the
patient
and/or
the
parents
will
be
helpful
in
guiding
isting discord
the clinician’s
assessment
andany
thatexof
assessment
andbetween
the
parents’
impressions.
Identifying
and
counseling
of the
patient
and family
about realistic
exchoices
of treatment,
aggressiveness
the
patient
and/or
the
parents
will of
betreatment
helpful and
inapproach,
guiding
isting
discord
between
the
clinician’s
assessment
that
of
pectations
for treatment.
and patient
counseling
of the
patient
and
about realistic
exchoices
of treatment,
of
treatment
the
theaggressiveness
willfamily
beevaluation,
helpful
inapproach,
guiding
Finally,
inand/or
addition
toparents
the medical
the
judgpectations
for
treatment.
and
counseling
of
the
patient
and
family
about
realistic
exchoices
treatment,
aggressiveness
of treatment
approach,
ment
ofofseverity
of disease
must
include
an assessment
of
Finally,
in
addition
to
the
medical
evaluation,
the
judgpectations
for
treatment.
and
counseling
of theemotional
patient and
familypsychosocial
about realistic
excurrent
and
potential
or
other
effects
ment
of severity
of disease
include
an assessment
of
in addition
to themust
medical
evaluation,
the judg8 Finally,
pectations
for
treatment.
on
the patient
or family.
For example,
what
might be considcurrent
and
potential
emotional
or
other
psychosocial
effects
ment
of severity
of disease
include
an assessment
of
Finally,
in addition
to may
themust
medical
evaluation,
the judgered
medically
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acne
be
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to children
with
on
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family.
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ment
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ered
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ered
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what might
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ered medically mild acne may be devastating to children with
Conclusions
Figure 2 Mild acne. A 9-year-old girl (left) with mild acne has no
inflammatory lesions. In contrast, a few inflammatory lesions are
Figure 2 Mild acne. A 9-year-old girl (left) with mild acne has no
visible this 14-year-old girl (right) with mild acne. Photos courtesy
inflammatory
lesions.
In contrast,girl
a few
inflammatory
lesions
Figure
2 Mild
acne.
A 9-year-old
(left)
with mildMD.
acne
has are
no
of Catalina
Matiz,
MD,
and Lawrence F.
Eichenfield,
visible
this
14-year-old
girl
(right)
with
mild
acne.
Photos
courtesy
inflammatory
lesions.
In
contrast,
a
few
inflammatory
lesions
are
Figure
22 Mild
acne.
A
girl
with
acne
Figure
Mild
acne.MD,
A 9-year-old
9-year-old
girl (left)
(left)
with mild
mildMD.
acne has
has no
no
of
Catalina
Matiz,
and
Lawrence
Eichenfield,
visible
this 14-year-old
girl (right)
withF.mild
acne. Photos
courtesy
inflammatory
inflammatory lesions.
lesions. In
In contrast,
contrast, aa few
few inflammatory
inflammatory lesions
lesions are
are
of Catalina
Matiz,
MD, and
Lawrence
F.mild
Eichenfield,
MD. courtesy
14-year-old
girl(right)
(right)with
with
mildacne.
acne.Photos
Photos
visible
this
14-year-old
girl
visible on
thisthis
14-year-old
girl
(right)
with
mild
acne.
Photos
courtesy
and
Lawrence
F
.
Eichenfield,
MD.
of
Catalina
Matiz,
MD,
F.
Eichenfield,
MD.
of Catalina Matiz, MD, and Lawrence F. Eichenfield, MD.
8
The diagnosis of acne usually is straightforward and can be
made by the patient’s history and physical examination. In
some cases, further diagnostic testing is indicated, and referral to a pediatric endocrinologist is recommended if a patient
has any signs of virilization. Although standardized assessment tools are not yet available for routine clinical use, clinicians must nevertheless qualitatively assess the severity of
acne. In addition to the clinician’s assessment, the perspective of4 the
patient
and the family,
as well as
theinhistory
of acne
Figure
Severe,
predominantly
comedonal
acne
a 10-year-old
girl. Photos courtesy of Catalina Matiz, MD, and Lawrence F.
Figure 4 Severe, predominantly comedonal acne in a 10-year-old
Eichenfield, MD.
girl.
courtesy
of Catalina
Matiz, MD,
F.
FigurePhotos
4 Severe,
predominantly
comedonal
acneand
in aLawrence
10-year-old
Eichenfield,
MD.
girl. Photos courtesy
of Catalina Matiz, MD,
anda Lawrence
F.
Figure
Figure 44 Severe,
Severe, predominantly
predominantly comedonal
comedonal acne
acne in
in a 10-year-old
10-year-old
Eichenfield,
MD.
girl.
Photos
courtesy
of
Catalina
Matiz,
MD,
and
Lawrence
F.
girl. Photos courtesy of Catalina Matiz, MD, and Lawrence F.
continued on page 15
Eichenfield,
Eichenfield, MD.
MD.
in
m
R
1.
2.
3.
4.
5.
6.
Medical and Psychosocial Impact of Acne
Richard G.and
Fried, MD,
PhD,* Guy F. Webster,Impact
MD, PhD, Lawrence
F. Eichenfield, MD,
Medical
Psychosocial
of
Acne
Sheila F. Friedlander, MD, Joseph F. Fowler Jr, MD, and Moise L. Levy, MD
†
‡
§
‡
¶
Richard G. Fried, MD, PhD,* Guy F. Webster, MD, PhD,† Lawrence F. Eichenfield, MD,‡
Sheila F. Friedlander, MD,‡ Joseph F. Fowler Jr, MD,§ and Moise L. Levy, MD¶
The direct and clinically obvious medical sequelae of acne vulgaris are well described.
Physical comorbidities associated with classic acne are quite rare. Often more difficult to
detect and measure are the short- and long-term psychosocial consequences of acne.
These frequently are devastating and life-altering and in some cases are life-threatening.
A
cne once was widely considered more a rite of passage
than a disease. Over time, awareness of the potentially
destructive impact of acne increased, along with the development of more effective drugs to treat it. The medical impact
generally includes scarring of the face, chest, and back; persistent alterations in pigmentation; and physical discomfort.
Fortunately, physical comorbidities associated with acne vulgaris are rare; the possibilities include acne fulminans and the
SAPHO syndrome (ie, synovitis, acne, pustulosis, hyperostosis, and osteitis).
*Yardley Dermatology Associates, Yardley, PA.
*Yardley Dermatology Associates, Yardley, PA.
†Jefferson Medical
†Jefferson
Medical College,
College,Philadelphia,
Philadelphia,PA.
PA.
‡Rady Children’s Hospital, UCSD School of Medicine, San Diego, CA.
‡Rady
Children’s Hospital, UCSD School of Medicine, San Diego, CA.
§University of
§University
ofLouisville,
Louisville,Louisville,
Louisville,KY.
KY.
¶Baylor
CollegeofofMedicine,
Medicine,Houston,
Houston,TX.
TX.
¶Baylor College
Publication of this article was sponsored by the University of Louisville,
Publication of this article was sponsored by the University of Louisville,
Continuing
Health
Sciences
Education,
Skin Skin
Disease
Education
FounContinuing
Health
Sciences
Education,
Disease
Education
dation,
and
an
educational
grant
from
Ortho
Dermatologics.
Foundation, and an educational grant from Ortho Dermatologics.
Guy F. Webster, MD, PhD, has been a consultant for Allergan, Cutanea,
Guy F. Webster, MD, PhD, has been a consultant for Allergan, Cutanea,
Cipher, Galderma, GlaxoSmithKline, Medicis, Ortho, and Quinnova.
Cipher, Galderma, GlaxoSmithKline, Medicis, Ortho, and Quinnova.
Lawrence
F. Eichenfield,
hasconsultant
served as afor
speaker
for Coria.
