The Diagnosis and

Management of
Mild to Moderate
Pediatric Acne Vulgaris
Successful management of acne vulgaris requires a comprehensive approach to patient care.
By Joseph B. Bikowski, MD

s a chronic, inflammatory skin disorder affecting susceptible pilosebaceous units of the face,
neck, shoulders, and upper trunk, acne presents unique challenges for patients and clinicians. Characterized by both non-inflammatory and
inflammatory lesions, three types of acne have been
identified: neonatal acne, infantile acne, and acne
vulgaris; pediatric acne vulgaris is the focus of this
article. Successful management of mild to moderate
acne vulgaris requires a comprehensive approach to
patient care that emphasizes 1.) education, 2.) proper skin care, and 3.) targeted therapy aimed at the
underlying pathogenic factors that contribute to
acne. Early initiation of effective therapy is essential
to minimize the emotional impact of acne on a
patient, improve clinical outcomes, and prevent
long-term sequelae, such as scarring.1,2

Part I: Acne Vulgaris Diagnosis

Epidemiology and Pathogenesis
Acne is estimated to affect 85 percent of the population in the US. While females are more likely to

24 | Practical Dermatology for Pediatrics

| May/June 2010

seek treatment, males tend to have more severe presentations. Acne typically begins between seven and
10 years of age and peaks between the ages of 16-19
years. A majority of patients clear by 20-25 years of
age, however some patients continue to have acne
beyond 40 years of age. So-called adult acne, persisting beyond the early-to-mid 20s, is more common
in women than in men. Given the hormonal mediators involved, acne onset correlates better with
pubertal age than with chronological age.

Take-Home Tips. Successful management of mild to moderate

acne vulgaris requires a comprehensive approach to patient care that
emphasizes 1.) education, 2.) proper skin care, and 3.) targeted
therapy aimed at underlying pathogenic factors that contribute to
acne. Given the importance of topical retinoids in acne management
and their ability to prevent microcomedos, most patients should be
started on a topical retinoid. Treatment is optimized with the addition
of a topical antimicrobial. Patients treated with systemic or topical
antibiotics should always undergo concomitant topical therapy with a
benzoyl peroxide-containing product, a strategy shown to reduce the
development of bacterial resistance.

Four pathogenic factors contribute to acne.

Elevation of dehydroepiandrosterone
(DHEA-S) levels associated with puberty is
generally considered an
inciting event.
Increased DHEA-S promotes increased sebum
production, which in
turn encourages the
proliferation of
Propionibacterium
acnes, a commensal
organism normally
found on the skin. Concurrently, abnormal keratinization of the follicular canal occurs with subsequent blockage of the follicle and build-up of sebum
A combination of sebum and keratinocytes collects in the follicle, leading to the formation first of a
clinically undetectable microcomedo and then of
clinically apparent open or closed comedones
(whiteheads and blackheads).3 In the case of the
closed comedo (whitehead), the follicle swells with
keratinous and sebaceous debris, but the follicular
opening remains constricted and is covered over by
epidermis. In the open comedo (blackhead), the follicular orifice widens as the follicle swells, but a
dark-colored mixture of keratinocytes, oxidized
lipids, and melanin forms a plug in this opening.
The material that collects in the comedo also contains the inflammatory by-products of P. acnes,
which is shown to induce antimicrobial peptide and
proinflammatory cytokine/chemokine expression.4
However, since the material remains contained in
the follicular unit, an inflammatory host response is
not initiated. If the contents spill out of the follicle
into the surrounding tissues of the dermis, an
inflammatory response is initiated, leading to the
formation of inflammatory papules and pustules. In
severe acne, nodules may form.
Acne is not caused by dirt, grease, grime, oil on
the skin, chocolate, soft drinks, nuts, pizza or any
other dietary components.5 Recent research attempt-

Photo courtesy of Joseph Bikowski, MD and DermEdOnline.com

Mild to Moderate Pediatric Acne Vulgaris

Types of Acne Lesions

ing to elucidate a causative link between diet and

acne has failed to definitively identify a relationship,
though some evidence suggests that diet can influence the course of acne. Specifically, high glycemic
load diets have been associated with exacerbation of
acne, and there is scant evidence implicating dairy
foods in the worsening of acne.6
Acne is a chronic disease that can be characterized by periods of exacerbations and remission, but
generally it is not classified as a progressive disease.1 Left untreated, a patient with mild disease at
age 10 will likely have mild disease at age 15,
while a patient with untreated severe disease at an
early age will likely have severe disease later in
adolescence.
Though not fully elucidated, hereditary influence
in acne has been identified; if both parents had
severe acne then the offspring has a high risk for
severe acne. Studies show that a family history of
acne is associated with earlier onset of acne and
recalcitrance.7

