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46]

CME ARTICLE

Acne in childhood: Clinical presentation, evaluation

and treatment
Akshay Kumar Jain, Manjaree Morgaonkar
Department of Dermatology, Venereology and Leprosy, Government Medical College, Kota, Rajasthan, India
ABSTRACT
Acne can be classified into neonatal acne, infantile acne, midchildhood acne and prepubertal acne depending on the age
of onset. There is limited literature available on acne in pediatric age group. This article provides an overview of clinical
presentation and pathogenesis of acne in children and proposes therapeutic guidelines.
Key words: Acne, children, dehydroepiandrosterone

INTRODUCTION

cne is a disease of pilosebaceous units.[1] It

is predominantly a dermatological problem
in adolescents, but neonates, infants, and young
children may also be affected.[2] Lesions of acne are
polymorphic and consist of comedones, papules,
pustules, nodules and sometimes scarring can also
be present. [3] There is not much literature available
on childhood acne, besides, its polymorphic
nature and contraindication of some drugs in
children make the evaluation and treatment of
childhood acne more difficult. This article presents
pathogenesis, evaluation and treatment of acne in
children.

NEONATAL ACNE
Neonatal acne may be hormonally mediated
because newborns with neonatal acne present
transient increase in circulating androgens.
Meanwhile in the neonatal period, sebaceous
glands are hyperplastic and increased androgenic
activity of the glands may be responsible of
neonatal acne development.
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DOI:
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Now the term neonatal cephalic pustulosis(NCP)

is used for neonatal acne. Up to 20% of newborns
can be affected by this condition in first few weeks
of life. [4,5] In this condition, erythematous papules
or pustules appear mainly over the cheeks, chin,
eyelids, neck but rarely upper chest, scalp and back
may be involved[Figure1]. Usually, comedones
are not seen [6,7] but early onset androgen driven
acne can present with comedones. The condition
is thought to occur due to the poral or follicular
colonization by Malassezia sympodialis and
Malassezia globosa. [79]
Many neonatal dermatoses can mimic NCP. Possibility
of Infections including bacterial, viral, or fungal should
be kept in mind. Milia, miliaria, sebaceous gland
hyperplasia, Transient neonatal pustular melanosis,
erythema toxicum neonatorum are noninfectious
conditions simulating NCP. Always exclude acneiform
eruption in neonate due to use of topical steroids,
ointments (acne venenata), maternal medications
during pregnancy(lithium, phenytoin, steroids).
Although rare but one should rule out congenital
adrenal hyperplasia (CAH) or other endocrinopathies
also.
Management
Course of NCP is benign and does not require any
treatment except assurance to parents. Lesions resolve
spontaneously without scarring. 2% ketoconazole
cream is effective.[10,11]
ADDRESS FOR CORRESPONDENCE
Dr.Akshay Kumar Jain,
B302, Indra Vihaar, Kota324005, Rajasthan, India.
Email:akshayrj@gmail.com

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Jain and Morgaonkar: Acne in childhood

INFANTILE ACNE
Infantile acne appears from the age of 6months
up to16months.[12,13] Occurrence is less than that
of neonatal acne. It is more common in boys.
Exact pathogenesis is still not known but it is
thought to occur due to high level of production of
dehydroepiandrosterone(DHEA) by fetal adrenal
glands and this additional androgen production in boys
further stimulates the sebaceous glands. High level
of DHEA stimulates sebaceous gland up to 1year of
age then disappears and reappears at adrenarche.[2,14]
Lesions of Infantile acne include closed and open
comedones, papules, and pustules occasionally cysts
and scar formation. Lesions generally resolve itself by
45years of age. Infants with infantile acne are more
prone to develop severe acne in their adolescence.[15]
Differential diagnosis should include acneiform
eruptions, chloracne, and persistent neonatal acne. If the
acne is severe and persistent, hyperandrogenemia should
be suspected. In such cases, proper evaluation of weight,
height, signs of precocious puberty (enlarged clitoris/
penis) and serum level of testosterone (free and total),
dehydroepiandrosterone sulfate (DHEAS), luteinizing
hormone(LH) and folliclestimulating hormone(FSH)
measurement becomes mandatory.
Management
For infantile acne, therapeutic approach is same as
that for acne in other age groups.[6,16] Comedonal
lesions and mild cases are managed by topical agents
like retinoids(tretinoin, adapalene), benzoyl peroxide
and topical antibiotics such as erythromycin. When
oral antibiotics are needed, erythromycin in doses
of 125250mg twice daily is given. In patients
with documented Propionibacterium acnes resistant
to erythromycin, trimethoprim/sulfamethoxazole
100mg orally twice daily can be used.[17] Tetracyclines
are contraindicated in children below 8years of age
because they can cause Permanent discoloration of
the teeth and abnormal skeletal development.
Intralesional injections of triamcinolone acetonide
in low concentration(2.5mg/kg) can be given for
nodules and cysts.[6] Isotretinoin is Food and Drug
Administration(FDA) approved drug for treatment
of nodulocystic acne only in children of 12years or
older,[12,18] but there are published reports suggesting
successful role of isotretinoin in younger children.
Dose of isotretinoin for infantile acne is not known
but dose range of 0.22.0mg/kg/day divided in
two daily doses for 414months in children up to
5years of age can be used.[12,13,1922] As isotretinoin is
2

available in capsules, it is problematic to administer

in children. The problem can be overcome by opening
the capsule in dim light and mixing the contents with
soft food like cheese and butter.[22] The capsule should
never be opened in light as isotretinoin is very labile
to light and heat. Another way of administration of
the capsule is to freeze it till it becomes solid and
then cut the capsule up to desired dose and mix it
with palatable food. Liver function tests, serum lipid
profile, complete blood count and skeletal growth
should be monitored regularly while patient is on
isotretinoin. Adverse effects of isotretinoin in infants
are mild and include dermatitis, reversible mood
changes, umbilical granulation tissue, elevation of
liver enzymes, periosteal thickening, and cortical
hyperostosis. Premature epiphyseal closure is
unlikely to occur at such low doses used in the
treatment of acne.