He hasOrtho
also
been an
investigator MD,
and/or
Johnson
& Johnson,
Sheila F. Friedlander, MD, has been a consultant for Astellas, Barrier TherSheila
F. Friedlander,
has been
a consultant
for Astellas,
apeutics,
Galderma, MD,
Graceway,
Novartis,
and sanofi-aventis.
She Barrier
has also
Therapeutics, Galderma, Graceway, Novartis, and sanofi-aventis. She
received grant research support from Atlanta, Amgen, Astellas, Barrier
has also received grant research support from Atlanta, Amgen, Astellas,
Therapeutics,
Galderma, Galderma,
Johnson & Johnson,
JohnsonLEO
&
Pharmaceuticals,
Novartis,
OrthoNeutrogena,
Photocure,
Pierre-Fabre,
Johnson, LEO Pharmaceuticals, Novartis, OrthoNeutrogena, Photocure,
RegeneRx,
and RegeneRx,
Dow.
Pierre-Fabre,
and Dow.
Joseph
F.
Fowler,
Jr,
MD,has
hasbeen
beenaaconsultant
consultantfor
forGalderma,
Galderma, Graceway,
Graceway,
Joseph F. Fowler, Jr, MD,
Hyland,
Stiefel, Triax,
Triax,
Hyland,Johnson
Johnson&&Johnson,
Johnson,Quinnova,
Quinnova,Ranbaxy,
Ranbaxy, Shire,
Shire, Stiefel,
and
Galderma, Medicis,
Medicis, Ranbaxy,
Ranbaxy,
andValeant.
Valeant.He
Hehas
hasbeen
been aa speaker
speaker for
for Galderma,
Shire,
an investigator
investigator for
for
Shire,Stiefel,
Stiefel,UCB,
UCB,and
andValeant.
Valeant. He
He has
has also been an
Abbott,
Centocor, Coria,
Coria,
Abbott,Taro,
Taro,Allerderm,
Allerderm,Allergan,
Allergan, Amgen,
Amgen, Astellas, Centocor,
Dermik,Dow,
Dow,Galderma,
Galderma, Genentech,
Genentech, Johnson
Johnson & Johnson,
Dermik,
Johnson, Medicis,
Medicis,
Novartis,Quinnova,
Quinnova,Shire,
Shire,Steifel,
Stiefel,Taisho,
Taisho, and
and 3M.
3M.
Novartis,
Moise
for for
GlaxoSmithKline
and SkinMoise L.
L.Levy,
Levy,MD,
MD,has
hasbeen
beena consultant
a consultant
GlaxoSmithKline
and
Skin-Medica.
Medica.
Address
Fried, MD,
MD, PhD,
PhD, 903
903 Floral
Floral Vale
Vale
Address reprint
reprint requests
requests to Richard G. Fried,
Professional
E-mail: [email protected].
[email protected].
ProfessionalPark,
Park,Yardley,
Yardley, PA
PA 19067. E-mail:
An impressive array of effective and safe drugs now is
available to clinicians, giving them the means to alleviate the
short-term burden of acne lesions in patients as well as tools
to prevent the long-term problem of physical scarring. Appropriate medical management also can help prevent common psychosocial sequelae, which may include decreased
self-esteem, depression, academic impairment, social withdrawal, decreased employability, and social stigmatization.
The
Scopeof
of
The
Scope
PsychosocialSequelae
Sequelae
Psychosocial
Acne can be responsible for long-term psychological damage
that can affect the ability to optimally love, work, and play,
with acne presenting at earlier ages and commonly continuing into adult years. It is well documented in the pediatric
literature that clinicians are seeing an earlier onset of acne
(see “Acne Epidemiology and Pathophysiology,” page 42), so
the duration of disease may be longer for some patients.1
Acne vulgaris can lead to short- and long-term difficulties
with depression, anxiety, anger, and impairment in self-image.2 Functionally, it can lead to difficulties with school, play,
and interpersonal relationships. Individuals with acne—regardless of age—are more likely to experience discrimination
in all aspects of life and often are subjected to ridicule and
rejection by their peers.
Sometimes clinicians and caregivers assume that mild acne
is not emotionally important. For a great number of patients,
this is true. However, some patients experience severe psychological effects from comedonal or mild inflammatory disease.2 In these patients, acne may be mild in clinical grading
but severe in psychological impact. Conversely, some patients with severe disease—markedly inflammatory acne,
pigmentary alteration, obvious signs of scarring—seem to
cope without a great deal of emotional burden. Thus, clinical
severity of acne may not always be a good predictor of psychological impact.
9
9
Friedetetalal
R.R.G.G.Fried
1010
Figure
Figure 11 Diffuse
Diffuse comedonal
comedonal lesions
lesions in
in an
an 11-year-old
11-year-old boy.
boy. Typically,
Typically, comedonal
comedonal acne
acne in
in preadolescents
preadolescents is
is not
not aa social
social
Figure
Diffuse
lesions
an
11-year-old
Typically,
comedonal
acneininpreadolescents
preadolescentsisisnot
notaasocial
social
problem
problem
unless
unlesscomedonal
acomedonal
a child
child has
haslesions
numerous
numerous
lesions
lesions
and/or
and/orboy.
aboy.
a diffuse
diffuse
distribution
distribution
of
of lesions.
lesions.
Figure
11 Diffuse
ininan
11-year-old
Typically,
comedonal
acne
problemunless
unlessaachild
childhas
hasnumerous
numerouslesions
lesionsand/or
and/oraadiffuse
diffusedistribution
distributionofoflesions.
lesions.Photos courtesy of Catalina Matiz, MD
problem
and Lawrence F. Eichenfield, MD
Body
Image
Body
Image
Body
Image
Body
Image
Body dysmorphic disorder has its origin at the point of a
Body
dysmorphic
disorderof
has
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Body
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origin
atatbody
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how
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earliest
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how
much
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how much
the body
is emphasized inearliest
his or awareness
her world.ofFamily,
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her
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Family,
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The
ever-growing
media
all
are
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The
ever-growing
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all areinpart
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The perfection
ever-growing
obsession
ourofsociety
with skin
and body
can
obsession
in
our
society
with
skin
and
body
perfection
can
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in our society with
anddistortions
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can
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with skin
or even
in self-perlead
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with
even
distortions
inself-perself-perlead
totoaapreoccupation
with
ororeven
ception.
Thus,
the young
person
whodistortions
looks in ainmirror
and
ception.
Thus,
the
young
person
who
looks
in
a
mirror
and
ception.
Thus, the
who looks
mirror and
must compare
hisyoung
or herperson
“imperfect”
imageintoa digitally
airmust
compare
his
or
her
“imperfect”
image
to
digitally
airmust
compare
his or her
“imperfect”
image
digitally inevairbrushed
photographs
of flawless
models
andto
celebrities
brushed
photographs
of
flawless
models
and
celebrities
inevbrushed
photographs
of flawlessblemishes,
models and
celebrities
inevitably sees
differences—pores,
and
imperfections.
itably
seesdifferences—pores,
differences—pores,
blemishes,
andimperfections.
imperfections.
itably
sees
blemishes,
The presence
of acne, especially
early inand
the
formative
periThe
presence
ofacne,
acne,
especiallyearly
early
theformative
periThe
especially
the
periods presence
of
body of
image
development,
canininlead
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an amplified
ods
of
body
image
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can
lead
to
an
amplified
ods
of of
body
image
development,
lead to must
an amplified
sense
being
different
and flawed.can
Clinicians
be aware
sense
being
different
and
flawed.