Acne Assessment
While several different acne grading scales have
been used in clinical trials, no standard method for
acne grading has been adopted into practice. The
Basic Acne Severity Index is a proposed method for
assessing acne severity based upon lesion type, number, and location.11

May/June 2010 |

Practical Dermatology for Pediatrics | 25

Mild to Moderate Pediatric Acne Vulgaris

Type of lesion. The lesion type is designated by a

grade. Since there are four primary lesion types,
there are four grades from I to IV. Importantly, these
grades simply describe a lesion morphology and are
not intended to represent a qualitative severity
ranking. For example, a Grade I lesion is no more
or less severe than a Grade IV lesion.
Grade I - comedo
Grade II - papule
Grade III - pustule
Grade IV - nodulo-cyst
Number of lesions. One to 10 lesions constitutes
mild acne. Moderate acne is 11 to 20 lesions. More
than 20 lesions is severe.
Location of lesions. Typical anatomic sites of
involvement include:
Head
Face
- Forehead
- Cheeks Right or Left
- Nose
- Chin
Ears

Acne vulgaris can have a strong psychosocial impact

on affected patients,12 with one studying showing
that mental health scores among affected adults
were worse than those for patients with asthma,
epilepsy, diabetes, back pain, arthritis, and coronary
artery disease.13 In surveys of affected teens and
adults acne has been shown to lead to decreased dating, sports, and eating out, impaired academic performance, and increased unemployment rates.14
Post inflammatory hyperpigmentation (PIH) or
persistent darkening of the skin in areas of healed
acne lesions can occur in patients of all skin types,
though it is more common in patients of color.15-17
PIH results from the deposition of melanin at the
site of previous inflammation and may persist indefinitely without treatment. Post-inflammatory erythema, by contrast, is reddening at the site of involvement that resolves over time.

Differential Diagnosis for Adolescent Acne

The differential diagnosis of acne vulgaris includes several
red face diseases.

Neck

Rosacea. Rosacea (sometimes called acne rosacea, though

this technically inaccurate term has fallen out of widespread use)
typically affects adults, with earliest onset usually reported in the
early-to-mid 20s. Open and closed comedones are not seen in
rosacea, although papules/pustules may be seen.

Torso
Shoulders
Chest
Back

When Laboratory Testing and Referral Are Indicated

While elevated androgen levels are implicated in the pathogenesis of acne vulgaris, in relatively rare instances androgen excess
associated with systemic diseases may contribute to atypical acne
presentations: early onset, severe presentation,8 or treatment
resistance. Simple laboratory tests aid diagnosis, though comprehensive specialist evaluation is indicated. Clinicians should be
aware of these potential diagnoses that may manifest with severe
or treatment resistant acne:
1. Delayed onset congenital adrenal hyperplasia.9
2. Adrenal or ovarian tumor.10
3. Cushings disease.10
4. Polycystic ovary syndrome.10

26 | Practical Dermatology for Pediatrics

Acne Impact and Sequelae

| May/June 2010

Perioral dermatitis. More common in women than men, the

pathogenesis of perioral dermatitis is not well understood. In fact,
perioral dermatitis is often used as an imprecise descriptor for
any eruption of unknown origin affecting the perioral area.
Allergic contact dermatitis may be implicated, as may misuse of
topical corticosteroids.
Drug-induced Folliculitis. A manifestation of a systemic drug
reaction, monomorphic lesions can form on the head, upper trunk
and proximal upper extremities. Commonly implicated drugs
include: corticosteroids, androgens, ACTH, lithium, isoniazid
(INH), phenytoin.
Pseudofolliculitis barbae (PFB). As a result of shaving, hair
shafts may perforate below the skin surface and become trapped,
leading to the formation of inflammatory papules.

Mild to Moderate Pediatric Acne Vulgaris

Photos courtesy of Joseph Bikowski, MD and DermEdOnline.com

Scarring is a common sequelae of

acne,18,19 and the risk may be increased
among patients who pick and pop
lesions, causing trauma to the follicular unit
and surrounding structures.
Early initiation of therapy is expected to
minimize the development of damaging
sequelae.1,2 Of note, particular therapeutic
agents, such as topical retinoids (discussed
below) can be useful to treat acne vulgaris
as well as post-inflammatory hyperpigmentation.15-17

Part II: Comprehensive Management of

Mild to Moderate Pediatric Acne Vulgaris
Effective management of acne vulgaris
requires a comprehensive approach to
patient management that depends on three
critical elements: patient education, good
basic skin care, and appropriate therapy.

