15 Yo
Ms. E is a pleasant, 15-year-old, white, female.
Source: Self, reliable source
Subjective:
Chief complaint: I have acne.
HPI: Patient states she has had inflamed bumps on her face for the past year or two. She has tried over-the-counter benzoyl peroxide 5%, which doesnt help too much. She has been using it for the past 4 months, every night. She has not tried any other medications.
Allergies: NKA
Current Mediations:
Benzoyl peroxide, 5%, applied nightly
Ortho-Cyclen: Ethinyl estradiol 0.035 mg and norgestimate 0.25 mg, 21 days of active tabs and 7 days of placebo
Pertinent History: None
Health Maintenance. Immunizations: Immunizations up to date
Family History: No cancer, cardiac, pulmonary or autoimmune disease in immediate family members
Social History: Patient lives with her older brother, mom and dad. She denies any use of nicotine, alcohol or drugs
ROS: Incorporated into HPI
Objective:
VS BP: 118/68, HR: 86, RR: 16, Temp 97.6, oxygenation 100%, weight: 140 lbs, height: 64 inches.
Ms. E is alert, awake, oriented x 3. Patient is clean and dressed appropriate for age
Cardiac: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
Respiratory: Clear to auscultation
Integumentary: Moderate inflammatory papules and pustules. Some erythema is present and mild scarring
Assessment:
Diagnosis: Moderate acne ICD-10: L70.9
Please answer the following:
Using the guidelines of the American Academy of Dermatology reviewed in this weeks lecture, what is your treatment plan (include specific dosage and frequency)? Why did you choose this treatment plan? In your answer, please describe, briefly, the pharmacodynamics (1 point) and pharmacokinetics (1 point) of your treatment choice and how they influenced your choice. Does the patient have any comorbidities that influenced your choice as well (1 point)? Are there any medical interactions to your choice (1 point)?
Document the education you would provide for this patient, specific to the prescribed medication(s). Please include information pertinent to the patient (2 points) and common potential adverse effects (2 points).
Evidence-Based Recommendations for the Diagnosis
and Treatment of Pediatric Acne
abstract
INTRODUCTION: Acne vulgaris is one of the most common skin con-
ditions in children and adolescents. The presentation, differential di-
agnosis, and association of acne with systemic pathology differs by
age of presentation. Current acknowledged guidelines for the diag-
nosis and management of pediatric acne are lacking, and there are
variations in management across the spectrum of primary and spe-
cialty care. The American Acne and Rosacea Society convened a panel
of pediatric dermatologists, pediatricians, and dermatologists with
expertise in acne to develop recommendations for the management
of pediatric acne and evidence-based treatment algorithms.
METHODS: Ten major topic areas in the diagnosis and treatment of
pediatric acne were identified. A thorough literature search was per-
formed and articles identified, reviewed, and assessed for evidence
grading. Each topic area was assigned to 2 expert reviewers who de-
veloped and presented summaries and recommendations for critique
and editing. Furthermore, the Strength of Recommendation Taxonomy,
including ratings for the strength of recommendation for a body of
evidence, was used throughout for the consensus recommendations
for the evaluation and management of pediatric acne. Practical
evidence-based treatment algorithms also were developed.
RESULTS: Recommendations were put forth regarding the classifica-
tion, diagnosis, evaluation, and management of pediatric acne, based
on age and pubertal status. Treatment considerations include the use
of over-the-counter products, topical benzoyl peroxide, topical
retinoids, topical antibiotics, oral antibiotics, hormonal therapy, and
isotretinoin. Simplified treatment algorithms and recommendations
are presented in detail for adolescent, preadolescent, infantile, and
neonatal acne. Other considerations, including psychosocial effects
of acne, adherence to treatment regimens, and the role of diet and
acne, also are discussed.
CONCLUSIONS: These expert recommendations by the American Acne
and Rosacea Society as reviewed and endorsed by the American Acad-
emy of Pediatrics constitute the first detailed, evidence-based clinical
guidelines for the management of pediatric acne including issues of
special concern when treating pediatric patients. Pediatrics 2013;131:
S163S186
AUTHORS: Lawrence F. Eichenfield, MD,a Andrew C.
