Acne in Childhood: An Update - Wendy Kim, DO; and Anthony J. Mancini, MD
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FEATURE
Acne in Childhood: An Update
Wendy Kim, DO; and Anthony J. Mancini, MD
A
cne is the most common chron-
ic skin disease affecting chil-
dren and adolescents, with an
85% prevalence rate among those aged
12 to 24 years.1 However, recent data
suggest a younger age of onset is com-
mon and that teenagers only comprise
36.5% of patients with acne.2,3 This ar-
ticle provides an overview of acne, its
All images courtesy of Anthony J. Mancini, MD.
pathophysiology, and contemporary
classification; reviews treatment op-
tions; and reviews recently published
algorithms for treating acne of differing
levels of severity.
Acne can be classified based on le-
sion type (morphology) and the age
group affected.4 The contemporary Figure 1. Comedonal acne. This patient has numerous closed comedones (ie, “whiteheads”).
classification of acne based on sev-
eral recent reviews is addressed below.
Acne lesions (see Table 1, page 419)
can be divided into noninflammatory
lesions (open and closed comedones,
see Figure 1) and inflammatory lesions
(papules, pustules, and nodules, see
Figure 2). The comedone begins with
Wendy Kim, DO, is Assistant Professor of In-
ternal Medicine and Pediatrics, Division of Der-
matology, Loyola University Medical Center,
Chicago. Anthony J. Mancini, MD, is Professor
of Pediatrics and Dermatology, Northwestern
University Feinberg School of Medicine, Ann
and Robert H. Lurie Children’s Hospital of Chi-
cago.
Address correspondence to: Anthony J. Man- Figure 2. Moderate mixed acne. In this patient, a combination of closed comedones, inflammatory pap-
ules, and pustules can be seen.
cini, MD, Division of Dermatology Box #107,
Ann and Robert H. Lurie Children’s Hospital of the microcomedone, which is a micro- 3) proliferation of Propionibacterium
Chicago, 225 E. Chicago Avenue, Chicago, IL scopic plug of the follicular ostia of acnes (considered the “acne organ-
60611; email: amancini@northwestern.edu.
the pilosebaceous unit. Four process- ism”); and 4) the release of inflamma-
Disclosure: Dr. Kim is an advisory board par-
es are necessary for an acne lesion to tory mediators.5 The sequence of these
ticipantfor Galderma. Dr. Mancini is a consul-
evolve: 1) altered shedding of the ke- events remains under investigation (ie,
tant, speaker, and advisory board participant
for Galderma.
ratinocytes that line the pilosebaceous some recent studies suggest that even
doi: 10.3928/00904481-20130924-13 unit; 2) increased sebum production; comedones may be preceded by inflam-
418 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:10 | OCTOBER 2013
FEATURE
matory events), but once the comedone
TABLE 1.
has formed it can proceed to become an
inflammatory lesion.6 Treatment is de- Acne Lesion Nomenclature
pendent upon the types and severity of
Lesion Type Comment
acne lesions that are present.
Comedone May be closed (“whitehead”) or open (“blackhead”); believed to
develop from microscopic plugs of desquamated cells from the
IMPACT ON QUALITY OF LIFE follicle; early treatment of comedones may help prevent progres-
Long regarded as a rite of passage sion to clinically inflammatory lesions.
of adolescence, it is now clear that acne Inflammatory lesion May be a papule, pustule, or nodule; related to inflammatory
patients suffer significant social and mediators, which increase in response to the P. acnes organism;
psychological impact from the disease. nodules often result in scarring.
Acne has been associated with anxiety, Post-inflammatory May be hypo- or hyperpigmentation, or erythema; changes may
low self-esteem, embarrassment, social change last for months to years.
withdrawal, and depression.7,8 In fact,
the psychological impact of acne has Scarring A sequela of inflammatory acne; often persistent and very difficult
been demonstrated to be as severe as to treat.