Patient Education
Inform patients that although acne cannot
be cured (i.e., taken away so that it never
comes back), it certainly can be controlled.
Setting appropriate expectations is important, including how long it will take treatment to take effect and the likely duration
of treatment. Note that the typical patient
may anticipate just six months of treatment
or less.12 Treatment must be used on a consistent basis, despite a common perception
among teens that acne is a transient disease.20 Initial results from therapies can be
expected in about four to six weeks. To
achieve best results with any regimen will
require eight to 16 weeks.
Advise patients to discontinue all overthe-counter skincare programs and therapies: No soaps, astringents, cleansers,
fresheners, toners, scrubs, facial masks or
cosmetic skin care programs. Given that
only a relatively small proportion of the
estimated population affected by acne

Figs 1-3. Post Inflammatory Erythema (top), Post Inflammatory

Hyperpigmentation (middle), acne scarring (bottom).

May/June 2010 |

Practical Dermatology for Pediatrics | 27

Mild to Moderate Pediatric Acne Vulgaris

seeks treatment from a physician, it seems reasonable to assume that a majority of patients have
tried over-the-counter therapies.21 Had non-prescription remedies provided benefit, the patient
would not be in the office, therefore, he or she
should be willing to abandon those therapies.
Dispel common myths related to the role of dirt,
hygiene, and diet in causing acne. If a patient insists
that particular fatty foods exacerbate acne, suggest
that the patient undertake attempt to eat a healthier
diet, as there is no known detriment to the avoidance of high-fat snacks.
Questions frequently arise regarding cosmetics and
acne. In the past, researchers used animal models to
test the comedogenic potential of raw materials used
in cosmetics, and the term acne cosmetica was
coined to describe acne suspected to be caused by
cosmetic products. However, new evidence suggests
that finished products formulated with comedogenic
ingredients may not induce acne.22 Patients may,
therefore, continue to use foundation, setting powder,
blush, eye color, lip color, and any other cosmetics
they wish. Despite the rarity of acne cosmetica,
patients may feel more confident choosing cosmetics
labeled as non-comedogenic/non-acnegenic.

Skin Care
Proper skin care is essential to support therapeutic
outcomes and help minimize possible side effects
of topical therapy. Moisturizers are known to provide benefits in the management of inflammatory
skin diseases and have been recognized as important adjuncts to therapy.23,24 Specifically, studies
show that concomitant use of effective moisturizers, mild cleansers and daily sunscreens enhance
skin tolerance and comfort among individuals using
topical retinoids.25
Paients should not use soap to cleanse the face or,
in the case of truncal acne, the chest and back. To
wash the face each morning and evening, a mild,
soap-free cleanser, such as Cetaphil (Galderma),
Aquanil (PersonCovey), or CeraVe (Coria), should be
applied with the fingertips and rinsed with water. A
gentle moisturizer (such as CeraVe Moisturizer
(Coria)) should be applied after cleansing.

28 | Practical Dermatology for Pediatrics

| May/June 2010

Sun protection is essential. Patients should apply

a broad-spectrum (UVA and UVB) sunscreen minimum SPF 15 to 30 to the face and all sun-exposed
skin each morning. Rather than recommend a specific product, encourage patients to select the product of their choice; if they like the look, feel and
smell of the formulation, they will want to use it.

Medications
Topical Therapy. A majority of patients with mild to
moderate acne will be managed quite adequately
with topical therapy alone. As noted above, there are
four main pathogenic factors in acne:
Increased androgen secretion
Increased sebum production
P. acnes proliferation.
Faulty keratinization
Currently, no topical therapy is available to modulate androgen levels or androgen receptors at the follicular level, nor are there topical therapies that can
modulate sebum production. However, topical therapies are available to:
Regulate keratinization
Decrease P. acnes colonization
Inhibit associated inflammation.
Topical retinoids primarily function to regulate
hyperkeratinization, preventing the formation of
microcomedones and encouraging resolution of clinically apparent comedones. They also confer antiinflammatory effects, i.e. reducing and preventing
erythematous papules and pustules.26-30
Despite treatment guidelines indicating that topical retinoidstretinoin, adapalene, tazarotene (See
table), are appropriate for use in a majority of
patients with mild to moderate acne,1,31 data suggest
topical retinoids may be underutilized.32,33
Several topical antibacterials and antimicrobials
have been shown to decrease or eradicate P. acnes.
Topical benzoyl peroxide has demonstrated activity
against P. acnes, and has the benefit of not being
associated with promoting antibacterial resistance.
Concentration-dependant irritation has been noted,
however, data show that 2.5% and 5% concentrations confer similar efficacy to 10% benzoyl peroxide.34 Benzoyl peroxide is also shown to confer

