ACNE CASE STUDIES*
Bernard A. Cohen, MD, FAAP†
A HEALTHY 4-WEEK-OLD INFANT WITH ACNE one study, lesion counts and selected biopsies were per-
formed for 22 infants with neonatal acne (the mean age
BAC KG ROUND AND TREATMENT PLAN at onset was 3 weeks).1 Some of the children had come-
The patient is a 4-week-old infant with widespread donal acne only, although papules and pustules were
lesions of the head and neck (Figure 1), including noted for more than 70% of the patients. A family his-
papules, pustules, and comedones. The lesions began tory of severe acne was identified for only 3 of the chil-
to appear shortly after birth. A full physical examina- dren. Biopsies revealed hyperplastic sebaceous glands
tion and review of systems were normal, and the child similar to those typically encountered in older children
was otherwise healthy. Watchful waiting, accompanied and adults with acne. The investigators also identified
by reassurance of the child’s parents, was chosen as the keratin plugging of the sebaceous follicles. Smears for
initial treatment for this patient. The lesions sponta- Pityrosporum ovale—the microorganism that is associ-
neously resolved over the following 3 weeks. ated with tinea versicolor and neonatal cephalic pustu-
losis—were negative. The authors proposed that these
~DECISION POINT~ findings support a role of transient sebaceous gland
What topical agents may be considered for the treat- activity stimulated by neonatal androgens.
ment of neonatal or infantile acne? As many as 20% of neonates exhibit a uniform pat-
tern of inflammatory red papules or pustules of the
Many infants and neonates develop rash that is cheeks, eyelids, forehead, occipital scalp, neck, and
characterized by varying degrees of acne, seborrheic upper chest. Comedones and scarring are absent.
dermatitis, milia, miliaria, tinea versicolor, sebaceous Although this presentation has been referred to as
hyperplasia, or neonatal cephalic pustulosis. Acne in neonatal cephalic pustulosis, it is unclear whether this
these patients may include both inflammatory and represents a condition that is distinct from neonatal
noninflammatory (comedonal) lesions. In an other- acne. Some researchers have suggested that neonatal
wise healthy child, neonatal or infantile acne is usual- cephalic pustulosis may reflect skin colonization by the
ly caused by increased sebaceous gland activity that is lipophilic yeast genus Malassezia. Bernier et al cultured
secondary to elevated adrenal androgens (in females), 102 consecutive neonates and their mothers for
or elevated adrenal or testicular androgens (in males). In Malassezia species, and related Malassezia carriage to the
probability of cephalic pustulosis; follow-up cultures
were performed for 56 of the children and their moth-
*Based on proceedings from a satellite symposium at
the Annual Meeting of the American Academy of Family
ers again after 3 weeks.2 At birth, 11 of the neonates and
Physicians on October 6, 2007, in Chicago, Illinois. 36 of the mothers were positive for Malassezia species.
†Director of Pediatric Dermatology, Johns Hopkins At 3 weeks, 29 of the neonates (52%) and 18 mothers
Children’s Center, Professor, Dermatology and Pediatrics, (32%) were positive. Malassezia carriage among the
Johns Hopkins University School of Medicine, Baltimore, neonates was associated with increased prevalence and
Maryland. severity of cephalic pustulosis between birth and the age
Address correspondence to: Bernard A. Cohen, MD,
FAAP, Professor, Dermatology and Pediatrics, Johns Hopkins of 3 weeks. It has been hypothesized that the uniform
University School of Medicine, East Baltimore Campus, lesions that characterize neonatal cephalic pustulosis
2105 PMOB, 200 North Wolfe Street, Baltimore, MD may result from follicular occlusion caused by an
21287. E-mail: email@example.com. inflammatory reaction to this lipophilic yeast.3
36 Vol. 8, No. 2 I February 2008
Evaluation of neonatal acne should include assess- the parents, is usually the best treatment for neonatal or
ment of growth parameters, evidence of precocious sex- infantile acne. Acne in these patients usually resolves
ual maturation, and blood pressure.4 In rare cases, spontaneously within 4 weeks. Low-risk topical agents
neonatal acne reflects an inborn error of adrenal metab- (eg, a topical benzoyl peroxide or topical antibiotic) for
olism, which will also produce other signs of hyperan- a short period of time may be considered when the
drogenism. In a child with severe acne and normal lesions persist. Alternatively, an oral antibiotic may be
growth parameters, assessment of bone age is a good considered in rare cases.6 For severe inflammatory acne
screening study to exclude endocrinologic disorders.5 in otherwise healthy infants, oral antibiotics may be
Watchful waiting, with reassurance and counseling of indicated to reduce the risk of scarring.
EVIDENCE-BASED PRACTICE RECOMMENDATION Figure 1. An Otherwise Healthy 4-Week-Old
Infant with Widely Distributed Papules and
I. Practice Recommendation: According to acne man- Pustules of the Head and Neck
agement guidelines developed by the American
Academy of Dermatology, laboratory endocrinologic
evaluation (eg, for androgen excess) is indicated for
children with acne who have signs of androgen excess
(eg, body odor, axillary of pubic hair, and cli-
toromegaly). In prepubertal children, testing of bone
age using a hand film is a specific screening method
for androgen excess that may be used before hormon-
Name of AAFP-Approved Source: American
Academy of Dermatology: Guidelines of Care for
Acne Vulgaris Management.
