Infantile acne

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Infantile acne
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Infantile acne is a form of acneiform eruption that occurs in infants from 6 weeks to 1 year of age. [1] Typical symptoms include inflammatory and noninflammatory lesions, papules and pustules most commonly present on the face. [2] [3] No cause of infantile acne has been established but it may be caused by increased sebaceous gland secretions due to elevated androgens, genetics and the fetal adrenal gland causing increased sebum production. [1] [2] [3] Infantile acne can resolve by itself by age 1 or 2. However, treatment options include topical benzyl peroxide, topical retinoids and topical antibiotics in most cases. [4]

Contents

Signs and symptoms

Infantile acne has a later onset and is less commonly seen than neonatal acne, occurring between 6 weeks to 1 year of age. It is also more commonly seen in boys rather than girls. [2] Infantile acne tends to be more inflammatory and wide spread than neonatal acne. It presents with both open and closed comedones, papules and pustules. [2] [5] [3] Cystic lesions are uncommon. Scarring can occur in severe cases. [6] [7] Very rarely, facial conglobate acne, a severe form of acne that involves extensive inflammation and nodule formation can develop and lead to extensive scarring. [2] [3] Lesions occur most commonly on the cheeks but can also appear on the chest and back. [3] More severe occurrences may lead to development of more severe forms of acne in adolescence. [2] [4]

Causes

The cause of infantile acne is not known for certain. Research into higher occurrence in boys rather than girls imply that higher than normal levels of testicular androgens can cause increased sebaceous gland secretions. [3] During the first 6–12 months of age, there is increased sebum production stimulated by luteinizing hormone (LH) and testosterone of testicular origin that stops after this period until adrenarche. Girls do not experience this. [1] [2]

Genetics and family history play a role in influencing sebaceous gland size and activity, pore size and inflammation that can increase risk of onset and presentation of infantile acne. [2] [3]

It is suggested that the fetal adrenal gland along with testicular androgen could be the cause of infantile acne. During the neonatal period, there is increased sebum production through an enlarged zona reticularis (an androgen producing area) on the fetal adrenal gland that gradually decreases to very low levels at around 1 years of age, coinciding with when infantile acne tends to resolve. [1] [2] The fetal adrenal gland produces androgens such as dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) that stimulate sebaceous glands. [2]

Diagnosis

Diagnosis is based on presentation of comedones primarily on the face of an infant of 6–12 months of age. Severity can be mild, moderate or severe and can be determined from the presence and distribution of comedones and inflammatory lesions such as papules and nodules. [5] [8] A physical may be followed up next with particular attention paid to signs of an endocrine disorder including normal growth and weight, testicular growth, breast development, hirsutism or growth of pubic hair. [5] [8] Hormonal workup may not be necessary unless one of these abnormalities is present, then work up of testosterone, DHEA, DHEAS, LH and FSH or referral to a pediatric endocrinologist specialist may be recommended. [1] [8]

Differential diagnosis

It is important to differentiate infantile acne from other forms of acneiform eruptions. Acne venenata infantum is a form of acne characterized by comedone formation and induced by chemical irritants on the skin. This can include comedogenic products such as lotions, ointments, creams and oils. Upon discontinuation of these products, lesions will heal within 6–8 weeks. [2]

Other conditions that should be considered include periorificial dermatitis, keratosis pilaris, sebaceous hyperplasia and infections. [4] [5] Pyodermas and panniculitis should be considered in severe cases of inflammatory acne or in cases of acne conglobata while hyperandrogenism should be ruled out in cases of persistent infantile acne. [2]

Treatment

Infantile acne is a self-limiting condition that resolves by itself within 6–12 months of occurrence or occasionally by ages 4–5 and does not require treatment in most cases but topical therapies can be used, especially in more severe cases. [1] [5]

The goals of treatment are to reduce sebum production, prevent formation of microcomedones, suppress the growth of bacteria and reduce inflammation. [8] As there are no US FDA approved medications for treatment of infantile acne due to lack of high quality trials in patients under 9, recommendations for treatment is based on observations in adult and adolescent populations. [3]

