Here’s a letter we received recently: “I am an avid reader of The Philippine STAR and was so glad to stumble upon your column ‘Under Your Skin’ I decided to personally write to you regarding my 13-year-old daughter.
“If you must know, our family is not blessed with good skin — I mean both my husband and I. I don’t know if genes have something to do with it, but our first and second children suffered from major acne breakouts in their teens and we’ve spent a small fortune for their treatments.
“My youngest is my 13-year-old daughter and my husband and I are wondering if we should start preventive skin treatments even when she still does not have serious skin concerns at this time. We’re just afraid that she might also suffer from bad skin eventually and by then it would already be very expensive to pay for treatments. What do you suggest — is 13 too young for a regular skin treatment?”
Acne or pimples have long been the bane of teenage existence. Unknown to most is that it’s a most common skin condition not only in adolescents but in children as well. Although often considered a disease of teenagers, in whom the prevalence is reported to be from 70 to 87 percent (http://pediatrics.aappublications.org/content/131/Supplement_3/S163 - ref-1), age 12 is no longer considered the lower end of the age range for acne onset. A study by Lucky et al revealed acne lesions in 78 percent of 365 girls, ages nine to 10. In addition, acne and other acneiform (acnelike) conditions occur at different ages, including neonates (four weeks old), infants, and young children, and may be associated with differential diagnoses or systemic pathology that differs from teenagers, sometimes associated with significant disease processes.
Acne has a tremendous negative psychological as well as physical effects that is why it is necessary that the problem be addressed early. Right now, I can really say that we already have the tools to minimize these problems. I usually tell my patients that essentially, all acne can be wiped out (meaning that there is a solution for each type of acne), but there is a need to figure out what is the least amount of skincare and medicine we need to do it, as each type of acne has a different approach to treatment.
There are issues of special concern in the treatment of preadolescents with acne (where your daughter falls under). The treatment of acne often involves the use of several medications that target either different types of acne lesions, different factors involved in the causation of acne, or different degrees of acne severity. Potential interactions between medications can add another layer of complexity to the management of acne in pediatric patients, as can concerns about systemic side effects and impact of medications on growth and development. Both age and form of presentation are relevant to the diagnosis of pediatric acne. Although there is some overlap in age and presentation of acneiform conditions, a panel consensus has been reached as follows:
• Adolescent (12-18 years of age): corticosteroid induced.
Differentials (other disease that may look like acne) include: demodex (parasitic mites within the hair follicle) folliculitis, gram negative folliculitis, pityrosporum folliculitis, malassezia folliculitis, perioral dermatitis etc.
• Pre-adolescent (7-12 years old): Under this is pomade acne or acne venenata (from the use of topical oil products), corticosteroid acne
Differentials: perioral dermatitis, keratosis pilaris, milium etc.
• Mid-childhood (1-7 years old): This is the scary one as it may be related to the following: adrenal tumor, congenital adrenal hyperplasia, cushing syndrome, gonadal tumors, ovarian tumors, PCOS, premature adrenarche (early sexual maturation), true precocious (showing features of an adult at an unusually early age) puberty.
• Medication induced: anabolic steroids, isoniazid, lithium, phenytoin, progestins, gold, dactinomycin.
It is essential to have a broad understanding of acne at different ages and to be aware of the differential diagnoses for each age group. Workup is based on age and physical findings. Physical examination should focus on type and distribution of acne lesions, height, weight, growth curve, and possible blood pressure abnormalities. Signs of precocious sexual maturation or virilization should prompt workup or a referral to a pediatric endocrinologist.
• Neonatal acne (a month old): This is estimated to affect up to 20 percent of newborns. The major controversy in this age group is whether the lesions truly represent acne or any one of the acneiform conditions. Although rare, some neonates may present with androgen-driven comedonal and inflammatory acne. Neonates may have true acne, although many self-limited papulopustular eruptions also occur.
• Infantile acne (two months to two years): This may begin at six weeks of age, last for six to 12 months or, rarely, for years. It is more common in boys and comes with comedones (blackheads/whiteheads) as well as inflammatory lesions, which can include papules, pustules, or occasional nodular lesions. Physical examination should include assessment of growth (height, weight, growth curve), testicular growth, breast development, presence of hirsutism or pubic hair, clitoromegaly (enlarged clitoris), and increased muscle mass. It is also important to distinguish true infantile acne from other similar cutaneous lesions, because there is some evidence that infantile acne predisposes infant to more severe adolescent acne. Most infantile acne is self-limited and not associated with underlying endocrine pathology. However, in patients with additional physical signs of hormonal deviation, a more extensive workup may be appropriate. No further workup is necessary for the majority of cases in the absence of hormonal abnormalities.
• Mid-childhood acne (1-7 years): This appears primarily on the face with a mixture of comedones and inflammatory lesions. Children between the ages of one and seven years old, however, do not normally produce significant levels of adrenal or gonadal androgens; hence, acne in this age group is rare. Mid-childhood acne is very uncommon and should warrant an endocrinologic workup for causes of hyperandrogenism.
• Pre-adolescent acne (7-12 years):
It is not uncommon for acne vulgaris to occur in pre-adolescents, as a result of normal adrenarche (early sexual maturation) and testicular or ovarian maturation. Acne may be the first sign of pubertal maturation. This is characterized by a predominance of comedones (blackheads/whiteheads) on the forehead and central face (the so-called “T-zone”) with relatively few inflammatory lesions. Early presentation may include comedones of the ear.
History and physical examination are most important in the assessment of this age group. Further workup is generally unnecessary unless there are signs of excess androgens (like PCOS), or if the acne is unusually severe, or is not responding to treatment..
In general, treatment of pediatric acne vulgaris is similar to acne treatment in older adolescents and adult. Although some acne may resolve without residual changes, inflammatory acne may result in the formation of significant scars. In darker skin, post-inflammatory hyperpigmentation (PIH-dark spots) is common. Residual erythema (redness) can occur as well.
It has been repeatedly demonstrated that acne can have a significant adverse impact on the quality of life, and that the level of distress may not correlate directly with acne severity. Reported social, psychological, and emotional symptoms were as severe as those reported by individuals with chronic medical conditions such as chronic asthma, epilepsy, diabetes, and back pain or arthritis. Adolescents, in particular, may be insecure about their appearance and vulnerable to peer opinions. Because social functioning and quality-of-life decrements may not correlate with disease severity, even mild acne may be more troubling to young patients than they are willing to admit. Therefore, at 13, your child is very vulnerable and treatment of her skin problems, particularly acne, is very important but the aesthetic aspect should not be the only concern here. The patient has to be evaluated properly for other possibly related internal problems. This is why I always tell people that acne is not an aesthetic problem but rather a skin disease that should be treated by a PDS board-certified dermatologist.
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