Specific Web Site of Supporting Evidence from
Approved Source: http://www.aad.org/pm/sci-
Figure 2. A 14-Year-Old Black Male with Mixed
Strength of Evidence: The American Academy of Comedonal and Inflammatory Acne
Dermatology expert consensus panel found little evi-
dence that routine endocrinologic evaluation is of
value for patients with acne, as most patients with acne
exhibit hormone concentrations within the normal
range. The panel identified 2 cohort studies with a
total population of 884 patients showing an associa-
tion between acne and androgen excess in patients
who have other signs of hyperandrogenism, and rec-
ommended hormonal testing for these individuals
(strength of recommendation, B). Bone age was iden-
tified as an effective screening tool for selecting candi-
dates for hormonal testing in prepubertal children
(consensus opinion; strength of recommendation, C).
Johns Hopkins Advanced Studies in Medicine I 37
HEALTHY TEENAGE BOY WITH SKIN OF COLOR The patient began therapy with adapalene 0.1%
REQUIRING ACNE THERAPY cream 3 times per week (Monday, Wednesday, and
Friday) at bedtime, and a benzoyl peroxide wash before
BAC KG ROUND AND TREATMENT PLAN showering. He was also instructed that treatment for 4
The patient is a healthy 14-year-old black male to 6 weeks might be necessary before his acne
with mixed comedonal and inflammatory acne (Figure improved, and he was instructed to continue treat-
2). He has used an over-the-counter acne scrub and ment even after his acne began to improve. He was also
cleanser without improvement. educated about skin care, including the use of gentle
cleansers to avoid skin irritation, avoiding washing
more than twice per day, and about the use of nonirri-
tating, noncomedogenic products such as moisturizer
EVIDENCE-BASED PRACTICE RECOMMENDATION
II. Practice Recommendation: Patients of color who Do topical acne therapies reduce postinflammatory
have acne are at high risk of scarring and postinflam- hyperpigmentation in patients of color with acne?
matory hyperpigmentation. Topical retinoids improve
acne symptoms and also reduce postinflammatory
hyperpigmentation in these patients.
Early and aggressive acne management is especially
important for patients of color who are at increased risk
Names of AAFP-Approved Sources: Jacyk WK. of postinflammatory hyperpigmentation and keloidal
Adapalene in the treatment of African patients. J Eur scarring.7,8 Although topical acne treatments may pro-
Acad Dermatol Venereol. 2001;15(suppl 3):37-42. duce skin irritation, they are also very effective for the
management of both comedonal and inflammatory
Taylor SC. Utilizing combination therapy for ethnic acne in patients with darker skin pigmentation. Some
skin. Cutis. 2007;80(1 suppl):15-20.
patients may require additional depigmenting therapy
Specific Web Sites of Supporting Evidence from (eg, with topical hydroquinone), although this is usual-
Approved Sources: http://www.ncbi.nlm.nih.gov/ ly not necessary. Topical retinoids or benzoyl peroxide
sites/entrez?Db=pubmed&Cmd=ShowDetailView& may be used as maintenance therapy to prevent forma-
TermToSearch=11843232&ordinalpos=10&itool=Ent tion of new comedones. Sunscreen and sun protection
rezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pub are important for all patients, including those with dark-
med_RVDocSum. ly pigmented skin.
Clinical studies have demonstrated that topical
retinoids are effective for acne therapy in patients of
Pubmed_ResultsPanel.Pubmed_RVDocSum. color, and that they also reduce postinflammatory
hyperpigmentation.9 The risk of irritation when begin-
Strength of Evidence: One study has specifically ning therapy may be minimized by initially applying
assessed the response to acne treatment in black the retinoid 2 to 3 times per week, and then gradually
patients. This open-label, single-group study of 65 increasing the frequency of application. Regardless of
patients conducted in South Africa found that topical the patient’s skin color, combination therapy for acne
adapalene 0.1% gel reduced the number of hyperpig-
is often more effective than treatment with a single
mented macules or the density of hyperpigmentation in
approximately 66% of the patients. A second random-
agent. One recent clinical study examined the efficacy
ized, investigator-blinded study of 167 patients of of a topical gel containing benzoyl peroxide 5% and
color found improved hyperpigmentation with adapa- clindamycin 1% for patients of different racial and
lene 0.1% gel or tretinoin microsphere 0.04% or 0.1% ethnic groups in a community setting. This topical
gel. The lower-strength tretinoin microsphere gel pro- combination was administered with one of 3 topical
duced a greater reduction in hyperpigmentation from retinoids—tretinoin microsphere 0.04%, tretinoin
baseline, possibly due to better tolerability (strength of microsphere 0.1%, or adapalene gel 0.1%.10 All 3 of
the regimens improved acne symptoms and reduced
hyperpigmentation in patients of color.
38 Vol. 8, No. 2 I February 2008
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relationship with neonatal cephalic pustulosis. Arch Dermatol.
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garis in skin of color. J Am Acad Dermatol. 2002;46(suppl
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Johns Hopkins Advanced Studies in Medicine I 39