Facing the Challenge of Acne Vulgaris in Pediatric Patients

16 Pages·2010·3.21 MB·English

A CME-CErtifiEd SupplEMEnt to
Skin & Allergy News
®
Facing the Challenge
of Acne Vulgaris in
Pediatric Patients
Introduction 3
Acne Epidemiology 4
and Pathophysiology
Diagnosis and Evaluation of Acne 6
Medical and Psychosocial 9
Impact of Acne
Perspectives on Therapeutic 12
Options for Acne: An Update
CME Post-Test and Evaluation Form 16
Faculty
Sheila F. Friedlander, MD
Chair
Professor of Clinical Medicine,
Lawrence F. Eichenfield, MD Pediatrics and Dermatology
Chief of Pediatric and Rady Children’s Hospital,
Adolescent Dermatology UCSD School of Medicine
Professor of Pediatrics and Medicine San Diego, CA
Models are for illustrative purposes only. (Dermatology)
Moise L. Levy, MD
Rady Children’s Hospital,
Specially for Children
UCSD School of Medicine
Chief, Pediatric Dermatology
San Diego, CA
Dell Children’s Medical Center
Release Date: June 2010
Austin, TX
Expiration Date of Activity for AMA PRA Credit: June 30, 2012 Joseph E. Fowler, Jr, MD Clinical Professor, Dermatology/Pediatrics
Estimated Time to Complete This Activity: 2.0 hour(s) Clinical Professor of Dermatology Baylor College of Medicine
University of Louisville Houston, TX
Louisville, KY
Guy F. Webster, MD, PhD
A continuing medical education activity held at the 34th Annual Richard G. Fried, MD, PhD Clinical Professor
Private Practice Department of Dermatology
Yardley Dermatology Associates Jefferson Medical College
Yardley, PA Philadelphia, PA
Jointly sponsored by This activity is supported by an educational grant from
and
A SupplEMEnt to Facing the Challenge of
Skin & Allergy News
®
Acne Vulgaris in Pediatric Patients
Release Date of Activity: June 2010 TARgET AUDIEnCE
The target audiences for this educational
Expiration Date of Activity for AMA PRA
supplement are dermatologists, pediatri-
Credit: June 30, 2012
cians, and other health care professionals
Estimated Time to Complete This Activity:
involved in the treatment of pediatric
2.0 hour(s)
patients with acne.
Reprinted from
To get instant CME credits online, go to
Seminars in Cutaneous STATEMEnT OF PROFESSIOnAl
http://louisville.edu/hsc/continuinged/
Medicine and Surgery PRACTICE gAP(S)
earn-ce-credits/acnevulgaris. (Type the
Untreated or ineffectively managed acne vul-
The manuscript was originally above address into your address bar in
published as a supplement to garis is associated with important physical
Internet Explorer. If you are unfamiliar with
Seminars in Cutaneous Medicine and psychosocial sequelae. The wide range
and Surgery, Supplement 1, Vol. 29, what an address bar is or how to access of topical and systemic treatments allows
No. 2S, June 2010. It has been yours, open Internet Explorer, then hold
clinicians to choose a regimen that is appro-
reviewed and approved by the faculty
down the control key and press the “O” key
priate for each patient. Further, with
as well as the Editors of Seminars in
Cutaneous Medicine and Surgery. on your keyboard. A dialogue box will open appropriate treatment, acne can be success-
– this is where you will type the above fully managed in almost every case. The
address. After you have typed the address, articles in this supplement provide an update
click OK to go to the evaluation.) on the epidemiology, pathophysiology, medi-
This continuing medical education
(CME) supplement was developed Upon successful completion of the online test cal and psychosocial impact, and treatment
from a clinical roundtable held during and evaluation form, you’ll be directed to a of acne vulgaris in pediatric patients. As much
Skin Disease Education Foundation’s webpage that will allow you to receive your of the most recent new information on acne
34th Hawaii Dermatology Seminar,
concerns an emerging subgroup—that is,
certificate of credit via e-mail. Please add
CME conference, Waikoloa, Hawaii,
children between about 8 and 11 years of
February 14-19, 2010. [email protected] to your e-mail “safe list.”
age—evidence and insights about younger
Once you have completed the evaluation,
Neither the editors of Skin & Allergy patients are presented and discussed.
News nor the Editorial Advisory you will be given a password. Please be sure Clinicians who provide health care to pediat-
Board nor the reporting staff to write it down; you will then be able to
ric patients with acne must have the latest
contributed to its content. The
access your certificate. Please note, certifi-
opinions expressed in this supplement clinical data and knowledge to individualize
cates will not be mailed, so be sure to print
are those of the faculty and do not their patients’ care.
necessarily reflect the views of a copy for your records. If you have any
lEARnIng ObJECTIVES
the supporter nor of the Publisher. questions or difficulties, please contact the
Upon completion of this activity, participants
University of Louisville School of Medicine
The faculty acknowledge the editorial will be better able to:
Continuing Health Sciences Education office
assistance of Global Academy for
• Assess and classify acne vulgaris in pedi-
Medical Education, LLC, an Elsevier at [phone].
business, and Joanne Still, Medical Writer, atric patients.
in the development of this supplement. JOInT SPOnSORShIP
• Describe the topical and systemic medi-
This activity has been planned and imple- cations available and suitable for use in
www.skinandallergynews.com
mented in accordance with the Essential Areas pediatric patients with acne.
and Policies of the Accreditation Council for
• Determine the type of medication and
Copyright © 2010 by Elsevier Inc. and its Continuing Medical Education (ACCME)
route of delivery appropriate for individual
Licensors. All rights reserved. No part of this
through the joint sponsorship of the University
publication may be reproduced or transmitted in patients, based on age, severity of dis-
any form, by any means, without prior written of Louisville School of Medicine Continuing ease, and other factors.
permission of the Publisher. Elsevier Inc. will Health Sciences Education (CHSE) and Skin
not assume responsibility for damages, loss, or • Counsel patients and parents regarding
Disease Education Foundation, an Elsevier
claims of any kind arising from or related to the management of the disease and
the information contained in this publication, business. CHSE is accredited by the ACCME to
review strategies for coping with acne.
including any claims related to the products,
provide continuing education for physicians.
drugs, or services mentioned herein.
DISClOSURE
DESIgnATIOn STATEMEnT As a sponsor accredited by the ACCME,
CHSE designates this educational activity for CHSE must ensure balance, independence,
a maximum of 2.0 AMA PRA Category 1 objectivity, and scientific rigor in all its spon-
Credit(s)™. Physicians should only claim sored educational activities. All faculty
credit commensurate with the extent of their participating in this CME activity were asked
participation in the activity. to disclose the following:
2 Facing the Challenge of Acne Vulgaris in Pediatric Patients
Volume 29, Number 2S June 2010
Introduction
Introduction
Recently, a panel of experts convened during the Skin verity,andtheeffectivenessofthoseregimensmustbemon-
DiseaseEducationFoundation’s34thHawaiiDermatol- itored,assessed,andadjustedasneeded.
ogy Seminar to discuss acne vulgaris in pediatric patients. Inyoungerpatients,inparticular,carefulfollow-upiskey
The goal of this panel discussion was to review the medical tooptimalmanagementbecauseinmanychildren,acnehasa
literature and clinical experience to provide clinicians with tendency to worsen with pubertal maturation. Thus, in pa-
an update on the epidemiology, pathophysiology, medical tients in the 8- to 11-year-old subgroup, changes in the ef-
and psychosocial impact, and treatment of acne vulgaris in fectivenessofmedicationsovertimearemorelikelytooccur
thaninolderpatients,whosediseaseismorelikelytostabi-
pediatric patients. Although new evidence and insights are
lize once an effective therapy has been identified (assuming
availableintheseareasthatapplytopeoplewithacneatany
consistencyofcompliancewiththeregimen).
age,agreatdealofthenewestinformationreferstothecon-
Inaddition,inyoungerpatientswithacne,thepsychoso-
ditioninyoungerpediatricpatients,thoseyoungerthanthe
cialimpactoftheconditionalsotendstovaryovertime.For
typical“adolescentacnepatient”whoisbetween12and18
example,mild-to-moderateacnemaynotbeespeciallyboth-
yearsofage.
ersometomany9-year-oldchildrenbutmaybecomemoreof
Acneiscommonlyobservedinhealthychildrenfrom8
anissuewhentheyentermiddleschool.
through 11 years of age in increasing numbers. This con-
Clinicianswhoprovidehealthcaretochildrenbetween8
dition is to be distinguished from the lesions found in
and18yearsofage—whetherindermatologic,pediatric,or
neonatalacneandacnethatoccursinpatientswithvarious
primarycaresettings—alreadyareawareoftheneedforap-
pathologic causes of premature adrenarche (a cause of
propriateassessmentandtreatmentofyoungerpatientswith
precocious puberty). acne.Theauthorshopethatthesearticleswillprovideinfor-
Inthesearticles,theauthorsdiscusstheevidenceconcern- mation of immediate practical use, and at the same time
ing the epidemiologic trends and underlying causes for this provideinsightintofutureresearchthatmayyieldclinically
downwardshiftinacneageofonset,aswellasapproachesto applicableevidenceoverthenextseveralyears.
recognizing the severity and type of acne and treating the
condition at any age. Furthermore, in all age groups, the LawrenceF.Eichenfield,MD
treatment regimens chosen must be matched to disease se- GuestEditor
1. Names of proprietary entities producing Johnson & Johnson, Quinnova, Ranbaxy, Moise l. levy, MD, has been a consultant
health care goods or services—with the Shire, Stiefel, Triax, and Valeant. He has been for GlaxoSmithKline and SkinMedica.
exemption of nonprofit or government a speaker for Galderma, Medicis, Ranbaxy, Sylvia Reitman, MbA, has nothing to
organizations and non–health-related Shire, Stiefel,UCB, and Valeant. He has
disclose.
companies—with which they or their also been an investigator for Abbott, Taro,
Joanne Still has nothing to disclose.
spouse/partner have, or have had, a rele- Allerderm, Allergan, Amgen, Astellas,
vant financial relationship within the past Centocor, Coria, Dermik, Dow, Galderma, guy F. Webster, MD, PhD, has been a con-
12 months. For this purpose, we consider Genentech, Johnson & Johnson, Medicis, sultant for Allergan, Cutanea, Cipher,
the relevant financial relationships of a Novartis, Quinnova, Shire, Stiefel, Taisho, Galderma,GlaxoSmithKline, Medicis, Ortho,
spouse/partner of which they are aware to and 3M. and Quinnova.
be their financial relationships.
Richard g. Fried, MD, PhD, has nothing ChSE Committee Members have no rele-
2. Describe what they or their spouse/part- to disclose. vant financial relationships with any
ner received (salary, honorarium, etc).
commercial interests: Carolyn Burns, MD;
Sheila F. Friedlander, MD, has been a con-
3. Describe their role. sultant for Astellas, Barrier Therapeutics, Dedra DeBerry, MA; Joyce Dunagan, MA,
4. No relevant financial relationships. Galderma, Graceway, Novartis, and sanofi- MSLS ; Linda H. Freeman, DNS, RN; Paul
lawrence F. Eichenfield, MD, has served aventis. She has also received grant Fultz; Terri Gipson, MSL; Ruth Greenberg,
as a speaker for Coria. He has also been an research support from Atlanta, Amgen, PhD; Lucy Juett, MS; Irene Litvan, MD; Loretta
investigator and/or consultant for Johnson & Astellas, Barrier Therapeutics, Galderma, Maldaner; Mike Mansfield, DMD; Ashlee
1085-5629/10/$-seefrontmatter©2010ElsevierInc.Allrightsreserved.
Johnson, Ortho Dermatologics, Stiefel, Hill Dermaceuticals, Johnson & Johnson, Melendez, RN, BSN; Lisa J. Pfitzer, MD; Robert
doi:10.1016/j.sder.2010.04.001
Galderma, and sanofi-aventis. LEO Pharmaceuticals, Novartis, Ortho Sexton, MD; Uldis Streips, PhD; Kathy M.
Joseph F. Fowler, Jr, MD, has been a con- Dermatologics, Photocure, Pierre-Fabre, Vincent, MD; Lori Wagner, MD; Stephen
sultant for Galderma, Graceway, Hyland, RegeneRx, and Dow. Wheeler, MD; Sharon K. Whitmer, EdD.
Facing the Challenge of Acne Vulgaris in Pediatric Patients 3
Acne Epidemiology and Pathophysiology
AcnSeheilEa fp. firdiedelamndeir,o Mldo,* glaywreancne fd. EicPhenafitelhd, oMpd,*h Joysesphi of. floowglery, Jr, Md,†
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;12yearsofageisnolongerthelowendofthe“normal”rangeforonsetofacne.
Theavailableepidemiologicevidenceraisesmorequestionsthanitanswersregardingthe
etiologyofthisdownwardshift.Morestudyisneededtoclarifywhetherthetrendtoward
anearlieronsetofpubertyintheUnitedStateshasinfluencedtheclinicalpictureofacne.
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.
In the past several years, clinicians have noted an earlier Sørensenandcolleagues1inDenmarkpublishedthelatest
onsetofacne—thatis,theappearanceofacneinpatientsas datafromtheCopenhagenPubertyStudy,inwhich824boys
young as 8 or 9 years of age. This clinical observation has wereevaluatedduringtheperiod1991-1993inacross-sec-
beensupportedbyepidemiologicevidencethatsuggeststhat tionalstudy,andcomparedwith704boyswhowereevalu-
theaverageageoftheonsetofpubertyhasdecreased. ated in a combined cross-sectional and longitudinal study
duringtheperiod2006-2008.Thepurposeofthestudywas
*Rady Children’s Hospital, UCSD School of Medicine, San Diego, CA. to assess trends in pubertal onset and the relationship of
*†URandivyeCrshitiyld orfe Lno’suHisovsilpleit,a Ll,oUuiCsvSiDlleS, cKhYo.olofMedicine,SanDiego,CA. those trends to body mass index in boys. The investigators
†‡YUanrdivleeyrs DityeromfaLtoouloisgvyi lAles,sLoociuaitsevsi,l lYea,rKdYle.y, PA. showedthattheonsetofpubertyoccurredsignificantlyear-
‡YardleyDermatologyAssociates,Yardley,PA.
