Pediatrics Rotation Exam

Pediatric EOR: Acne vulgaris (ReelDx)

600 REEL-DX-ENHANCED

Neonatal Acne

Patient with neonatal acne will present as → a 4-week old baby boy brought in by mother with c/o of a red rash on the sides of his face. She states that the rash has been present for a week now. It does not appear to itch at this time. On PE, you note comedones, papules on the lateral aspect of his face.

Patient will present as → a 14-year-old boy with dozens of erythematous papules, pustules, and cysts. On closer exam, he also has atrophic scars on the lateral forehead, consistent with permanent scarring from previous acne lesions. He is started on topical retinoids and topical benzoyl peroxide. You suggest that he also consider a systemic retinoid if this topical therapy does not work.

Acne is a chronic inflammatory skin disorder that is most commonly seen in areas with the highest concentration of sebaceous glands.

  • It is most commonly seen on the face, upper chest & back. It is the MC skin problem of adolescence.
  • It affects both sexes equally; more severe in males than in females. Onset can be as early as 8 years of age and can proceed into adulthood. The pilosebaceous unit (comprising of the hair follicle along with its associated sebaceous gland) is chronically inflamed leading to the formation of micro-comedo.

Acne is characterized by areas of open comedones (blackheads) incomplete blockage, closed comedones (whiteheads) complete blockage, papules, pustules, nodules or cysts.

  • Nodules & cysts are more likely to cause scarring.
  • Papules & pustules are ruptured comedones that have become infected by Propionibacterium acnes.

The hallmark of acne pathogenesis involves 3 components:

  • Increased production of sebum
  • Increased keratin production
  • Bacterial overgrowth by P. acnes.

Androgens can stimulate sebum production and can become a risk factor for acne formation as seen in hyperandrogenism caused by polycystic ovarian syndrome (PCOS) or by androgen-producing tumors.

Neonatal acne is seen in newborn up to first 8 weeks of life. It is typically limited to the face and responds well to ketoconazole 2% cream.

Diagnosis is typically clinical. Lab studies are typically not necessary. In a woman with resistant acne, hyperandrogenism should be suspected.

Acne severity is graded into: mild, moderate or severe based on the number & type of lesions. The stages of acne are:

Differential diagnosis includes

  • rosacea (in which no comedones are seen)
  • corticosteroid-induced acne (which lacks comedones and in which pustules are usually in the same stage of development)
  • perioral dermatitis (usually with a more perioral and periorbital distribution)
  • acneiform drug eruptions.

Patients should be educated on the use of medications and cosmetics. It typically takes about 4-6 weeks to see improvements on the face and another 3-4 months for the upper back. Oils and greases should be avoided. Anxiety and depression can result especially in adolescents. A diet low in carbs can also improve the symptoms of acne. Pharmacologic treatment depends on the severity.

