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Acne, highly prevalent and an often pernicious issue, is commonly observed in teens. Although also seen in adults, acne in children and adolescents are often marked by a variable course with negative effects on wellbeing and quality of life. To explore the different dimensions of acne in the pediatric population, we spoke with clinical dermatologists who are actively involved in the management of acne in children, adolescents, and young adults.
Causes, Subtypes, and Prevalence
Anna Grossberg, MD, director of pediatric dermatology at Johns Hopkins Children’s Center, told us that there are several different subtypes of acne in children and adolescents, and the causes of acne in the various pediatric age groups can be quite distinct from causes in adult acne. “By far, the most common types of acne in the pediatric population are pre-adolescent and adolescent acne, which have similar causes as adult acne,” she stated. In this type of acne, “acne vulgaris,” the sebaceous oil glands enlarge under the influence of increased levels of androgens. “There is a much higher oil output, and this contributes to clogging of the pores,” Dr Grossberg explained. “But the pores themselves are also more vulnerable to clogging, as they hold onto their dead skin cells instead of allowing them to shed to the surface normally.” Ultimately, she added, the immune system can create an overactive inflammatory response to clogged pores and bacteria, sometimes resulting in the appearance of inflamed pimples, pus bumps, and cysts and nodules.
In the pediatric population, acne has been an overriding concern accompanied by variable levels of severity. “As many as 85% to 90% of teens will have acne at some point, and about 75% to 80% of girls 9 to 10 years of age will develop acne,” Dr Grossberg noted. She stated that there is an increased number of adolescents presenting to clinics for acne, most likely due to heightened awareness around the disorder. “This [awareness] includes the pediatricians and parents, who know that early referrals can often provide the best results, as well as teens themselves, who are much more aware of their appearance as well as potential treatments,” she said. “Increased social pressures and exchange of information via social media are also things that my teenage patients reference directly.”
Emotional Effects
Dr Grossberg stated that acne can exert a significant emotional and psychological toll on children and adolescents, particularly in preteen and teenage patients. “Quality of life studies have shown that the social, psychological, and emotional symptoms associated with acne are often as severe as in other chronic medical conditions such as asthma, epilepsy, diabetes, and cystic fibrosis,” she commented. “Parents and even some physicians may be quick to discount acne as just a ‘cosmetic problem’ or ‘rite of passage,’ but these data suggest acne is weighing on these adolescents very heavily, and the severity of the acne does not always correlate with the level of distress it causes.” Dr Grossberg said that she suspects the psychosocial impact of acne has been exacerbated by social media.
Risk for Acne in Adulthood
Although some adolescents with acne eventually “outgrow” their condition completely, Dr Grossberg stated that approximately 12% to 30% of patients may continue to experience acne into adulthood. “However, we do also hear about acne coming up as a new issue in some adults who never experienced acne as preteens or teens,” she added. “In these scenarios, it’s extremely important to take a complete medical history to make sure that another medical problem or medication is not contributing to the acne.” But medication or medical issues may not always be a contributor to adult acne, she added. “Often [in these cases], acne is caused by similar factors as in teens, including continued hormonal effects on the pores and oil glands.”
Treatment Considerations
Dr Grossger indicated that treatments for acne vary, as management is typically individualized for the severity and subtype of acne. “For example, very mild comedonal acne might be most effectively treated with topicals only, whereas if acne becomes more moderate to severe and more inflammatory, a combination of topical and oral medications may be utilized, including hormonal treatments in some cases,” she stated. “We also take into account the age of the patient when selecting the best regimen, as many treatments require very consistent routines and can cause side effects that younger children might be more sensitive to.” The presence of scarring may also dictate treatment choice, she noted.
“In general, the goals of acne treatment are to reduce sebum production, prevent the pores from clogging, prevent bacterial overgrowth, and reduce any inflammation in order to prevent long-term blemishes or scarring,” Dr Grossberg explained. The only treatment that “mechanistically” accomplishes these goals is isotretinoin, she said, and “for this reason, it is considered to be a gold standard treatment for acne that is more moderate to severe or is causing scarring, or if other regimens fail.” Dr Grossberg noted that addressing the impact of hormones on pores and oil glands is also critical, and several topical and oral medications are available to do this.
Unfortunately, insurance coverage can serve as a significant barrier to treatment planning in acne management, said Allison Darland, MD, an assistant professor of dermatology at Michigan Medicine. In addition, Cindy Wassef, MD, an assistant professor at Rutgers Center for Dermatology, noted that while topical antibiotic washes and retinoids can be helpful, compliance is an issue in pediatric patients. “Applying topical medications once or twice a day can be hard to remember at that age,” Dr Wassef said, “but engaging the parents can be helpful to ensure medications get used.”
Why Early, Effective Treatment is Critical
Given the emotional toll acne can place on children and teens, Dr Grossberg believes the most important reason to address the disorder is to positively influence an adolescent’s self-esteem. “As mentioned before, the psychosocial toll that acne takes is immense,” she said. “Helping clear up their skin can have incredible effects on a teen’s self-confidence. We’ve seen improvements in mood disorders, such as depression, as a result of successful acne treatments.”
Dr Grossberg added that the prevention of long-term problems, such as scarring, is also an important driver for early and effective management of acne in the pediatric population. “Even if a younger preteen or teenager isn’t bothered by their acne when we see them, we do know that there are many adults who have permanent scars that resulted from untreated acne who experience significant regret that they were not more proactive in their treatment of their condition as adolescents,” she said. “We try to take these important patient experiences and use them to explain to teens the importance of pursuing acne treatment now, to prevent some of these problems and possibly even regrets down the road.”