§Baylor College of Medicine, Houston, TX. lierduring2006-2008(withameanageof11.66years)than
§BaylorCollegeofMedicine,Houston,TX.
¶Jefferson Medical College, Philadelphia, PA. in1991-1993(meanage,11.92years).
¶JeffersonMedicalCollege,Philadelphia,PA.
PPuubblliiccaattiioonn ooff tthhiiss CCMMEE aarrttiiccllee wwaass ssppoonnssoorreedd bbyy tthhee UUnniivveerrssiittyy ooff LLoouuiissvviilllele A number of articles have been published considering
CoCnotnintiuniunigngH HeaelathlthS SciceinencecsesE Edduuccaatitoionn aanndd SSkkiinn DDiisseeaassee EEdduuccaatitoionn whetherandwhysexualmaturationmaybeoccurringearlier
Foundation and supported by an educational grant from Ortho
FoundationandsupportedbyaneducationalgrantfromOrthoDerma- intheUnitedStates,2–11buttheconclusionsregardingtheUS
Dermatologics.
tologics.
data have been mixed. The National Health and Nutrition
SShheeiillaa FF.. FFrriieeddlalannddere,r,M MDD,h, ahsabse beneeanc ao ncsounltsaunlttafonrt Afosrte Allasst,elBlaarsr,i eBraTrrhieerr-
apTehuetircasp,eGuatlidcse,r Gmaal,dGerrmacae,w Gayra,cNeowvaayr,t Nis,oavnadrtissa,n aonfid- asvaennotfiis-.aSvhenethisa.s Sahlseo Examination Surveys and other surveys have not clearly
rehceaisv aeldsog rreacnetivreedse garracnht rseuspeparocrht sfruopmpoArtt lfarnomta, AAtlmangtean, ,AAmsgteelnla, sA,sBtealrlraise,r demonstrated whether pubertal age is decreasing over time,
Barrier Therapeutics, Galderma, Hill Dermaceuticals, Johnson &
Therapeutics,Galderma,HillDermaceuticals,Johnson&Johnson,LEO nor have they established whether socioeconomic and racial
Johnson, LEO Pharmaceuticals, Novartis, Ortho Dermatologics,
PhPahromtoacceuureti,c Pailes,rreN-Fovabarrtei,s ,ReOgertnheoRxD, earnmd aDtoolwog.ics, Photocure, Pierre- factors may affect this. Nevertheless, epidemiologic evidence
Fabre,RegeneRx,andDow.
Lawrence F. Eichenfield, MD, has served as a speaker for Coria. He has doessupporttheimpressionofmanyclinicians—includingthe
LawrenceF.Eichenfield,MD,hasservedasaspeakerforCoria.Hehasalso
alsobeen an investigator and/or consultant for Johnson & Johnson, authors—that the average age of puberty has decreased.7,9
beenaninvestigatorand/orconsultantforJohnson&Johnson,Ortho
Ortho Dermatologics, Stiefel, Galderma, and sanofi-aventis.
Dermatologics,Stiefel,Galderma,andsanofi-aventis. Someproposethatnutritionmaybeoneexplanationforear-
JJoosseepphh FF.. FFoowwlleerr,, JJrr,, MMDD,, hhaass bbeeeenn aa ccoonnssuultltaanntt foforr GGaaldldeerrmmaa,, GGrraacceewwaayy, , lieronsetofpubertyintheUnitedStates—thatis,thateither
Hyland, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Stiefel, Triax,
Hyland,Johnson&Johnson,Quinnova,Ranbaxy,Shire,Stiefel,Triax, better nourishment accounts for the change, or that obesity
and Valeant. He has been a speaker for Galderma, Medicis, Ranbaxy,
andValeant.HehasbeenaspeakerforGalderma,Medicis,Ranbaxy,
Shire, Stiefel, UCB, and Valeant. He has also been an investigator for contributestoeitherachangeinpubertalstatusorachange
Shire, Stiefel, UCB, and Valeant. He has also been an investigator for
Abbott, Taro, Allerderm, Allergan, Amgen, Astellas, Centocor, Coria, inacnepresentation.
Abbott, Taro, Allerderm, Allergan, Amgen, Astellas, Centocor, Coria,
Dermik, Dow, Galderma, Genentech, Johnson & Johnson, Medicis,
DeNromviakr,tisD, oQwu,inGnaolvdae,r mShai,reG, Setnieenfetle, cTha,isJhooh,n asnodn 3&M.Johnson, Medicis,
Novartis,Quinnova,Shire,Steifel,Taisho,and3M.
RRiicchhaarrdd GG.. FFrriieedd,, MMDD,, PPhhDD,, hhaass nnootthhiinngg ttoo ddiisscclloossee.. AcAncen,eS, Seexxuuaall Maturation,
MMooiissee LL..L Leevvy,y,M MDD,,h ahsasb ebeenena cao ncosunlstaunlttafnotr fGolra xGolSamxoitShmKliitnheKalinnde Saknind- and Pathophysiology
Maturation, and Pathophysiology
Skin-Medica.
Medica.
GGuuyy FF.. WWeebbsstteerr,, MMDD, ,PPhhDD, ,hhaass bbeeeenn a acoconnsusultlatannt tfofor rAAlllelergrgaann, ,CCuutatanneeaa, ,
A number of studies have examined the onset of acne in
CiCpihpehre,rG, Galadledremrma,aG, GlalxaoxSomSmithitKhlKinlien,eM, Medeidciics,isO, Ortrhtoh,oa, nadndQ Quiuninnonvoav.a.
relationship to sexual maturation, Propionibacterium acnes
AAddddrreessss rreepprriinntt rreeqquueessttss ttoo:: SShheeiillaa FF.. FFrriieeddllaannddeerr,, MMDD,, 880055 FFrroosstt SStrtreeeett, ,
SuSiuteit6e 0620,2S, aSnanD Dieigeog,oC, CAA9 29122132.3E. -Em-maial:ils: fsrfireideldalnadnedre@[email protected]. colonization, and sebaceous gland activity. Lucky and co-
4 Facing the Challenge of Acne Vulgaris in Pediatric Patients
2 1085-5629/10/$-seefrontmatter©2010ElsevierInc.Allrightsreserved.
doi:10.1016/j.sder.2010.04.002
Acneepidemiologyandpathophysiology 3
Acneepidemiologyandpathophysiology 3
AAccnneeeeppiiddeemmiioollooggyyaannddppaatthhoopphhyyssiioollooggyy 33
workers were the first to demonstrate that a surge in dehy- ofhumansebocytes.Itisnotknownwhetherimmunization
workers were the first to demonstrate that a surge in dehy- ofhumansebocytes.Itisnotknownwhetherimmunization
wdwrooorrekkpeeirrassnwwdreeorrseetetthhroeenfifierrsssuttlttfooatedd,eeammhooannrssbttirrnaagtteeertthhofaattpuaabsseuurrrtggyee,iiisnnaddsseeohhcyyi--- owoffohhuuuldmmmaannedsseeiabbtooecctyyhtteeessd..eIIvtteiisslonnpoomttekknnntooowwfnnacwwnhheeeittnhheehrruiimmmammnsuu.nniizzaattiioonn
droepiandrosteronesulfate,aharbingerofpuberty,isassoci- wouldmediatethedevelopmentofacneinhumans.
dadtrreoodeeppwiiaaitnnhddrrtoohssetteeorrnoosnneeetssouufllffaaactteen,,eaa.1hh2aaOrrbbthiinneggreesrrtuooffdppieuusbbbeeyrrttyyL,,uiissckaayssssooancciid-- wwoouullddmmeeddiiaatteetthheeddeevveellooppmmeennttooffaaccnneeiinnhhuummaannss..
ated with the onset of acne.12 Other studies by Lucky and
caaotteelddleawwgiiuttehhs1tt3hh–ee15oosnnhssoeewtt eoodff aatcchnnaeet..c1122omOOetthhdeeorrnassttluuaddciineeess bbgeyynLLeuuracclkklyyypaarnnedd-
colleagues13–15 showed that comedonal acne generally pre-
ccccooeeddlllleeeeddaaggoouutteehhssee11rr33––ee11xx55ttsseehhrrnnooaawwlleessddiiggttnnhhssaaoottffccppoouummbbeeeeddrrttooyynnaaaannllddaaccttnnhheeaattggeeeellnneeeevvrraaaattlleellddyyhhppoorreerr---- NNootteess oonn AAccnnee
cmceeoddneeddelooettvhheeelsrrpeexxretteedrrinncaatelldssiimggnnossreooffseppvuuebbreeerrattyycnaaenn.ddtthhaatteelleevvaatteeddhhoorr-- NPNaooNtttheeoosstepoosh nnoynsAA iAocccnnloneeeg y
monelevelspredictedmoresevereacne. Pathophysiology
mmooAAnnnneeoolltteehhvveeeerrllssiinnppttrreeeerrddeessiiccttiittnneeggddllmmiinnooeerrooeeffsssseettvvuueeddrryyeeiiaassccttnnhheeee..ccoorrrreellaattiioonnooffsseebbaa-- PiPnaaPYtthhaoootuhpponhhpgyyhessyriisooPiollooalotgggiyyeynts
cceeooAAuunnssooggtthhllaaeennrrddiinnaattcceettrriieevvssiittttiiyynn,,ggPPlliiaanncceenneeoossffccssoottuullooddnnyyiizziissaatttthhiiooeenncc,,ooaarrnnrrddeellaappttuuiioobbnneerroottffaallsseeaabbggaaee--.. iiinnn iYYYn oooYuuuonnnugggngeeeerrrrPPP Paaaattttiiiieeeennnnttttssss
cMceeooouuurssegglallaatonnsddaaanccdttiivvciiottlyyl,,eaPPguaaccennsee16sscccooonlloodnnuiizzcaatettiidoonna,,loaannngdditppuuudbbineerrattlaaslltaauggdeey..
Mourelatosandcolleagues16conductedalongitudinalstudy Thepresentationofacneinyoungerpediatricpatientstypi-
Thepresentationofacneinyoungerpediatricpatientstypi-
MMdeoomuuorreenllsaatttrooasstiaannngddthccooatll,lleeiaanggiuutieeassll11y66,ccaoonnsmdduuacclltteendduaamllbooennrggiiottfuuddfoiilnnliaaclllessttsuusddeyy-
demonstrating that, initially, a small number of follicles se- TcTahhleleyppdrrieefssfeeernnsttaafrttoiioomnntoohffaaatcconnbeeseiinnrvyyeooduuinnnggpeerratppieeenddtiisaattwrriiiccthppaaattliiaeetnnettrssottnyyppseii--t
callydiffersfromthatobservedinpatientswithalateronset
dcdreeemmteoosnnessbttrruaamttiinn,ggantthhdaattth,,aiinntiittthiiaaellllnyy,,umaa ssbmmeraallollfnnsuuemmcrbbeteeirrngoofffoffoollllillciicclelleesssassneed--
crete sebum, and that the number of secreting follicles and cocaafllllayycnddeiiff.ffeeTrrhsseffrroopmmresttehhnaatttaootibbossneerrivvneeddyoiinnunppgaaettiireennpttasstiwweniittthhsaatellnaattdeesrrootonnssbeeett
of acne. The presentation in younger patients tends to be
ctchrreeettaeersseeeabbsuuommft,,haaennsddkittnhhaathttattthhceeonnnuutamminbbeethrreoosffessfeeocclrrlieecttliiennsgginffoocllrlleiiccallseeesswaainnthdd
theareasoftheskinthatcontainthesefolliclesincreasewith ocohffaaarccannceete..rTTizhheeedppbrryeessneeonnnttiaanttiiflooannmiimnnayytooouruynn,ggceeorrmppeaadttiioeennnattssl ltteeesnnioddnssstt.ooThbbeee
tathhgeeeaaarrneedaasspoouffbttehhreetasslkksiitnnagttehh.aaTtthccioosnnstttaauiinndytthhseehssoeewffooedlllliitcchlleeasstciinnhccilrrdeeraaessneewwwiihtthho characterized by noninflammatory, comedonal lesions. The
ageandpubertalstage.Thisstudyshowedthatchildrenwho cechxhpaarrlaaanccttaeetrrioiizzneeddfobbryythnnioosnndiiinnffflfleaaremmnmmceaattioosrrdyye,,tcceoormmmieenddeoodnnoaallnlleethssiieoonnbass..siTTshhoeef
adaggeeeveaalnnoddpppauucbbneeerrtthaaallvsstteaagggeer..eaTTthheiirsssssettuubdduyymsshhpoorwwodeeuddcttthhioaanttccahhsiillddwrreeelnnl wwashhooa explanationforthisdifferenceisdeterminedonthebasisof
develop acne have greater sebum production as well as a etehxxeppllaaafnnoaarettiimoonnenfftooirrontthheiidsseddviiiffdffeeerrneecnnecc.eeItiissisddceeltteeearrrmmtiihnnaeetddseoobnnumtthheeinbbnaasseiicsseoos-ff
dgdreeevvaeetlleoorppdeaanccnnsieetyhhoaafvvPeeaggcnrreeeaasttieenrrthsseeebbsuuemmbumpprr-oopddruuodccttuiioocinnngaassarwweaeesllllofaatssheaa theaforementionedevidence.Itisclearthatsebuminneces-
greaterdensityofPacnesinthesebum-producingareasofthe tsthhareeyaafffooorrreePmmaeecnnntteiioosnnceeoddloeenvviiizddaeetinnoccnee..oIIftttiihsseccllseekaairrntt,hhaaalttossneegbbuuwmmithiiinnsthnneeeccieemss---
gsgkrreeinaatt.eeHrrddoweennessviiettyyr,ooPffPPacaanccnneseessciionnlotthhneeizssaeetbbiouunmma--lpporrnooedd,uuaccsiinndggemaarroeenaassstoorffattthhedee sary for P acnes colonization of the skin, along with the im-
skin. However, P acnes colonization alone, as demonstrated mssaaurryyneffoorrresPPpaaoccnnnseeesstcchooalltoornneiiszzuaaltttiisoonninootffhttehhdeeessvkkeiilnno,,paamllooennnggtowwfiiittnhhflttahhmeemiimma---
bsskkyiinnn..aHHsaoolwwcoeelvvoeenrri,,zPPataaioccnnneecssoccuoonllootsnn,iizzdaaidttiioonnnotaallcooonnreer,,elaaassteddeewmmitoohnntsshttrreaadtteeedd- muneresponsethatresultsinthedevelopmentofinflamma-
by nasal colonization counts, did not correlate with the de- mtmouruynneeprraeepssupplooenns,sseepttuhhsaattturrleeesss,uullattnssdiinnntthhoeeduddleeevvsee.llooYppommuneegnnettrooffpiianntiflfleaanmmtsmmdaao--
bvbeyylonnpaamssaaellncctooolloofnnaiiczznaatteii,ooannltcchooouuunngtthss,,nddaiisddalnncooottloccnooirrzrraeetllaaiotteenwwdiiidtthhintthhceereddaseee-- tory papules, pustules, and nodules. Younger patients do
velopmentofacne,althoughnasalcolonizationdidincrease tdtooerrvyyelppoaapppfuuollleelissc,,upplauursspttuululleegsss,,anaanndddvinnsioobddleuuclleeossm.. eYYdooouunnneggsee,rrbupptaattthiieeennytthssaddvooe
vwveeilltoohppimmnceernnettasooiffnaagccanngeee,,.aalltthhoouugghhnnaassaallccoolloonniizzaattiioonnddiiddiinnccrreeaassee developfollicularplugsandvisiblecomedones,buttheyhave
withincreasingage. dndeoevvteeylleootppbffooeglllluiiccnuulltaaorrppprlluuoggdssuaacnneddsuvviifssfiiicbbilleeencctoosmmebeeuddmoonneetoss,,sbbuuupttptthhoeertyylhhaaarvvgeee
wwiittThhhiiennccnrreeewaasseiisnntggdaaaggtaee..concerning acne pathophysiology dem- not yet begun to produce sufficient sebum to support large
The newest data concerning acne pathophysiology dem- nnnouottmyybeeettrbbseeoggfuuPnnattcooneppsrrbooddacuutcceeeriassuu.fffificciieenntt sseebbuumm ttoo ssuuppppoorrtt llaarrggee
onTTsthhraeetenneethwwaeetssttthddeaartteaalacctooionnnccseehrrinnpiisnnggbeaatccwnneeeenppaathtthheoodppehhvyyessliioooplloomggeyynddteeommfP-- numbersofPacnesbacteria.
