As a pediatrician I entertain a lot of questions about acne. When children reach adolescence some have more trouble with this skin condition than others.

Many parents elect to send their child to a dermatologist for childhood acne. Some children with severe disease or disease refractory to treatment should be referred to a specialist -- but most cases can easily be treated by a child’s primary care physician.

Elizabeth Landolfo, MD, director of the Pediatric Primary Care Clinical Practice at Duke, gives some thoughtful suggestions.

-- Dennis Clements MD, PhD, MPH

Elizabeth Landolfo, MD

Acne occurs most commonly during adolescence and affects more than 85 percent of teenagers.

Acne is caused by blockage of the hair follicle and the sebaceous gland that surrounds it. Acne is commonly referred to as pimples, spots, or zits -- and in medical terminology as comedones (blackheads and whiteheads), inflammatory papules, pustules, and nodular or cystic acne.

The most difficult aspects related to the treatment of acne are:

• Understanding ton the part of the parent and the adolescent that the resolution of the acne will take time. Whatever treatment is used, more medicine will not make it get better quicker (especially with topical medication)
• Sometimes certain treatments make the acne get worse before it improves
• What works for one person does not necessarily work for another

As a first consideration it is important to review general good skin care. All of these suggestions are related to trying to keep oil off the face that can clog pores. The following are recommended:

• Wash face gently with warm water twice per day and pat dry
• Avoid rubbing, popping, squeezing lesions
• Avoid hair and skin products that contain oil. Look for products that are “non-comedogenic” (does not clog pores)
• Try to keep hair and hands away from face
• Use sun protection
• Avoid tanning booths and self-tanning products

Acne Treatments

Treatment of acne is based on the severity:

Mild acne: blackheads, whiteheads and an occasional pustule

Mild acne can often be handled by over-the-counter medications, such as benzoyl peroxide preparations, applied once to twice daily. Prescription medications that are useful can be the combination topical (skin surface only) benzoyl peroxides / antibiotic preparations or very low dose topical retinoid.

Moderate to moderately severe acne: mild acne plus pustules and papules that cover from ¼ to ¾ of the face

Moderate to moderately severe acne usually requires some combination of topical therapy plus the addition of an oral antibiotic. Occasionally the discussion of the use of hormonal therapy with oral contraceptives in females can be helpful. It is important to emphasize that these therapies take time to see results. And oral antibiotics need to be tailored for the patient.

Severe acne: inflammatory pustules with deep cysts and possible evidence of scarring

This type of acne should receive prompt referral to a dermatologist for a discussion of the use of an oral retinoid (form of Vitamin A) plus some combination of the therapies listed above.

There are potential serious side effects (birth defects in the developing fetus) from the use of oral retinoid and a discussion of these side effects must occur prior to prescribing the medication. In fact, two forms of birth control are required for female patients before a prescription is written for an oral retinoid.

Self-Esteem

While treating acne, it is important to recognize the impact the disease has on the self-esteem of the adolescent. Engaging children in the understanding and treatment of their acne will improve the outcome.

It is important for children to understand how to apply topical medications. The most common reasons for discontinuing treatments is that the medication made their acne worse, their face got reddened, cracked and peeled, or their favorite shirt got bleached by the medications.

This stresses the importance of taking the time to properly discuss and review the use of the medications that you prescribe.

But whatever is used, after several years the acne will improve anyway. The hope is that the conversation during the treatment will help preserve the adolescent’s self-esteem as much as possible. And the frequent visits can also allow the opportunity to have conversations about other topics on the adolescent’s mind.

--Elizabeth Landolfo, MD, is director of the Pediatric Primary Care Clinical Practice at Duke.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.