that of patients with insulin-dependent
diabetes, cystic fibrosis, cancer, epi-
lepsy, and some psychiatric disorders.8
Several recent publications have ence higher rates of depression and based on the age of onset of the dis-
addressed body dysmorphic disorder suicide than their peers. Cotterill and ease: neonatal acne occurs from birth
(BDD), which is defined as a life-al- Cunliffe10 described 16 dermatology through age 4 weeks; infantile acne has
tering preoccupation with a minimal patients who completed suicide, and al- its onset between age 1 and 12 months;
or imperceptible flaw in appearance, in most half of this cohort had acne. Gupta mid-childhood acne occurs from age 1
acne patients.7,9 It occurs in an estimat- and Gupta11 showed that active suicidal year through age 6 years; and preado-
ed 2% of the general population, but it ideation was found in 5.6% of acne pa- lescent or prepubertal acne occurs from
has been estimated to occur in 6.7% of tients who were screened in a dermatol- age 7 to 11 years.4 The specific type of
patients in a general dermatology clinic ogy clinic setting. Acne patients had a acne, based on this classification sys-
and up to 14% of patients in a cosmetic higher score on the Carroll Rating Scale tem, helps to determine whether other
dermatology clinic.9 These patients are for Depression (CRSD) than patients evaluations (eg, for an underlying endo-
frequently dissatisfied with medical with alopecia areata, atopic dermatitis, crinologic abnormality) are indicated.
treatment and procedural outcomes, and psoriasis involving less than 30%
which makes adherence more chal- of the body surface area, suggesting a Neonatal Acne
lenging.7 A high percentage (36.7%) higher rate of depression than patients Neonatal acne may affect up to 20%
of acne patients with barely percep- with other chronic skin conditions. of infants, although this figure is dif-
tible or mild acne were found to meet These statistics underscore the impor- ficult to confirm because there may be
subjective criteria for BDD via survey, tance of recognizing the detriment to overlap with other papulopustular con-
and patients who had received therapy body image and potential self-harm that ditions (eg, erythema toxicum neonato-
with isotretinoin were twice as likely as acne patients may experience. Such ob- rum, eosinophilic folliculitis, transient
controls to meet subjective criteria for servations also highlight the utility of neonatal pustular melanosis, milia, mil-
BDD (15.5% of patients who had never early institution of therapy for acne. iaria). The lesions of neonatal acne may
used isotretinoin vs. 31.8% of patients present from birth to age 4 weeks. Usu-
who had used isotretinoin).7 Important- CONTEMPORARY ally, this type of acne is characterized
ly, more than one-third of acne patients CLASSIFICATION by inflammatory lesions (papules and
with barely perceptible to mild acne The term pediatric acne is used to pustules), although comedones may oc-
reported severe disabling symptoms of describe acne that occurs from birth casionally be present. The latter are be-
preoccupation with their acne.7 through age 11 years, with acne occur- lieved by some acne experts to be more
It is important to be aware of the ring from age 12 years through adult- indicative of infantile acne than neona-
potential psychosocial ramifications of hood referred to as adolescent acne. Pe- tal acne. Neonatal acne is believed to
acne given that these patients experi- diatric acne can be further subdivided be caused by increased production of
PEDIATRIC ANNALS 42:10 | OCTOBER 2013 Healio.com/Pediatrics | 419
FEATURE
dehydroepiandrosterone (DHEA), in
association with a large androgen-pro-
ducing zona reticularis in the fetal adre-
nal glands. There is also transplacental
passage of androgens, which stimulate
sebaceous glands, as well as testicular
production of androgens. From birth
through age 6 to 12 months, boys also
have pubertal levels of testosterone,
which might explain why acne is more
common in male infants than in female
infants.12
Figure 3. Neonatal cephalic pustulosis. This newborn had numerous pustules over the forehead and
cheeks, and improved dramatically following therapy with a topical antifungal cream. In recent years, a more pustular pre-
sentation of neonatal acne has been de-
scribed and termed neonatal cephalic
pustulosis (see Figure 3). A relationship
between this condition and increased
colonization with (or hypersensitivity
to) Malassezia furfur, M. sympodialis,
or other species has been suggested.
In a 1996 cohort of 13 neonates, pus-
tule smears from the faces and necks
were notable for M. furfur in eight pa-
tients, whose skin all cleared rapidly
following application of ketoconazole
cream.13 Subsequent studies have been
inconsistent in their findings, but many
experts still recommend consideration
of topical antifungal therapy in neo-
nates with severe pustular acneiform
Figure 4. Infantile acne. This infant has numerous open comedones (“blackheads”) with occasional in- eruptions.14-16
flammatory papules.