onstratethattherelationshipsbetweenthedevelopmentofP nnuummbbeerrssooffPPaaccnneessbbaacctteerriiaa..
ooacnnnssettrrs,aattieenfltthhaaamttmtthhaeetirroeenllaa,ttaiioonnndsshhhiiypppssebbrkeeettwwraeeteeinnniztthhateeioddneevvaeerlleoomppmmoreeenncttooomffPP-
acnes,inflammation,andhyperkeratinizationaremorecom-
apacclennxeesst,,hiinnanflflaapmmremmviaaottuiioosnnly,,aahnnaddsbhheyyeppneerrrkkeeecrroaagttniinniziizzeaadtt.iiooInnnaathrreeemmpaoosrrteeitccoowmmas--
pbppellleeelixxxevttthhhedaaannnthppparrrteee,vvviiiinoooiuuutisssallllyyylyhhh,aaaassskbbbeeeereeeannntinrrreeeizccceooodgggnnnpiiilzzzueeegddd...dIIIennnvetttlhhhoeeepsppp,aaatssshttteiiintttwwwanaaasss- CCooCnnoccnlluuclssuiisooinnonsss
believedthat,initially,akeratinizedplugdevelops,thenan- CCoonncclluussiioonnss
bdbeerolliigeeevvneedds ctthhauaatts,,eiinnseiittbiiaaallcllyyeo,,uaaskkeegrrlaaanttiidnniizzaeecddtivppalltuuioggndd,eePvveealloocnppesss,,ttphhreeonnlifaaennr--- EpidemiologicevidencefromUSstudieshassupportedtheclin-
drogens cause sebaceous gland activation, P acnes prolifer- EpidemiologicevidencefromUSstudieshassupportedtheclin-
aaddttrreeoossgg,,eennaannssddccaattuuhhsseeee ssiieemmbbmmaaccuueennooeeuussrrggeessllaappnnooddnnssaaeeccttiippvvrraaoottddiioouunncc,,eessPP aaiinnccnnflfleeaassmmppmmrrooaallttiiiiffooeennrr--.. EiiEccppaalliiddiimmeemmppiirrooeellssoossggiiooiiccnneeoovvffiiddmmeeaannnnccyyeeffpprrrrooaammccttiiUUttiiSSoonnsstteeuurrssddiirreeeessgghhaarraaddssiissnnuuggppaappnnoorreettaaeerrddlliieetthhrreeaaggcceelliinnoo--ff
aHHatteooessww,,eeaavvnneerrdd,,eettvvhhiieeddeeiinnmmcceemmhhuuaannsseeeemmrreeeessrrppggooeennddsssseehhooppwwrrooiiddnnuuggcctteehhssaattiiiinnnnflflflflaaaammmmmmmmaaaattttiioooorrnnyy.. iooiccnnaasslleeiimmttooppffrrppeessuussbbiiooeennrrttyyoo..ff77,,mm99FFaannuuyyrrttpphhrreeaarrcciittnniittvviiooeessnntteeiiggrrssaattrriieeooggnnaassrrddaarriinneeggnnaaeenneeddeeeeaaddrrlliitteeoorrccaallggaaeerriiooffyyff
HeeHvvooeewwnntteessvveeccrraa,,nneevvppiirrddeeeeccnneeddcceeeehhmmaaiissccrreeoommcceeoorrmmggeeeeddddoossnnhheeoowwffooiinnrrmmggaatthhttiiaaoottnniinnaaflflnnaaddmmtthhmmaaaattttootthhrryyee ootthhnneesseeffttaaccoottffoopprrssuubbtthheeaarrttttyymm..77,,99aayyFFuubbrreetthhaaeessrrssooiinnccvviiaaeettsseettddiiggaawwttiiiiootthhnnsstthhaaiirrsseessnnhheeiieeffttdd..eeTTddhhtteeooeeccaallaarrrrlliiiieeffyyrr
eddevveeeevvnneettlloossppccmmaanneennppttrreeooccffeeppddlleeuuggmmssiicciissrrooiinnccooflflmmuueeeennddccooeennddee,,ffttoooorrmmssooaammttiieeoonnddeeaaggnnrrddeeeett,,hhbbaayytt ttiihhnnee-- tothhneesefftaaccottfooarrcssnttehhnaaottwmmiaasyysebbeeenaamssssooorcceiiaafrtteeeqdduwweniittthhlyttihhniisspassthhieiiffntt..tsTTbhheeetweeeaaerrnlliiee8rr
onsetofacnenowisseenmorefrequentlyinpatientsbetween8
dfldeaevmveemllooapptmmioeennncttaoouffseppdlluubggyssPiissaiicnnnflfleuus.ee1nn7cceedd,, ttoo ssoommee ddeeggrreeee,, bbyy iinn--
flammationcausedbyPacnes.17 oaonnndssee1tt1ooffyaaeccannrseeonnfooawwgeii.ssRsseeeeecnnenmmteoovrrieedfferrneeqqceuueerenngttllayyrdiinninppgaaattiiceennnettsspbbateehttwwopeeheennys88-
and11yearsofage.Recentevidenceregardingacnepathophys-
flflaammThmmeoaattriiiooenns rcceaaguuassreedddinbbgyytPPheaaccsnneeeqssu..11e77nce of events in acne devel-
Theories regarding the sequence of events in acne devel- aiaonnlddog11y11hyyeeelaaprrsssooeffxaapgglaeei..nRReethcceeenndttieefvvfeiiddreeennnccceeeirrneeggpaarrrddesiinnenggtaaacctinnoeenppoaaftthhaoocppnhheyyissn--
iology helps explain the difference in presentation of acne in
opTTmhheeenootrrhiieeassverreeeggvaaorrlddviienndggittnhhreeecsseeeqqnuuteeynneaccrees.ooIffteeisvveeknnnttosswiinnnaathccnnateePddaeecvvneeell--s
opmenthaveevolvedinrecentyears.ItisknownthatPacnes iyiooolluooggnyygehhreevllepprsssueesxxppolllaadiiennrttchhheeildddriieffffneerraeennndcceeteiiennnappgrreeersssee.nnttaattiioonn ooff aaccnnee iinn
youngerversusolderchildrenandteenagers.
ocooppnmmtreeinnbttuhhteaasvveetoeevvinooflllvvaeemddmiinnatrrieeoccneennthttryyoeeuaagrrssh..IIattciitssivkkanntiooowwnnnottfhhtaahttePPinaanccnnaeetess
contributestoinflammationthroughactivationoftheinnate yyoouunnggeerrvveerrssuussoollddeerrcchhiillddrreennaannddtteeeennaaggeerrss..
cicmoonnmttrruiibbnuuettseeyssstttooemiinn,flfliaanmmclmmudaaittniioognncttohhmrroopuuleggmhheaancctttiivvanaattdiiootnnolool-fflittkhheeeriinnecnneaapttee-
immune system, including complement and toll-like recep- References
itimmormms,uuannneedssyytsshttaeetmmp,,eiinnroccxlluuisddoiimnnggeccpoommropplillfeeemmraeetonnrtt-aaacnntddivttaootelllld--lliikkreeecrreeepccteeopprs-- References
tors, and that peroxisome proliferator-activated receptors RReeffeerreenncceess
gtppptpooeaaaarrnrrrrsstttts,,iiiiaaaaaaallllrllllnnyyyyeddrrrrkeeeenttgggghhouuuuaawllllttaaaantttteeeeppteettttohhhhrrooieeeenxxppppfliissrrrruooooooemmddddnuuuueecccccettttppiiiifoooorrooonnnnlllliiioooocffeeffffurrsssslaaeeeeattbbbbroouuuucrr--mmmmoaarcc....n1111tt7777eiivvoSSSSaaceeeettycccceetooooddennnns—ddddrree,,,,cctaaaaeehnnnnppaddddtttoorrrrioooorrsss----, 1111.... SStStSiiøøøømmrrrreeeeiinnnnnnggsssseeeeiinnnnnnKKKKhh,,,,eeAAAAaakkkkllttsssshhggggyyllllaaaaDDeeeeddddaaeeeenniiLLLLss,,,,hhPPPPeeeebbttttooeeeeyyrrrrsssssseeee::nnnnAAJJJJssHHHHssoo,,,,cceeeeiittttaaaaaattiilllloo::::nnRRRRsseeeeccccwweeeennnniitttttthhcccchhhhbbaaaaoonnnnddggggyyeeeessssmmiiiinnnnaassppppssuuuuiibbbbnneeeeddrrrreettttxxaaaa..llll
gaggneeennndsssroaaagrrreeeenkkksnnndoooowwwnnnnottttooojuiiisnnntflflflmuuueeeednnnicccaeeetefffoooalllclllniiiccceuuutlllhaaarrrrocccuooogrrrnnnheeesoooecccbyyyatttceeeessso———usttthhhgaaalatttniiisssd,,, tJJtiimmCClliiiinnnnggEEiinnnnddoohhcceerraaiillnntthhooyyllMMDDeeaattnnaaiibbsshh9955bb::oo22yy66ss33::--22AA77ssss00oo,,cc22iiaa00tt11iioo00nnss wwiitthh bbooddyy mmaassss iinnddeexx..