Benzoyl peroxide

Benzoyl peroxide (BPO) is first line for mild cases of infantile acne due to its safety and effectiveness. BPO concentrates within cells of sebaceous follicles where it generates free radicals to oxidize proteins in bacteria such as P. acnes. This leads to bacterial death. [9] It additionally works as a mild comedolytic and anti-inflammatory. [8] No bacterial resistance has been reported from BPO usage and in fact it can help limit resistance to antibiotics. [8] [9] Common side effects include burning, stinging, scaling and dryness at the sight of application and can be managed by reducing quantity applied, frequency of application, using a less potent product and use of non-comedogenic moisturizers. [3] [1]

Retinoids

Topical retinoids both alone and in combination are also first line for treating mild to moderate cases of acne. Safety and efficacy has been demonstrated in individuals 12–18 years of age. [8] Retinoids prevent formation of comedones and promote comedolysis by binding to retinoic receptors and normalizing growth of keratinocytes. [8] [10] Tretinoin and adapalene have demonstrated efficacy in reducing inflammation. [10] Adapalene as a newer retinoid is thought to be more effective and better tolerated than others in this class. [10] As a topical product, it has similar side effects to topical BPO of burning, stinging, drying and scaling which can be managed much the same way. [3] Reducing the potency of initial treatment, using a non-comedogenic moisturizers, and applying a small amount on the whole face rather than spot-treating may reduce severity of side effects. [3] [8]

In severe cases, oral isotretinoin may be recommended to prevent scarring. [6] Dosing ranges from 0.2 mg/kg/day to 2 mg/kg/day for several months to over a year with careful monitoring. [6] [1] [3] Monitoring may include complete blood count with differential and baseline liver function and lipids tests followed by routine liver function and lipid tests while on treatment. [1] [5]

Antibiotics

Topical antibiotics

Topical antibiotics are often used in cases of inflammatory infantile acne in combination with another topical treatment to prevent emergence of antibiotic resistance especially for periods longer than a few weeks. [5] [8] Clindamycin and erythromycin are the most commonly prescribed topical antibiotics for acne with coverage for S. aureus and P.acnes . [10] These bacteriostatic antibiotics interfere with bacterial protein synthesis, preventing formation of free fatty acids by these bacteria that cause inflammation. [9]

Oral antibiotics

In severe cases of infantile acne, especially with the presence of nodules and cysts with risks of scarring, oral antibiotics may be used. [3] First line therapy is erythromycin with sulfamethoxazole-trimethoprim as a secondary choice in cases of P. acnes resistance. It is suggested not to use tetracyclines due to risks of permanently staining teeth in children under the age of 7. [3] Side effects of erythromycin include gastrointestinal upset. [8] There has however been concerns about resistant P. acnes due to widespread usage of antibiotics, and therefore steps taken to minimize resistance such as use in combination with BPO is highly recommended by experts. [8]

Epidemiology

Infantile acne effects around 2% of children with a higher occurrence in males rather than females. Of around 9.2 million visits to outpatient care for pediatric acne, 3% or 276,000 visits, were due to neonatal and pediatric acne in the United States from 2000 to 2010. [5]

See also

Related Research Articles

<span class="mw-page-title-main">Acne</span> Skin condition characterized by pimples

Acne, also known as acne vulgaris, is a long-term skin condition that occurs when dead skin cells and oil from the skin clog hair follicles. Typical features of the condition include blackheads or whiteheads, pimples, oily skin, and possible scarring. It primarily affects skin with a relatively high number of oil glands, including the face, upper part of the chest, and back. The resulting appearance can lead to lack of confidence, anxiety, reduced self-esteem, and, in extreme cases, depression or thoughts of suicide.

