Acne vulgaris is by far the most common skin disease affecting adolescent patients. It affects the majority of teens at some point during puberty with a peak incidence between ages 15 and 18 years.1 Up to 20% of patients will have moderate to severe acne and are at risk of scarring.2 As children are entering puberty at a younger age, acne is also occurring earlier and seen with increasing frequency in preadolescents (age 7–11 years).3
Although acne can be the primary reason for a visit to the pediatrician, it is often a secondary concern the family adds on to the end of a well-child visit or sports physical. Worse yet, the patient often does not raise their concern for acne at all, despite the obvious pimples on their face. It is then up to the provider to “suggestively sell” acne treatment, as patients are often too embarrassed to do so or have misconceptions about causes of acne and what are effective treatments.4 Addressing a patient's acne is important because the psychosocial effects can be profound. Acne can adversely affect self-image and is associated with feelings of frustration and depressed mood in adolescents. It can contribute to social isolation and an overall decrease in quality of life.5
Given these potential psychological effects, it is vital that pediatric providers have an “acne action plan” in their armamentarium. In this review, we discuss how to develop simple and effective treatments for acne and provide tips for achieving the best results for teens and preadolescents with the disorder.
The Pathogenesis of ACNE
Understanding the basic pathogenesis of acne both aids the clinician's comprehension of the disease and helps guide treatment selection. Acne is a multifactorial primary inflammatory disorder of the skin that involves a complex interplay between innate immunity, the microbiome, and numerous other internal and external influences. The four main pathogenic factors that lead to the development of acne include (1) abnormal keratinization, (2) increased sebum production, (3) Cutibacterium acnes (formerly Propionibacterium acnes), and (4) inflammation. In addition to these main causes, there are many modifying factors that contribute to acne pathogenesis to varying degrees. These include hormones, particularly in disorders with hyperandrogenism such as polycystic ovarian syndrome; genetics (which can influence acne severity); environmental factors such as humidity and pollution; and dietary influences such as a hyperglycemic diet or intake of whey protein powders.6,7Figure 1 illustrates how available acne treatments work together to affect as many of the main pathogenic factors as possible and why combination therapy is key to achieving treatment success.
Pathogenesis of acne.
Categorizing and Grading ACNE
When physically evaluating a patient with acne, the first step is for the clinician to assign a grade to assess severity. This will help guide initial and subsequent therapy. In clinical trials, this is called the Investigator Global Assessment (IGA), which is a quick subjective assessment of how severe the acne is at that point in time. Only active acne is included in the subjective assessment. Post-inflammatory erythema, hyperpigmentation, and scarring, all of which are common sequelae from acne, should not be counted in the subjective assessment but are important to note when choosing medications and for counseling the patient. Although all acne is inflammatory pathogenetically, clinically, acne is often divided into noninflammatory and inflammatory lesion types for the purpose of treatment selection and determining severity. Noninflammatory acne is defined by the presence of open and closed comedones, which are known to patients as “whiteheads” and “blackheads,” respectively. Inflammatory acne is characterized by papules, pustules, and nodules. Table 1 summarizes a quick acne assessment that can be completed in less than 1 minute.
A Quick Acne Assessment
Approach to Initial Treatment
Once the severity has been determined, an acne treatment algorithm can then be applied. Initial treatment with a combination therapy using a retinoid and benzoyl peroxide (BP), with or without the addition of an oral antibiotic depending on severity, is almost universally employed for all but the mildest acne. Figure 2 combines examples of acne severity with common treatment regimens with proven efficacy. Clinicians should emphasize to patients that treatments such as topical tretinoin are not only a form of treatment but also prevention; therefore, medications should be applied all over the affected areas and not used as a spot treatment.
Acne treatment algorithm. PIH = postinflammatory hyperpigmentation. Asterisk indicates “or another antibiotic” (eg, minocycline, erythromycin, azithromycin, trimethoprim-sulfamethoxazole).
Setting expectations is vital to the successful treatment of adolescent acne. In a survey of 140 patients with acne, the average expected interval to significant improvement of acne was 2.8 weeks.8 Even in patients with severe acne, patients thought they should improve by 8 weeks. However, it typically takes 8 to 12 weeks of consistent treatment to determine if the routine is effective. Comedones typically take longer to heal than inflammatory lesions, so this fact should be clearly communicated to the patient.