aaaaancncnttdddiivvrrroooiittgggyyeee,,nnntthhssseedddyyoooaannnllssoooootttjjjhhuuuaasssvvttteemmmaaeeenndddiiiiimmaaattteeeppaaaaacccccttnnnooeeennttthhhkkrrreeooorruuuaagggttiihhhnnsssiizzeeeaabbbttaaaiiooccceeennooo..11uuu77sssTTggghhlllaaaiirrnnnddddd,, 2222.... JBB1B1JB22iiiiCCrrrr77oooollii::nn11FFFF00MMMMEE00nn,,,,--LLLLdd11uuuuoo00cccccc22rrkkkk,,iiyyyynn11ooAAAA99ll99WWWWMM55,,,,eeHHHHttaauuuubbsssstttt99eeee55rrrr::GGGG2266AAAA33,,,,--eeee22tttt77aaaallll00::::,,PPPP22uuuu00bbbb11eeee00rrrrttttaaaallllssssttttaaaaggggiiiinnnnggggiiiinnnnbbbbooooyyyyssss....JJJJPPPPeeeeddddiiiiaaaattttrrrr
aaooccxxttiiiiddvviiiizzttyyee,,ddttllhhiippeeyyiiddaassllssiinnoosshheeaabbvvuueemmaannccaaiimmnnppssttaaiiccmmttuuoollnnaattkkeeeeiirrnnaaflflttiiaannmmiizzmmaattaaiioottoonnrr..yy1177mmTTeehhddiirriiddaa--,, 33.. 1EE122uu77llii::nn11gg0000SS--YY11,,00HH22,,ee11rrmm9999aa55nn--GGiiddddeennss MMEE,, LLeeee PPAA,, eett aall:: EExxaammiinnaattiioonn ooff UUSS
ottoooxxrriissdd,,iizzaaeennddddlliiiittppiiiiddsssscciillnneeaassrreettbbhhuuaammtt iiccnnaaflflnnaammssttiimmmmaauuttoollaarrttyyeeppiinnrrflfloottaaeemmiinnmmssaaccttaaoonnrryymmmmeeeeddddiiaaiiaattee-- 33.. EppEuuuubblliieennrrggttyySS--ttYYiimm,, HHiinneeggrrmmddaaaattnnaa--ffGGrrooiiddmmddee11nn99ss4400MMttEEoo,,11LL99ee99ee44PPffAAoorr,,sseeeettccuuaallll::aarrEEttxxrraaeemmnnddiinnss::aaPPttiiaaoonnnneelloofififfnnUUddSS--
taatooccrrnnssee,,..11aa77nnddTThhiitteessiieess mmcclleeeeaaddrriiaatttthhooaarrttssiiiinnnnflflccaalluummddmmeeaacctteeoorrrrttyyaaiinnpprrmmoottaaeettiirrnniissxxccmmaanneettmmaalllleeooddppiirraaoottee-- piipnnuuggbbssee..rrPPtteeyydd--ttiiiiaammttrriiiinnccggss33dd::aaSStt11aa77ffrr22oo--mmSS1199111199,,44220000tt00oo8811((99ss99uu44ppppffooll))rrsseeccuullaarrttrreennddss::PPaanneellfifinndd--
taaeccinnneea..s11e77sTT,whheehssieechmmaeerddeiipaattrooerrssseniinntccinlluusddeeebucceemrrtt;aaiiitnnhmmasaabttrreiiexxnmmsheeottaawllllnooppthrrooa--t 44.. iFFinnooggsssstt..eePPrreeTTddAAiiaa,,ttrrVViiccoossoo33rrss::SSAA1177WW22,,--SSWW1199ee11bb,,bb22ee00rr00LL88SS,,((sseeuuttppaappll::ll))AAnntthhrrooppoommeettrriiccaannddmmaatt--
tttteheeiiiennnaaapsssreeeosssd,,,uwwwchhhtiiiiocccnhhhoaaarrrfeeethppperrrseeeessseeemnnntttatiiirnnnixssseeembbbuuuetmmmal;;;loiiitttphhhroaaassstebbbineeeeeeannnsesssshhhdoooewwwcrnnneattthhhseaaasttt 44.. FuuFoorraassttttiieeoorrnnTTmmAA,,eeaaVVssoouuoorrrreessmmAAeeWWnnttss,,WWooffeeccbbhhbbiilleeddrrrrLLeennSS,,,,eeaattggeeaassll::55AAttnnootthh11rr44ooppyyooeeaammrrssee,,ttrriiiinnccaaaannbbddiirrmmaaccaaiiaatt--ll
tatathhhfftteeeeerrpppttrrrhhoooeeddduuurreecccsstttooiiiooolluunnnttoooiioofffnnttthhhooeeeffsssaaeeeccmmmnneeaaatttllrrreeiiissxxxiioommmnnsseeetttwwaaallliilllttooohhpppttrrrrroooeetttaaeeettiiimmnnnaaaeesssnneeettsss..11ddd77,,eee11ccc88rrreeeaaassseeesss ucc5c5ucoooo99rraammmm11tt,,iimmmmoo11nnuuuu99nnnn77mmiiii77tttteeyyyyaa————ssuuTTTTrreehhhhmmeeeeeeBBBBnnoooottggggssaaaaoolllluuuuffssssccaaaahhiiHHHHllddeeeerraaaaeerrrrnntttt,,SSSSaattttgguuuueeddddssyyyy55.... AAAAttoommmm11JJJJ44CCCCyyeelllliiiiaannnnrrssNNNN,,iiuuuunnttttrrrraa3333bb0000iirr::::5555aacc8888ii2222aa----ll
aafftteeFFrroottuuhhrreetthhrr,,eeaassoonnlldduuttfifiiioonnnnaallllooyyff,,aaiiccttnnaaeellssllooeesshhiiooaassnnssbbeewweeiinntthhsshhttrrooeewwaattnnmmtteehhnnaatttt..11tt77hh,,11ee88 sseebbaa-- 55.. 5HH599aa11rrll,,aa11nn99WW7777RR,,GGrriillllooGGPP,,CCoorrnnoonnii--HHuunnttlleeyyJJ,,eettaall::SSeeccoonnddaarryysseexxcchhaarraacc--
cceeooFFuuoossuurrggttllhhaann,,ddaanniiddss ppfifiaannrraattllllooyyff,,aaiittnnaaeellssuuoorroohheeaannssddbbooeecceerrnniinnsseehhoooorrwwggnnaanntt;;hhiiaattttiittsshhnneeoosstteebbyyaaee--tt 55.. HttHeearraiirrssllttaaiinnccssWWooRRff,,bbGGooyyrriissllll11oo22GGttPPoo,,CC1177oorryynneeooaannrriiss--HHooffuunnaaggttlleeee::yyTTJJhh,,eeeettUUaall..::SSSS..eeHHccooeennaallddtthhaarryyEExxsseeaaxxmmcciinnhhaaaattrriiaaooccnn--
ckkceennoooouuwwssnnggllhhaaoonnwwddssiisseebbppaaaaccrreettoooouuffssaaggllnnaaeennuuddrrooaaeeccnnttiiddvvooiittccyyrriimmnneeiigghhoorrttggbbaaeenn;;mmiieettddiissiiaanntteeooddttuuyyeess--tt tSSteeuurrrriissvvtteeiiccyyss..JJooPPffeebbddooiiyyaattssrr11992255::tt22oo99113377--22yy99ee77aa,,rr11ss99oo77ff99aaggee::TThheeUU..SS..HHeeaalltthhEExxaammiinnaattiioonn
kiknnngoowwthnnehhnooewwurssoeeebbnaadcceeooocuurissnggellaainnnddflaaamccttmiivvaiitttyyormmyiiggahhpttpbbareeammtuees,ddiibaattueetddtuuhssis-- 66.. SHHSuueerrrrvvmmeeyyaa..nnJJ--GGPPeeiiddddddiiaaeettnnrrss9955MM::22EE99,,33WW--22aa99nn77gg,,11LL99,,77KK99oocchhGG::SSeeccoonnddaarryysseexxuuaallcchhaarraacc--
iriinnnepgggrettthhhseeeentnnnseeeauuunrrroooaeeernnnedddaooofocccrrrriiinnnpeeeoteiiinnnnflflfltiaaaammmlrmmmesaaaetttaooorrrrcyyyhaaainppppppthaaarrreaaaftttuuuutsssu,,,rbbbe.uuu1ttt7 ttthhhiiisss 66.. HttHeeeerriirrssmmttiiaaccnnss--iiGGnniibbddooddyyeessnn::ssEEMMssttEEiimm,,aaWWtteeaassnnffggrrooLLmm,,KKtthhooeecchhNNGGaatt::iiooSSnneeaaccllooHHnnddeeaaaallrrttyyhhssaaeennxxdduuaaNNlluucctthhrraaiittrriiaaooccnn--
rrreeepppAArrrnneeesssooeeettnnnhhttteesssrraaaiinnnnnttrraaaiirrrggeeeuuaaaiinnfffoooggrrrlliipppnnoooeettteeeoonnnfftttrriiieeaaassllleerrraaeeerrssscceeehhaaarrrcccccoohhhnncciiinnneerrtttnnhhhsseeetthhfffuuueetttuuupprrrooeeess...ss111ii777bbiilliittyy tEE1E1tEee00xxxxrraaaa22iissmmmm22ttii--iiiicc11nnnnss00aaaaii22ttttnniiii88oooobb,,nnnnoo22SSSSyy00uuuuss00::rrrr11vvvvEEeeeessyyyyttiimmIIIIIIIIIIIIaa,,,,ttee1111ss9999ff8888rroo8888mm----99994444tthh....eeAAAANNrrrrccccaahhhhttiiPPPPooeeeennddddaaiiiillaaaaHHttttrrrreeAAAAaallddddtthhoooollllaaeeeennssssccccddMMMMNNeeeeuuddddttrrii1111ttii5555oo5555nn::::
ooffAApprrnneeoovvtteehhnneettrriinniinnggttrraaiiccggnnuueeii..nnNNggllaaiikknnaaeettoossuuffjjrriieeaassnneeaaddrrcccchhoollcclleeooaannggccuueeeerrnnss11ss99ttddhheeeevvppeeoolloossppssiieebbddiilliiaattnnyy 77.. 1HH100ee22rrmm22--aa11nn00--22GG88iidd,,dd22ee00nn00ss11MMEE:: RReecceenntt ddaattaa oonn ppuubbeerrttaall mmiilleessttoonneess iinn UUnniitteedd
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pappgoooarrritttneeedsddttttPhhhaaaatttcniiimmmesmmminuuunnnviiiizzzvaaaotttiiioooannnndrrreeetssshuuuallltttteeetdddheiiinnnimppprrrmooouttteeencccitttziiivvvedeee iiimmmmimmmceuuuannnliiistttoyyy 88.. KwwKaahhppeellnnoowwppuuiittbbzzeePPrrBBttyy,,OOiissbbppeerrrreefificceeoollddcciiSSooEEuu::ssRRiinneeeeggxxiiaarrmmllssiiiinnnnaattttiihhooeennUUoonnffttiitthheeeeddaaSSggtteeaallttiieemmss::iittIImmffoopprrllddiicceeaafifittnniiooiinnnnggss
adadagggeeaaavviiieennnllsosostttppeePPPddaaaaacccnnnnntteeeiisssbbooiiinnnddiivvveessiiivvvttoooooaaaPPnnnaadddccnnttteehhhssaaaaatttnntttddhhheeeddeeiiimmmccrreemmmaauuusseennnddiiizzztteeehhdddeeiimmmrrppiiicccrreeeooddaaauulllsssccooo-- wffcfcwfoooooohhrrrrmmeeeeeennmmvvvvaaaappiittlllluuttuuuueebbaaaaeeeettttssiiiirroooottoonnnnyyffiittaaaasshhnnnneeppddddrrLLeeaattttccrrrrwwooeeeeccaaaassiioottttoommmmnnuueeeessWWnnnniittttnnii....llkkggDDDDiiiinnrrrrrrllssuuuussggggPPiinneeaaaaddnnnnttiihhddddaaeettrrttttiiUUhhhhccnneeeeEErrrriiaaaattnneeppppddddeeeeoouuuuSSccttttttrriiiiaaiiccccnnttsssseeeessaaaa::SSnnnnooIIddddmmcciippeeeeeettllxxxxyyiieeeecc..ccccaaPPuuuuttiieettttooiiiiddnnvvvviieeeess--
ddttiieeoovvnneeoollooffppiinneettddeerraallnneeuuttiikkbbiioonndd--ii88ee,,ssaattoopprrPPoottaaeecciinnnneeiissmmaannppddoorrddttaaeennccttrreeiinnaasstteehhddeettddhheeeevviirreellppoorrppoommdduueenncc--tt caacottorrmmiiccmmss11iitt00ttee44ee::99ss33oo66ff--tt99hh44ee11LL,,aa11ww99ss99oo99nnWWiillkkiinnssPPeeddiiaattrriiccEEnnddooccrriinneeSSoocciieettyy..PPeeddii--
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Facing the Challenge of Acne Vulgaris in Pediatric Patients 5
Diagnosis and Evaluation of Acne
Diaglanwroenscei sf. EaichnendfielEd,v Mad,l*u Joasetpiho fn. fowolefr, AJr, cMnd,†e Sheila f. friedlander, Md,*
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
cheekssometimesmaybeconfusedwithearlyacnevulgaris.Screeningtests,particularly
boneage,maybeconsideredtosupporttheclinicaldiagnosisinyoungerchildren.Further
testing usually is not indicated unless patients show signs of virilization.
Semin Cutan Med Surg 29:5-8 © 2010 Elsevier Inc. All rights reserved.
Thepresentationofacnevulgarisdiffersaccordingtothe In contrast, acne in younger patients typically is nonin-
ageatonset.Thesignsandsymptomsofacnevulgarisin flammatory, characterized by comedones on the nose, mid-
patients 12 years of age and older has been thoroughly and face, and forehead (Fig. 1). The number of lesions ranges
welldescribedandinmostcasesarereadilyrecognized.Of- fromjustafewto100ormore.Inastudyofatopicalmed-
tenthesepatientshavebothnoninflammatorylesions(come- ication, Eichenfield and colleagues1 found that the median
dones) and inflammatory lesions (papules, pustules, and/or number of lesions in 8- to 11-year-old children enrolled in
cysticlesions). theirclinicaltrialwasbetween50and60.Inmorethanone
halfofthesepatients,thelesionswerelocatedontheforehead
*Rady Children’s Hospital, UCSD School of Medicine, San Diego, CA. or forehead plus other facial areas; approximately 4 in 10
*RadyChildren’sHospital,UCSDSchoolofMedicine,SanDiego,CA.
†University of Louisville, Louisville, KY. children had comedonal lesions on the nose or nose plus
†UniversityofLouisville,Louisville,KY.
‡Baylor College of Medicine, Houston, TX. otherfacialareas.
‡BaylorCollegeofMedicine,Houston,TX.
§Jefferson Medical College, Philadelphia, PA.
§JeffersonMedicalCollege,Philadelphia,PA.
PPuubblliiccaattiioonn ooff tthhiiss CCMMEE aarrttiiccllee wwaass ssppoonnssoorreedd bbyy tthhee UUnniviveerrssiittyy ooff LLoouuisisvvilillele
Continuing Health Sciences Education and Skin Disease Education
ContinuingHealthSciencesEducationandSkinDiseaseEducationFoun-
Foundation and supported by an educational grant from Ortho
dationandsupportedbyaneducationalgrantfromOrthoDermatologics.
Dermatologics.
LawrenceF.Eichenfield,MD,hasservedasaspeakerforCoria.Hehasalso
Lawrence F. Eichenfield, MD, has served as a speaker for Coria. He has also
beenaninvestigatorand/orconsultantforJohnson&Johnson,Ortho
been an investigator and/or consultant for Johnson & Johnson, Ortho
Dermatologics,Stiefel,Galderma,andsanofi-aventis.
Dermatologics, Stiefel, Galderma, and sanofi-aventis.