Krakowski, MD,a Caroline Piggott, MD,a James Del Rosso,
DO,b Hilary Baldwin, MD,c Sheila Fallon Friedlander, MD,a
Moise Levy, MD,d Anne Lucky, MD,e Anthony J. Mancini, MD,f
Seth J. Orlow, MD, PhD,g Albert C. Yan, MD,h Keith K. Vaux,
MD,i Guy Webster, MD, PhD,j Andrea L. Zaenglein, MD,k,l and
Diane M. Thiboutot, MDl
aDivision of Pediatric and Adolescent Dermatology, Rady
Childrens Hospital, San Diego and Departments of Pediatrics and
Medicine (Dermatology), University of California, San Diego, San
Diego, California; bSection of Dermatology, Valley Hospital
Medical Center, Las Vegas, Nevada; cDepartment of Dermatology,
SUNY Downstate Medical Center, Brooklyn, New York; dPediatric/
Adolescent Dermatology, Dell Childrens Medical Center, Austin,
Texas, Department of Dermatology, UT Southwestern Medical
School, Dallas, Texas and Departments of Pediatrics and
Dermatology, Baylor College of Medicine, Houston, Texas;
eDepartments of Dermatology and Pediatrics, University of
Cincinnati College of Medicine and Cincinnati Childrens Hospital
Medical Center, Cincinnati, Ohio; fDepartments of Pediatrics and
Dermatology, Northwestern University Feinberg School of
Medicine and Division of Dermatology, Ann & Robert H. Lurie
Childrens Hospital of Chicago; gThe Ronald O. Perelman
Department of Dermatology, New York University School of
Medicine, New York, New York; hSection of Pediatric Dermatology,
Childrens Hospital of Philadelphia, Philadelphia, Pennsylvania
and Departments of Pediatrics and Dermatology, Perelman
School of Medicine at the University of Pennsylvania;
iDivision of Pediatrics and Hospital Medicine, Rady Childrens
Hospital, San Diego, California and Department of Pediatrics,
University of California, San Diego, California; jDepartment of
Dermatology, Jefferson Medical College, Thomas Jefferson
University, Philadelphia, Pennsylvania; kDepartment of
Dermatology, The Pennsylvania State University College of
Medicine; and lDepartment of Pediatrics, Penn State Hershey
Childrens Hospital, Hershey, Pennsylvania
KEY WORDS
pediatric acne, acne treatment, combination acne therapy,
retinoids, benzoyl peroxide, bacterial resistance, isotretinoin,
hormonal therapy, acne guidelines, acne algorithm, neonatal
acne, infantile acne, mid-childhood acne, preadolescent acne,
American Acne and Rosacea Society, AARS
(Continued on last page)
PEDIATRICS Volume 131, Supplement 3, May 2013 S163
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Acne vulgaris is one of the most com-
mon skin conditions in children and
adolescents.Althoughoftenconsidered
a disease of teenagers, in whom the
prevalence is reported to be from 70%
to 87%,1 12 years of age is no longer
considered the lower end of the age
range for acne onset.2 A study by Lucky
et al3 revealed acne lesions in 78% of
365 girls ages 9 to 10. In addition, acne
and other acneiform (acnelike) con-
ditions occur at different ages, in-
cluding neonates, infants, and young
children, and may be associated with
differential diagnoses or systemic pa-
thology that differs from teenagers.
There are issues of special concern in
treatment of preadolescents with acne.
The majority of clinical trials for acne
medications are conducted in patients
12 years of age or older. As a result,
there is little published evidence re-
garding the safety and efficacy of many
acne medications in pediatric patients.
Furthermore, the treatment of acne
often involves use of several medi-
cationsthattargeteitherdifferenttypes
of acne lesions, different factors in-
volved in the pathogenesis of acne, or
different degrees of acne severity. Po-
tential interactions between medi-
cations can add another layer of
complexity to the management of acne
in pediatric patients, as can concerns
about systemic side effects and impact
of medications on growth and de-
velopment. The psychosocial impact of
acne can be significant, as canissues of
adherence to treatment regimens.
Currently, detailed, acknowledged guide-
lines for the diagnosis and manage-
ment of acne in pediatric patients are
lacking. Recognizing the need to ad-
dress special issues regarding the
diagnosis and treatment of acne in
children of various ages, a panel of
experts consisting of pediatric der-
matologists, pediatricians, and der-
matologistswithexpertise inacnewas
convened under the auspices of the
American Acne and Rosacea Society,
a nonprofit organization promoting
research, education, and improved
careofpatientswithacneandrosacea.