The patient's skin care routine should be reviewed and considered when individualizing an acne treatment plan. A gentle cleanser and bland moisturizer are recommended for use with the prescribed acne treatments. Scrubs, astringents, and harsh, oil-reducing cleansers can irritate the skin, making it difficult to tolerate topical acne medications. Addressing potential irritation at initiation of treatment can increase adherence. Typically, irritation will arise within the first couple weeks of treatment but can improve over time. It can be managed with use of a moisturizer after washing and applying medication. If still irritating, patients can use the treatments every other day, and slowly increase use to daily. Additionally, it is important to elicit the teen's everyday routine to determine a regimen suitable for them. For example, if a patient only showers in the evening, recommending BP wash to their trunk in the morning will likely lead to compliance issues.
Many acne treatments are over-the-counter items, which results in the potential for confusion and incorrect product selection. Having a good handout listing specific products may help ensure the patient purchases the correct product. Incorporating these considerations into your evaluation of adolescent acne improves the likelihood of a successful treatment regimen. The Society for Pediatric Dermatology has an excellent acne handout in English, Spanish, and French available for download on their website ( https://pedsderm.net/for-patients-families/patient-handouts/#Anchor-Acne).
In early, preadolescent acne, comedones predominate and are distributed across the forehead and chin in the “T-zone.” For these cases, over-the-counter salicylic acid or BP is a good start, with the goal of getting young teens in the habit of washing their face and caring for their acne.
Most cases of mild acne can be managed with a topical BP and a topical retinoid, although mild cases may respond to single-agent treatment (eg, BP or salicylic acid (Figure 3).
Mild acne. Few papules and pustules, no nodules, and limited comedones.
Patients with moderate acne should be started on both a topical BP and a topical retinoid, with the addition of an oral antibiotic if there is generalized acne or if scarring is noted (Figure 4).
Moderate acne. Several papules and pustules, one to two nodules, and few to many comedones.
For severe acne, patients should be started on a triple-therapy regimen: topical BP, topical retinoid, and oral antibiotic. In female patients, the addition of a hormonal agent is also reasonable. It is important to note that there are many different combinations that may effectively be used, as well as different strengths of many of the medications. The above is a general guideline, but all treatment regimens should be tailored to the individual patient (Figure 5).
Severe acne. Many papules and pustules, and may have many nodules and comedones.
Approach to Maintenance Therapy
Patients should be re-evaluated after 3 months of treatment. At this follow-up visit, the provider should reassess the patient's acne using the quick acne assessment (Table 1). The presence of post-inflammatory hyperpigmentation or erythema, as well as scarring are important to note but they are not included in the active acne assessment. If the patient is doing well (clear or almost clear), then the patient should be maintained on the topical routine (ie. retinoid and BPO). Maintenance regimens and options for management changes based on acne severity at the follow-up visit are listed in Figure 2.
The patient and parent or guardian should also be counseled on the difference between an active lesion and post-inflammatory hyperpigmentation. If post-inflammatory hyperpigmentation is significant, consider adding azelaic acid to the routine while continuing the topical retinoid, as both can help even out skin color. Distinguishing between these two diagnoses can help prevent dissatisfaction or cessation of treatment if post-inflammatory hyperpigmentation remains.
Successful management of adolescent acne extends beyond medication selection. It is vital to recognize the difference between treatment failure and poor adherence. Up to 64% of acne patients are not consistent with their acne routine, with worse adherence noted in younger age groups.9 Therefore, at each visit, the clinician should evaluate the patient's skin care routine, motivation to treat acne, and expectations of treatment. Important treatment guidelines are summarized in Table 2.
Important Acne Treatment Guidelines
When to Refer
If the patient fails to improve on triple therapy, or improvement is not maintained after the completion of the antibiotic course, then the patient should be referred to a dermatologist. Additionally, patients with severe, nodulocystic acne and those with significant scarring should be started on triple combination therapy and referred to dermatology to evaluate for possible isotretinoin treatment. Consider adding a combined oral contraceptive pill in female patients, as effective contraception is an iPLEDGE (a risk management program designed to further the public health goal of eliminating fetal exposure to isotretinoin) requirement for isotretinoin use.
Common ACNE Treatments
Topical retinoids are the backbone of acne therapy and are used for initial treatment and for maintenance of acne. They are vitamin A derivatives that are both anti-inflammatory and comedolytic.10 Different retinoids bind to different retinoic acid receptors, which lead to minor differences in activity, tolerability, and efficacy. Adapalene and tretinoin are the retinoids most commonly used by primary care providers for treatment of acne. Tazarotene is another topical retinoid approved for acne but not commonly used by pediatricians due to its teratogenicity and select insurance coverage. Side effects from all retinoids include dryness, peeling, erythema, irritation, and mild photosensitivity.