JosephF.Fowler,Jr,MD,hasbeenaconsultantforGalderma,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,
andValeant.HehasbeenaspeakerforGalderma,Medicis,Ranbaxy,
and Valeant. He has been a speaker for Galderma, Medicis, Ranbaxy,
Shire, Stiefel, UCB, and Valeant. He has also been an investigator for
Shire, Stiefel, UCB, and Valeant. He has also been an investigator for
AbAbbobtot,ttT, aTraoro,,A Alllelerdrdeermrm,, AAlllleerrggaann,, AAmmggeenn,, AAsstteellllaass,, CCeennttooccoorr,, CCoorriaia, ,
DeDremrmiki,kD, Dowow,,G Gaaldldeerrmmaa,, GGeenneenntteecchh,, JJoohhnnssoonn && JJoohhnnssoonn,, MMeeddicicisis, ,
NNovoavratirst,isQ, Quiuninnonvoav,aS, hShirier,e,S Stetiiefefel,l,T Taaiisshhoo,, aanndd 33MM..
SShheeiillaa FF.. FFrriieeddlalannddere,r,M MDD,h, ahsabse beneeanc ao ncsounltsaunlttafonrt Afosrte Allasst,elBlaarsr,i eBraTrrhieerr-
apTehuetircasp,eGuatlidcse,r Gmaal,dGerrmacae,w Gayra,cNeowvaayr,t Nis,oavnadrtissa,n aonfid- asvaennotfiis-.aSvhenethisa.s Sahlseo
rehceaisv aeldsog rreacnetivreedse garracnht sreuspeparocrht sfruopmpoArtt lfarnomta, AAtlmangtean, ,AAmsgteelnla, sA,sBtealrlraise,r
ThBearrarpieeru tTichse,rGapaleduetrimcsa,, GHaillldDeremrmaa, cHeuiltli cDalesr,mJoahcnesuotnic&alsJ,o Jhonhsnosno,nL E&O
PhJoarhmnsaocne,u LtiEcOals P,hNaromvaarcteisu,tiOcarltsh, oNNoevuartrtiosg, eOnrath,oPNhoeutotrcougreen,aP, iPerhroet-oFcaubrree, ,
RePgieernreeR-Fxa,barned, RDeogwen.eRx, and Dow.
MMooiissee LL..L Leevvy,y,M MDD,,h ahsasb ebeenena cao cnosunlstuanlttafnotr fGolra xGolSamxoitShmKliitnheKalinnde Saknind-
MSekdiinca-M. edica.
Figure1 Mildacneinaprepubertalboy.Acneinpediatricpatients
GGuuyy FF.. WWeebbsstteerr,, MMDD, ,PPhhDD, ,hhaass bbeeeenn aa coconnsusultlatannt tfofor rAAlllelergrgaann, ,CCuutatanneeaa, ,
CiCpihpehre,rG, Galadlderemrma,a,G GlalaxxooSSmmitihthKKlilninee,,M Meeddiciciiss,, OOrrtthhoo,, aanndd QQuuiinnnnoovvaa.. betweenapproximately8and11yearsofagetypicallypresentsas
AAddddrreessss rreepprriinntt rreeqquueessttss ttoo LLaawwrreennccee FF.. EEiicchheennffiieelldd,, MMDD,, 88001100 FFrroosstt SSttrreeeett,, mildcomedonaldiseaseonthenose,midface,andforehead.Pho-
SuSiuteite6 0620,2S, aSnanD Dieigeogo,,C CAA9 922112233..E E--mmaaiill:: lleeiicchheennfifieelldd@@rrcchhssdd..oorrgg.. tographcourtesyofMoiseL.Levy,MD.
6 Facing the Challenge of Acne Vulgaris in Pediatric Patients
1085-5629/10/$-seefrontmatter©2010ElsevierInc.Allrightsreserved. 5
doi:10.1016/j.sder.2010.04.003
6 L.F.Eichenfieldetal
6 L.F.Eichenfieldetal
Table 1 Differential Diagnosis of Acne in Younger Pediatric Differential Diagnosis
TaaTnbadlbelAe1d 1oD lDiefifsfefcereernennttitPaialalt DDieiinaagtgsnnoossiiss oof fAAcncen eini nYoYunoguenrg PeerdPiaetdriicatric DifDfeiffreernetnitaiallD Diiaaggnnoossisis
aannddA Addoolleesscceenntt PPaattiieennttss TomandFriedlander2publishedacase-illustratedreviewof
Pubertal/postpubertal (�12-18 years of age)
aTconmecaonnddFitriioendslatnhdaetrm2ipmuibcliaschneedtahrcoauseg-hillcuhsitlrdahteododreavniedwado-f
PuPbueCbrtoearrltt/aipclo/opsstotpesurtbopeiudrbt-aienlr dt(a≈ul1c(2e�-d118a2 cy-1ne8earsy eoaf rasgoef)age)
aoclensececnocned.itTiohnesctohnatdmitiiomnisctaocnbeethcoronusigdhercehdildinhovoadrioanuds aagde-
CoDCrteoicmrotsioctedoresoxtidef-roionlilddiuc-cuineliddt iuasccende acne
DeDGmeroamdmeox-dn feeoxlgliacfotuillvlitieicsufoliltliisculitis ogrleosucpesncaer.eTshhoewcnonidnitTioanbslet1o.bDeisctoinngsuidisehreindginbevtwareieonusacangee
GrGKamerar-amnteo-gnsaeitsigvaept ifilovalerliicsfuolliltiicsulitis ganrodupansoatrheershdoewrmnaintolToagbiclec1o.nDdiitsitoinngourishdiinsegasbeettwypeeicnalalycnies
KeMKraeatrolaastissos speiiszlaiarpisi(lparitiysrosporum) folliculitis aenasdiearninotvheerrydyeorumnagtoplaotgieinctcs:oTnrduiteioinnfloarmdmisaetoasreyatycpniecaisllryaries
MaMPlaaasplsaueslzasiare zs(Piaaitryc(rpooiistdpyoorsoruissmpo) froulmlic)ulfiotislliculitis einasciehrilidnrevnerbyeytwouenengp1aatinednt8s:yTeraurseoinfflaagme.matoryacneisrare
PaPPpuaelpraiuor lrsaaarlrcsdoaeidrrcomosaiisdtiotissis inHchoiwlderveenr,baentwinecernea1seainndth8eyperoardsuocftioagneo.fadrenalandrogens
PePPriesoreraiuol drdaoelfromdlealirtcimtuislaittiistisbarbae (adHreonwaercvhere,)acnaninbceregainseaisnetahrelyparso7duycetaiorsnooffaagder,3enanaldanacdnreogmenays
PsTPeiusndeeouafdoflolaifccouilelliiticisu bliatirsbabearbae o(acdcruernaasrcahnee)acralynsbigegninofapsuebarelrytya,se7veyneabresfoofreagthe,e3aapnpdeaacrnanecmeaoyf
PTirnTeeipnau efbaaecfrieataicli/epieripubertal (�8-11 years of age) opcucbuicrahsaairnineabrloythsigbnoyosfapnudbegritryls,,eavreenolbaerfodreevethloepamppeneatrianngcierlosf,
PrPeprAeupcbuneebrteavrlet/anplee/rnpiapeturaibpoeurrbtpaeolr t(ma≈la8d-(�1e18a y-c1en1aersy( feoraof rmasgtoehf)eaugsee) of
panudbitceshtiaciurlianrbenotlahrgbeomysenantdingbirolys,sa(Treaobllaer2d)e.vDeelormpmateonlotginicgciornls-,
AcAncen tvoeepnviecenanaletoani alo-tbra aposoermdpaodpmero aadcduneceta s c)ne(fromtheuseof
adnitdiotnessttihcuatlasrheonulaldrgbeemreunletdinobuotyvsia(Thaibstloer2y).aDnderpmhaytsoilcoagliecxcaomn--
A(frnotgmoipo tifihcbear luoosmiel- aobsfa tsooerpdiacdapler oonidlo-umbcatasse)sde pbraocdeuuctms)
dinitaitoionnstihnactlusdheoukledrabteosriuslepdilaoruist,vmiailhiaistaonrdyamnidcrpohcyysstisc,alroesxaacmea-
AnACgnioogrfitibiocrfioobmsrtaoesmr ooarid sa-dionerdnaoumdceeand soeambcaanceesuembaceum
ifnroamtiocnoirnticclousdteerokiedraetoxpsiosspuirlearoisr,omthileiarcaanudsems,icpreorciyosrtisfi,criaolsadceera-
CoCFrtloiacrtotswicteaorrsottisde-rioniddu-cinedd uaccende acne
FlaFKtl eawrtaawrttosasritsspilaris fmroamtiticso,ratnicdodsteemrooiddiecxidpoossius.r4e,5orothercauses,periorificialder-
KeKMraeitlroiaastiso spiislarpisilaris maItfittihs,eraenidsdneomevoiddiecnidcoestios.4s,u5ggestanyoftheseothercauses—
MiMMliaiolilaluscum contagiosum andIftuhnelreessissnigonesviodfenhcoertmoosungaglepstatahnoyloogfytheasreeonthoeterdcaounsest—he
MoMPlleuorslilcouursmacl ucdmoenrtmcaoganitotistaiusgmiosum apnhdysuicnalleessxasmiginnsatoiofnh—oramcnoenianl tphaitshaogleoggyroaurpecnaontbedecoonnstihde-
PePSrieyorrraiinol grdaoelrmmdaeasrtimtisatitis perheydsiacsalneoxrammainl,artieoqnu—iriancgnenoinftuhritshaegrecglirnoiucpalcwanobrkeucpo.nTsihde-
MSyiSrdiyn-crgihonmigldoahsmoaosd/prepubertal (1-7 years of age) einreddicaatsionnosrmfoarl,furerqthueirrindgiangonofsutrictheterstcilningicianl wyoourknugepr. Tanhde
MMidiAd-cd-chrehilnidldahlhoootudom/dp/orpresrpeupbuebretarlt a(1l-(71 -y7eayresa orsf aogfea)ge) ionlddeicraptieodniastrfiocrpfautiretnhtesrwditiahganconsetiacretessutminmgairnizeydouinngTearblaen3d.
ACdornegneanlittualmaodrrsenal hyperplasia
Adrenal tumors olderpediatricpatientswithacnearesummarizedinTable3.
CCounshgienngi’tsalsaydnrdernoamlehyperplasia
Congenital adrenal hyperplasia
CGuosnhaidnagl’stusmyonrdsrome Evaluation of Severity
CuGOshoviannrgai’dasna slyttnuudmmrooomrrses EvaElvuaalutaiotinono offS Seevveerriittyy
Gonadal tumors
In clinical research studies, lesion counts—quantifying the
OPovlayrciaynstitcumovoarsry syndrome
Ovarian tumors
PPorelymcaytsutriceoavdarerynasrycnhderome Innumclibneircaalnrdesteyaprecshosftuledsiieosn,sl—esiaonndcionuvnetsst—igaqtouranantidfyipnagtitehnet
Polycystic ovary syndrome
PTrrueempatruerceocaidoruesnaprucbheerty nseuvmerbiteyr/iamnpdrotyvpeemseonftlsecsoiorenss—areanudseidnvtoesetvigaalutoarteadnidsepaasteiesne-t
Premature adrenarche
AnTyruaegeprecocious puberty sveevrietryitayn/idmapsrsoevsesmtreenattmsceonrtesefafirceaucsye.dHtooweevvaelur,atneodsitsaenadsearsde--
True precocious puberty
AnAycangeevenenataorpomadeacne(fromtheuseof vizeerditymaenthdoadssheasssbtreeeantmweidnetleyffiacccaecpy.teHdofworevtheer,anssoessstamnednatrdo-f
Any age
Acntoepviceanleonial-tbaaoserdpopmroadduectasc)ne(fromtheuseof iazcendeminerthooudtinheasclbineiecnalwpirdaecltyicaec,caenpdteadqfouraltihtaetiavseseesvsamlueanttioonf
Acne venenata or pomade acne
Biltaotpeircaallnoeilv-ubsasceodmperoddouncictsu)s aisc,nbeyidnerfionuittiinoen,csluinbijceacltpivrea.cEtixcpe,eratnsddoaaqguraeleitgateinveereavllayluoantitohne
(from the use of topical oil-based products)
BilBCatihelalroaterl irnnaealvtnuesed vcauormsoemcdoaomtniieccduhosyndicroucsarbons (chloracne) ifsa,cbtoyrdsethfiantitsihoonu,lsdubbjeeccotinvsei.dEexrpeder.tAsdqouaalgitraeteivgeenasesreaslslymoenntthoef
CCholrotircinoastteedroaidrsom(taotpicichaly,dirnohcaalerbdo,nosra(lc)hloracne)
Chlorinated aromatic hydrocarbons (chloracne) faaccnteorssetvheartitsyhoisuludsebfeucloinnsihdeelrpeidn.gAthqeuaclliitnaticiviaenasdseescsidmeenhtoowf
CDoemrtiocdoisctiedroosidiss (topical, inhaled, oral)
Corticosteroids (topical, inhaled, oral) aacgngreessseivveerietayrliystureseaftumleinnthefeflopritnsgshthoueldclibneic.ian decide how
DFaecmiaoldaincigdioosfiibsromas (tuberous sclerosis)
Demodicidosis aggArletshsoivuegheacrolyuntrteiantgmleesnitoenfsfoorbtsvisohuosulyldmbaey.notbepractical
FFalactiawlaarntsgiofibromas (tuberous sclerosis)
Facial angiofibromas (tuberous sclerosis) orArelathsoonuagbhlecoouuntstiidnegolefsaiorensseoarbcvhiosuesttliynmg,aaynnoovtebraellpirmacptriecsa-l
FInlafetcwtiaorntss(bacterial, viral, fungal)
FlaIKnt efweraacrtttoisosnissp(bilaacritserial, viral, fungal) osirorneaosfownahbeltehoerutasipdaetioefnatrheasesajrucshtsaetfteiwng,,aamnoovdeerraaltleilmyplarregse-
MInfeKedceitrcioaanttosios (nibsa-icpntidelaruiracilse, dvir(aal,n faubnogalilc) steroids, dactinomycin, sniuomnboefrw,ohremthaenryalpesaitoiennstchanasbjeumstaadfee(wF,igas.m2o-4d)e.raGteenlyerlaarllgye,
MKeerdatigocosailtsdi op,niilsa-iorninsdiuacziedd, l(iathniaubmo,licphsetenryotoidins,,dparocgtiensotminysc)in, nthuemgbreera,teorrmthaennyulemsiboenrsocfaninbfleammamdaeto(Fryigsle.s2io-4n)s.,Gtheneemraollrye,
MedMicaigltiioaolnd-,inisdouncieadz i(da,nlaitbhoiluicm s,tperhoeidnsy,t odianc,tipnroomgeycsitnin,s) tsheveegreretahteerdtihseeasneu.mInbearddofitiionnfl,amanmyaetvoirdyenlecseioonfss,ctahrerinmgoorer
goldMM, isiilloiiaanriaiazid, lithium, phenytoin, progestins) sdeyvsepriegmtheentdaitsieoanses.hIonualdddbiteiocno,nasnidyeervedideansceanofinsdcaicraritnogr oorf
MiMMliaiolilalursiacum contagiosum dyspigmentation should be considered as an indicator of
MiMPliaeorrilialoursificcuimalcdoenrmtaagtiiotissum
MoPRlleourssiacoucrmiefia ccioanltdageiromsuamtitis Table 2 Screening Tests for Androgen Excess
RepPrienRrtieoordsifiawcciietahal dpeerrmmaistsitiiosn.2,4 TaTbalebl2e 2S cSrcereeneinnigngT Teessttss ffoorr AAnnddrrooggeenn EExxcceessss
Rosacea Bone age (physiological assessment of androgenicity)
Reprintedwithpermission.2,4 bone age (physiological assessment of androgenicity)
BLaobnoeraatgoery(ptehsytssiological assessment of androgenicity)
Adapted with permission.2,4 laLbaoDbroaHrtEoarAtoy/ rDtyeHstteEssAts-S
DHDFEoHAll/EiDcAHle/ED-AsH-tSiEmAu-lSating hormone
As previously discussed (see “Acne Epidemiology and
FoFFlloricellleeic-tsleetis-mstoutilsmatteuinrlgao tnhineogrm(ohorontreomtaolnteestosterone)
PatAhsopphryevsiiooluosglyy,”dpisacgues4s2e)d, th(seeeear“lAiecsnteprEepseidnetmatiioonlogoyf aacnnde
FrFLeerue tteeesintteoizssittneorgsotnheeor or(omnre oton(toearl tteosttaolstteersotnoes)terone)
Pteanthdosptohybseionloognyi,n”flpaamgme 2at)o,rtyhebeecaaruliseestspebreusmenptartoiodnucotfioancnine
LuLPteuriotneliazinicnitgzin ihnogrmhoonrmeone
tyeonudnsgteorbpeatnieonntisnuflsaumamllyatiosrnyobtescuafufisceiesnetbluymhigphrotdouscutipopnoirnt
PSreovleanctteinen-�-hydroxyprogesterone
Prolactin
yhoiguhngneurmpbateiresntosfuPsruoapliloyniisbancotetrisuumfficaicennetslybhaicgtheritao.sHupigphorPt
Seventeen-�-hydroxyprogesterone
hacignhesncouumnbtse,rsinotfurPnr,oppiroonmibpatctaerviiugmoroaucnsecsubtaanceteoruias.imHmiguhnPe RepSrienvteedntweeitnh-αpe-hrmydisrosxioynp.r4ogesterone
RDeHpErAin,teddehwyidthropeeprimanisdsroiosnte.4rone; DHEA-S, dehydroepiandrosterone
arecsnpeosncoseunintss,uinscteuprtnib,lperopmatpietnatsv,iganordouinsflcaumtamnaetooursyipmampuulnees Reprinted with permission.4
DHEsuAl,fadteeh.ydroepiandrosterone; DHEA-S, dehydroepiandrosterone
raepsppeoanr.se in susceptible patients, and inflammatory papules DHEsAu, ldfeahtyed.roepiandrosterone; DHEA-S, dehydroepiandrosterone sulfate.