Clinicians
must
be
aware
of theofof
fact
that,
againstand
thisflawed.
backdrop,
acne may
bebe
a aware
trigger
sense
being
different
Clinicians
must
of
the
fact
that,
against
this
backdrop,
acne
may
be
a
trigger
a contributor
to,this
body
image disorders,
asbe
studied
and
offor,
theorfact
that, against
backdrop,
acne may
a trigger
for,
contributor
to,body
body
imagedisorders,
asstudied
studiedand
and
33disorders,as
described
by Bowe to,
and
colleagues.
for,
ororaacontributor
image
3
described
by
Bowe
and
colleagues.
3
described by Bowe and colleagues.
Acne
Impact:The
The Age
Acne
Impact:
AgeVariable
Variable
Acne
Impact:
The
Age
Variable
Acne
Impact: The Age Variable
Again, the psychological impact of acne comes from what the
Again,
the
psychological
impact
ofacne
acne
comes
from
whatthe
the
patientthe
sees
in the mirror,
from of
what
one’s
peers
convey,
and
Again,
psychological
impact
comes
from
what
patient
sees
in
the
mirror,
from
what
one’s
peers
convey,
and
from messages
from
parents.
differ
according
patient
sees in the
mirror,
fromThese
what typically
one’s peers
convey,
and
from
messages
from
parents.
These
typically
differ
according
to the
age of the
patient.
Adolescence
for many,
not most,
from
messages
from
parents.
These typically
differifaccording
theage
ageofofthe
patient.
Adolescence
formany,
many,
not
most,
adolescents
isthe
apatient.
time
of Adolescence
volatile
emotion.
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a most,
strong
toto
the
for
not
adolescents
is
a
time
of
volatile
emotion.
There
is
a
strong
need for immediate
and consequential
adolescents
is a timegratification,
of volatile emotion.
There is athinking
strong
need
for
immediate
gratification,
andconsequential
consequential
thinking
oftenfor
is limited.
Above
all, achieving
and
maintaining
a sense
need
immediate
gratification,
and
thinking
often
limited.
Aboveall,
all,achieving
achieving
andmaintaining
maintaining
sense
of control
is ofAbove
paramount
importance
to
adolescents,
who
often
isislimited.
and
aasense
of
control
is
of
paramount
importance
to
adolescents,
who
haveisdifficulty
controlling
their emotions
and behavior.
ofoften
control
of paramount
importance
to adolescents,
who
often
have
difficulty
controlling
their
emotions
and
behavior.
The
younger
patient
with acne
not behavior.
burdened
often
have
difficulty
controlling
theirgenerally
emotionsisand
The
younger
patient
with
acne
generally
is
not
burdened
with
same patient
severe emotional
that
the burdened
adolescent
Thethe
younger
with acne lability
generally
is not
with
thesame
sameFurther,
severeemotional
emotional
labilitypresentation
thatthe
theadolescent
adolescent
experiences.
the comedonal
that is
with
the
severe
lability
that
experiences.
Further,
the
comedonal
presentation
that isin
is
common in younger
tends to presentation
be less of an issue
experiences.
Further, patients
the comedonal
that
common
in
younger
patients
tends
to
be
less
of
an
issue
in
common in younger patients tends to be less of an issue in
10
peer acceptance and ridicule, unless lesions are especially
peer
acceptance
andridicule,
ridicule,unless
unlesslesions
lesionsare
areespecially
especially
numerous
(Fig. 1).
peer
acceptance
and
numerous
(Fig.
1).
Researchers
numerous
(Fig. have
1). explored the psychosocial impact of acne
Researchers
haveexplored
explored
thepsychosocial
psychosocial
impactofstudies
ofacne
acne
inResearchers
younger patients
only indirectly.
No controlled
have
the
impact
in
younger
patients
only
indirectly.
No
controlled
studies
been performed
in which
psychological
sequelae
was
inhave
younger
patients only
indirectly.
No controlled
studies
have
beenperformed
performedthe
whichpsychological
psychological
sequelae
was
examined,
including
and severitysequelae
of
depression
have
been
ininincidence
which
was
examined,
including
the
incidence
and
severity
of
depression
and anxiety
specifically
childrenand
whoseverity
are between
8 and 11
examined,
including
the in
incidence
of depression
and
anxiety
specifically
inchildren
childrenwho
who
arebetween
between
and11
11
years
of agespecifically
with
acne. in
Nevertheless,
certain
observations
can
and
anxiety
are
88and
years
of
age
with
acne.
Nevertheless,
certain
observations
can
be made
andwith
conclusions
drawn aboutcertain
recognizing
and possibly
years
of age
acne. Nevertheless,
observations
can
be
made
and
conclusions
drawn
about
recognizing
and
possibly
preventing
psychological
sequelae
in
these
younger
patients.
be made and conclusions drawn about recognizing and possibly
preventing
psychological
sequelae
these
younger
patients.
For adolescent
patients,
having
many
peerspatients.
with acne
preventing
psychological
sequelae
ininthese
younger
For adolescent
adolescent
patients, having
having many
many
peers
with acne
acne
“normalizes”
the experience.
However,
younger
patients
with
For
patients,
peers
with
“normalizes”
the
experience.
However,
younger
patients
with
acne may feel
isolated and
“different.”
For patients
example,
an
“normalizes”
the experience.
However,
younger
with
acne
may
feel
isolated
and
“different.”
For
example,
an
8-year-old
patient
with even
mild, comedonal
acne (Fig.an
2)
acne
may feel
isolated
and “different.”
For example,
8-year-old
patient
with
even
mild,
comedonal
acne
(Fig.
typically ispatient
in the with
minority
his or her school
peers—
8-year-old
evenamong
mild, comedonal
acne (Fig.
2)2)
typically
theminority
minority
among
hisor
orher
herdo
school
peers—
the childisis
has
most (oramong
all) of her
peers
not. There
are
typically
ininacne,
the
his
school
peers—
the
child
has
acne,
most
(or
all)
of
her
peers
do
not.
There
are
twochild
main
concerns—that
stigmatization
that
of
the
has
acne, most (or of
all)early
of her
peers do not.and
There
are
two
main
concerns—that
of
early
stigmatization
and
that
chronicity
of disease. Earlyofstigmatization
can result
in that
lifelong
two
main concerns—that
early stigmatization
and
ofof
chronicity
disease.
Early
stigmatization
canresult
result
lifelong
psychic injury
with all
the stigmatization
imagined
functional
impairments.
chronicity
ofofdisease.
Early
can
ininlifelong
psychic
injury
with
all
the
imagined
functional
impairments.
Several
authors
have
the relationship
between
psychic
injury
with all
the examined
imagined functional
impairments.
Severalauthors
authors
haveexamined
examined
therelationship
relationship
between
chronicity
of dermatologic
diseasethe
and
an
increasedbetween
negative
Several
have
chronicity
of
dermatologic
disease
and
an
increased
negative
4
4
–7
–7
psychological
impact.4 –7 Itdisease
chronicity
of dermatologic
and an increased
negative
can be assumed
that an individual
psychological
impact.
It
can
be
assumed
that
an
individual
4
–7
psychological
impact.
whose acne begins
earlier
have
the condition
a longer
It will
can be
assumed
that an for
individual
whose
acne
begins
earlier
will
have
the
condition
foraaalonger
longer
periodacne
thanbegins
a patient
withwill
later
acne
onset,
and that
longer
whose
earlier
have
the
condition
for
period
than
a
patient
with
later
acne
onset,
and
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4
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theincidence
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the
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Figure 2 Preadolescents with even mild comedonal acne—such as
Figure
22 Preadolescents
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Figure
with
even
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Figure
2 Preadolescents
Preadolescents
with
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comedonal
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as
this
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feel
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and
isolated
because
they
have
acne
while
most
(or
all)
of
their
peers
do
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Photos
this
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while
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Photos
courtesy
ofacne
Catalina
Matiz,
and
Lawrence
F. Eichenfield,
MD.
they
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Figure
2 Preadolescents
withMD,
even
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they
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most
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of
their
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do
not. Photos
Photos
courtesy
of
Catalina
Matiz,
MD,
and
Lawrence
F.