The expert panel was charged with
developing recommendations for the
management of pediatric acne and
evidence-based treatment algorithms.
Amemberoftheexpertpanelservedas
liaison to the American Academy of
Pediatrics and as part of the recom-
mendation writing group.
METHODS
The expert panel identified special
issuesinthediagnosisandtreatmentof
acne and acneiform conditions in pe-
diatric patients across various ages.
Ten major topicareaswerespecified by
the panel (Table 1). A thorough English-
language literature search was perfor-
med for each topic area, and identified
articles were reviewed utilizing a
patient-centered approach to grading
evidence available to the expert panel.4
Relevant clinical trial registries and
data filed with the Food and Drug Ad-
ministration (FDA) were included in the
data review.
Each topic area was assigned to 2 ex-
pert reviewers, who developed and
presented an in-depth summary and
recommendations for further critique
and editing. The Strength of Recom-
mendation (SOR) Taxonomy ratings for
the recommendation for a body of evi-
dence is noted throughout the article.4
This taxonomy addresses the quality,
quantity, and consistency of evidence
and allows authors to rate individual
studies or bodies of evidence. The tax-
onomy emphasizes the use of patient-
oriented outcomes that measure
changes in morbidity or mortality. The
authors reviewed the bodies of evi-
dence for each of the recommenda-
tions and assigned one of the following
SOR: an A-level recommendation is
based on consistent and good-quality
patient-oriented evidence; a B-level
recommendation is based on inconsis-
tent or limited-quality patient-oriented
evidence; and a C-level recommenda-
tion is based on consensus, usual
practice, opinion, disease-oriented ev-
idence, or case series for studies of
diagnosis, treatment, prevention, or
screening. This article summarizes the
resultant consensus recommenda-
tions for the evaluation and diagnosis
of pediatric acne, as well as a series of
treatment algorithms to assist health
care practitioners in the management
and treatment of acne in pediatric
patients.
CATEGORIZATION AND
DIFFERENTIAL DIAGNOSIS OF
PEDIATRIC ACNE
Both age and form of presentation are
relevant to the diagnosis of pediatric
acne. Although there is some overlap in
age and presentation of acneiform
conditions, the consensus of the panel
regarding relevant age categories is
presented in Table 2. These ranges are
approximate. In girls, age of onset of
menarche may be a better delineating
point between preadolescence and
TABLE 1 Topic Areas Researched and
Discussed by Expert Panel
Pediatric Acne Categorization and Differential
Diagnosis of Acne
Evaluation of Pediatric Acne by Age/Classification
Evidence-based Treatment Review for Pediatric
Acne
OTC products
BP treatment
Topical retinoids, antibiotics, and fixed-dose
combination products
Oral antibiotics: age-related issues, safety, and
resistance
Isotretinoin pediatric patients with severe acne
OC use and hormonal therapy
Pediatric Acne Treatment Considerations
Previous treatment history
Costs
Ease of use/regimen complexity and adherence
Vehicle selection
Active scarring
Side effects
Psychosocial impact
Diet
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adolescence. In general, acne is un-
complicated by systemic disease, but
in some cases it may be a cutaneous
manifestation of underlying pathology.
It is essential to have a broad un-
derstanding of acne at different ages
and to be aware of the differential di-
agnoses for each age group. Table 3
presents a differential diagnosis for
acne in each age group.57 Workup is
based on age and physical findings.6
The physical examination should focus
on type and distribution of acne
lesions, height, weight, growth curve,
and possible blood pressure abnor-
malities. Signs of precocious sexual
maturation or virilization should prompt
workup and/or a referral to a pediatric
endocrinologist.8
Consensus Recommendation:
Acneiform eruptions from the neo-
natal period through adolescence
may be broadly categorized by age
and pubertal status.
Neonatal Acne
Neonatal acne is estimated to affect up
to 20% of newborns.9 The major con-
troversy in this age group is whether
the lesions truly represent acne or one
of a number of heterogeneous pap-
ulopustular acneiform conditions typi-
cally without comedones, such as
neonatal cephalic pustulosis (NCP) or
transient neonatal pustular melanosis.