<span class="mw-page-title-main">Isotretinoin</span> Medication primarily used to treat severe acne

Isotretinoin, also known as 13-cis-retinoic acid and sold under the brand name Accutane among others, is a medication primarily used to treat severe acne. It is also used to prevent certain skin cancers, and in the treatment of other cancers. It is used to treat harlequin-type ichthyosis, a usually lethal skin disease, and lamellar ichthyosis. It is a retinoid, meaning it is related to vitamin A, and is found in small quantities naturally in the body. Its isomer, tretinoin, is also an acne drug.

<span class="mw-page-title-main">Folliculitis</span> Human and animal disease of follicles

Folliculitis is the infection and inflammation of one or more hair follicles. The condition may occur anywhere on hair-covered skin. The rash may appear as pimples that come to white tips on the face, chest, back, arms, legs, buttocks, or head.

<span class="mw-page-title-main">Sebaceous gland</span> Gland to lubricate the hair and skin

A sebaceous gland is a microscopic exocrine gland in the skin that opens into a hair follicle to secrete an oily or waxy matter, called sebum, which lubricates the hair and skin of mammals. In humans, sebaceous glands occur in the greatest number on the face and scalp, but also on all parts of the skin except the palms of the hands and soles of the feet. In the eyelids, meibomian glands, also called tarsal glands, are a type of sebaceous gland that secrete a special type of sebum into tears. Surrounding the female nipple, areolar glands are specialized sebaceous glands for lubricating the nipple. Fordyce spots are benign, visible, sebaceous glands found usually on the lips, gums and inner cheeks, and genitals.

<span class="mw-page-title-main">Seborrhoeic dermatitis</span> Skin disese

Seborrhoeic dermatitis, sometimes inaccurately referred to as seborrhoea, is a long-term skin disorder. Symptoms include red, scaly, greasy, itchy, and inflamed skin. Areas of the skin rich in oil-producing glands are often affected including the scalp, face, and chest. It can result in social or self-esteem problems. In babies, when the scalp is primarily involved, it is called cradle cap. Dandruff is a milder form of the condition without inflammation.

<span class="mw-page-title-main">Hidradenitis suppurativa</span> Human disease

Hidradenitis suppurativa (HS), sometimes known as acne inversa or Verneuil's disease, is a long-term dermatological condition characterized by the occurrence of inflamed and swollen lumps. These are typically painful and break open, releasing fluid or pus. The areas most commonly affected are the underarms, under the breasts, and the groin. Scar tissue remains after healing. HS may significantly limit many everyday activities, for instance, walking, hugging, moving, and sitting down. Sitting disability may occur in patients with lesions in sacral, gluteal, perineal, femoral, groin or genital regions; and prolonged periods of sitting down itself can also worsen the condition of the skin of these patients.

<i>Cutibacterium acnes</i> Species of bacterium

Cutibacterium acnes is the relatively slow-growing, typically aerotolerant anaerobic, gram-positive bacterium (rod) linked to the skin condition of acne; it can also cause chronic blepharitis and endophthalmitis, the latter particularly following intraocular surgery. Its genome has been sequenced and a study has shown several genes can generate enzymes for degrading skin and proteins that may be immunogenic.

<span class="mw-page-title-main">Rosacea</span> Skin condition resulting in redness, pimples and swelling, usually on the face

Rosacea is a long-term skin condition that typically affects the face. It results in redness, pimples, swelling, and small and superficial dilated blood vessels. Often, the nose, cheeks, forehead, and chin are most involved. A red, enlarged nose may occur in severe disease, a condition known as rhinophyma.

<span class="mw-page-title-main">Benzoyl peroxide</span> Chemical compound with uses in industry and acne treatment

Benzoyl peroxide is a chemical compound (specifically, an organic peroxide) with structural formula (C6H5−C(=O)O−)2, often abbreviated as (BzO)2. In terms of its structure, the molecule can be described as two benzoyl (C6H5−C(=O)−, Bz) groups connected by a peroxide (−O−O−). It is a white granular solid with a faint odour of benzaldehyde, poorly soluble in water but soluble in acetone, ethanol, and many other organic solvents. Benzoyl peroxide is an oxidizer, but it is principally used as in the production of polymers.