Eichenfield,
MD.
courtesy
of Catalina
Catalina
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Lawrenceand
F. Eichenfield,
Eichenfield,
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this
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courtesy
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they have acne while most (or all) of their peers do not. Photos
courtesy of Catalina Matiz, MD, and Lawrence F. Eichenfield, MD.
likelihood of functional impairment, worsening of the conlikelihood
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increases
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such
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risk.
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as
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addition,
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as
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can
exacerbate
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a
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6
as
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suicide
because
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boys,
facial-scarring
acne
to
the
battle
to
improve
skin
and
spirit
at
the
same
time.
as lithium, can exacerbate acne, creating a “vicious cycle” quality
6
to
the
battle
improve
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and
spirit
the
same
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6 such
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Clinicians
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to the
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same
time.
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and
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with
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and
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ascan
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Clinicians
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asavigilant
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as
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6
patients
as we
we
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with of
adolescents,
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forsame
similar
warning
to the battle
to improve
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and spiritalert
at
the
time.
signs
and
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significant
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patients
as
we
are
with
adolescents,
alert
for
similar
warning
signs
and
symptoms
of
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psychological
impact.
signs
and
symptoms
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and
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These
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These
include
change
in
social
group,
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patients
as
we
are
with
adolescents,
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for
similar
warning
social
group
or
from
obligations
and
social
inter-aaa
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from
social
group
or
withdrawal
from
obligations
and
social
intersocial
or
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and
intersigns
and
symptoms
of significant
psychological
impact.
action,
more-than-usual
irritability,
or apathy.
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social group
group
or withdrawal
withdrawal
from obligations
obligations
and social
social
interaction,
more-than-usual
irritability,
or
apathy.
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action,
more-than-usual
irritability,
or
apathy.
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These
include
a
change
in
social
group,
withdrawal
from
warning
sign
of
emotional
impact
is
overzealous
channeling
action, more-than-usual irritability, or apathy. Anothera
warning
sign
emotional
is
overzealous
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warning
sign
of
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is
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andsuch
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it
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as
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of
energy
into
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where
it
is
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to
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such
as
action,
more-than-usual
irritability,
or
apathy.
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schoolwork,
or
“escape”
books,
video
games,
television
of energy into places where it is safe to hide, such as food,
food,
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or
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or
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signmovies.
of
overzealous
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books, isvideo
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movies.
shows,
andinto
movies.
of energy
places where it is safe to hide, such as food,
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and
movies.
schoolwork, or “escape” books, video games, television
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shows, and movies. Parents of
Counseling
of
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Most
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with acne are of
brought
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Most
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acne
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Most
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patients
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attention
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parents
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concern
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patients with acne
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Young
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attention
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concern
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attention
by
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parents
because
of
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theyoung
cause
of the lesions. They question whether their child is too
attention by their parents because of concern about the cause
of
the
lesions.
They
question
whether
their
is
young
of
the
lesions.
They
question
whether
their child
child
isa too
too
young
Most
younger
patients
withthe
acne
are brought
clinician’s
to
have
acne and
whether
appearance
of to
lesions
might
of
the
lesions.
They
question
whether
their
child
is
too
young
to
have
acne
and
whether
the
appearance
of
lesions
to
havethe
acne
andparents
whether
the appearance
appearance
ofabout
lesions
might
attention
bypresence
their
of concern
the might
cause
signify
of an because
underlying,
hormonal
abnormality
to
have
acne
and
whether
the
of
lesions
might
signify
the
presence
of
an
underlying,
hormonal
abnormality
signify
the
presence
of
an
underlying,
hormonal
abnormality
of
the
lesions.
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question
whether
their
child
is
too
young
or
other
medical
problem.
signify the presence of an underlying, hormonal abnormality
or
other
medical
or
medical
problem.
to
have acne
andproblem.
whether the appearance of lesions might
or other
other
medical
problem.
signify the presence of an underlying, hormonal abnormality
or other medical problem.
However, some parents of preadolescents have difficulty
11
However,
of
preadolescents
have
difficulty
However,
some
parents
of
have
difficulty
with
the ideasome
that parents
their child
has acne, while
others
may
However,
some
parents
of preadolescents
preadolescents
have
difficulty
with
the
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child
has
acne,
while
others
may
with
that
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while
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riteofofpreadolescents
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aaunable
rite
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rite
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in
excessively
concerned,
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to
tolerate
any
imperfection
refuse
any
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because
of
a
belief
that
acne
repretheir
offspring.
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type
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concern
also
may
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in
their
offspring.
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type
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also
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offspring.
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indisents
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cate
loss
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my handsome
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This
type
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excessive
concern
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handsome
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cate
loss
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handsome
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pretty
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cate the
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handsome
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my
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handsome
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Parents
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need tolittle
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the
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understand
the
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the
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the
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the
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acnehas
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the
importance
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donal
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condition, even if the patient currently has only mild comecomedonal
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practitioner
should
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acne
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of
the
skin
but
also
to
prevent
emotional
damage
by
donal disease. The purpose of treatment is not only to avoid
scarring
of
the
skin
but
also
to
prevent
emotional
damage
by
scarring
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the
skin
but
also
to
prevent
emotional
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condition,
even
if
the
patient
currently
has
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comeminimizing
or
preventing
the
burden
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it
is
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by
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or
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the
burden
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it
is
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the
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is
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important
to
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the
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both
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vidual
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their
parents).
Concern
and
interest
in
treatment
varies
greatly
in
the
Concern
and
interest
in
treatment
varies
greatly
in
cooperate
with
treatment
suggestions
(provided
treatment
is
younger
acne
patient.
Acne
often
is mild
in younger
patients,
Concern
and
interest
in
treatment
varies
greatly
in the
the
younger
acne
patient.
Acne
often
is
mild
in
younger
patients,
younger
acne
patient.
Acne
often
is
mild
in
younger
patients,
not
part
of
a
power
struggle
with
their
parents).
and unless
is being
school
or is particularly
younger
acnechild
patient.
Acnetaunted
often isatmild
in younger
patients,
and
unless
child
is
at
is
and
unless aaaand
childinterest
is being
being
taunted
at school
school
orstrongly
is particularly
particularly
Concern
varies
greatly
inmotithe
appearance-conscious,
heintaunted
ortreatment
she may
not
beor
and
unless
child
is
being
taunted
at
school
or
is
particularly
he
she
not
strongly
motiappearance-conscious,
he aor
oroften
she ismay
may
not
be
strongly
motiyoungertoacne
patient.
Acne
mild
in be
younger
patients,
vated
comply
with
treatment
regimen.
However,
he
or
she
may
not
be
strongly
motivated
to
comply
aataunted
treatment
regimen.
However,
vated
to
comply
with
regimen.
However,
and
a child
iswith
being
at school
or is particularly
younger
patients
often
are anxious
to please
their parvatedunless
toacne
comply
with
a treatment
treatment
regimen.
However,
younger
acne
patients
often
are
anxious
to
please
theirmotiparyounger
acne
patients
often
are
anxious
to
please
he
or
she
may
not
be
strongly
ents
and
will
“allow
treatment”
to
occur
if
it
is
important
to
younger acne patients often are anxious to please their
their parparents
and
will
“allow
treatment”
to
occur
if
it
is
important
to
ents
and
will
“allow
treatment”
to
occur
if
it
is
important
vated
to
comply
with
a
treatment
regimen.
However,
the
parent.
In
these
patients,
the
key
to
compliance—
both
ents and will “allow treatment” to occur if it is important to
to
the
parent.