Although rare, some neonates may
present with androgen-driven come-
donal and inflammatory acne.8,10 NCP
pustules are usually confined to the
cheeks, chin, eyelids, and forehead, but
the scalp, neck, and upper chest and
back may be involved.8 Its pathogene-
sis may involve colonization with
Malassezia species, a normal com-
mensal of infant skin, or may represent
an inflammatory reaction to a yeast
overgrowth at birth.8,10 NCP is typically
mild and self-limited, and reassuring
the parents is usually the only man-
agement needed. If lesions are nu-
merous, 2% ketoconazole cream may
reduce fungal colonization.11 New-
borns also may present with or develop
transient neonatal pustular melanosis,
with pustules on the chin, neck, or
trunk. Within 24 hours, these pustules
rupture, leaving hyperpigmented mac-
ules with a rim of faint white scale.10
Consensus Recommendation:
Neonates may have true acne, al-
though many self-limited papulo-
pustular eruptions also occur on
the faces of neonates. In infants
and younger children (,7 years
of age) with significant acne vulga-
ris, evaluation for signs of sexual
precocity, virilization, and/or growth
abnormalities that may indicate an
underlying systemic abnormality
(endocrinologic diseases, tumors,
gonadal/ovarian pathology) and ap-
propriate workup and/or referral to
a pediatric endocrinologist may be
warranted. (SOR: C).
Infantile Acne
Infantile acne may begin at 6 weeks of
age and last for 6 to 12 months or,
rarely, for years. It is more common in
boys and presents with comedones as
well as inflammatory lesions, which
can include papules, pustules, or oc-
casionally nodular lesions. Physical
examination should include assess-
ment of growth including height,
weight, and growth curve; testicular
growth and breast development; pres-
ence of hirsutism or pubic hair; clito-
romegaly; and increased muscle
mass.12 Should workup for a hormonal
anomaly be considered, a pediatric
endocrinology referral and/or bone
age and serologic evaluation of follicle-
stimulating hormone,luteinizinghormone,
testosterone, and dehydroepiandros-
terone sulfate levels are recommended.
No further workup is necessary for the
majority of cases in the absence of
hormonal abnormalities. It is also im-
portant to distinguish true infantile
acne from other similar cutaneous
lesions, because there is some evidence
that infantile acne predisposes to more
severe adolescent acne.13 Infantile acne
may be treated with topical antimicro-
bial agents; topical retinoids; noncycline
antibiotics, such as erythromycin; and,
occasionally, isotretinoin, though all are
without FDA indication for use in this
age group.
Consensus Recommendation:
Most infantile acne is self-limited
and not associated with underlying
endocrine pathology. However, in
patients with additional physical
signs of hormonal abnormality,
a more extensive workup and/or
referral to a pediatric endocrinol-
ogist may be appropriate. (SOR: C).
Mid-Childhood Acne
Mid-childhood acne presents primarily
onthefacewithamixtureofcomedones
and inflammatory lesions.10 Children
between the ages of 1 and 7 years,
however, do not normally produce
significant levels of adrenal or gonadal
androgens; hence, acne in this age
group is rare. When it does occur, an
endocrine abnormality should be sus-
pected. A workup by a pediatric endo-
crinologist is usually warranted to rule
out adrenal or gonadal/ovarian pa-
thology including the presence of
androgen-secreting tumors. Increased
bone age and accelerated growth, as
evidenced by deviation from standard-
ized age-appropriate growth curves,
are important indicators of the effects
TABLE 2 Expert Panel Consensus: Pediatric
Acne Categorized by Age
Acne Type Age of Onset
Neonatal Birth to #6 wk
Infantile 6 wk to #1 y
Mid-childhood 1 y to ,7 y
Preadolescent $7 to #12 y or menarche
in girls
Adolescent $12 to #19 y or after
menarche in girls
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of excess androgens. In addition to treat-
ments to address androgen-secreting
tumors or congenital adrenal hyper-
plasia, the treatment of mid-childhood
acne is similar to that of adolescent
acne except that oral tetracyclines are
usually not an option in childrenyounger
than 8 years of age because of the risk
of damage to developing bones and
tooth enamel. Hormonal therapy could
be used if warranted by endocrinologic
pathology.8
Consensus Recommendation:
Mid-childhood acne is very uncom-
mon and should warrant an endo-
crinologic workup for causes of
hyperandrogenism. (SOR: C).
Preadolescent Acne
It is not uncommon for acne vulgaris to
occur in preadolescents, as a result of
normal adrenarche and testicular/
ovarian maturation. Acne may be the
first sign of pubertal maturation.8 In
fact, with the trend toward earlier age
of onset of adrenarche and menarche,
there appears to be a downward shift
in the age at which acne first appears.