Adapalene gel (0.1% and 0.3%) is available by prescription. The 0.1% gel is also available over-the-counter and is a convenient and cost-effective option for patients and, when combined with BP, is a complete routine for mild to moderate acne. Additionally, combination adapalene (0.1% or 0.3%) plus BP gels are available as a prescription. If covered by insurance, this is a convenient, one-step treatment good for mild to moderate acne or can be combined with once-daily doxycycline for moderate to severe acne.
Generic preparations of tretinoin are photo-labile and may be inactivated by BP via oxidation, so they are typically applied at night and at a different time than BP.11 The cream formulation is available in 0.025%, 0.05%, and 0.1%. Alcohol-based gels (0.01% or 0.025%) can be irritating and should be reserved for teens with oily and tolerant skin. The microgel formulations (0.04%, 0.06%, 0.08%, or 0.1%) may be better tolerated, are stable in light, and can be used concomitantly with BP.
Other Topical Acne Treatments
Salicylic acid is a beta-hydroxy acid and mild comedolytic agent. It is frequently found in over-the-counter acne treatments. Salicylic acid is generally well tolerated and a good option for those with mild to mild comedonal acne. It is available as a wash, wipe on pad, and in various creams and gel formulations.
BP works as an antimicrobial agent by creating free radicals that kill Cutibacterium acnes. There has been no resistance to date, and it helps to prevent resistance when used in combination with topical and systemic antibiotics.12,13 Additionally, it acts as a mild comedolytic and anti-inflammatory agent.14 It is conveniently formulated as a wash for use on the chest and back in the shower. Leave-on cream, lotion, and gel preparations are good for localized use on the face. BP may cause skin irritation, and lower strengths (2.5%–5%) may be better tolerated by patients with sensitive skin. Patients and their parents should be warned about the potential bleaching of towels and clothing by BP.
Clindamycin 1% solution or gel is being used less often in acne due to concerns for antibiotic resistance, but it is an option for mild to moderate acne. It should not be used as monotherapy but used in combination with BP to prevent resistance.
Erythromycin plus BP and clindamycin plus BP topical combination gels are available as fixed combinations by prescription. They are used less frequently than in the past but remain an option for select patients with mild to moderate acne.
Dapsone gel is a topical agent typically used for mild, inflammatory acne and is good option for those with sensitive skin. The topical formulation does not require G6PD (glucose-6-phosphate dehydrogenase) testing.15 It is important to counsel patients not to use with BP as it can temporarily stain the skin orange.
Azelaic acid cream is a dicarboxylic acid that works as both an anti-inflammatory and a comedolytic agent. It is generally well tolerated and is added to maintenance routines for patients with post-inflammatory hyperpigmentation, as it helps in lightening the lesions.16
Systemic Acne Treatments
Doxycycline is recommended for patients with moderate to severe acne and is typically prescribed at a dose of 100 mg daily to twice daily. It can be given with food to prevent gastrointestinal upset. Another common side effect is photosensitivity. It should be used in conjunction with a topical retinoid and BP and never as monotherapy. Antibiotics are ideally used for 3 or 4 months. Clinical improvement is often able to be maintained with the topical regimen after completion of the course.17
Minocycline is typically used as a second-line agent for patients requiring systemic antibiotic therapy but who cannot tolerate doxycycline. This is due to the potential for more severe side effects, including pseudotumor cerebri. It is prescribed at a doses of 100 mg daily to twice daily. Other non-cycline antibiotics (including erythromycin, azithromycin, and trimethoprim-sulfamethoxazole) are used less frequently for acne.
Combined oral contraceptives (COC) are often used as a second-line treatment for adolescent girls and are considered a safe long-term treatment option for acne that cannot be controlled with topical treatments alone. COC block both adrenal and ovarian production of androgens and have been shown in a meta-analysis of available data to be as effective as oral antibiotics at 6 months.18 Many COC preparations have demonstrated efficacy. In general, third- and fourth-generation progestins (desogestrel, gestodene, norgestimate, drosperinone) are preferred as they are less androgenic. A COC commonly used for acne is norgestimate/ethinyl estradiol.