Mild to Moderate Pediatric Acne Vulgaris

comedolytic and kerAcne Medication Action Chart

atolytic effects.35
Anticomedonal AntiAntiRetinoids
Topical antibiotics
Effects
P.
acnes
inflammatory
(clindamycin or
Generics
+
+++
Tretinoin
erythromycin) also

Retin-A
Micro
Pump
0.04%,
0.1%
(Ortho
confer activity
Dermatologics)
against P. acnes and
Atralin 0.05% (Coria Laboratories)
have demonstrated
Tretin-X 0.01%, 0.025%, 0.05%, 0.1% (Triax )
anti-inflammatory
36
effects. Their use as
Differin Gel 0.1%, 0.3% (Galderma)
+
+++
Adapalene
monotherapy has
largely diminished
+
+++
Tazorac Cream 0.1% (Allergan)
Tazarotene
given the substantial
body of data showing Anti-microbial
Anticomedonal AntiAntithat use of BPO in
Effects
P. acnes inflammatory
combination with a
NeoBenz Micro (Intendis)
+
+++
Benzoyl
topical antibiotic
Benzefoam 5.3% (Onset Therapeutics)
Peroxide
confers greater effi Benzagel 5%, 10% (Sanofi-Aventis)
cacy, enhances tolerability compared to
+
+++
Clindamycin or Cleocin T 1% (Pfizer)
either agent alone,
Erythromycin Akne-mycin 2% (Coria)
and obviates concerns about develop+
+++
Clindamycin/ Duac Gel, CLI 1%/BPO 5% (Stiefel)
ing resistance.35
BenzaClin, CLI 1%/BPO 5% (Sanofi-Aventis)
Benzoyl
Several fixed-com Acanya, CLI 1.2%/BPO 2.5%(Coria)
Peroxide
bination formulations
Anticomedonal AntiAntiare available that feaOther
Effects
P.
acnes
inflammatory
ture benzoyl peroxide
along with clin Aczone gel 5% (Allergan)
+++
Dapsone
damycin. A novel
combination of ben++
Epiduo 0.1%/2.5% (Galderma)
+
+++
Adapalene/
zoyl peroxide and
BPO
adapalene is now
available for once++
+
+++
Clindamycin/ Ziana, CLI 1.2%/tretinoin 0.025% (Medicis)
daily use in the manTretinoin
agement of acne vul+ signifies secondary effect
+++ signifies primary effect
- signifies no effect
garis. In trials, adapalene-BPO fixed-dose
combination gel was more effective than either comfound that dapsone gel was safe and effective when
ponent as montherapy, with safety similar to that of
used for up to 12 months.38
37
each component and vehicle.
Optimal treatment of acne depends on the initiaTopical dapsone, a relative newcomer to the martion of therapy aimed at multiple pathogenic feaket, is the first primarily anti-inflammatory topical
tures of the disease, and the majority of patients
treatment for acne. Analysis of pooled data from
with mild to moderate acne are best treated with a
three studies involving 1,306 patients age 12 to 15
combination of topical therapies.1,31,39 Given the

May/June 2010 |

Practical Dermatology for Pediatrics | 29

Mild to Moderate Pediatric Acne Vulgaris

morning. In the case of fixed combination adapalene/benzoyl peroxide, it is

indicated for once daily application.
Systemic Therapy. Patients with moderate acne that does not adequately
respond to topical therapy, who have a
history of recurrence, or who have a significant inflammatory component to acne
may be candidates for systemic therapy.
Systemic antibiotics, which confer general anti-inflammatory effects and are able
to reduce the number of
Propionibacterium acnes,40 may also be
useful for truncal acne when topical interventions
present a treatment challenge due to difficulties in
application.
Drugs of the tetracycline class, such as doxycycline and minocycline are considered first-line systemic antibiotic therapy for moderate to severe presentations.40,41 However, a review of case reports

Therapeutic Pearl: To minimize patient co-pay costs, many prescribers write for a three month supply. However, pharmacies
increasingly will not dispense multi-month prescriptions. With a
prescription for Doryx 75mg, #90; One tablet PO, QD a patient
may receive just 30 pills with instructions to return for a refill.
As noted, Doryx tablets can be broken in half without disrupting
the delayed release mechanism, thereby preserving the beneficial
GI effect profile. To save patients at least one months copay,
write for Doryx 150mg #30 and instruct the patient to split the
tablet in half, taking 75mg, which is one half tablet per, day.

importance of topical retinoids in the management

of acne and their ability to prevent the formation of
the early microcomedo, most patients should be
started on a topical retinoid each evening.
Treatment is optimized with the addition of a topical antimicrobial, either topical benzoyl peroxide or
benzoyl peroxide/antibiotic combination, each

Case 1
Baseline

A retinoid: Differin, Retin-A Micro, Tazorac,

or generics
OR
A retinoid/BPO combination: Epiduo
OR
A clindamycin/benzoyl peroxide combination:
Acanya, BenzaClin, Duac, or generic
A topical retinoid may be preferrable to treat current lesions, prevent recurrence, and
address PIE. Use of topical BPO in conjunction with topical clindamycin is important to
help prevent bacterial resistance.