In
these
patients,
the
key
to
compliance—
both
the
In
these
the
key
to
compliance—
both
younger
acne
often
are
please
theirthat
parshortand
long-term—is
to choose
a sensible
regimen
is
the parent.
parent.
In patients
these patients,
patients,
theanxious
key
to to
compliance—
both
shortand
long-term—is
to
choose
aa sensible
regimen
that
is
shortand
long-term—is
to
choose
sensible
regimen
that
ents
and
will
“allow
treatment”
to
occur
if
it
is
important
to
most
likely
to
be
used.
By
definition
that
means
a
treatment
short- and long-term—is to choose a sensible regimen that is
is
most
likely
to
be
used.
By
definition
that
means
a
treatment
most
to
used.
By
means
aa treatment
the parent.
In be
these
patients,
the
to compliance—
both
that
islikely
effective,
well
tolerated,
easykey
tothat
use,
and palatable
to a
most
likely
to
be
used.
By definition
definition
that
means
treatment
that
is
effective,
well
easy
use,
and
palatable
to
9 Many
that
is and
effective,
well tolerated,
tolerated,
easyagree
tosensible
use,
andregimen
palatable
toisaaa
shortlong-term—is
to choose
ato
that
parent.
preadolescents
will
to incorporate
applithat
is
effective,
well
tolerated,
easy
to
use,
and
palatable
to
9 Many preadolescents
parent.
will
agree
to
incorporate
appli9
9 Many
parent.
Many
preadolescents
will agree
agree
to
incorporate
applimost
to be
used.
definition
that
means
a treatment
cationlikely
of
a topical
agentBy
into
their
daily
routine—much
like
parent.
preadolescents
will
to
incorporate
application
of
aa topical
agent
into
their
daily
routine—much
like
cation
of
topical
agent
into
their
daily
routine—much
that
is
effective,
well
tolerated,
easy
to
use,
and
palatable
toina
tooth-brushing—again,
because
they
still
have
an
interest
cation of a topical agent into their daily routine—much like
like
because
they
still
have
an
interest
in
9
because
they
still
have
an
interest
parent.
Many
preadolescents
will
agree
to
incorporate
applipleasing
a
parent
rather
than
rebelling.
tooth-brushing—again, because they still have an interest in
in
pleasing
a
parent
rather
than
rebelling.
pleasing
rebelling.
cation
of aaa parent
topicalrather
agent than
into their
daily routine—much like
pleasing
parent
rather
than
rebelling.
tooth-brushing—again, because they still have an interest in
Conclusions
Conclusions
pleasing
a parent rather than rebelling.
Conclusions
Conclusions
Conclusions
Given the wide range of medical treatments available, it is
Given
range
of
it
Given the
thetowide
wide
range treat
of medical
medical
treatments
available,
it is
is
possible
effectively
almost treatments
every case available,
of acne. With
Given
the
wide
range
of
medical
treatments
available,
it
is
Conclusions
possible
to
effectively
treat
almost
every
case
of
acne.
With
possible
to
effectively
treat
almost
every
case
of
acne.
With
appropriate,
early
treatment,
no
patient
should
have
to
enpossible to effectively treat almost every case of acne. With
appropriate,
early
treatment,
no
patient
have
to
enappropriate,
early
treatment,
no
patient
should
have
to
Given
the wide
range
of medical
treatments
available,
is
dure
severe
inflammatory
acne,
theshould
attendant
for
appropriate,
early
treatment,
no with
patient
should
haverisk
to itenendure
severe
inflammatory
acne,
with
the
attendant
risk
for
dure
severe
inflammatory
acne,
with
the
attendant
risk
for
possible
to
effectively
treat
almost
every
case
of
acne.
With
both
physical
and
psychological
scarring.
dure severe inflammatory acne, with the attendant risk for
both
physical
and
psychological
both
physical
and
psychological
scarring.
appropriate,
treatment,
patient
have
to enAssumptions
when no
andscarring.
how toshould
institute
medical
both
physicalearly
andabout
psychological
scarring.
Assumptions
about
when
and
how
to
institute
medical
Assumptions
about
when
and
how
to
institute
medical
dure
severe
inflammatory
acne,
with
the
attendant
risk
for
therapy
in a young
patient
not be
made
Assumptions
about
whenwith
and acne
how should
to institute
medical
therapy
in
a
young
patient
with
acne
should
not
be
made
therapy
in aa young
young
patientage.
withParent
acne and
should
not be
beassessmade
both
physical
and
psychological
scarring.
by
a patient’s
chronologic
clinician
therapy
in
patient
with
acne
should
not
made
by
aa patient’s
age.
Parent
clinician
assessbyAssumptions
patient’s
chronologic
age.
Parent
and
clinicianmedical
assessabout when
and
how and
to institute
ment
of acnechronologic
severity
and
physical/emotional
impact
by
a patient’s
chronologic
age.
Parent
and
clinician
assessment
ofserve
acne
severity
and
physical/emotional
ment
severity
and
physical/emotional
impact
therapy
a young
patient
with
acne of
should
not beimpact
made
should
as guiding
determinants
intervention.
Forment of
ofinacne
acne
severity
and
physical/emotional
impact
should
serve
as
guiding
determinants
of
intervention.
Forshould
serve
as
guiding
determinants
of
intervention.
by
a
patient’s
chronologic
age.
Parent
and
clinician
assesscontinued
on
page
15
should serve as guiding determinants of intervention. ForForment of acne severity and physical/emotional impact
11
should serve as guiding determinants of intervention. For-
Perspectives on Therapeutic Options for Acne:
An Update
Perspectives on Therapeutic
Lawrence for
F. Eichenfield,
MD,*
Joseph
F. Fowler Jr, MD, Richard G. Fried, MD, PhD,
Options
Acne:
An
Update
Sheila F. Friedlander, MD,* Moise L. Levy, MD, and Guy F. Webster, MD, PhD
†
‡
§
¶
Lawrence F. Eichenfield, MD,* Joseph F. Fowler Jr, MD,† Richard G. Fried, MD, PhD,‡
Sheila F. Friedlander, MD,* Moise L. Levy, MD,§ and Guy F. Webster, MD, PhD¶
It is clear that acne vulgaris often has medical and psychosocial implications that can range
from mild to severe. To minimize these risks, evaluation and appropriate treatment are necessary, even in the younger pediatric patient. This article provides an overview of the current
information on the topical and systemic treatment of acne, including innovative delivery options
and new formulations and combinations of existing medications.
M
edical intervention for acne rarely is contraindicated.
The appearance of inflammatory facial lesions is an
indication for early, aggressive treatment. Early, aggressive
intervention should also be considered in patients with a
family history of severe acne, regardless of the current severity of their own disease.
†University of
†University
ofLouisville,
Louisville,Louisville,
Louisville,KY.
KY.
‡Yardley
DermatologyAssociates,
Associates,Yardley,
Yardley,
‡Yardley Dermatology
PA.PA.
¶Jefferson
¶Jefferson Medical
Publication
of this College,
CME article
was sponsored
Philadelphia,
PA. by the University of Louisville
Continuing Health Sciences Education and Skin Disease Education
Publication of this CME article was sponsored by the University of Louisville
Foundation
supported
by an
educational
Ortho
DermaContinuingand
Health
Sciences
Education
andgrant
Skin from
Disease
Education
tologics.
Foundation and supported by an educational grant from Ortho
Lawrence
F. Eichenfield, MD, has served as a speaker for Coria. He has also
Dermatologics.
JosephDermatologics,
F. Fowler, Jr,Stiefel,
MD, has
been a consultant
for Galderma, Graceway,
Galderma,
and sanofi-aventis.
Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Stiefel, Triax,
Joseph
. Fowler,He
Jr, MD,
has been
a consultant
for Galderma,
and FValeant.
has been
a speaker
for Galderma,
Medicis,Graceway,
Ranbaxy,
Hyland,
Johnson
&
Johnson,
Quinnova,
Ranbaxy,
Shire,
Stiefel, Triax,
Shire, Stiefel, UCB, and Valeant. He has also been an investigator
for
Dermik, Dow, Galderma, Genentech, Johnson & Johnson, Medicis,
Novartis,
Shire, Steifel,
Taisho,
and 3M.
Dermik,Quinnova,
Dow, Galderma,
Genentech,
Johnson
& Johnson, Medicis,
Richard
G. Fried,
MD, PhD,
has Stiefel,
nothingTaisho,
to disclose.
Novartis,
Quinnova,
Shire,
and 3M.
Sheila F. Friedlander, MD, has been a consultant for Astellas, Barrier TherRichard
G. Fried,
MD, PhD,
has nothing
to disclose.
apeutics,
Galderma,
Graceway,
Novartis,
and sanofi-aventis. She has also
received
grant research
from
Atlanta, Amgen,
Astellas,Barrier
Barrier
Sheila
F. Friedlander,
MD,support
has been
a consultant
for Astellas,
Therapeutics,Galderma,
Galderma,
Graceway,
Novartis,Johnson
and sanofi-aventis.
She
Therapeutics,
Hill
Dermaceuticals,
& Johnson, LEO
has also receivedNovartis,
grant research
support from Atlanta,
Amgen,
Astellas,
Pharmaceuticals,
OrthoNeutrogena,
Photocure,
Pierre-Fabre,
Galderma, Hill Dermaceuticals, Johnson &
RegeneRx,
and Dow.
Novartis,
MoiseJohnson,
L. Levy,LEO
MD,Pharmaceuticals,
has been a consultant
forOrthoNeutrogena,
GlaxoSmithKlinePhotocure,
and SkinPierre-Fabre, RegeneRx, and Dow.
Medica.
Moise
Levy, MD,
been
consultant
for GlaxoSmithKline
and
Guy
F. L.
Webster,
MD,has
PhD,
has abeen
a consultant
for Allergan, Cutanea,
Skin-Medica.
Cipher,
Galderma, GlaxoSmithKline, Medicis, Ortho, and Quinnova.
Address
reprint requests
to Lawrence
Eichenfield,for
MD,
8010 Frost
Street,
Guy F. Webster,
MD, PhD,
has beenF.
a consultant
Allergan,
Cutanea,
Suite
602,Galderma,
San Diego,GlaxoSmithKline,
CA 92123. E-mail:
[email protected].
Cipher,
Medicis,
Ortho, and Quinnova.
Address reprint requests to Lawrence F. Eichenfield, MD, 8010 Frost Street,
Suite 602, San Diego, CA 92123. E-mail: [email protected].
doi:10.1016/j.sder.2010.04.005
12
Even in younger pediatric patients with mild disease—many
of whom are not particularly bothered by a relatively small number of comedones—treatment is indicated when a clinician
identifies any current evidence or potential for physical scarring.
At the very least, younger patients with mild acne—and their
parents—should receive therapy in the form of education about
the condition, signs and symptoms to note that should prompt
a visit with a clinician, and proper skin care that will provide a
foundation for acne treatment in the likely event that it is needed
in the future. Regardless of the severity (or mildness) of acne,
treatment certainly is indicated in the presence of, or when there
is risk for, psychological morbidity.
The type of treatment chosen to initiate therapy should be
determined by the severity of the acne, regardless of the patient’s age. Factors to consider when making an assessment of
disease severity are the extent of affected areas (mild, moderate, or severe), the types of lesions (noninflammatory comedones; inflammatory papules, pustules, nodules), and the
presence or absence of scarring and/or dyspigmentation. A
number of treatment guidelines have been published, reflecting a broad consensus regarding an approach that begins
with topical treatment whenever appropriate, systemic therapy whenever necessary, and limiting use of antibiotics—
oral or topical—whenever possible.1-3
TopicalTherapy
Therapy
Topical
A broad variety of topical treatments are available for initial
therapy of
1).1).
AllWith
of these
have
therapy
ofacne
acnevulgaris
vulgaris(Table
(Table
theproducts
exception
of
a specific gel
indication
use is
in approved
patients 12
of patients
age and
tretinoin
0.05%, for
which
foryears
use in
older,
but
products
are used
in similar
in
10
years
of these
age and
older, allalso
of these
products
have aways
specific
children
younger
than
12
years
of
age.
Despite
this
wideindication for use in patients 12 years of age and older;
spread practice,
onlyproducts
a few studies
have
been
to
nevertheless,
these
also are
used
in completed
similar ways
datechildren
in whichyounger
the authors
examined
safety, this
and
in
than
12 yearstheofefficacy,
age. Despite
widespread practice, only a few studies have been completed
to date in which the authors examined the efficacy, safety, and
13
Table 1 Topical Prescription Agents for Acne
Table 1 Topical Prescription Agents for Acne
Antibiotics/Antimicrobials
Antibiotics/Antimicrobials
Azelaic acid (Azelex® 20%, Allergan, Inc., Irvine, CA)
Azelaic
acid
(Azelex® 20%, Allergan, Inc., Irvine, CA)
Benzoyl
peroxide*
Clindamycin
(Cleocin T® [solution, gel, lotion], Pharmacia & Upjohn Company, Division of Pfizer, Inc., New York, NY;
Benzoyl
peroxide*
®
®
Clindagel(Cleocin
Topical
1%, gel,
Galderma
Laboratories,
LP, Fort
Worth,
TX; ClindaMax
Lotion,
[solution,
lotion], Pharmacia
& Upjohn
Company,
Division
of Pfizer, Inc., Gel,
New York,
NY;Pharmaderm, A
Clindamycin
T®Gel,
®
Division
of
Nycomed
US,
Inc.,
Melville,
NY;
Evoclin
Foam,
Stiefel
Laboratories,
Inc.,
Research
®
®
Clindagel Topical®Gel, 1%, Galderma Laboratories, LP, Fort Worth, TX; ClindaMax Gel, Lotion, Pharmaderm, Triangle Park, NC)
Dapsone
Gel
Inc.,
Irvine,
CA) Stiefel Laboratories, Inc., Research Triangle Park, NC)
® Foam,
A Division(Aczone
of Nycomed
US,5%,
Inc.,Allergan,
Melville, NY;
Evoclin
Erythromycin* ®
Dapsone
(Aczone Gel 5%, Allergan, Inc., Irvine, CA)
Sodium sulfacetamide*
Erythromycin*
Topical retinoids
Sodium
sulfacetamide*
Adapalene
(Differin® Gel 0.3%, Cream 0.1%, Galderma Laboratories, LP, Fort Worth, TX)
Tazarotene (Tazorac® 0.05% and 0.1% Cream and Gel, Allergan, Inc., Irvine, CA)
Topical
retinoids
Tretinoin (Retin-A Micro®, Ortho Dermatologics, A Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc., Los
® Gel 0.3%,
® Gel Cream
Adapalene
0.1%,
Galderma
Laboratories,
FortWorth,
Worth, TX)
TX)
Angeles,(Differin
CA; Atralin
0.05%,
Coria
Laboratories,
Ltd., LP,
Fort
®
Tazarotene
(Tazorac
0.05%
and
0.1%
Cream
and
Gel,
Allergan,
Inc.,
Irvine,
CA)
Combination medications
®, Ortho Dermatologics,
Adapalene–benzoyl
(Epiduo Gel®A, Division
Galderma
Laboratories, LP, Fort
Worth, TX) Inc., Los Angeles, CA;
Tretinoin
(Retin-A Microperoxide
of Ortho-McNeil-Janssen
Pharmaceuticals,
® Topical Gel, Dermik Laboratories, a business of sanofi-aventis U.S. LLC,
®
Benzoyl
peroxide–clindamycin
(BenzaClin
Atralin Gel 0.05%, Coria Laboratories, a division of Valeant Pharmaceuticals North America, Aliso, Viejo, CA)
Bridgewater, NJ; Duac®, Stiefel Laboratories, Inc., Research Triangle Park, NC; Acanya® Gel, Coria Laboratories, a
Combination
medications
division of
Valeant Pharmaceuticals North America, Aliso, Viejo, CA)
® Laboratories,
Adapalene–benzoyl
peroxide (Epiduo (Benzamycin
Gel®, Galderma
Fort Worth,
TX)
Benzoyl peroxide–erythromycin
Topical Gel,LP,
Dermik
Laboratories,
a business of sanofi-aventis U.S. LLC,
Bridgewater,
NJ)
Benzoyl
peroxide–clindamycin
(BenzaClin® Topical Gel, Dermik Laboratories, a business of sanofi-aventis U.S. LLC,
® Gel, Coria
Sodium
sulfacetamide–sulfur
Lotion,
Dermik
Laboratories,
a business
of sanofi-aventis
Bridgewater,
NJ; Duac®, Stiefel (Sulfacet-R
Laboratories,®Inc.,
Research
Triangle
Park, NC; Acanya
Laboratories, U.S. LLC,
Bridgewater,
NJ) Pharmaceuticals North America, Aliso, Viejo, CA)
a division of Valeant
® Gel, Medicis, Scottsdale, AZ)
Tretinoin-clindamycin
(Ziana(Benzamycin
® Topical Gel, Dermik Laboratories, a business of sanofi-aventis U.S. LLC, Bridgewater, NJ)
Benzoyl
peroxide–erythromycin
®
Sodium sulfacetamide–sulfur (Sulfacet-R Lotion, Dermik Laboratories, a business of sanofi-aventis U.S. LLC, Bridgewater, NJ)
*Available under a variety of brand
names and in generic form.
