Pediatric Acne: What Signs are Concerning?

Pediatric acne was discussed in a presentation at Maui Derm NP+PA Fall 2021 by Raegan Hunt, MD, PhD, service chief of pediatric dermatology at Texas Children’s Hospitals and assistant professor of dermatology and pediatrics at Baylor College of Medicine, both in Houston, Texas. 1

Her aim was to explain how to diagnose and treat acne in pre-adolescent children and determine when to investigate early acne to rule out endocrinological abnormalities.

Her first question was whether neonatal acne or infantile acne was more concerning. The answer was infantile acne. Although neonatal acne (benign cephalic pustulosis) can develop when a patient is 0 to 1.5 months old, there are usually no comedones, cysts, or scars for the doctor to think about, and the treatment is a gentle skin cleanser, topical antifungal medication, and keep an eye on the area, Hunt explained.

On the other hand, infantile acne is uncommon and more common in male patients with onset between 1.5 and 12 months at risk of scarring. It is also associated with a higher risk of acne in adolescents and has comedones, inflammatory papules and nodules. Typical treatment, according to Hunt, would be topical medications such as benzoyl peroxide, retinoids and azelaic acid or systemic medications such as erythromycin, trimethoprim/sulfamethoxazole (TMX-SMX – not in patients younger than 3 months), and off-label isotretinoin.

Isotretinoin is for painful or cystic acne, Hunt explained, and because very young children can’t swallow the capsules, there are soft gel capsules filled with the drug that can be pulled out with a needle if necessary or frozen and cut to hide in food. . She said a workup isn’t usually necessary because the infantile acne isn’t associated with an endocrinopathy, but looks for signs of accelerated growth and advanced tanner staging.

What about mid-childhood acne vs pre-adolescent acne? Which is more concerned?

Hunt said that acne in mid-childhood can be a sign of much deeper problems, as it is associated with endocrinological conditions, such as a tumor, Cushing’s syndrome or premature adrenarche. This requires an endocrine work-up. The tests included follicle-stimulating hormone (FSH), luteinizing hormone (LH), dehydroepiandrosterone sulfate (DHEAS), cortisol, free and total testosterone, 17-OH progesterone, and a bone age X-ray.

The clinical findings of mid-childhood acne are comedones, inflammatory papules, and nodules beginning between 1 and 7 years of age. It carries a risk of scarring, and treatment includes topical retinoids, benzoyl peroxide, and oral antibiotics. Hunt stressed that tetracycline derivatives should be avoided in pediatric patients under 8 years of age.

Pre-adolescent acne has the same clinical findings, treatment, and risk of scarring as mid-childhood acne, but the onset is from 8 to 12 years of age. According to Hunt, no endocrine work-up is usually required for this patient group.

She went on to explain a previous case of an 11-year-old patient on adalimumab for Crohn’s disease who had pustules on the nose who had not been treated with topical retinoids, topical antibiotics, doxycycline and had a poor response to intralesional triamcinolone injection. . The patient was advised against other oral antibiotics or isotretinoin.

Hunt diagnosed him with demodicosis, which she treated with 2 doses of approximately 200 mcg/kg of oral ivermectin one week apart and topical permethrin 5% cream once daily for 1 week. When there are pimples on the nose that don’t go away with regular acne treatment, demodicosis may be the right diagnosis, she explained.

Although demodex is low in childhood and increases with age, Hunt said, it may be associated with conditions such as Langerhans cell histiocytosis, leukemia, lymphoma and HIV in children. She said it may also affect pediatric patients with periorificial dermatitis.

Finally, she spoke on the topic of acne in transgender patients and how over 90% of transmale youth experience acne problems that can be caused or exacerbated by testosterone used in gender-affirming therapy. Hunt explained that it is for this reason that it is recommended that acne be checked every 3 months after starting testosterone

Furthermore, she said that moderate to severe acne in transmasculine patients was associated with an increased risk of depression (adjusted odds ratio of 2.4) and anxiety (adjusted odds ratio of 2.7).3 To help combat this problem, she recommended a combination of estrogen. -progestin oral contraceptive pills and isotretinoin. The oral contraceptive pill may be rejected by the patient because of its female hormone connotation.

On the other hand, isotretinoin has its own risk in trans youth, such as an increased risk of hepatotoxicity from testosterone. In addition, the drug can cause depression, anxiety or suicidal thoughts, Hunt discussed. The iPLEDGE program has a risk assessment and mitigation strategy for isotretinoin, but it requires registration and pregnancy testing based on the gender assigned at birth.

Isotretinoin is not recommended for patients who are pregnant or may become pregnant, and long-term testosterone is not considered a reliable form of birth control, Hunt concluded.


Raegan Hunt, MD, PhD had no disclosures.


1. Hunt R. Pediatric acne. Session presented at: Maui Derm NP+PA Fall 2021 Conference Program; October 1, 2021; Accessed October 1, 2021. Asheville, North Carolina

2. Kosche C, Mansh M, Luskus M, et al. Dermatological Care for Sexual and Gender Minority/LGBTQIA Youth, Part 2: Recognition and Management of the Unique Dermatological Needs of SGM Adolescents. Children’s Dermatol. 2019;36(5):587-593. doi:10.1111/pde.13898

3. Braun H, Zhang Q, Getahun D, ​​​​et al. Moderate to severe acne and psychological symptoms in transmasculine subjects who received testosterone. JAMA dermatology. 2021;157(3):344-346. doi:10.1001/jamadermatol.2020.5353

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