30 | Practical Dermatology for Pediatrics

| May/June 2010

This patient was treated with a topical

retinoid applied QHS.

Week 4

Photos courtesy of Joseph Bikowski, MD and DermEdOnline.com

A 16-year-old female presents with grade I,

mild acne of the face. The patient has mild
post-inflammatory erythema (PIE).
The regimen for this patient should begin
with regular use of sunscreens and mild skincare: Aquanil, CeraVe Cleanser, or Cetaphil
Gentle Skin Cleanser
Appropriate therapy for this type of presentation is once-daily, topical application of:

Mild to Moderate Pediatric Acne Vulgaris

published between 1966 and 2003 found a lower

rate of adverse events with doxycycline than with
minocycline.42
Minocycline has been shown to cause rare but
potentially serious systemic adverse events, including autoimmune disorders such as lupus-like syndrome, hepatitis, and arthritis, as well as hypersensitivity reactions.41 A newer, extended-release
minocycline formulation (Solydyn, Medicis) has
been shown to significantly reduce inflammatory
acne lesions while decreasing the rate of dosedependent acute vestibular adverse events associated with minocycline.43

Doxycycline may be associated with gastrointestinal

side effects, especially with immediate release formulations. A slow-release formulation featuring entericcoated doxycycline hyclate pellets encased in capsules
(Doryx, Warner-Chilcott) is associated with significantly less nausea, vomiting, and abdominal discomfort
compared to uncoated doxycycline hyclate powder
encased in capsules.44,45 Of note, these tablets can be
broken and even crushed and sprinkled over applesauce without impeding the slow-release mechanism.46
Although doxycycline has been associated with photosensitivity, this phenomenon is uncommon, with no
cases documented in the US from 1966 to 2003.42

Case 2
A 14-year-old male presents with grade I, II, and III, moderate to
severe acne of the face and neck.
He should be instructed to discontinue any OTC topical agents,
use sun protection daily, and to cleanse affected areas with gentle cleansers: Aquanil, CeraVe Cleanser, or Cetaphil Gentle Skin
Cleanser.
Appropriate therapy is
1. Topical:
A clindamycin/benzoyl peroxide combination: Acanya,
BenzaClin, Duac, or generic

2. Systemic
Antibiotic (minocycline or doxycycline): Doryx, Dynacin,
Minocin, Solodyn, or generic
The patient should be informed that the systemic antibiotic is
intended for short-term control of acne and the topical regimen
will be continued for long-term maintenance. Use of topical
benzoyl peroxide in conjunction with the oral antibiotic is
important to minimize reliance on the systemic agent and help
prevent bacterial resistance. If improvement is not seen at
week 4, consider referral to a dermatologist.

A retinoid:
Differin, Retin-A
Micro, Tazorac, or
generics
OR
A retinoid/BPO
combination:
Epiduo

This patient was

treated with a topical
retinoid QHS,topical
clindamycin/BPO
formulation QAM,
and oral doxycline
QD.

Baseline

Week 4

May/June 2010 |

Week 8

Practical Dermatology for Pediatrics | 31

Photos courtesy of Joseph Bikowski, MD and DermEdOnline.com

AND

Mild to Moderate Pediatric Acne Vulgaris

Patients treated with systemic or topical antibiotics should always undergo concomitant topical
therapy with a benzoyl peroxide-containing product,
a strategy shown to reduce the development of bacterial resistance.47 In addition, a topical retinoid is of
primary value in acne management and may be
used in conjunction with a systemic antibiotic.
Dr. Bikowski has served on the speaker's bureau or advisory
board or is a shareholder or consultant to Allergan, Coria,
Galderma, Stiefel/GlaxoSmithKline, Intendis, Medicis,
Promius, Quinnova, Ranbaxy, and Warner-Chilcott.
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Martin JP, Ramos-E-Silva M, See JA, Shear N, Wolf J Jr; Global Alliance to Improve Outcomes
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32 | Practical Dermatology for Pediatrics

| May/June 2010