appear.
Facing the Challenge of Acne Vulgaris in Pediatric Patients 7
Diagnosisandevaluationofacne 7
Diagnosisandevaluationofacne 7
DTaiabgleno3siIsndaincdateivoanlusaftoiornFoufrtahcenreDiagnosticTestinginPatients 7
With Acne
DDTiaiaabgglennoo3ssiiIssndaanincddaeteivvoaanlluusaatftoiioornnFoouffrtaahccennereDiagnosticTestinginPatients 77
TWabiCltehh3AildIcnrnedenicbaetitownesefnor8Faunrdth1e1ryDeiaargsnoofstaigceTwesitthinagcinnePatients
With Acnsehould be referred for further workup by a
TTaabblCleeh33ildIInnreddniiccabatetiitoownnesseffnoorr8FFauunrrdtthh1ee1rrDyDeiiaaagrgsnnooosfsttaiicgceTTewessittthiinnaggciinnnePPaattiieennttss
WWTaiitCtbhhlheAAil d3ccrn nIespneenhedodibcuieaaltdttwriiobceneesen nrfeo8dfroe aFcrnurrdeirntdh1oe1floor yrgDeifisauatrrgstinhf:ooefsrtaiwcg oeTrewksuittiphngba ycinna ePatients
WithA Accnnspeeheiodsuialrdtericbcaeelcnriedtfroeacrnrrteinddoefloosrpgiifstuetrtiahf:peprrwooprrkiautpebthyearapy,
CChhiillddrreeannndbb/eeottwwreeeenn88aanndd1111yyeeaarrssooffaaggeewwiitthhaaccnnee
ChildASrccernnesps ebheheeoniodstuiuiwnallrdgtdeereicbtbcneaee sel8ctr nrsaeiedtnffraeoeadrrcrn er1rretei1pnddd eyoefrefloofosaorrpgrrsifimfstu uoetrerfttid hahfa:peegarprenr wwdwooopiytrrrihkkei auuladtpcpenabbetbyhyneaoarrampayl,
shouAldc nbprpaeeeene srdiddesuii/falaoetrttserrrrr,iiccecaadneel cfndnoid/dtroro oafrcucnrrrtitinhndoeoelrloo swgpgoiiisstrettkuiiaffp::p bpyro ap prieadtieattrhice rapy,
endoAASTchcccrenirnneaeepoenlainoidstsigi/neiorrgsneerttcc tiheafa:asllccstsiittsrraiaagrnnnetstpddoeeefrsfsvoppirriiimtltieezeadaatpipoappnnrrdoo(appynrridieiaarlotdteegaettbnhhneeeorrxraacmppeyays,l,s):
• SAccAnreareacee nncissndedu i/rl/neleootgcrsrraa,ttlceaeisndtrtdasg/nroato rrdweetsphpeitref oarpmpreodpraiantde tyhieerladpya, b normal
SSTahcncAerdreer/dopeeevrasnnatuiiinnneltcggnset,tdteheasasnbtstdoss/nsoaaeigrrreneasgppeoeefrrffvooirrrmimlizeeaddtioaannndd(ayyniideerlldodgaaebbnnneooxrrmcmeaaslls):
• TShcABererrcoepeecdnsaseyiutunilleelgottnsr sdta,te,otsahaertnandssd dag//rsoroeiogr rpwnestrhfoorfmveirdil iaznadti oyniel(da nabdnroogrmenal e xcess):
TTrhehseAAGeucdeplptcvnasaae,tit itinaleaeencnlnrdeattm/dtohhearaabdtssuogrnssarieiogtginwnoassngtheooffvviirriilliizzaattiioonn((aannddrrooggeenneexxcceessss))::
• ThAAABPec udcopccbvdaeaeiytcilnleeeoncorrdtaear ohtdtaeearxdbdsi olsglgnaigrrreoonywswa htogthahfe ivririlization (androgen excess):
Pe–d iAaBAGAtdcdoercvivdnceaayilntenpaorccaladeettmidoededranb btgtouosrnronaaweetgitaohaegngsee12 and older require further
– BGBPAdoduoevidbdnaayiyignctancoooelodddrmsoo tabrraixcotinulwlera aoartyrgikoehunapirand/or referral if:
PeS–dc iGaPGBrteoueeredibnncnyiiict tiopanadalolgotrmmirteaeaanxstttiuutlsslrraaaaarttgyiriooeehnnspai1err2foarnmdeodldaenrdryeiqeuldireabfunrotrhmeral
Pe–d iPaPGtudruerebniibacsiiitgcucapnllot aoomsrtrs,iaeataatinxuxcnitrildlsalwla/atiaoororygyrrnkehhusaapii1rra2nadn/odrorledfeerrrraelqiuf:ire further
PPeeSSd–dici iagaPrtntedurrsebiiicacincogip pnfnoaagrovt tiasiiretextienliiniclslzttatssawsrtyaaio aohggrrnakeeeiusrsappr11ee2ar2fnpoaadrrnen/mdsodeeroodnrlltedda,feeneirnrdrcrrraelyeulqiqediuufli:dinirrgeea:bffuunrrotthrhmeerral
Screreesnuinltgs,teasntds/oarre performed and yield abnormal
PediaStirgAicndrdce siiapaasnagoguttnfnlihteoovsonsis,srtttisiailisc icnazdnagww/itegoioosorrrr ink1kcu2uaap pnoresraa nonplddrde//eosorrer rnrereteq,ffueeiinrrrrcreaa lfulludiirffi:t:nhge:r
diagSSSncoicgAArsrenetclioesecapnn noweiitnnfchoggviroakistrtueiei(lsmpsisz ttnaaassinltgeiaadorrr/oineeocrraapp fnrreeeeesmrrfffepooarrrrlremeamsle peeidfadn:ttata,ennirnddnc)ylyuiieedlliddngaa:bbnnoorrmmaall
• ScAAHrerrclieeoerasnsspnuiuuenttllgchtitss siotam,e,ssaia(stmnnsd dnaa//ilrgeooerr rpoicerarffneosrmmaelde apnadt tyeiernld) abnormal Figure 3 Moderate pediatric acne in a 10-year-old girl. This photo
SSreiiggsAHInunnlilfsorstesspro,uo etafitfclniivsvitdaiymir/roii(llrmiizzaaatltieioononraafrreeempparrleeessepenanttt,t,eiirnnncc)lluuddiinngg:: Fdiegmureon3stMraotedserthateetpyepdiciaatlridcisatcrnibeuitniona 1o0f-myeoadr-eorladtegaircln.eT,hwishpichhotios
• SigAAHAAIIPnnncloclioffsoraeral spypeonrnuecfetqtt itchyvchuliiissioitoeraaymtisnsliici(zi(tsmsmamotnaniavoeililagengenr rrasioioiecrcerresaas fnfpneesrsmmesaaellneet,p pinaactttltueedrrninn))g: Fdminiegoemunrreeotnpo3srntoMrmathotieednseecrtnhhatteeeoektnpysept.hdiPceiaahftlooridtrcoeishatcecroanibudeur,titneniosoynase1oo,f0fa-nCmydaeotacadrhl-eioinrnlaadtaeMngadiarcltin.iszeT,l,ehMswissDhppi,rchohaomntidos-
RReepprriinn–––––tt eeHIIPIIPTHIIPIPTTAAHIIddnnnnnnnnnrrroclioooiiffffofffffruuurwwreraerlererrslllspsyeennnyyyeeenriirurruetttquctqccccccttqtqqhhtiichtuliiiytyyyulaaaiuuuslliiiitoeiissppassssmtlllyetteeesnyeemt yymtttnooo(nnniiiiitrrsmcccc tmmbbbtttm naeeemommmiioooiesslsssgvevvvnsseeeeiiir aaaaiitttsoinnnnoocyyyrrrrersinnasssiii seeeefe..neeee44sssssssssmale pattern) FdmidmiLFdmimiLLnnnniiegaaaeegoeoeoeoemuwwwmmuInrnnnrrrrrneeeeerrroteototteeenpnnpppo3nnnooo3asrssnrrrnnncccdtottoooMreeeMrrdmammmtaattthFFFothhhiottietiiieee...dneeednnnisssoEEEeeeeeeccccrtnnriiittnnnhhhhhaccchhatttttehhheteeeeeetoeeoooeeeeeeoktnkkknnnttnnnppyyyssssfififiepettpp.ttt...hdeeehhhhdiiiPclllPPPeccieeeiedddaaahaahhhft,,,lffftllooroooooocrMMMidtirddtttrrrlccoeoooieeeiiiDDDnshsshhhaatcttccci...ecreeecrrcooooaniaaaniibiubbduuudddeaeuruu,rrrn,,,tittttittnennnneeein’iisosooosssoooynyyyannassssqeeee1o1oooou,oo,,,f0fff0faffaaaa-n-CnnnlCCCmymmyiddddtaeaaaeoaootatttacacccdtaaaddrrhilhhh-llle-eeiviiioioniiirnnnrrnennnlalaaaaaaddtttaaaaeeeeMnMMMgnnngvadiaadddiaaraaarcccltlltttin.iiiinn.uiiisssszzzzeTeeTa,l,,,lll,,,eheeethMMMMsiwssswwiiossssssDhDDDhhnppppppi,ii,,,,rcrrrcchhohoooahhaaatoomnmmmnnnhttidiiodddoes-ss---
Reprin–t eTTPdrrouuwlynnictcchyaaspltliecoor bmboeveiasssrsiiititeoyysn.4 LLaasawswIenrrseesnnamccdeeednFFit.t.iEoEoinifcchahtceeonnnfiefiteehsllededv,,ceMMlriiDDnty.i.csiahno’usldquinacliltuadtievetheevpalautiaetniotn’s,sethlfe-
RRmeeopprrrieinn–tste eedTdvreuwwrniietcthhadlppi soeeebrramemssiiesist,sysiaioosnns..4h4ouldthepresenceofhyperpigmen- aassssIeenssssammdeednnitttioaonnfdatcotnheethspeeavrceelrniinttysic’siiahmnop’usrledqsusiniaoclinltusa.dtiIevdetehneetvipafylauitniaegtnioatnn’s,ysetehlxfe--
istingdiscordbetweentheclinician’sassessmentandthatof
mtaRetopiorrienntesdie nwvitedhr paeerrmkdieisssrieo-nas.ks4ein,ansedshpoautlidenthtse.presenceofhyperpigmen- aathsssseIIeennsspssaaammdtdieedednnniitttttiiooaoannnfndadttcoot/nhoeetrthhspteeehavrecceellrinipinnttayisicrc’esiiiaahnmnnot’ps’ussrlwedqqsuiusilnaliaolclibinlttuaesat.dtiihIvevdeeetelhpneeefvtvuiapaflyllauuiitnaniaetgtiniogoatunnn’si,,ydsteitehnhlxfege--
mtatoIiornenasienvceldaraserskdicei,sre-5as-ksyeien,aanrse,dslhoponaugtliidetuntdhtsie.npalressteundcye,oLfuhcykpyerapnigdmceonl-- aaaicsssshtsssioeeenisssgcsssemmmdsieeesonnncftotttroarodefnfaadabtccmetnntheweeenesspteee,avnvareegetrrhngiittretyysec’sssilshhmiinovopieuucnrlildeadesnsisis’nnisococanllfususstd.dreeIeesdasttmethhmneeetenippfntyaatitatniaineegpdnnpattt’rn’shsoyassaeteecllxhoff---f,