MIDCHILDHOOD ACNE
Acne in age group of 17years is called as midchildhood
acne. Acne in this age is of very rare occurrence as
production of androgen by fetal adrenal gland is
maximum up to 1year of age and then stops but recurs
at adrenarche. So presence of acne in midchildhood
almost always points toward hyperandrogenism.[23]
Differential diagnosis includes CAH, gonadal/
adrenal tumors, precocious puberty or underlying
endocrinopathy(Cushings syndrome) and keratosis
pilaris. Careful examination and lab tests should be
performed to reach the cause of midchildhood acne.
Physical examination for precocious puberty, bone age
measurements, growth chart maintenance and serum
FSH, LH, testosterone, DHEA, prolactin, cortisol, and
17 ahydroxyprogesterone level are recommended. If
there is any abnormality in these parameters, patient
should be referred to an endocrinologist. Treatment is
same as that for infantile acne.

PREPUBERTAL ACNE
Prepubertal acne is the appearance of acne before true
puberty that is due to maturation of ovary and testis.
During adrenarche, there is an increase in secretion
of DHEA and DHEAS by adrenal glands leading to
activation of sebaceous gland. Age of adrenarche is
67years in females and 78years in males. DHEAS
is secreted from the adrenal gland. Raised Serum
level of DHEAS is associated with increased sebum
production in prepubartal age, so the causative factor
for prepubertal acne, can be attributed to adrenal

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Jain and Morgaonkar: Acne in childhood

androgens.[24] In this age, there is little adrenal

production by gonads and their maturation takes
place 34years after adrenarche. Excess androgen by
ovary in this age can be due to benign or malignant
tumor or more commonly due to polycystic ovary
disease(PCOD).
Lesions of prepubertal acne mainly consist of
comedones, with or without inflammatory lesions.
Central area of the face(midforehead, nose, and chin)
is mainly affected[17][Figure2]. Lesions may appear
before any other signs of pubertal development.
Acne can be the first sign of pubertal maturation in
girls and may present before pubic hair and areolar
development.[25]
Differential diagnosis is similar to midchildhood acne
and include precocious puberty, millia, lupus miliaris
disseminatus faciei, childhood granulomatous rosacea,
childhood granulomatous periorificial dermatitis

Figure 1: Neonatal cephalic pustulosis: Multiple erythematous papules and

pustules over cheeks, comedones are absent

and acneiform eruption due to certain drugs like

phenytoin, steroids or isoniazide etc.
Severe acne in prepubertal age raises the possibility
of hormonal abnormality. In girls with severe
prepubertal acne, ultrasonography of the pelvis should
be performed to rule out the possibility of PCOD or
less commonly, benign or malignant tumor of the
ovary. Lab investigations should include serum levels
of free or total testosterone, DHEAS and a ratio of
LH to FSH.
Management
Treatment depends on grading of acne. Mild cases
can be managed by topical therapy alone including
tretinoin, benzoyl peroxide, and azelaic acid. Topical
retinoids should be started gradually, and gentle
cleansing of the face is recommended to remove surface
sebum and keratin. For inflammatory lesions use of
topical antibiotics(erythromycin, azithromycin) is
recommended. If lesions are severely inflamed, oral
antibiotics(erythromycin, tetracycline, azithromycin,
sulfamethoxazole) can be administered. Tetracycline
should never be given if the child is less than 8years
of age. Monotherapy should be avoided as this can
lead to the development of resistance. Therefore, it is
recommended to use antibiotics along with benzoyl
peroxide or tretinoin. If there is nodulocystic acne, use
of oral isotretinoin may be necessary.
Hormonal therapy is considered when etiology of
acne is CAH or polycystic ovary syndrome. Oral
contraceptives or antiandrogen can be prescribed
in case of polycystic ovary syndrome.For CAH, low
doses of oral corticosteroids are given.[25] If benign
or malignant tumor of the ovary is the underlying
cause of acne then, gynecological reference is
recommended.

CONCLUSION

Figure 2: Prepubartal acne: Comedones over mid-forehead

Acne has varied manifestations according to age.

Many other dermatoses can be confused with acne
especially in children. Neonatal acne is selflimiting
and rarely needs any treatment. Infantile acne can
be a predictor of more severe acne in adolescence. In
the treatment of childhood acne, contraindication
of oral tetracyclines should be considered. Use of
oral isotretinoin has proven to be successful in
infantile and midchildhood acne but currently it is
FDA approved only for children above 12years of
age. Further studies are needed to prove its safety in
children in doses used for adult acne. Severe acne in

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Jain and Morgaonkar: Acne in childhood

children of any age warrants careful evaluation to rule

out endocrinal abnormalities.

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How to cite this article: Jain AK, Morgaonkar M. Acne in childhood:
Clinical presentation, evaluation and treatment. Indian J Paediatr Dermatol
2015;16:1-4.
Source of Support: Nil, Conflict of Interest: Nil

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