Preadolescent acne is characterized by
a predominance of comedones on the
forehead and central face (the so-
called T-zone) with relatively few in-
flammatory lesions.10 Early pre-
sentation may include comedones of
the ear.
History and physical examination are
the most important parts of the as-
sessment in this age group. Further
workup is generally unnecessary un-
less there are signs of excess andro-
gens.7 Polycystic ovary syndrome
(PCOS) or another endocrinologic ab-
normality may be considered when the
acne is unusually severe, accompanied
by signs of excess androgens, or is
unresponsive to treatment.14 Pelvic ul-
trasound is not considered useful for
diagnosis of PCOS because it is non-
specific.
Treatment of uncomplicated pre-
adolescent acne is comparable to that
of acne in older age groups, as dis-
cussed later. It is important in this age
group to elicit the patients level of
concern regarding his or her acne,
which may not always be concordant
with parental concern.
Consensus Recommendation:
Preadolescent (712 years) acne is
common and may precede other
signs of pubertal maturation. Workup
beyond history and physical is gen-
erally unnecessary unless there
are signs of androgen excess, PCOS,
or other systemic abnormalities.
(SOR: B).
PEDIATRIC ACNE CLASSIFICATION
AND SEVERITY ASSESSMENT
In general, treatment of pediatric acne
vulgaris is similar to acne treatment in
older adolescents and adults and is
based on acne pathophysiology. The
pathogenesis of acne involves the in-
terplay of 4 factors: sebaceous hyper-
plasia under the influence of increased
androgenlevels,alterationsinfollicular
growthanddifferentiation,colonization
of the follicle by Propionibacterium
acnes (P acnes), and consequent im-
mune response and inflammation.15
A useful clinical categorization of acne
is based on predominate morphology:
comedonal with closed and open
comedones (whiteheads and black-
heads); inflammatory, with erythema-
tous papules, nodules, or cystlike
nodular lesions; or mixed, where both
types of lesions are present. The micro-
comedo is the not-clinically-apparent
precursor of both comedonal and in-
flammatory lesions. It is a product of hy-
peractive sebaceous glands and altered
follicular growth and differentiation.
Reduction in existing microcomedones
and prevention of the formation of new
ones is central to the management of
all acne lesions.16
Comedones form as a result of in-
creased cell division and cohesiveness
ofcellsliningthefollicularlumen.When
these cells accumulate abnormally, mix
with sebum, and partially obstruct the
follicular opening, they form a closed
comedo (whitehead). If the follicular
opening is larger, the keratin buildup is
TABLE 3 Differential Diagnosis of Acne in
Younger Pediatric and Adolescent
Patients
Adolescent (1218 y of age)
Corticosteroid-induced acne
Demodex folliculitis
Gram-negative folliculitis
Keratosis pilaris
Malassezia (pityrosporum) folliculitis
Papular sarcoidosis
Perioral dermatitis
Pseudofolliculitis barbae
Tinea faciei
Preadolescent ($7 to #12 y of age)
Acne venenata or pomade acne (from the use
of topical oil-based products)
Angiofibromas or adenoma sebaceum
Corticosteroid-induced acne
Flat warts
Keratosis pilaris
Milia
Molluscum contagiosum
Perioral dermatitis
Syringomas
Mid-Childhood (17 y of age)
Adrenal tumors
Congenital adrenal hyperplasia
Cushing syndrome
Gonadal tumors
Ovarian tumors
PCOS
Premature adrenarche
True precocious puberty
Any Age
Acne venenata or pomade acne (from the use of
topical or oil-based products)
Bilateral nevus comedonicus
Chlorinated aromatic hydrocarbons (chloracne)
Corticosteroids (topical, inhaled, and oral)
Demodicidosis
Facial angiofibromas (tuberous sclerosis)
Flat warts
Infections (bacterial, viral, and fungal)
Keratosis pilaris
Medication-Induced (anabolic steroids,
dactinomycin, gold, isoniazid, lithium, phenytoin,
and progestins)
Milia
Miliaria
Molluscum contagiosum
Periorificial dermatitis
Rosacea
Adapted from Tom and Friedlander6 and Krakowski and
Eichenfield.7
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more visible and can darken to form an
open comedo (blackhead). Follicular
colonization with P acnes leads to in-
flammation via the production of inflam-
matory mediators and the formation of
inflammatory papules and pustules.