  • Comedonal acne: topical retinoids are very effective for treatment of comedonal acne. Tretinoin 0.025% cream can be used effectively. A major side effect is skin irritation caused by tretinoin. For this reason, patients who have skin irritation with the use of tretinoin can use adapalene gel 0.1%. Another treatment for comedonal acne is the use of benzoyl peroxide 2.5%.
  • Mild inflammatory acne (grade 2): Benzoyl peroxide + or _ topical antibiotic + keratinolytic agent (alpa-hydroxy acids, salicylic acid, azelaic acid).
  • Moderate inflammatory acne (grade 3): add systemic antibiotic (doxycycline, minocycline, Bactrim) to grade 2 regimen.
  • Severe inflammatory acne (grade 4): as in grade 3 or isotretinoin. Isotretinoin is a vitamin A analog that reduces production of sebum, reduces keratin overgrowth and reduces the formation of 5 alpha-dihydrotestosterone and androgen receptor binding capacity. For this reason, isotretinoin is the only medication that can permanently treat acne. ABSOULTELY CONTRAINDICATED IN PREGNANCY. Two serum pregnancy tests should be performed before the initiation of treatment. Serum pregnancy test should be obtained every month afterward. Two forms of birth control should be started. Other treatment options for severe acne include intra-lesional injection with triamcinolone and laser therapy.
Question 1
Which of the following statements about the epidemiology of acne is true?
A
During adolescence, acne vulgaris is more common in females than in males
B
During adulthood, acne vulgaris is more common in men than in women
C
African Americans have a higher prevalence of pomade acne
D
Neonatal acne most often requires treatment with topical retinoids
Question 1 Explanation: 
Acne is common in North American white persons. African Americans have a higher prevalence of pomade acne, probably stemming from the use of hair pomades. During adolescence, acne vulgaris is more common in males than in females. In adulthood, acne vulgaris is more common in women than in men. Acne or acneiform lesions, such as in neonatal cephalic pustulosis, may be present in the first few weeks and months of life, when a newborn is still under the influence of maternal hormones and when the androgen-producing portion of the adrenal gland is disproportionately large. This neonatal acne tends to resolve spontaneously. However, some neonates require therapy, with topical retinoids sometimes used.
Question 2
Which of the following is recognized in the pathogenesis of acne vulgaris?
A
Down-regulation of vascular cell adhesion molecule-1 (VCAM-1)
B
Presence of Propionibacterium granulosum
C
Stunted sebum production
D
Keratinocyte proliferation and decreased desquamation
Question 2 Explanation: 
The pathogenesis of acne vulgaris is multifactorial. The key factor is genetics. Acne develops as a result of an interplay of the following four factors: 1. Release of inflammatory mediators into the skin 2. Follicular hyperkeratinization, with subsequent plugging of the follicle 3. Follicular colonization by Propionibacterium acnes 4. Excess sebum production Research has shown that inflammatory responses actually occur before hyperkeratinization. Cytokines produced by CD4+ T cells and macrophages activate local endothelial cells to up-regulate inflammatory mediators, such as VCAM-1, intercellular adhesion molecule 1 (ICAM-1), and human leukocyte antigen (HLA)-DR in the vessels around the pilosebaceous follicle. Follicular hyperkeratinization involves increased keratinocyte proliferation and decreased desquamation, leading to sebum- and keratin-filled microcomedones.
Question 3
Which of the following characterizes nodulocystic acne?
A
Open and closed comedones without inflammatory papules and nodules
B
Comedones, inflammatory papules, and pustules
C
Comedones and a few papulopustules
D
Comedones, inflammatory lesions, and large nodules (> 5 mm in diameter)
Question 3 Explanation: 
In comedonal acne, patients develop open and closed comedones, but may not develop inflammatory papules or nodules. Mild acne is characterized by comedones and a few papulopustules. Moderate acne has comedones, inflammatory papules, and pustules. Greater numbers of lesions are present than in milder inflammatory acne. Nodulocystic acne is characterized by comedones, inflammatory lesions, and nodules greater than 5 mm in diameter. Scarring is often evident.
Question 4
Which of the following is considered first-line therapy for almost all patients with acne?
A
Topic retinoid monotherapy
B
Antimicrobial therapy monotherapy
C
Topic retinoid and hormonal cotherapy
D
Topic retinoid and antimicrobial cotherapy
Question 4 Explanation: 
Current consensus recommends a combination of topical retinoid and antimicrobial therapy as first-line therapy for almost all patients with acne. The superior efficacy of this combination, compared with either monotherapy, results from complementary mechanisms of action targeting different pathogenic factors. Retinoids reduce abnormal desquamation, are comedolytic, and have some anti-inflammatory effects, whereas benzoyl peroxide is antimicrobial with some keratolytic effects and antibiotics have anti-inflammatory and antimicrobial effects.
Question 5
Which of the following should be used with caution in teenagers suspected of depression or suicidal thoughts?
A
Spironolactone
B
Isotretinoin
C
A combination of trimethoprim and azithromycin
D
Surgical treatment
Question 5 Explanation: 
Acne can be a very depressing situation. It can alter personality development in the adolescent stage and may facilitate hostility, anger, and antisocial behavior. Associated mood changes and depression have also been reported during treatment. Isotretinoin may heighten feelings of depression and suicidal thoughts. Although a cause-and-effect relationship has not been established, patients should be informed of this potential effect and must sign a consent form acknowledging they are aware of this potential risk. Isotretinoin is also teratogenic and is Category X, with no indication for its use during pregnancy.
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