Tretinoin-clindamycin (Ziana® Gel,
Medicis, Scottsdale, AZ)
*Available under a variety of brand names and in generic form.
tolerability of topical acne medications in patients between 8
and 11 years of age.
When acne is very mild, involving a small number of lesions, a benzoyl peroxide product can often be effective for
initial therapy. For mild-to-moderate comedonal acne, there
is general agreement that treatment should be initiated with a
topical retinoid. For significant or severe comedonal disease,
retinoid therapy should be used, either alone or in combination with another agent.
Topical retinoids (tretinoin, adapalene, or tazarotene) represent the cornerstone of therapy for almost all patients with
acne vulgaris1 and are effective and safe, with good tolerability in both younger (8-11 years) and older (12-18 years)
subgroups of pediatric patients.
Matiz and colleagues4 completed an open-label, 12-week
study of the efficacy, safety, and tolerability of 0.04% tretinoin gel in 40 patients between 8 and 12 years of age (mean
age, 10.7 years). The medication was provided in a pump
dispenser, and dosage instructions were determined by the
number of pumps (patients were told to apply 2 pumps of the
medication once a day, at night). All the subjects had mild-tomoderate acne. The primary efficacy end point was the change
in the Evaluator’s Global Severity Score at week 12; the secondary efficacy end point was the Investigator’s Global Evaluation at
week 12. Evaluations were performed at baseline and at weeks
3, 6, and 12. At week 12, the mean Evaluator’s Global Severity
Score showed significant improvement over baseline (P �
0.001). Safety was evaluated by signs and symptoms of cutaneous irritation (erythema, dryness, peeling, burning/stinging, and
itching). All patients had at least mild skin irritation, but no
patient discontinued because of side effects (1 patient discontinued because of worsening acne). These findings support those
reported by Jorizzo and colleagues,5 who studied the use of
tretinoin microsphere 0.04% gel in a group that included patients as young as 11 years of age.
SystemicTherapy
Therapy
Systemic
Systemic therapy is less commonly needed in younger patients with acne than in older adolescents, but only because
most patients in the younger group tend to have milder,
noninflammatory disease. Systemic therapy should be considered and used in patients 8 to 11 years of age—without
hesitation—when needed. This includes the use of oral antibiotics as first-line therapy, along with a topical retinoid, in
patients with inflammatory acne and in those with scarring
acne regardless of disease severity. The oral antibiotics most
commonly used for treating acne are minocycline and doxycycline.6 (Tetracycline and erythromycin, once the most frequently prescribed agents for acne, are used less commonly
today because of increased P acnes resistance to these drugs.6)
Antibiotics in the tetracycline class can be used in children as
young as 8 years of age but should be avoided in younger
patients because of the potential for adverse effects on the
bones and teeth. In cases of refractory acne, when 3 to 4
months of treatment with appropriate combinations of topical retinoids and systemic antibiotics have not controlled the
disease, other systemic therapy may be considered.
There is broad experience with oral contraceptives being used
for contraception in teenagers; therefore, so most clinicians feel
13
Table 2 Combination Retinoid-Based Therapy for Acne
Table 2 Combination Retinoid-Based Therapy for Acne
The combination of a topical retinoid and antimicrobial agent remains the preferred approach for almost all patients with
•acne.
The combination of a topical retinoid and antimicrobial agent remains the preferred approach for almost all patients with acne.
This
attacks3 3ofof
4 major
pathogenic
acne: abnormal
desquamation,
Propionibacterium
acnes
• Thiscombination
combination attacks
thethe
4 major
pathogenic
factorsfactors
of acne:ofabnormal
desquamation,
Propionibacterium
acnes colonization,
colonization, and inflammation.
and inflammation.
Retinoids are anticomedogenic and comedolytic and have some antiinflammatory effects, whereas benzoyl peroxide is
•antimicrobial
Retinoids are anticomedogenic
and comedolytic
and have
some antiinflammatory
effects, whereas
benzoyl peroxide
is antimicrobial
with some keratolytic
effects and
antibiotics
have antiinflammatory
and antimicrobial
effects.
with
some keratolytic
antibiotics have
antimicrobial
effects. more than 16,000 patients.
The
superior
efficacy effects
of thisand
combination
has antiinflammatory
been shown in and
clinical
trials involving
Fixed-dose
combination
products
withhas
a topical
retinoid
and an
antimicrobial
provide
improved
patient convenience that
•
The superior
efficacy of this
combination
been shown
in clinical
trials
involving more
than 16,000
patients.
may translate to improved adherence; those without an antibiotic in the formulation may minimize the development of
•bacterial
Fixed-doseresistance
combination
products
with a topical
and an
antimicrobial
provide improved
patient
convenience
that maymay
translate
(level
IV evidence);
on retinoid
a theoretic
basis,
retinoid–benzoyl
peroxide
combination
products
be the
to
improved
adherence;
those
without
an
antibiotic
in
the
formulation
may
minimize
the
development
of
bacterial
resistance
(level
IV
most desirable.
evidence); on a theoretic basis, retinoid–benzoyl peroxide combination products may be the most desirable.
comfortable with prescribing hormonal therapy in older adolescents. Expert opinions vary on when it is safe to initiate hormonal therapy in younger girls, but there is general agreement
that hormonal therapy should not begin until at least 1 year after
menarche. The current standard for prescribing hormones for
contraception is that a gynecologic evaluation and Papanicolaou
test are not necessary if the patient is not sexually active. In
general, pediatric dermatologists have adopted a similar approach when using these agents for treating acne. The patient
and her family should be asked about risk factors for contraceptive use, including smoking, a history of migraine headaches or
cardiac or thromboembolic disease, or a strong family history of
thromboembolic disease.
Isotretinoin may be used (albeit as an off-label use) for any
patient with severe, refractory acne, including patients between 8 and 11 years of age. Appropriate counseling and
standard precautions observed with adolescents apply to
these younger children as well.