Nodular acne is characterized by a
predominance of large inflammatory
nodules or pseudocysts and is often
accompanied by scarring or the pres-
ence of sinus tracts when adjacent
nodules coalesce.
Acne severity may be classified clini-
callyasmild,moderate,orseverebased
on the number and type of lesions and
the amount of skin involved. Although
therearenumerousgradingsystemsby
whichtodefineacneseverity,thereisno
agreed-upon standard, and interpre-
tation is subjective. Many grading sys-
tems are most useful for research
purposes. For clinical purposes, sim-
plicity is key. Typically, patients as-
sessments do not correlate well with
either those of physicians or published
severity scales.17 The panel noted that
severity scales frequently overemphasize
inflammatory lesions. For example, in
some research settings, a patient
might be classified as having mild
acne because he or she has only a few
inflammatory lesions in the presence
of hundreds of closed comedones. In
such cases, the patient (and the phy-
sician) is more likely to consider his
or her acne to be severe. Determin-
ation of severity can be modified by
extent of involvement and scarring as
well.
Although some acne may resolve with-
out residual changes, inflammatory
acne may result in the formation of
significant scars. In darker skin, post-
inflammatory hyperpigmentation (PIH)
is common. Residual erythema can oc-
cur as well. These changes are most
often reversible but can take many
months to fully resolve. Recognizing
these as secondary changes is impor-
tant when determining the efficacy of
treatment as patients may not recog-
nize the improvement or think they
have scarring. Effective and early
treatment is essential to prevent
scarring as well as postinflammatory
changes and to limit the long-term
physical and psychological impact of
acne.
It has been repeatedly demonstrated
thatacnecanhaveasignificantadverse
impact on quality of life, and that the
level of distress may not correlate di-
rectly with acne severity.18,19 In 1 study,
assessments using several quality of
life instruments revealed deficits for
acne patients who did not correlate
with clinical assessments of severity.20
Reported social, psychological, and
emotional symptoms were as severe as
those reported by individuals with
chronic medical conditions such as
chronic asthma, epilepsy, diabetes, and
back pain or arthritis. Adolescents, in
particular, may be insecure about their
appearance and vulnerable to peer
opinions. Because social functioning
and quality-of-life decrements may not
correlate with disease severity, even
mild acne may be more troubling to
young patients than they are willing to
admit.21
Consensus Recommendation:
Acne can be categorized as pre-
dominately comedonal, inflamma-
tory, and/or mixed. Presence or
absence of scarring, PIH, or ery-
thema should be assessed. Sever-
ity may be broadly categorized as
mild, moderate, or severe. (SOR: A).
APPROACH TO PEDIATRIC ACNE
THERAPY
The therapeutic objectives in acne are
to treat as many age-appropriate
pathogenic factors as possible by re-
ducing sebum production, preventing
the formation of microcomedones,
suppressing P acnes, and reducing in-
flammation to prevent scarring.
Although no single acne treatment,
apart from isotretinoin, addresses all 4
pathogenic factors, it is now clear that
many of the medications traditionally
used to treat acne actually act by more
than 1 mechanism. In addition to tar-
geting the largest number of patho-
genic factors, the approach to pediatric
acne should be to use the least ag-
gressive regimen that is effective while
avoiding regimens that encourage the
development of bacterial resistance.
Educatingapatient(andparents)about
reasonable expectations of results and
discussing management of treatment-
related side effects can maximize
both compliance and efficacy.
Numerous medications are available to
treat acne. Design of an effective regi-
men is facilitated by an increased un-
derstanding of the mechanisms of
action, the side effect profile, and the
indications and contraindications of
key antiacne agents discussed later.
OVER-THE-COUNTER TREATMENT
OPTIONS
Nationwide television commercials and
magazine ads abound with over-the-
counter (OTC) products. Although largely
untested in controlled clinical trials,
many of these products are considered
somewhat effective, particularly for
patients with mild acne. Those which
have been tested include salicylic acid-
containing topical products and many
benzoyl peroxide (BP) products de-
scribed in further detail later. Salicylic
acid has revealed some efficacy in acne
trials, although when tested head-to-
head with other topicals, particularly BP,
it is generally less effective.22,23 Nonpre-
scription, nonbenzoyl-peroxide-containing
products appear to be somewhat ef-
fective for the treatment of acne, espe-
cially mild acne, though there is limited
published evidence supporting their
efficacy in the treatment of acne.
