Treating Acne In Children

by Jeff Cersonsky, MD, FAAP

Q: “I’ve tried everything for my child’s acne, but it continues to get worse.  It’s really affecting his self-esteem.  What can I do?”

A: There are as many theories on acne treatment out there as there are products on the shelves, and anyone walking into a drug store looking for an acne preparation knows how many medications are available.  In fact, like most over-the-counter choices, there isn’t much to choose between them once you understand what acne is and what you need to treat it.

Acne (blackheads, whiteheads, pustules, and cysts) occurs in the sebaceous glands of adolescents or adults.  These glands are present in the greatest number on the face, back and chest, and begin to produce sebum in the greatest quantities as the sexual hormones (estrogens and testosterone) increase with adolescence.  The sebum becomes colonized with bacteria (usually Propionibacterium acnes) which break down the sebum into byproducts (free fatty acids) that stimulate inflammation. As inflammation increases, the risk of scars also increases.  Once scars form, they are essentially permanent, although various surgical procedures can minimize the cosmetic effect of the scars.

Emotions also seem to affect the development of acne.  It seems to be no coincidence that an unsightly pimple appears right before the big dance. No one is clear on this association, though stress-induced pheromone production might induce increased sebum (oil) production.

The principles of acne treatment involve the decrease of the cosmetic problem and the prevention of scarring.  Since adding oil only increases the effective sebum, oily skin or hair preparations should be avoided.  Good skin cleansing is essential but cleansers containing abrasives should not be used because they may increase the inflammation.

Treatment of acne should follow a few caveats: (1) Treatment should be sequential, using the weakest medication first and giving it a fair trial before moving on to something stronger, (2) A minimum of two weeks of continuous treatment is needed to evaluate whether a treatment is effective, and (3) Pustular acne requires more aggressive therapy to prevent scarring.   The reason that treatment requires two weeks to evaluate effectiveness is that pimples can take up to two weeks to appear, so what we are preventing are pimples which might not be evident for 2 weeks.

Benzoyl peroxide is the primary treatment for acne.  This oxidizing agent decreases both the growth of Propionibacterium acnes and the conversion of sebum to free fatty acids, which ultimately decreases inflammation.  Over-the-counter benzoyl peroxide is available as a cream or lotion in strengths of 5% and 10%.  The cream and lotion are comparable in their efficacy and should be applied after cleansing once or twice a day.  This is essentially the only effective medication available over the counter.

Treatment usually starts with 5% Benzoyl peroxide (BP) cream or lotion and then progresses if necessary to 10% BP cream or lotion.  If a good trial of these over-the-counter medications has been unsuccessful, prescription medications are the next step.  The first is good old BP again, but in a gel form, which is 4 times stronger than the cream or lotion.  (Therefore, 5% BP gel is twice as strong as 10% lotion.)  If 5% BP gel and then 10% BP gel are unsuccessful, then either a topical antibiotic, an oral antibiotic (usually a tetracycline), or a vitamin A product (Retin-A) are tried. At this point a dermatologist is frequently consulted.  Under a dermatologist’s supervision, a strong form of oral Vitamin A—Accutane—can be tried for potentially scarring, severe forms of acne.  This medication has several cautions: (1) Blood tests should be regularly done primarily to rule out any liver dysfunction and (2) When used in adolescent girls or women, care must be taken that there is absolutely no possibility of pregnancy.  Accutane is a potent teratogen, meaning it frequently causes serious birth defects if taken during pregnancy.  However, Accutane can cause a complete remission of acne, one that can last a lifetime.

Medications for acne (except oral antibiotics) possess one common side-effect: skin dryness.  The more potent the medication, the more serious this side-effect.  Occasionally the dryness, peeling, and itching result in poor tolerance by the child and the medication must be discontinued.  Sun exposure should be minimized when taking oral tetracyclines or using Retin-A or Accutane because an exaggerated effect of the sun (either sunburn or sunstroke) can occur.  Again, careful monitoring must take place with anyone on Accutane.

Some would wonder why I have not heretofore mentioned the effect of diet on acne.  Numerous studies have shown NO effect of diet on acne, despite the conviction of many people that certain foods do affect acne.  It certainly makes sense to eat a low-fat, high-fiber diet rich in fruits, vegetables, and lean proteins.  If someone notices that their body seems to react negatively to certain foods, either with breakouts of acne or other symptoms, they should certainly avoid them.

Too often, those with acne suffer in silence for years before seeking professional help.  With the arsenal of effective treatments available, they could be spared much misery by asking their doctor for help.

(Note: Questions to Dr Jeff Cersonsky can be sent to his e-mail address at jmcdii@erols.com or to his office at 30 Quaker Farms Road, Southbury, CT 06488. He cannot respond to all questions nor give medical direction for specific children, but he can give helpful general advice. Previous articles can be found on his Web site at www.erols.com/jmcsdii/page2.html.)