mtlditlmtllldiadidiatdiatcenaeeeennnnaaaaooooooatpppaaaaoflttnnoflflflflIminIIIiignnnnggggoooornattoornnnaaaauaeuuuuaaaaemtttnemmmmnnttleeelllleooeeeedasaaasannnaaaasmissssmmmmeiieonc6nnnncccc6666tttvcvcccnniiiannnnaaaaooslessssaaalelldddtaaetttthaaaeeeehhhhttrlllroooooaslaaeessseeoiooooccciiiirrsrrrrrrsssnannnnwyooottkdiwwwwyyyykkdiiicchhcccpnnneippppeeaineaaaa,eeee,,,saasrrsssrrcdrrrrcccceddddette-e--5eeeeeee555nnnnna.sasssspqqqppppt-tttt---keskkeeeescchyhhhhyyyuuuueuuuu.ei....aaiieaneeeaaaa,nnbAeee,bbbbAAAArrataaattttannnnrraenneeeelrllllrrrtsiitttttsrttttcccerrrr,eennh,,,hhhhhhhhhttttteeedsddsaggeaaaaoleeeeoooohlllholoooooollllupuuuuppoeaaoeeeegnfffggggnnngaallggggaauaaaauigiiiissiiigggtrrhttrrrrrrrrhhhhnnnlooliilliiiiillllllllddetsyeetttflflflssssyyyysssssuuuunmmnncwtccccaaawwwwtdddddddddhtahttaaaammmaaseassieeeeraaaaiiierrrre.nyy..nnnvsrvvvvssssrrrrmmmpiapiiiieaaaeeeeabbnaaaannnnllraaalllllllreeogsooooggggessssetttstsssttttooopsppppsaairiiiitrrrrtttesessssrrrmoussmmmmoooouuunyyynssunuuuudnnnndddooeceeeecslllgssssyggggyyyneeeeccnnnnueuuuu,,,,psssiitppppttttaoaaaaaaoiiiLrlLLLorrrrooollllfttooooflelllleeeeeeufynnnuuuhfyfyfyfyhdddddddcsssscccysssstyttttiiiiike,,,hkkkeeeechhhhpccccwwpviiiyvvvvtoyyyttttooooettteoiieooooeeeeurttuuuuriiirrarrrrrrrrhhpaaassspgeggggeeeenonnnooooihiiiihhhhddgfcdgmmmffffccccdddtttttmiiolmoooollllffaoaaaaoooopppmffcmmmmcccteuuftttteffffooooeoooeeeenanessaaaaeeeerrrrlrrrrlllsee---ssss,-----------,,,, aitcapitcapaitcaptcapmapmco8shsshhhshnhnshnhnnueneeeetttseseeeeeiodciiodcodcodcdcrFFFenennnnttrittttiiisiiihsapgceaaaapppggccccttnnnccccssteentttteeeoaooooaaamimaaadiiiiooddssssottuooootttpuuuullliiffiiiiillleneeasonnnnneeessoooannnnyyyncnnnssccsnnnftsssss,,,fffssssoeeitootetdeeeetttetftttffffiiivvrlorrarlllloooonnnarrrnidaeepiiiiddeaaaneeernnrrrrnnnntnrrannnoaaadaaagdbiitggggbbotttttdtttttdddtrdddrrrrmemmmyyeeerte/oteeee///oooodddthnotthoooafaaaaewfeeewwffffiiiooaertterrrttttntttnnnmtimmmmmtttftfeiiieeahpthhhhooopttttetttee,l,,,ddheiehhhaeeeennneeeeannnlenaiirnnnnaaaeyreeesspmgeppppgggettttt.ttttttee.hnoooga....hhnpgggaaaapppFaaotretttttrrreetassaaaoitsiiiietttseeeeeereeeeirrrhhhc’rscc’sssoeneeennnnilseieellsssenmmnminnnmiitittttiiinnnxvvvvtatttmmmauuaaaapisaepiissseeelcnccnnnnmnssrnnneeeroiiiwdettwwwaddddeeaadddeeerpsnssnnisssiiiiiiiisofsllffffsnnccclllsss’’’alieaaaaslllisstaaaoccom,ohmmmmooolllabllaanbbbnwfeuufffsisseiiiieeeseeesrlslllltddssttth.vvvy.yyyyrerrreepeehaaaaIehhhIeeesssadsaaaadtlllaesaaaeeessuuuaaybbbbbmetlmmmetttlllnnpmcaaapppmmmonoooonhtttefieeuffftuuuutiiieugeeeuuuaanionnoooitttttfnhfnnnsslllltsyttnnnyssrttrrrrtttoiaiiee,,,aaeiiieeeennnbacnnnnaaassnnaaaaatttgpigesspppldhhhlllladdimmiiiigpgggpppaslceeeasssstutttuuurnottttrrreneehihhiiiiooooijjjfciiinynnccccyduuuadddfaaaaaaestttittdddeeciiieeeeecccincnnnxxhdoxxxxxggghhhooootgggg--fs,---------ffff,,, L.F.Eichenfieldetal
atacaoppnmoottteteeodnnonttinioaaaltlleccaootchnnnassetee.qsqcuuaeernnriccneegooafflisinnoflflmaammaymmbaaettooarrsyysolleecssiaiiootenndss,,wiittitiihssiidmmifppfuoosrre-- mceureeFrFdnriientnmnaaotlellfladyyns,i,cediiavnnleplryoaaidttdmyeddniiilotttdiifiaooaldnnceinsmtteeooaomstttehihaoeeymnbammuleseeodtddreiiiocvncataachlslletueeardvvtpiaeanlsluguayancattohtiiaooocsnsnhso,e,ilcstdtishharmeleeneejjfnuuwfetddicgtgoth-s-f
tctaaonnmtttetoodonnnooatteleatthchnaatet.ssccaarrrriinnggaallssoommaayybbeeaassssoocciiaatteeddwwiitthhddiiffffuussee mcmobunoeerdnntrhyettenooitmpffaaasnstegeidevevneeprtirosiiotsttyyerunefooatsfimfaodldirleiiyssmt.eeoaFaossotpeeiroamemnrxeauunalsmstotstrpiiwonlnetchc,hllowueurddhhpeeaastdaaymnncahinagaoshssssetoeembcsssiesoammtlcioeeoenfnnnftestaicldooltysf-f in the family, may affect the classification of acne and may
ccoommeeddoonnaallaaccnnee.. coceduurniefrrfidrtrhecemnuentltpetaadanantidciddeaonplpllteoyosottmceerennifnlattdicimaaeallicelebynmme.ecFooamtotuiiroaosyneenxabaoallefmoodtrrpheoovleettaih,hrsewetoarrhtwppiannsstygymcecthxohigopochseshotoriicblcediienaarlclceeeoneffnfwfweesciicidtttthhss- mediatethesubsequentdiscussionoftherapy.
oeoanrcnentdtehh.meeppedaattiicieeannllttyoomrrfifaladmmaiicllyyn..eFFmoorrayeexxbaaemmdppelvleea,,swwtahhtiaanttgmmtoiiggchhhttibbldeercceoonnnwssiiiddth--
eerreeddmmeeddiiccaallllyymmiillddaaccnneemmaayybbeeddeevvaassttaattiinnggttoocchhiillddrreennwwiitthh References
1. EichenfieldLF,MatizC,etal:Open-labelstudytoassessefficacyand
Conclusions tolerabilityoftretinoingelmicrosphere0.04%inpreadolescentpatients.
Pediatrics
The diagnosis of acne usually is straightforward and can be 2. TomWL,FriedlanderSF:Acnethroughtheages:Case-basedobservations
made by the patient’s history and physical examination. In throughchildhoodandadolescence.ClinPediatr(Phila)47:639-651,2008
3. ZouboulisCC:Acneandsebaceousglandfunction.ClinDermatol22:
somecases,furtherdiagnostictestingisindicated,andrefer-
360-366,2004
raltoapediatricendocrinologistisrecommendedifapatient
4. Krakowsi AC, Eichenfield LF: Pediatric acne: Clinical presentations,
has any signs of virilization. Although standardized assess- evaluation,andmanagement.JDrugsDermatol6:589-593,2007
menttoolsarenotyetavailableforroutineclinicaluse,clini- 5. KroshinskyD,GlickSA:Pediatricrosacea.DermatolTher19:196-201,
2006
cians must nevertheless qualitatively assess the severity of
6. LuckyAW,BiroFM,SimbartlLA,etal:Predictorsofseverityofacne
acne. In addition to the clinician’s assessment, the perspec-
Figure 2 Mild acne. A 9-year-old girl (left) with mild acne has no vulgaris in young adolescent girls: Results of a five-year longitudinal
inflammatory lesions. In contrast, a few inflammatory lesions are Ftiigvuereof4thSeevpeartei,epnrteadnodmtihneanfatlmyicloym,aesdwonelallaasctnheeinhiast1o0ry-yoefara-conlde study.JPediatr130:30-39,1997
Figure 2 Mild acne. A 9-year-old girl (left) with mild acne has no
visiblethis14-year-oldgirl(right)withmildacne.Photoscourtesy girl. Photos courtesy of Catalina Matiz, MD, and Lawrence F.
Finigfluarem2maMtoilrdyalecsnieo.nAs.9In-yceoarn-torladst,giarlfe(lwefti)nflwaimthmmaitlodryaclneseiohnassanroe Figure4 Severe,predominantlycomedonalacneina10-year-old
ofCatalinaMatiz,MD,andLawrenceF.Eichenfield,MD. Eichenfield,MD.
FFivniiiggsfluuiarbreemle22mthMaMitsoiill1rddy4a-alycecensnaieeor..n-oAAsl.d99In-g-yyirecelaoa(rrnr--itoogrllahddstt)g,gwiiarrliltf(he(llweemfftti)i)nldwflwaaiitmtchhnmemm.aiPitllodhdroyaatcoclnnesseecioohhnuaasrssteannsrooye gFiigrul.reP4hoSteovserceo,uprrteedsyomofinCanattalylincoamMeadtoizn,aMlaDcn,eanindaL1a0w-ryeenacr-eolFd.
ivionnifflsflCiaabmamlteammtlihaanittasoor1rMyy4a-lltyeeisezsia,ioorMnn-ossD.l.d,IInangnirccdloo(Lnnratitrgwraahsrstett),,nwacaeiftfeheFww.mEiiiinnlcdflflhaaeammncnfimmee.aladPttoo,hrrMoyytDollees.ssciiooonnussrtaearsreye FFEgiiigigrcuulhr.reeePn44hfioSSeteelodvvse,errMceeo,,Dupp.rrrteeeddsyoommoifinnCaannatttlalyylinccooammMeedadtooiznn,aalMlaaDccnn,eeaininndaaL11a00w--yryeeenaarcr--eoollFdd.
ofCatalinaMatiz,MD,andLawrenceF.Eichenfield,MD. Eichenfield,MD.
vvviiisssiiibbbllleee otthnhi istsh11is44 1--yy4ee-ayarre--aoorl-ldodlgdgi irgrllir((lrr (iigrgihhgtht))t)ww wiittihhthmm miilliddldaa acccnnneee...P PPhhhoootttooosss cccooouuurrrttteeesssyyy ggiirrll.. PPhhoottooss ccoouurrtteessyy ooff CCaattaalliinnaa MMaattiizz,, MMDD,, aanndd LLaawwrreennccee FF..
ooofff CCCaaatttaaallliiinnnaaa MMMaaatttiiizzz,,, MMMDDD,,, aaannnddd LLLaaawwwrrreeennnccceee FFF.. .EEEiicicchhheeennnffiifieeelldldd,, ,MMMDDD... EEiicchheennfifieelldd,,MMDD.. continued on page 15
8 Facing the Challenge of Acne Vulgaris in Pediatric Patients
Medical and Psychosocial Impact of Acne
Medriicchaardl Ga. fnrided, MPds, pyhcd,h* Gousy fo. Wceibastler,I mMdp, pahdc,† tlaowrfenAce cf. nEiechenfield, Md,‡
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.
Physicalcomorbiditiesassociatedwithclassicacnearequiterare.Oftenmoredifficultto
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.
Semin Cutan Med Surg 29:9-12 © 2010 Elsevier Inc. All rights reserved.
Acne once was widely considered more a rite of passage An impressive array of effective and safe drugs now is
than a disease. Over time, awareness of the potentially availabletoclinicians,givingthemthemeanstoalleviatethe
destructive impact of acne increased, along with the devel- short-termburdenofacnelesionsinpatientsaswellastools
opmentofmoreeffectivedrugstotreatit.Themedicalimpact to prevent the long-term problem of physical scarring. Ap-
generallyincludesscarringoftheface,chest,andback;per- propriate medical management also can help prevent com-
sistentalterationsinpigmentation;andphysicaldiscomfort. mon psychosocial sequelae, which may include decreased
Fortunately,physicalcomorbiditiesassociatedwithacnevul- self-esteem, depression, academic impairment, social with-
garisarerare;thepossibilitiesincludeacnefulminansandthe drawal,decreasedemployability,andsocialstigmatization.
SAPHOsyndrome(ie,synovitis,acne,pustulosis,hyperosto-
sis,andosteitis). The Scope of
The Scope of
Psychosocial Sequelae
Psychosocial Sequelae
*Yardley Dermatology Associates, Yardley, PA.