Infantile Acne
Infantile acne begins sometime in
the first year of life, typically between
ages 4 to 6 weeks and age 1 year. It is
more common in boys than in girls and
is more likely than neonatal acne to be
predominantly comedonal (see Figure
4). Inflammatory lesions may or may
not be present, but if present they may
occasionally be severe. Nodules can
also occur occasionally, and when in-
fantile acne is moderate to severe, scar-
ring may result (see Figure 5). In pa-
tients with infantile acne, the physical
examination should include a growth
assessment as well as evaluation for any
features of precocious puberty or an-
Figure 5. Infantile acne. The mild scarring present in this infant highlights the importance of considering
early therapy for patients with moderate or severe involvement. drogen excess, including axillary odor,
420 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:10 | OCTOBER 2013
FEATURE
breast development, clitoromegaly,
TABLE 2.
presence of axillary and/or genital hair,
Therapeutic Options for Neonatal, Infantile, and Mid- and increased muscle mass. If concerns
Childhood Acne are present, laboratory workup and/or
referral to a pediatric endocrinologist
Type of Acne Therapeutic Options
are recommended. Sidebar 1 (see page
Neonatal No therapy; topical azole antifungal cream (ie ketoconazole) if
423) lists the recommended laboratory
markedly pustular.
evaluation when androgen excess is
Infantile Benzoyl peroxide; topical retinoid (if primarily comedonal); topical
antibiotic (if significant inflammatory component); oral non-cycline
suspected.14,15,17
antibiotic (ie erythromycin, if moderate to severe inflammatory
disease); consider androgen excess when severe. Mid-Childhood Acne
Acne that begins in children aged 1
Mid-childhood acne Same as above for infantile acne; evaluation for androgen excess to 7 years is termed mid-childhood acne
always indicated. and is never considered normal. The
neonatal adrenal gland continues to se-
crete high levels of androgen through
age 1 year, and then the zona reticularis
of the adrenal gland is quiescent until
TABLE 3.
adrenarche, around age 7 years. Late-
Fixed-Dose Combination Prescription Acne Therapies onset congenital adrenal hyperplasia,
true precocious puberty, and androgen-
Active Ingredients Product Age Indication secreting tumors are a few of the poten-
BP and clindamycin BenzaClin gel (Dermik) ≥ 12 years tial underlying causes of mid-childhood
Duac gel (Stiefel Labs) ≥ 12 years acne, and laboratory evaluation should
Acanya gel (Medicis Pharma) ≥ 12 years be performed in all patients presenting
BP and adapalene Epiduo gel (Galderma) ≥ 9 years with acne onset during this time (see
Clindamycin and Ziana gel (Medicis Pharma) ≥ 12 years
Sidebar 1, page 423).16,18 Table 2 lists
tretinoin Veltin gel (Stiefel Labs) ≥ 12 years
recommended therapies for neonatal,
infantile, and mid-childhood acne.
BP and erythromycin Benzamycin gel (Dermik) ≥ 12 years
BP = benzoyl peroxide.
Preadolescent Acne
Preadolescent acne, which presents
between age 7 and 11 years, is similar
TABLE 4.
in presentation to adolescent acne, and
Topical Retinoids Used for Acne Therapy* it is considered by most experts to be a
common initial sign of impending pu-
Retinoid Available Formulations Comment bertal maturation. Comedones tend to
Adapalene Cream, gel, solution, lotion Considered the least irritating of the topical predominate (see Figure 6, page 423),
retinoids; very lipophilic, so concentrates in the especially in the “T zone” (ie, across
pilosebaceous unit; pregnancy category C; brand the forehead, on the nose and on the
name Differin (Galderma).
chin) of the face, but inflammatory le-
Tretinoin Cream, gel, microsphere Considered the original topical retinoid; preg- sions may also be present. This form
gel nancy category C; Atralin (tretinoin 0.05% gel)
of acne is likely becoming more com-
approved down to 10 years of age; brand names
also include Retin A, Retin A Micro (Medicis), Avita mon, in parallel with the downward
(Mylan). trend in the timing of onset of puberty
Tazarotene Gel, cream, foam Also approved for treatment of psoriasis; that has been observed over the past
pregnancy category X; brand names include century.19-21 The severity of preadoles-
Tazorac(Allergan), Fabior (GlaxoSmithKline). cent acne may be predictive of the fu-
*Unless otherwise noted, all are approved by the US Food and Drug Administration for patients aged 12 years and older. ture, as Lucky and colleagues22 found
in a longitudinal study that adolescent
422 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:10 | OCTOBER 2013
FEATURE
SIDEBAR 1.