<span class="mw-page-title-main">Comedo</span> Medical condition

A comedo is a clogged hair follicle (pore) in the skin. Keratin combines with oil to block the follicle. A comedo can be open (blackhead) or closed by skin (whitehead) and occur with or without acne. The word "comedo" comes from the Latin comedere, meaning "to eat up", and was historically used to describe parasitic worms; in modern medical terminology, it is used to suggest the worm-like appearance of the expressed material.

Acne is acneiform eruptions. It is usually used as a synonym for acne vulgaris, but may also refer to:

<span class="mw-page-title-main">Clobetasone</span> Chemical compound

Clobetasone (INN) is a corticosteroid used in dermatology, for treating such skin inflammation as seen in eczema, psoriasis and other forms of dermatitis, and ophthalmology. Topical clobetasone butyrate has shown minimal suppression of the hypothalamic–pituitary–adrenal axis.

<span class="mw-page-title-main">Feline acne</span> Medical condition

Feline acne is a problem seen in cats primarily involving the formation of blackheads accompanied by inflammation on the cat's chin and surrounding areas that can cause lesions, alopecia, and crusty sores. In many cases symptoms are mild and the disease does not require treatment. Mild cases will resemble dirt on the cat's chin, but the "dirt" will not brush off. More severe cases, however, may respond slowly to treatment and seriously detract from the health and appearance of the cat. Feline acne can affect cats of any age, sex or breed, although Persian cats are also likely to develop acne on the face and in the skin folds. This problem can happen once, be reoccurring, or even persistent throughout the cat's life.

Acne conglobata is a highly inflammatory disease presenting with comedones, nodules, abscesses, and draining sinus tracts.

<span class="mw-page-title-main">Neonatal acne</span> Medical condition

Neonatal acne, also known as acne neonatorum, is an acneiform eruption that occurs in newborns or infants within the first 4-6 weeks of life, and presents with open and closed comedones on the cheeks, chin and forehead.

Acne mechanica is an acneiform eruption that has been observed after repetitive physical trauma to the skin such as rubbing, occurring from clothing or sports equipment. In addition to those mechanisms, the skin not getting enough exposure to air also contributes to the formation of acne mechanica. It is often mistaken as a rash that forms on sweaty skin that is constantly being rubbed, but in reality, it is a breakout of acne mechanica. The term "acne" itself describes the occurrence in which hair follicles in the skin get clogged by oil, dead skin cells, dirt and bacteria, or cosmetic products and create a pimple. Pimples can vary in type, size, and shape, but the sole basis of them occurring is the same - the oil gland in the pore becomes clogged and sometimes infected, which creates pus in order to fight the infection and subsequently causes the development of swollen, red lesions on the skin.

Gnathophyma involves swelling of the chin. It is a type of lesion associated with rosacea, a common chronic inflammatory skin disorder of the sebaceous glands characterized by redness, swelling, and acne-like pustules.

Eruptive vellus hair cysts are small lesions that occur most often in the chest wall, abdomen and extremities, often with a crusted surface. EVHC may occur randomly, or it can be inherited as an autosomal dominant trait; sporadic cases usually appear at 4–18 years of age. The cysts appear similar clinically to steatocystoma multiplex, as well as acneiform eruptions and milia. Histopathology is the basis of diagnosis. Retinoids, surgery, and lasers are used as treatment modalities.

<span class="mw-page-title-main">Pimple</span> Type of comedo

A pimple is a kind of comedo that results from excess sebum and dead skin cells getting trapped in the pores of the skin. In its aggravated state, it may evolve into a pustule or papules. Pimples can be treated by acne medications, antibiotics, and anti-inflammatories prescribed by a physician, or various over the counter remedies purchased at a pharmacy.

<span class="mw-page-title-main">Sebaceous adenitis</span> Skin disease

Sebaceous adenitis in an uncommon skin disease found in some breeds of dog, and more rarely in cats, rabbits and horses. characterised by an inflammatory response against the dog's sebaceous glands, which can lead to the destruction of the gland. It was first described in veterinary literature in the 1980s.

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