ACNE

Definition: A chronic inflammatory disease of the sebaceous (oil) glands characterized by pimples and pustules occurring primarily on the face, back, and chest.

Note: There is no need for a teenager to grow up with severe scarring due to acne. Today there are good treatments that can minimize the long-term cosmetic ill effects caused by this condition.

1. What causes this condition to occur in my child?

Acne is triggered by hormone changes in adolescence. Children with acne have oil (sebaceous) glands that tend to produce more sebum (oil). They also have pores that tend to plug more easily. These plugs are made of sebum and dead skin cells. When the pore becomes plugged, bacteria are trapped in the pore, and the pore becomes inflamed, resulting in a pimple. Genetics also plays a role, and some families are more prone to develop acne than others. Unlike what many people think, acne is not due to dirt or not washing your face enough.

2. Is there any way to predict how bad it will get?

Signs that a child may develop more severe acne include earlier age of onset, family history, and being male. As a general rule, males tend to have more severe acne than females. The earlier acne starts (i.e., before age thirteen), the more severe it may be. Children prone to develop bad acne often have family members who had severe or scar- ring acne. The presence of deeper, tender, cyst-type acne lesions or scarring is a sign of more severe acne, and children with these signs should seek treatment early.

3. What can I do to prevent it from getting worse?

Face washing is not enough. The best thing you can do is to start treatment early. In general, it takes eight weeks for any acne treatment to start working, so if you do not see any improvement from your child’s over-the-counter acne treatment after eight weeks, you may need to consider prescription treatment. Your child should avoid squeezing pimples; this makes the pore more inflamed and increases the risk of scarring. Children should also not scrub their faces harshly or use abrasive cleansers, since this can inflame the skin more. Things that touch or fit tightly against the skin can plug pores, so your child should keep his or her hair, hands, head- bands, caps, hair products (gels, hair sprays, etc.), and sports gear off of the face, forehead, shoulders, and back as much as possible.

Products (moisturizers, sunscreens, cosmetics) used on the face and body should be oil free and noncomedogenic (proven not to cause acne). If possible, teens should avoid jobs in places such as fast food restaurants or auto shops, where the skin will be in contact with oil or grease that can aggravate acne.

4. Does diet affect acne?

This is an area of much debate. In general, there are no specific foods that are proven to worsen acne. It is always a good idea to limit junk food as much as possible, but this may not have any bearing on your child’s acne. If there is one particular food that consistently seems to worsen your child’s acne, then avoiding that food may help.

5. What skin cleanser should be used?

A mild, nonabrasive, nondrying cleanser applied with clean hands or a clean washcloth and warm (not hot) water once or twice daily is recommended. For acne, medicated cleansers containing either benzoyl peroxide or salicylic acid can be used, but they may cause skin irritation or dryness, especially if used in combination with prescription acne medications. Astringents are usually not needed, but may be helpful for teenagers with very oily skin.

6. What about Retin A, benzoyl peroxide, and topical antibiotics?

Retinoids (Tretinoin [Retin A, Renova, or Avita], adapalene [Differin], and tazarotene [Tazorac]) are vitamin A–derived medica- tions and are some of the most effective acne medications that we have. They come in cream or gel forms. Retinoids gently exfoliate the dead skin cells and prevent the first step of acne formation, which is the plugging of the pores. By keeping the pores open, pimple formation is prevented. Retinoids are effective for all types of acne lesions. Like most acne medications, they are best used on a consistent basis on the entire acne-prone area (rather than spot-treating individual pimples only). Using the medication on all acne-prone areas helps to prevent future pimples from forming. Retinoids work well alone or in combination with other therapies but should be applied sparingly and no more than once daily to limit dryness and irritation, which are common side effects. Because they can make the skin more sensitive to the sun, sunscreens and sun protection should be used. They should not be used by teens who are pregnant.

     Benzoyl peroxide is another standard acne therapy. Like the retinoids, it is effective for all types of acne lesions and may be used alone or in combination with other therapies. It has antibacterial as well as antiplugging effects. Benzoyl peroxide is available as a wash or as a leave-on topical (a cream or gel applied to the skin). Dryness is a common side effect and can usually be prevented by applying a gentle moisturizer and stopping the medication for a few days. Some individuals may develop a skin allergy to this medication, so if severe redness or irritation develop, you should consult your child’s doctor. Benzoyl peroxide may bleach clothing, towels, or bedding.

     Topical antibiotics decrease the acne-causing bacteria (Propionibacterium acnes) on the skin but have no effect on plugging of the pores. They work best for inflammatory acne (red bumps, pus bumps, and cysts). It is best not to use topical antibiotics alone as a single therapy. Using topical antibiotics in combination with a retinoid or benzoyl peroxide improves the effectiveness of the medications and makes it less likely that the acne bacteria will develop resist- ance to the antibiotic over time.

7. What about oral antibiotics?

For teenagers with severe inflammatory acne that does not respond to topical therapy alone, oral antibiotics can be very helpful. As with topical antibiotics, oral antibiotics do not prevent plugging of the pores, so they are not helpful for non inflamed acne lesions, such as black- heads, and are best used in combination with a retinoid or benzoyl peroxide. They should not be used alone as the only acne therapy.

     The most commonly used oral antibiotic is the tetracycline family (tetracycline, doxycycline, or minocycline). In general, oral antibiotics are used for a period of several months until the acne is improved and can be controlled with topical medications alone, but use for longer periods of time may be required for some individuals. Courses of less than one month are generally not effective.

      These medications are usually well tolerated but can cause nausea if taken on an empty stomach. They can also cause sun sensitivity, so sun protection and sunscreen use is important when taking these medications. For females, taking any oral antibiotic can increase the likelihood of developing a vaginal yeast infection; signs of this include vaginal itching or irritation and a whitish discharge. Oral tetracyclines should not be taken if your child is pregnant. It is common for teenagers to prefer the convenience of oral antibiotics, so they may be tempted to stop their topical medications. For best results, it is very important that they continue using their other medications as prescribed.

8. What about Accutane (oral isotretinoin)?

Oral isotretinoin (Accutane) is the most potent medication currently available for acne. Because this medication can cause birth defects if taken by a pregnant female and because laboratory monitoring is required, this medication should be reserved for severe acne only. It is most effective for severe cystic or scarring acne that has failed to respond to at least three months of maximal combination therapy (oral antibiotic plus a topical retinoid and another topical medication). All patients must be entered into a registry by a physician registered to use this medication, and females must use two methods of birth control to prevent pregnancy. It is not effective for females with hormonal types of acne, such as acne related to polycystic ovary syndrome.

9. When should we consider a dermatologist?

If your child’s acne has not responded to over-the-counter therapy or to the medications prescribed by his or her primary care physician, consultation with a dermatologist would be recommended. If your child has severe or scarring acne, if severe acne runs in your family, or if your child develops significant acne at a very young age, you may want to consider seeing a dermatologist sooner.

10. When do you want to see my child again regarding this condition?

Because most acne therapies require a minimum of eight weeks to start working, follow-up two to three months after starting therapy is generally recommended. Earlier follow-up may be needed if prob- lems, such as irritation or other medication side effects, develop. A temporary worsening of the acne four to six weeks after starting treatment is not uncommon and is considered normal; medications should be continued, and the acne typically gets better over the next several weeks. 

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