Recommended Laboratory
Evaluations for the Child
with Acne and Suspected
Androgen Excess
• Luteinizing hormone
• Follicle-stimulating hormone
• Dehydroepiandrosterone sulfate
• 17-hydroxyprogesterone
• Free and total testosterone
• Prolactin
• Bone age
girls with more severe acne were more
likely to have had more comedonal Figure 6. Preadolescent acne. This 9-year-old female has a combination of closed comedones and in-
and inflammatory lesions as early as flammatory papules, which were limited to the “T zone” distribution on the forehead, nose, and chin.
age 10 years. This cohort also was also
more likely to undergo earlier men- active ingredients in these products are Topical retinoids play a paramount
arche than those girls who had had often benzoyl peroxide (BP) or salicylic role in the treatment of acne. They
mild preadolescent comedonal acne.22 acid. BP has been available since 1934 are vitamin A derivatives (either natu-
and works by creating free radicals that rally occurring or synthetic) that bind
ACNE THERAPY destroy the acne organism, P. acnes. Ad- to retinoid receptors in the skin. They
The following sections apply to ado- ditionally, it reduces the release of reac- work within the nucleus to alter down-
lescent acne, although preadolescent tive oxygen species from neutrophils, stream signals affecting inflammatory
acne is usually treated with similar thereby reducing inflammation.24 BP pathways and proliferation.26,27 Spe-
agents (albeit often in “off-label” fash- has gained favor in recent years given cifically, retinoids normalize follicular
ion). An exhaustive discussion of acne its utility in acne therapy combined with keratinization and prevent the micro-
therapy is beyond the scope of this ar- the lack of development of resistance to comedone from forming; therefore,
ticle (for more information, the reader this agent. It has also been shown to de- they play a preventive role in the treat-
is directed to recent reviews12,16,23). crease the development of resistance to ment of acne in addition to their benefi-
concomitant antibiotics utilized as part cial effects on the existing comedones.
TOPICAL THERAPY of the acne regimen.25 BP is available It is important to educate patients on
Proper skin cleansing should always in a variety of washes and “leave-on” proper use and expectations with topi-
be discussed with acne patients. Al- gels, in strengths ranging from 2.5% to cal retinoids. These agents may result
though the patient may be under the im- 10%. Although previously available by in some peeling, redness, and irritation,
pression that scrubbing to remove dirt prescription, BP washes are now avail- primarily with initial use.28 These side
and oil will improve the appearance of able exclusively on an over-the-counter effects tend to decrease after 4 weeks
acne, such overmanipulation may actu- basis. However, it is also found in sev- of regular use and can be minimized
ally increase inflammation and, hence, eral fixed-dose combination products by alternate-night (or every third night)
should be discouraged. Cleansing once available by prescription (see Table 3, application during initiation, if needed.
to twice daily with warm water and a page 422). Patients should be warned It should be reiterated that topical reti-
gentle acne wash should be encour- about the potential bleaching of linens noids should be applied as a thin film at
aged.16 The use of scrubbing devices and clothing by BP. Salicylic acid is a bedtime to all “fields” where the patient
or abrasive sponges should be discour- keratolytic agent that may be beneficial gets acne, and not as spot therapy. Table
aged for most patients. for mild comedonal acne. It is available 4 (see page 422) lists the available topi-
Many over-the-counter products and in washes, pads, and other over-the- cal retinoids, along with their strengths,
“systems” for acne are available. The counter products. vehicles, and proprietary names.
PEDIATRIC ANNALS 42:10 | OCTOBER 2013 Healio.com/Pediatrics | 423
FEATURE
TABLE 5. SIDEBAR 2.
Common Oral Antibiotics Used for Acne Therapy General Guidelines in Oral
Antibiotic Therapy for Acne
Antibiotic Recommended Dose Potential Adverse Events / Comment • Continue oral antibiotics for at least 2 to 3
Doxycycline 50 mg-100 mg BID GI upset, pill esophagitis, sensitivity in the sun months to assess for response
(including photo-onycholysis), dental discol- • Oral antibiotic therapy should be
oration (not recommended < 8 years of age), combined with a topical regimen that
IBD, hepatitis, vaginal candidiasis; subantimicro- includes:
bial dosing also used at 20 mg BID; available in B
enzoyl peroxide (either as part of a
delayed-release formulation. “leave-on” regimen or as a wash), in an
Minocycline 50 mg-100 mg BID Cutaneous and mucosal hyperpigmentation, drug effort to minimize the development of
hypersensitivity with hepatitis and pneumonitis, bacterial resistance; and
lupus-like syndrome, Stevens Johnson syndrome, Topical retinoid, to more effectively treat
vaginal candidiasis, vestibular effects, dental comedones and for their role in preven-
discoloration (not recommended < 8 years of tion of the development of new acne
age), IBD, photosensitivity (less than doxycycline), • Educate patients to expect a 3- to
pseudotumor cerebri; available in extended- 6-month period of therapy (occasionally
release formulation. longer), with the goal of discontinuing the
Tetracycline 250 mg-500 mg BID GI upset, pill esophagitis, sensitivity in the sun, oral treatment as early as feasible (while
hepatic dysfunction, dental discoloration (not continuing the topical maintenance
recommended < 8 years of age), IBD. regimen).