Spironolactone is an antiandrogen commonly used in adult women with acne. Data for its use in teenage girls are limited but it may be of benefit in girls with polycystic ovarian syndrome or other signs of hyperandrogenism such as hirsutism.19 Doses of 50 mg to 100 mg once to twice daily are used. Spironolactone can cause menstrual irregularity, breast tenderness, and fatigue that can often be controlled with concomitant use of a combined oral contraceptive. As it is also a potassium-sparing diuretic, it can cause hyperkalemia in patients with impaired renal function and on select medications.
Isotretinoin is a systemic retinoid that is used in treating severe acne, or recalcitrant moderate acne. Typical courses are 5 to 6 months long, although for patients with severe acne, especially on the trunk, they may be longer. The most common adverse effect is dryness of the skin and mucosae. Rare but serious side effects include pseudotumor cerebri, extreme hyperlipidemia, and liver dysfunction. Isotretinoin is a known teratogen. In the United States, all providers who prescribe isotretinoin and patients who receive the drug must register with a pregnancy risk management program such as iPLEDGE, which mandates monthly pregnancy tests for patients of childbearing age and monthly counseling for all patients. Because of these restrictions, most pediatricians do not prescribe the medication; nonetheless, they should be aware of when to refer to dermatology for its use and of side effects patients might present with while taking isotretinoin.
Pediatric providers are often on the frontlines of treating acne, and they have the ability to make a significant impact in the lives of their adolescent patients. As clinicians, it is important to recognize the psychosocial burden that acne causes and appreciate the importance of its treatment. Although this article is not a comprehensive review of all acne treatments or guidelines, it is a general overview of practical acne management in this age group.
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- Bhate K, Williams HC. Epidemiology of acne vulgaris. Br J Dermatol.2013;168(3):474–485. doi:10.1111/bjd.12149 [CrossRef] PMID:23210645
- Davis SA, Sandoval LF, Gustafson CJ, Feldman SR, Cordoro KM. Treatment of preadolescent acne in the United States: an analysis of nationally representative data. Pediatr Dermatol. 2013;30(6):689–694. doi:10.1111/pde.12201 [CrossRef] PMID:23876222
- Desai KP, Martyn-Simmons C, Viner R, Segal TY. Help-seeking behaviours, opportunistic treatment and psychological implications of adolescent acne: cross-sectional studies in schools and hospital outpatient departments in the UK. BMJ Open. 2017;7(9):e016964. doi:10.1136/bmjopen-2017-016964 [CrossRef] PMID:28939579
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- Silverberg NB. Whey protein precipitating moderate to severe acne flares in 5 teenaged athletes. Cutis. 2012;90(2):70–72. PMID:22988649
- McEvoy B, Nydegger R, Williams G. Factors related to patient compliance in the treatment of acne vulgaris. Int J Dermatol. 2003;42(4):274–280. doi:10.1046/j.1365-4362.2003.01611.x [CrossRef] PMID:12694492
- Zaghloul SS, Cunliffe WJ, Goodfield MJD. Objective assessment of compliance with treatments in acne. Br J Dermatol. 2005;152(5):1015–1021. doi:10.1111/j.1365-2133.2005.06357.x [CrossRef] PMID:15888162
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- Lookingbill DP, Chalker DK, Lindholm JS, et al. Treatment of acne with a combination clindamycin/benzoyl peroxide gel compared with clindamycin gel, benzoyl peroxide gel and vehicle gel: combined results of two double-blind investigations. J Am Acad Dermatol. 1997;37(4):590–595. doi:10.1016/S0190-9622(97)70177-4 [CrossRef] PMID:9344199
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A Quick Acne Assessment
|1. Determine lesion types
||Comedones, papules/pustules, nodules
|2. Quantity of lesion types
||Few, several, many
|3. Determine extent
||Limited to half the face or entire faceGeneralized to face, back, chest, and shoulders
|4. Identify postinflammatory changes
||Erythema, hyperpigmentation, scarring
|5. Assess acne severity
||Clear, almost clear, mild, moderate, severe
Important Acne Treatment Guidelines
A topical retinoid plus benzoyl peroxide is first-line therapy for inflammatory acne
Neither topical nor systemic antibiotics should be used as monotherapy for acne treatment
Oral isotretinoin should be first-line therapy for very severe (nodulocystic and conglobate) acne
Most patients with acne should receive maintenance therapy with a topical retinoid with or without benzoyl peroxide. Topical antibiotics should not be used as acne maintenance therapy
At present, services including laser, intense pulsed light, and photodynamic therapy should not be considered first-line treatment for inflammatory acne
Early and effective treatment is important to minimize potential risk for acne scarring