March 1997
MIAMI BEACH, Fla. — When deciding on the course of treatment for adolescent acne vulgaris, there are a variety of factors that the pediatrician should consider, according to Patricia A. Treadwell, MD, associate professor of dermatology and pediatrics at Indiana University.
Does the patient have oily or dry skin? How recently did the patient wash his or her face? What kinds of cosmetics and hair-care products is the patient using? Is the patient emotionally distressed because of severe facial acne? [see sidebar]
These questions, among others, should form the basis of the physician's choice of therapy, said Treadwell, who is also chief of pediatric dermatology at Riley Children's Hospital in Indianapolis. "It is important to think about the pathogenesis of acne in terms of choosing what you might use to treat it," she said at the 32nd Annual Pediatric Postgraduate Course sponsored by Miami Children's Hospital here.
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Treadwell pointed out that the primary goal of any treatment should be to limit scarring. "An adult patient came to see me and asked that I treat his acne, when in fact, his acne was gone. What was left was scarring," said Treadwell. "Most of the patients who have acne have active acne for a period of years and then a decrease in the amount of inflammation. It is important to treat acne during the time that it is active to avoid scarring."
Acne occurs in 80% to 85% of adolescents. The areas that tend to be involved are those that have a higher concentration of sebaceous glands, such as the face, the upper back and the chest. Acne originates in microcomedones. The microcomedone can become either an open comedone, which is known as a whitehead or a closed comedone, which is known as a blackhead. "The closed comedone actually can become an open comedone," Treadwell said, "but the open comedone — despite the fact that people don't like the way they look — actually does not progress to anything further."
When debris that is contained within a follicle is released into the surrounding dermis, an inflammatory reaction occurs. Deep inflammation produces nodules, which according to Treadwell, are the lesions that patients are concerned about.
Treatment often relies on limiting the acne-producing process. Treadwell tells her patients to gently cleanse the face and to avoid scrubbing with either scrub brushes or products that have 'beads' in them because these tend to be irritating. She usually recommends a mild soap, and advises against picking at the lesions. "Picking at a lesion can cause a deeper scar and more difficulty," Treadwell said.
In some cases she recommends the use of a moisturizer. "The majority of adolescents who have acne have very oily faces; but there are some who have a combination of atopic dermatitis and acne and in that case their face will feel dry enough [due to acne treatment] to use a moisturizer. When I allow the use a moisturizer, I tell them specifically to use a noncomedogenic one. This indicates that it has been tested on a rabbit ear model to make sure that it doesn't make the acne worse."
Treadwell advises her patients that the makeup they wear to conceal acne may actually worsens it, and suggests that if lesions appear around the scalp line, they should consider using different types of hair-care products and refrain from getting hair sprays and gels on the face.
Treadwell points out that sunscreen can be helpful, but recommends that a noncomedogenic type be used. Adolescent athletes will often have acne mainly where they are wearing helmets or something occlusive on their face, such as swimming goggles, so this is something to be considered, she said.
There is very little inflammation associated with comedonal-type acne; only the open comedones are non-progressive. Treadwell says topical tretinoin (Renova, Retin-A, Ortho Dermatological) is the best agent that she has found for removing comedones. "The main difficulty that I experienced with using the topical tretinoin is that it tends to be very irritating. If you have an adolescent who has very oily skin, they can tolerate it fairly well, but if there is any dryness or if they are dried out by any of the other products then the topical tretinoin can be very irritating," she said.
Because of this, she usually starts with the lowest strength of the topical cream, which is 0.025%. In some instances she recommends that the patient apply it only every other day. She advises that the tretinoin be applied in the evening, because there is an issue of photosensitivity.
Topical tretinoin cream is available in strengths of 0.025%, 0.05% and 0.10%. Gel is available in 0.01% and 0.025%; and liquid is available in 0.05%. "Very occasionally I'll use the liquid, which tends to be the most drying," Treadwell said.
For inflammatory papules, Treadwell typically recommends a benzoyl peroxide preparation. "One thing to keep in mind is that in a managed-care environment if you are told you can only get one product to use for acne, benzoyl peroxide should be the one," said Treadwell. "It is a comedylitic; an anti-inflammatory and an antibacterial preparation so it is very helpful."
Studies of benzoyl peroxide have shown that efficacy is not increased, but drying is in higher strengths. It is available as a liquid soap in strengths of 5% and 10%, which tends to be the mildest in terms of drying. It is available in [water-based] gels of 2.5%, 5% and 10%; and acetone gels of 5% and 10%. The water based-gel is less drying than the acetone variety, Treadwell said.
Another treatment option is topical antibiotics, which are used primarily to decrease the colonization of propionic bacteria into acne. Propionibacterium acnes, Staphylococcus albus, and Pityrosporon ovale play an etiologic role in acne. Topical antibiotics can be used along with benzoyl peroxide. Treadwell recommends that if they are both being used that the topical antibiotic be applied first.
"Typically if a patient is using benzoyl peroxide and topical tretinoin, I'll have them apply the benzoyal peroxide in the morning and the topical tretinoin at night," she said. Topical antibiotics are available in solutions, in gels and in lotions. Clindamycin, which is available in a lotion, tends to be the least irritating, according to Treadwell.
Treadwell also uses oral antibiotics in combination with benzoyl peroxide. Tetracycline is her first choice in an oral antibiotic, she says, primarily because of its low cost. It's main disadvantage is that it has to be taken on an empty stomach. "I had one mother tell me that her two teenage boys would never be able to take tetracycline because they never had empty stomachs," said Treadwell, "That certainly is a disadvantage in the adolescent population, however, if it is given on a twice-a-day or once-a-day dosage that disadvantage is avoided to some extent. Remember that you are not looking for blood level, you are looking for concentration in the sebaceous glands. So once or twice a day is sufficient," she said.
Isotretinoin (Accutane, Roche Laboratories) is also an effective treatment. Treadwell recommends its use in cases of sever acne where other therapies have failed. Treadwell always counsels patients that the initial improvement that they can expect to see is fewer active lesions. Isotretinoin is given for a course of 20 weeks, and should be prescribed with strict admonition that it be taken only if there is no chance that a pregnancy will occur during the course of treatment.
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