Erythromycin 250 mg-500 mg BID Marked GI upset, diarrhea, prolongation of QT • Discuss potential side effects and warn-
interval, increasing resistance in acne; no longer ings of oral antibiotic therapy.
recommended by most experts. • Routine laboratory monitoring is not
Cephalexin 250 mg-500 mg BID Vaginal candidiasis, rare drug reactions; routine recommended in the absence of underly-
use for acne not recommended. ing conditions that may predispose the
patient to toxicities (ie hepatic or renal
Trimethoprin- 80 mg/400 mg to 160 Severe drug reactions, bone marrow suppression,
insufficiency)
sulfamethoxa- mg/800 mg drug hypersensitivity syndrome; routine use for
zole acne strongly discouraged. Adapted from Eichenfield and Mancini,12 Eichenfield et al,16
Thiboutot et al,23 Tsankov et al,33 Webster and Graber,34
Zaenglein and Thiboutot,35 and Del Rosso and Kim36
BID = twice daily; GI = gastrointestinal; IBD = inflammatory bowel disease.
cetamide in acne products to mask its
odor. Sodium sulfacetamide is available
as a solution or lotion.
Topical antibiotics, including eryth- combination product, is highly recom- Several topical, fixed-dose combina-
romycin and clindamycin, are used in mended when topical antibiotics are tion therapies have been approved for
the treatment of inflammatory acne and used. Dapsone 5% gel (Aczone, Aller- the treatment of mild-to-moderate acne
are aimed at the reduction of P. acnes. gan) was recently approved for acne. It vulgaris (see Table 3, page 422). The
These agents are typically applied once has been shown to reduce inflammatory advantages of these therapies include
daily. Clindamycin is available as a lesions in as early as 2 weeks, with the the improved adherence they offer (via
1% gel, solution, lotion, and foam, and safety of twice-daily use being demon- simplification of the treatment regimen)
erythromycin is available as a 5% gel strated for up to 1 year in patients aged and the complementary mechanisms of
and solution. Monotherapy with topi- 12 to 15 years.29,30 Hemolytic anemia action of the individual components.
cal antibiotics is not recommended be- can occur in patients with glucose- The fixed-dose combination products
cause of their prolonged onset of action 6-phosphate dehydrogenase (G6PD) currently available include products
and the likelihood of bacterial resis- deficiency when treated with oral dap- containing BP and clindamycin, BP
tance.25 Since the 1970s, the resistance sone, but this effect seems very unlikely and adapalene, BP and erythromycin,
of P. acnes to erythromycin as well as in G6PD-deficient patients treated with and tretinoin and clindamycin. These
clindamycin has increased dramati- topical dapsone.31 Sulfur exhibits anti- agents are typically applied once to
cally.25 Concomitant use of BP, either bacterial and keratolytic properties, and twice daily. To obtain US Food and
as a wash or as part of a fixed-dose it is often combined with sodium sulfa- Drug Administration (FDA) approval
424 | Healio.com/Pediatrics PEDIATRIC ANNALS 42:10 | OCTOBER 2013FEATURE
for these products, manufacturers need
to show that the combination product TABLE 6.
demonstrates increased efficacy com-
Treatment Recommendations Based on Acne Severity
pared with the individual components
(the “monads”) and the vehicle.
Type of Acne Initial Therapy Inadequate Response
Mild BP or topical retinoid or topical com- Add BP or retinoid if not already
Oral Therapy bination therapy (ie, BP/antibiotic using, or change topical retinoid
Although only two oral antibiot- combination, retinoid/BP combina- concentration/type/formulation,
ics (minocycline extended-release for tion, or retinoid/antibiotic combina- or change topical combination
moderate and severe acne and doxycy- tion plus BP) therapy.
cline delayed-release for severe acne) Moderate Topical combination therapy (ie, Change topical retinoid concentra-
are FDA-approved for the treatment retinoid/BP combination, BP/anti- tion/type/formulation, or change
biotic combination plus a retinoid, topical combination therapy; or
of acne, the use of oral antibiotics has
or retinoid/antibiotic combination add/change oral antibiotic; or con-
been common practice for decades. The plus BP) or oral antibiotic + topical sider hormonal therapy for female
goal of antibiotic therapy is to reduce retinoid/BP combination patients; or consider isotretinoin
the P. acnes count and therefore the referral.