Sulfur, sodium sulfacetamide, and
resorcinol are active ingredients in
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several OTC dermatology niche prod-
ucts. Sulfur exhibits mild antibacterial
and keratolytic properties.24 Because
of sulfurs distinctive odor, it is often
combined with sodium sulfacetamide
to mask the scent.25 It is often used in
adult female acne because of its fa-
vorable tolerability.26,27 Resorcinol also
has mild antimicrobial properties and
is typically formulated in a 2% con-
centration in combination with 5%
sulfur.
One common acne myth is that poor
hygiene and improper cleansing cause
acne.21,28 The role of facial cleansing in
acne is to remove makeup, dirt, and
excess oil.29 Use of the wrong, too
harsh cleanser can disrupt skin bar-
rier, increase transepidermal water
loss, encourage bacterial coloniza-
tion, promote comedones, and cause
symptoms of burning and stinging.30,31
Typically, twice-daily washing with a
gentle soap-free, pH-balanced cleanser
is recommended. Antibacterial washes,
other than BP, have not been shown to
be useful in the treatment of acne.
Facial toners can decrease oiliness and
remove makeup and traces of dirt. They
are a common component of several
prepackaged combination acne treat-
ment regimens. Patients should be cau-
tious not to overuse facial toners
becausetheycanbeirritating.Ifirritation
occurs, this will adversely affect the
tolerability of acne medications.
Another common acne myth is that use
of cosmetics worsens acne. On the
contrary, use of concealing oil-free,
noncomedogenic makeup can im-
provepatientqualityoflifeanddoesnot
worsen the severity of acne.32,33 Use of
cosmetics in patients with acne has not
been shown to delay treatment re-
sponse either.
BP has been shown to be the most
widely studied of OTC products and has
shown to be one of the most versatile,
safe, inexpensive, and effective acne
therapies.34,35 Its lipophilic nature per-
mits it to penetrate the stratum cor-
neum and enter the pilosebaceous unit
where P acnes resides. It acts via the
generation of free radicals that oxi-
dize proteins in the P acnes cell wall.
It also has been shown to have mild
comedolytic36 and antiinflammatory
properties.37,38 BP helps limit the de-
velopment of P acnes resistance to
antibiotics and also provides increased
efficacy incombinationwithretinoids.39,40
So far, antibiotic resistance to BP has
not been reported.4144
Although issues regarding genotoxicity
havebeenraisedinthepast,BPhasnow
been labeled as GRASE (generally
regarded as safe and effective) by the
FDA, and all topical monotherapy
products have been made available OTC
since 2011. Labeling includes advice to
avoid the eyes, lips, and mouth. The
product can cause bleaching of hair
and clothing, and risk of increased
sunburn and the need for photo-
protection also are mentioned. BP fre-
quently causes dryness, erythema, and
peeling upon initiation of treatment.
Starting with lower concentrations (eg,
2.5%) and utilizing more emollient
vehicles if needed can help alleviate
these discomforts. Allergic contact
dermatitis to BP occurs in 1 in 500
people and should be considered if
a patient complains of itching and
swelling of the eyes.
BP is available in a variety of for-
mulations and in concentrations rang-
ing from 2.5% to 10%. There is some
evidence that higher concentrations do
not increase efficacy but are more ir-
ritating. However, the back may be
a special site circumstance, where
increasing concentration or prolonged
contact leads to increased efficacy.45
Formulations include a variety of topi-
cal leave-on preparations as well as
washes that permit patients to remove
BP from the skin, reducing the possi-
bility of bleaching of clothing, bedding,
or towels.38 It has been suggested that
short-contact BP therapies do not sig-
nificantly reduce bacterial load, but data
are lacking. However, they can be effec-
tive if left on the skin for the duration
recommended by the manufacturer.
Consensus Recommendations:
BP is generally regarded as a safe
and effective medication that may
be used as monotherapy or in top-
ical combination products for mild
acne or in regimens of care for
acne of all types and severities.
(SOR: A).
BP may minimize development of
antibiotic-resistant P acnes when
used with topical or systemic anti-
biotics. (SOR: C).
PRESCRIPTION TREATMENT
OPTIONS: SINGLE AGENTS
Topical Retinoids
Topical retinoids, as monotherapy and
in topical combination products, are
usedroutinelyfor thetreat
