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                                              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:                                   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-
  al testing.

  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:
  ence/_docs/ ClinicalResearch_Acne%20Vulgaris.pdf.
                                                                             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

                                                                        and sunscreen.
                                                                                           ~DECISION POINT~
 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:                         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
 recommendation, B).
                                                                        the regimens improved acne symptoms and reduced
                                                                        hyperpigmentation in patients of color.

38                                                                                                    Vol. 8, No. 2   I   February 2008

     Oral antibiotics are often used for patients with                                 REFERENCES
 severe acne, or for patients with moderate acne who
 have not responded adequately to topical therapies.             1. Katsambas AD, Katoulis AC, Stavropoulos P. Acne neonato-
                                                                     rum: a study of 22 cases. Int J Dermatol. 1999;38:128-130.
 For patients who are treated with oral antibiotics, the         2. Bernier V, Weill FX, Hirigoyen V, et al. Skin colonization by
 addition of topical benzoyl peroxide or retinoid ther-              Malassezia species in neonates: a prospective study and
                                                                     relationship with neonatal cephalic pustulosis. Arch Dermatol.
 apy accelerates the response to treatment and reduces               2002;138:215-218.
 the risk of developing resistance to the oral antibiot-         3. Bergman JN, Eichenfield LF. Neonatal acne and cephalic
 ic.11 Other factors that may reduce the risk of                     pustulosis: is Malassezia the whole story? Arch Dermatol.
  antibiotic resistance include avoiding the use of oral         4. Herane MI, Ando I. Acne in infancy and acne genetics.
 and topical antibiotics with chemically different                   Dermatology. 2003;206:24-28.
                                                                 5. Strauss JS, Krowchuk DP, Leyden JJ, et al. Guidelines of care
 antibiotics and using oral antibiotics for the shortest             for acne vulgaris management. J Am Acad Dermatol.
 time possible.                                                      2007;56:651-663.
                                                                 6. Cantatore-Francis JL, Glick SA. Childhood acne: evaluation
                                                                     and management. Dermatol Ther. 2006;19:202-209.
 CONCLUSIONS                                                     7. Callender VD. Acne in ethnic skin: special considerations for
                                                                     therapy. Dermatol Ther. 2004;17:184-195.
     Neonatal and infantile acne are common and typi-            8. Taylor SC, Cook-Bolden F, Rahman Z, Strachan D. Acne vul-
                                                                     garis in skin of color. J Am Acad Dermatol. 2002;46(suppl
 cally resolve spontaneously after a few weeks. In                   2):S98-S106.
 patients of color, acne is often accompanied by postin-         9. Grimes P, Callender V. Tazarotene cream for postinflamma-
                                                                     tory hyperpigmentation and acne vulgaris in darker skin: a
 flammatory hyperpigmentation. Combinations of                       double-blind, randomized, vehicle-controlled study. Cutis.
 topical agents (eg, benzoyl peroxide, antibiotic,                   2006;77:45-50.
 and retinoid) improve acne symptoms in patients                 10. Taylor S. Paper presented at: 31st Hawaii Dermatology
                                                                     Seminar; March 3-9, 2007; Maui, HI.
 of color, and may also improve postinflammatory                 11. Zaenglein AL, Thiboutot DM. Expert committee recommendations
 hyperpigmentation.                                                  for acne management. Pediatrics. 2006;118:1188-1199.

Johns Hopkins Advanced Studies in Medicine   I                                                                                  39

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