inflammatory stimulus. Oral antibiot- Severe Combination therapy (oral antibiotic Consider changing oral antibiotic
ics are typically viewed as “anti-in- plus topical retinoid plus BP, with or and consider oral isotretinoin; con-
flammatory” treatment for acne, rather without topical antibiotic) sider hormonal therapy for female
patients.
than treatment for a true infection.32,33
By reducing the overall P. acnes load, BP = benzoyl peroxide.
Adapted from Eichenfield et al16
bacterial lipases (and therefore triglyc-
erides and subsequent free fatty acids)
are reduced as well. Oral antibiotics are
typically recommended when there is a Hormonal therapies, including spi- program is to reduce fetal exposure to
suboptimal response to a topical thera- ronolactone and combined oral contra- isotretinoin by requiring monthly preg-
peutic regimen, when there is wide- ceptive pills, are potentially effective nancy tests in females of childbearing
spread disease (ie, extensive truncal therapies in some patients with ado- age. Unfortunately, a recent retrospec-
disease) for which topical therapy alone lescent or young adult acne. Patients tive study of pregnancies occurring
may not be feasible, and when there is most likely to respond include females during isotretinoin use revealed that
greater overall severity that seem un- of childbearing age with acne accentu- iPLEDGE has not made a significant
likely to respond to topical treatments ated on the neck and in the mandibular impact in this regard.37 Isotretinoin is
alone.16,23,34 regions, those with perimenstrual flares most appropriately prescribed by der-
Chlortetracycline, the first antibiotic in their acne, those with hirsutism or matologists (or other clinicians familiar
in the cycline class, was introduced other features of androgen excess, and with its use); further discussion of this
in 1948.33 Antibiotics in this class are those with a poor response to conven- topic is beyond the scope of this article.
still first-line therapy for patients older tional treatments.
than 8 years with moderate-to-severe Oral isotretinoin is an extremely ef- DESIGNING A TREATMENT
inflammatory acne. Tetracycline, how- fective treatment for nodulocystic acne, REGIMEN
ever, has become less desirable in the and it was approved for use in 1982. Table 6 is a summary of recently
era of newer-generation cyclines, such It should be considered in patients published acne-treatment algorithms,
as minocycline and doxycycline, given with severe or resistant acne vulgaris with suggestions for initial therapy
its limitations related to dosing on an in whom the likelihood for scarring is and subsequent treatment modifica-
empty stomach and gastrointestinal considered significant. Isotretinoin is a tions based on acne severity. When
intolerance. Table 5 (see page 424) known teratogen, a fact that led to the developing a treatment plan for acne
summarizes the oral antibiotics most development of the iPLEDGE program. patients, one must evaluate the type
commonly used for acne therapy. Some iPLEDGE is an FDA-mandated regis- and severity of lesions as well as the
general guidelines in oral antibiotic tration program for prospective patients potential psychosocial impact. It is
therapy for acne are listed in Sidebar 2 as well as prescribing physicians and important to take into account the pa-
(see page 424). dispensing pharmacies. The goal of the tient’s perspective on their acne, as
PEDIATRIC ANNALS 42:10 | OCTOBER 2013 Healio.com/Pediatrics | 425FEATURE
some with even mild acne may be ex- ated and less drying than their prior ing of acne lesions indicate that most in-
flammatory lesions arise from comedo-
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have permanent scarring. The pathogenesis of acne is com-
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al. Body dysmorphic disorder among
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PFIZER INC
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impact of the iPLEDGE program on
SLACK INCORPORATED isotretinoin fetal exposure in an integrated
6900 Grove Road, Thorofare, NJ 08086 health care system. J Am Acad Dermatol.
Curbside Pediatrics...................................................................................................................................................395 2011;65(6):1117-1125.
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While every precaution is taken to ensure accuracy, Pediatric Annals cannot guarantee against occasional
changes or omissions in the preparation of this index.
Erratum:
At the request of the authors, the online article by Linda Van Horn, PHD, RD
and Eileen Vincent, MS, RD, “The CHILD 1 and DASH Diets: Rationale and
Translational Application” (September 2013) contains updated nutritional infor-
mation in the Tables that differs from the print version. It can be seen at Healio.
com/Pediatrics. Search the authors’ names to view those revisions.
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