*YardleyDermatologyAssociates,Yardley,PA.
†Jefferson Medical College, Philadelphia, PA.
†JeffersonMedicalCollege,Philadelphia,PA. Acnecanberesponsibleforlong-termpsychologicaldamage
‡‡RRaaddyy CChhiillddrreenn’s’ sHHoospspitiatla,l U,UCCSDSD ScShcohoolo olfo MfMedeidciincien, eS,aSna DniDegioeg, oC,AC.A. that can affect the ability to optimally love, work, and play,
§§UUnniivveerrssiittyy ooff LLoouuisisvvilillele, ,LLoouuisivsivlillel,e K,KY.Y.
withacnepresentingatearlieragesandcommonlycontinu-
¶¶BBaayylloorr CCoolllleeggee oof fMMeeddicicininee, ,HHoouustsotonn, T,TXX..
ing into adult years. It is well documented in the pediatric
Publication of this article was sponsored by the University of Louisville,
Publication of this article was sponsored by the University of Louisville,
ContinuingHealthSciencesEducation,SkinDiseaseEducationFoun- literature that clinicians are seeing an earlier onset of acne
Continuing Health Sciences Education, Skin Disease Education
daFtoiounn,daantidonan, aenddu acnat eiodnuaclagtiroannatl fgrroamnt Ofrrotmho ODrtehrmo Dateorlmogaitcosl.ogics. (see“AcneEpidemiologyandPathophysiology,”page42),so
RRiicchhaarrdd GG.. FFrriieedd,, MMDD,, PPhhDD, ,hhaass nnooththiningg toto didsicslcolsoes.e. thedurationofdiseasemaybelongerforsomepatients.1
Guy F. Webster, MD, PhD, has been a consultant for Allergan, Cutanea,
Guy F. Webster, MD, PhD, has been a consultant for Allergan, Cutanea, Acnevulgariscanleadtoshort-andlong-termdifficulties
Cipher,Galderma,GlaxoSmithKline,Medicis,Ortho,andQuinnova.
Cipher, Galderma, GlaxoSmithKline, Medicis, Ortho, and Quinnova. withdepression,anxiety,anger,andimpairmentinself-im-
LawrenceF.Eichenfield,MD,hasservedasaspeakerforCoria.Hehasalso
Lawbreeenncea Fn. Einicvheesntifgiaetldor, ManDd,/ ohrasc osenrsvueldta anst af osrpeJaokhenrs foonr C&orJoiah. nHseo nh,asO arltshoo age.2Functionally,itcanleadtodifficultieswithschool,play,
been an investigator and/or consultant for Johnson & Johnson, Ortho
Dermatologics,Stiefel,Galderma,andsanofi-aventis. and interpersonal relationships. Individuals with acne—re-
Dermatologics, Stiefel, Galderma, and sanofi-aventis.
SheilaF.Friedlander,MD,hasbeenaconsultantforAstellas,BarrierTher- gardlessofage—aremorelikelytoexperiencediscrimination
Sheila F. Friedlander, MD, has been a consultant for Astellas, Barrier
apeutics,Galderma,Graceway,Novartis,andsanofi-aventis.Shehasalso
Therapeutics, Galderma, Graceway, Novartis, and sanofi-aventis. She in all aspects of life and often are subjected to ridicule and
receivedgrantresearchsupportfromAtlanta,Amgen,Astellas,Barrier
has also received grant research support from Atlanta, Amgen, Astellas, rejectionbytheirpeers.
Therapeutics,Galderma,HillDermaceuticals,Johnson&Johnson,LEO
Barrier Therapeutics, Galderma, Hill Dermaceuticals, Johnson &
Pharmaceuticals,Novartis,OrthoNeutrogena,Photocure,Pierre-Fabre, Sometimescliniciansandcaregiversassumethatmildacne
Johnson, LEO Pharmaceuticals, Novartis, OrthoNeutrogena, Photocure,
RePgieernreeR-Fxa,barned, RDeogwen.eRx, and Dow. isnotemotionallyimportant.Foragreatnumberofpatients,
JJoosseepphh FF.. FFoowwlleerr,, JJrr,, MMDD,, hhaass bbeeeenn aa ccoonnssuultltaanntt foforr GGaaldldeerrmmaa,, GGrraacceewwaayy, , this is true. However, some patients experience severe psy-
HHylyanladn,dJ,o Jhonhsnosnon& &J oJohhnnsosonn,,Q Quuininnnoovvaa,,R Raannbbaaxxyy,, SShhiirree,, SSttiieeffeell,, TTrriaiaxx, , chologicaleffectsfromcomedonalormildinflammatorydis-
anadndV aVlaelaenatn.t.H Heeh haassb beeeenn aa ssppeeaakkeerr ffoorr GGaallddeerrmmaa,, MMeeddiicciiss,, RRaannbbaaxxyy, ,
ease.2Inthesepatients,acnemaybemildinclinicalgrading
ShSihreir,eS, tSietifeefle,lU, UCCB,B,a nanddV Vaaleleaannt.t. HHee hhaass aallssoo bbeeeenn aann iinnvveessttiiggaattoorr foforr
AbAbbobtot,ttT, aTraoro,,A Alllelerdrdeermrm,, AAlllleerrggaann,, AAmmggeenn,, AAsstteellllaass,, CCeennttooccoorr,, CCoorriaia, , but severe in psychological impact. Conversely, some pa-
DeDremrmiki,kD, Dowow,,G Gaaldldeerrmmaa,, GGeenneenntteecchh,, JJoohhnnssoonn && JJoohhnnssoonn,, MMeeddicicisis, , tients with severe disease—markedly inflammatory acne,
NNovoavratirst,isQ, Quiuninnonvoav,aS, hShirier,e,S Stetiiefefel,l,T Taaiisshhoo,, aanndd 33MM.. pigmentary alteration, obvious signs of scarring—seem to
MMooiissee LL..L Leevvy,y,M MDD,,h ahsasb ebeenena cao cnosunlstuanlttafnotr fGolra xGolSamxoitShmKliitnheKalinnde Saknind-
copewithoutagreatdealofemotionalburden.Thus,clinical
MSekdiinca-M. edica.
severityofacnemaynotalwaysbeagoodpredictorofpsy-
AAddddrreessss rreepprriinntt rreeqquueessttss ttoo RRiicchhaarrdd GG.. FFrriieedd,, MMDD,, PPhhDD,, 990033 FFlloorraall VVaalele
PrPorfoefsessisoinoanlaPl aPrakrk,,Y Yaardrdleleyy,, PPAA 1199006677.. EE--mmaaiill:: ddeerrmmsshhrriinnkk@@ggmmaaili.lc.coomm.. chologicalimpact.
Facing the Challenge of Acne Vulgaris in Pediatric Patients 9
1085-5629/10/$-seefrontmatter©2010ElsevierInc.Allrightsreserved. 9
doi:10.1016/j.sder.2010.04.004
1100 RR..GG..FFrriieeddeettaall
10 R.G.Friedetal
10 R.G.Friedetal
FFiigguurree11 DDiiffffuusseeccoommeeddoonnaalllleessiioonnssiinnaann1111--yyeeaarr--oollddbbooyy..TTyyppiiccaallllyy,,ccoommeeddoonnaallaaccnneeiinnpprreeaaddoolleesscceennttssiissnnoottaassoocciiaall
Figure1 Diffusecomedonallesionsinan11-year-oldboy.Typically,comedonalacneinpreadolescentsisnotasocial
Fippgruroorebbl1leemmDiuuffnnullseeesssscaoamcchheidilldodnhhaaalsslennsuuiommneesrroionuusasnllee1ssi1ioo-nnysesaaarnn-dodl//doorrbaaoydd.iiffTffuuyspseeicddaiilssltytrr,iibbcuoumttiiooenndooonffallelessaiicoonnness..inpreadolescentsisnotasocial
problemunlessachildhasnumerouslesionsand/oradiffusedistributionoflesions.
problemunlessachildhasnumerouslesionsand/oradiffusedistributionoflesions. Photos courtesy of Catalina Matiz, MD
and Lawrence F. Eichenfield, MD
BBooddyy IImmaaggee ppeeeerr aacccceeppttaannccee aanndd rriiddiiccuullee,, uunnlleessss lleessiioonnss aarree eessppeecciiaallllyy
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psychicinjurywithalltheimaginedfunctionalimpairments.
psycSSheeivvceeirrnaajlluarayuuttwhhioothrrssahlhlaatvvheeeeiemxxaaammgiininneeedddfutthnhecetirroeenllaaattliioiomnnspshhaiiiprpmbbeeentttwws.eeeenn
AAccAnnceeneIImm Impppaaaccctt:t::T TThhheee AAAgggeee VVVaraaiarrbiiaalebbllee Several authors have examined the relationship between
Acne Impact: The Age Variable cchhSrreoovnneiriccaiilttyyauootffhddoeerrrsmmhaaattvooellooeggxiiccamddiiissneeeaadsseetahanneddraeanlnatiiinnoccnrrseehaaisspeeddbnneteewggaaetteiinvvee
Acne Impact: The Age Variable chronicityofdermatologicdiseaseandanincreasednegative
cphpsrsyoycnchhicooiltlooyggoiicfcaadlleiirmmmppaaatccottl..o44g––77icIIttdcciasanenabbseeeaaasnsssduumamneedidnttchhraeatatsaaenndiinnnddeigivvaiitddivuueaall
AAggaaiinn,,tthheeppssyycchhoollooggiiccaalliimmppaaccttooffaaccnneeccoommeessffrroommwwhhaatttthhee
psychologicalimpact.4–7Itcanbeassumedthatanindividual
Again,thepsychologicalimpactofacnecomesfromwhatthe pwwsyhhcoohssoeeloaacgcninceeablbieemggiipnnassceeta.a4rr–ll7iieeIrrtwcwaiinllllbhheaavvaesesttuhhmeececodonntdhdiaitttiiooannnfifonordraiavllioodnnuggaeelrr
Appgaaattiiinee,nnttthsseeeepesssyiinnchtthoheleommgiicirrarrlooirrm,,ffprroaocmmtowwfhhaacatntoeonnceoe’’mssppeeseeefrrrsosmccoonwnvvheeayyt,,taahnnedd
whoseacnebeginsearlierwillhavetheconditionforalonger
patientseesinthemirror,fromwhatone’speersconvey,and wppheeorrisiooeddactthnhaeannbaeagppinaatstiieeenanrttlwiweiritthwhilllaalttheerarvaaeccnntheeeoocnnossneetdt,,iatainnoddnttfhoharattaaalolloonnnggegererr
pffarrtooimemntmmseeesessssaaiggneetsshfferroommmirpproaarrre,enfnrttoss.m.TTwhheehssaeetttoyynppeiic’csaapllllyeyeddrsiifffcfeeorrnaavcceccyoo,rraddniindngg
periodthanapatientwithlateracneonset,andthatalonger
frommessagesfromparents.Thesetypicallydifferaccording pddeuruirroaadttiiotohnnaonoffaaaccpnnaeetiieinnncctrreweaaisstehessltathhteeerrriaissckknoeoffoaannnseeegtg,aaattinivvdeeptphssayytcchahoololloongggiieccraall
frttooomtthhmeeeaasggseeagooeffstthhfreeopmpaatptiieaenrnett.n.AtAsd.doTolhleeessscceeenntyccpeeifcfooarrllmymdaaninfyfye,,riifafcnncooottrmdmionosgstt,,
durationofacneincreasestheriskofanegativepsychological
totheageofthepatient.Adolescenceformany,ifnotmost, diiummrapptaaicoctnt..44ofacneincreasestheriskofanegativepsychological
toaaddtoholeleesasccgeeennottsfstiihsseaapttaiimtmieeenoto.ffAvvdooollaalettiisllceeeenemmceoofttoiioornnm..aTTnhhyee,rreiefinissoaatmssttroroosntn,gg
impact.4
adolescents is a time of volatile emotion. There is a strong impact.4
andneoeeeleddscffooernritimsmmimseeaddtiiaiamtteeeggroraafttivififiocclaaatttiiioloenn,e,amannoddticcooonnn.ssTeeqqhuueereennttiiisaallatthhsitinrnokkniinnggg
needforimmediategratification,andconsequentialthinking
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oftenislimited.Aboveall,achievingandmaintainingasense
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Warning Signs
of control is of paramount importance to adolescents, who
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oftenhavedifficultycontrollingtheiremotionsandbehavior. Ever-growing numbers of children are taking psychiatric
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The younger patient with acne generally is not burdened medications,representingeithertheoveruseofpsychotropic
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with the same severe emotional lability that the adolescent drugs in children or an increasing incidence of anxiety and
weeixxthppeetrrhiieeennsccaeemss..eFFsuuervrttehhreeerr,e,mtthhoeetioccnooammleeladdbooinnliaatlyl ptphrreaestseetnnhtteaattaiiodononlettshhcaaettntiiss dddrueepgprsreeissnssiiocohnnildddiirsseoonrrddoeerrrssa,,noorrinbbcoorttehha..sWWinghheeinnncaaiccdnneeenocoeccccouufrrsasnaaxssiaaetccyoommanoodrr--
experiences. Further, the comedonal presentation that is depressiondisorders,orboth.Whenacneoccursasacomor-
ecxcoopmmermmieononcneisinn. yFyoouuurtnnhggeeerrr,pptahatteiieencnottssmtteeednnoddnssattloopbbreeeslleeesnssstaootfifoaannnitishsssauuteeiisinn dbbeipiddreccsoosnnioddniittdiiooinsnowrwdiietthhrsa,anonryybpporrteehee.xxWiisstthiinnegngpapcssnyycechhoiicaacttrruiicrcsddaiisssoaorrcddoeemrr,,ottrhh-ee
common in younger patients tends to be less of an issue in bidconditionwithanypreexistingpsychiatricdisorder,the
common in younger patients tends to be less of an issue in bidconditionwithanypreexistingpsychiatricdisorder,the
10 Facing the Challenge of Acne Vulgaris in Pediatric Patients