ManagingFactors
Factors
Managing
That
AffectTolerability
Tolerability
That
Affect
An issue that most clinicians encounter frequently is the variable tolerability of topical agents. For example, benzoyl peroxide is associated with a low rate of true contact allergy,
whereas a substantial number of patients who use some benzoyl peroxide products may complain of dryness and/or irritation, without true allergy. Many patients may have no such
difficulties with other benzoyl peroxide products—including
benzoyl peroxide–antibiotic and benzoyl peroxide–retinoid
combination therapy. Similarly, topical retinoids often are
well tolerated by younger, prepubertal patients, particularly
when less-irritating formulations are used in accordance with
appropriate instruction.
To improve tolerability of topical agents that tend to be drying
or irritating early in the course of treatment, gradual dosing can
be considered. For example, the use of a retinoid twice a week or
every other day for the first few weeks of the regimen may be
helpful; after this time, daily use can be instituted. Moisturizers
can also be used to decrease irritation.
The active ingredient of a topical preparation is a very
important component of efficacy, but the vehicle also is an
14
important component of drug tolerability. These factors, in
turn, affect whether the medication works—not just because
of its efficacy but also because of any impact it may have on
the use of and compliance with the medication regimen.
Although no differences may exist between generic topical
medications in the active ingredient, a difference in the vehicle means that the medication is different. As a result, a patient may have a different response (or lack of response) to
the same medication in a different vehicle, and less-irritating
products may be more likely to “work” because the patient is
more compliant with therapy.
In addition, any patient’s skin care routine can have a great
effect on the tolerability of topical medications. This variable
is too often overlooked when tolerability is a particular concern with a medication (as in the examples cited above) or
with an individual patient. This is a variable that is always
considered in clinical trials of topical agents—the investigators specify or proscribe certain activities or exposure to certain substances or products for the duration of the study. For
example, researchers specify how facial cleansing is to be
done, and with what products, as well as whether a moisturizer can be used and, if so, what type.
Patients and caregivers should understand that the goal of
washing the skin is not to scrub away acne; instead, the goal
is to cleanse and prepare the skin for accepting and tolerating
the topical medication that will be applied. Overzealous
washing and the use of astringent cleansers do not prevent
future acne lesions but only increase the risk for irritation and
reduced tolerance of the medication.
Long-TermMaintenance
Maintenance
Long-Term
Systemic therapy with oral antibiotics can be very helpful in
bringing moderate-to-severe disease under control. However, once adequate control is achieved, it is reasonable to use
regimens that minimize antibiotic exposure. Many patients
do well with subsequent use of a topical regimen with a
combination retinoid plus antibiotic or retinoid plus benzoyl
peroxide combination (Table 2 lists available retinoid-based
agents for acne). Maintenance therapy with topical retinoids
or retinoid combinations may obviate the need for long-term,
systemic antibiotics.7
ly
at
th
n.
amin
ees
ge
nd
he
n.
er
hal
o-
nt
ed
16
Conclusions
Conclusions
Conclusions
Early-onset acne appears to be occurring more frequently
Early-onset
to beand
occurring
more Disease
frequently
and
warrantsacne
earlyappears
counseling
intervention.
at
and age
warrants
counseling
and
intervention.
Disease
at
any
and of early
any severity
can be
managed
successfully
with
anyavailable
age and of
any severity
be managed
with
the
agents
used ascan
monotherapy
orsuccessfully
in combination.
the available
agents
used as
monotherapy
or in combination.
From
the limited
studies
that
have been undertaken
in paFrom
the
limited
studies
that
have
been
undertaken
patients with early-onset acne, the response appears
to beinsimtients
with
early-onset
acne,
the
response
appears
to
be
similar for both inflammatory and noninflammatory lesions in
ilar for both
and noninflammatory
patients
with inflammatory
acne who are between
8 and 11 yearslesions
of age.in
patients with acne who are between 8 and 11 years of age.
References
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The2010.
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Abstract P714
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the severity
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theofaffected
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Results
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should
the130:30-39,
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and
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should
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is that
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156:22-31,
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shortand long-term
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D, Gollnick H,devastating
Bettoli V, et al:consequences.
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Guidelines of2007
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AmLeyden
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vulgaris
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DM:
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A, Eichenfield
L, et al:
open-label study
the
tolerability
of tretinoin
gelAn
microsphere.
0.04 %toinassess
a pump
efficacy
and
tolerability
of
tretinoinisgel
microsphere.
% in can
a Acadpump
in early
and preadolescents:
Presented
at the0.04
American
Thedispenser
diagnosis
of acne
usually
straightforward
and
be
dispenser
in early
and
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Presented
at examination.
the
American
emy
of Dermatology
68th,
Annual and
Meeting;
Miami,
Florida;
MarchAcad5-9,
made
by
the
patient’s
history
physical
In
emy ofAbstract
Dermatology
2010.
P714 68th, Annual Meeting; Miami, Florida; March 5-9,
some cases, further diagnostic testing is indicated, and refer2010. Abstract
P714 R, Nighland M: Tretinoin microsphere gel in
5. Jorizzo
J, Grossman
ral younger
to a pediatric
endocrinologist
is recommended
if a patient
5.
Jorizzo
J,acne
Grossman
R,
Nighland
M:
Tretinoin 2008
microsphere
gel in
patients.
J Drugs
Dermato
7:S9-S13,
(suppl)
hasdelRosso
any signs
of virilization.
Although
standardized
assessyounger
acne
patients.
J Drugs Dermato
7:S9-S13,
2008
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G: Optimizing
use
of oral
antibiotics
in (suppl)
acne vulgaris.
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G:yet
Optimizing
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in acne
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Clin
27:33-42,
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ment
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of tazarotene
L.F.vulgaris:
Eichenfield
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minocycline
maintenance
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acne
A doubleacne.
In
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the Shalita
clinician’s
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the
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maintenance
therapies
acne Dermatol
vulgaris: A142:605doubleblind,
randomized,
parallel-group
study.inArch
tive612,
of the
patient andparallel-group
the family, as
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as the
history142:605of acne
blind,
randomized,
study.
Dermatol
2006
in the
612,family,
2006 may affect the classification of acne and may
Conclusions
Conclusions
in
m
R
1.
2.
3.
4.
5.
6.
mediate the subsequent discussion of therapy.
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the
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therapy
and
urgency
for K,
intervention.
One
that
can
16.
Mourelatos
Eadydecisions
EA, Cunliffe
WJ, assumption
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in sebum
excretion
propionibacterial
colonization
in preadolescent
children
urgency
intervention.
One
assumption
that
and
should
beforand
made
is that failure
to intervene
cancan
lead
to
with and
Br J failure
Dermatol to
156:22-31,
2007can lead to
should
be without
made acne.
is that
intervene
shortand
long-term
devastating
consequences.
17. Thiboutot D, Gollnick H, Bettoli V, et al: New insights into the manageshortlong-term
devastating
consequences.
mentand
of acne:
An update from
the Global Alliance
to Improve Outcomes in
acne group. J Am Acad Dermatol 60:S1-S50, 2009 (suppl)
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Alestas T, Ganceviciene R, Fimmel S, et al: Enzymes involved in the
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sebaReferences
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Mol
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Nakatsuji
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Huang CP, et al: Antibodies elicited by inacti29:241-246,
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R. G. Fried
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uate the IL-8 production in human sebocytes. J Invest Dermatol
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Facing the Challenge of Acne Vulgaris in Pediatric Patients CME Post-Test Answer Sheet and Evaluation Form
Release Date of Activity: June 2010 • Expiration Date of Activity for AMA PRA Credit: June 30, 2012 • Estimated Time to Complete This Activity: 2.0 hour(s)

Facing the Challenge of Acne Vulgaris in Pediatric Patients

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