Live Blog: Acne in the Pediatric Population – Fred Ghali, MD
In this live blog from the Annual Summer SDPA Conference in Las Vegas, Fred Ghali, MD, presented a lecture on “Acne in the Pediatric Population.” Here are some of the highlights.
Dr. Ghali covered a wide range of acne-related topics, including the basics of acne (prevalence, epidemiology, family dynamics, and differential diagnosis), common treatment options (including topical, oral, and hormonal therapies), and recent updates related to acne issues. Dr. Ghali also mentioned some unique situations related to athletes and acne.
An estimated 45 million people in the United States have acne vulgaris, with a prevalence of approximately 85% in the population 15-24 years of age. The disease is more common and more severe in males than in females, but acne typically lasts longer in females. The direct cost of acne may exceed $1 billion per year in the United States.
Acne is a Chronic Disease
Dr. Ghali pointed out that acne is a chronic disease. Your patients may commonly ask, “Will my acne ever go away,” which is a difficult question to answer, especially for the female patients. Up to 70% of acne cases are mild, but 30% of cases are more severe and may need years of treatment management. Dr. Ghali said that it’s important to assess the family dynamics during an appointment. Who is really there to see the doctor – the child, the parent or both? Adherence and compliance will be higher with patients when the child/teen is also motivated to follow the treatment course. Sometimes we see “mild” cases that the child and/or parent wishes to pursue the “strongest” meds off the bat. On the other hand, we also see “severe” cases that the child and/or parent feel is quite “normal” or “part of being a teen” and doesn’t require treatment.
Dr. Ghali also spoke about the importance of antibiotic stewardship. The CDC has been promoting a multidisciplinary initiative to ensure that patients receive the right antibiotic, at the right dose, at the right time, and for the right duration. Prolonged topical or oral antibiotic therapy for acne vulgaris is best accompanied by the use of BPO to optimize efficacy and mitigate the emergence of less sensitive P acnes strains. The goals are to optimize antimicrobial therapy, lessen the risk of adverse events, promote therapeutic cost (effectiveness), improve patient outcomes, and reduce/stabilize antimicrobial resistance. Dr. Ghali recommends seeing patients for initial follow up at two months. Topical antibiotics are taken for as long as the acne is active. On the hard question of oral antibiotics, Dr. Ghali said that while it seems longer than he would like, his goal is “several months.” With regards to monitoring oral antibiotics, routine monitoring of TCN, minocycline, doxycycline, and erythromycin is not supported in the literature, and Ghali said that he tends to check the patient if they are on minocycline for long periods. Serious side effects are mainly idiosyncratic and best detected by history and symptomatology.
The High-Impact Competitive Athlete
Many teenage acne patients are also competitive athletes. These patients often have unique needs. Playing football, in particular, can bring on severe acne. Shoulder pads and chin-straps can take mild acne into flares of severe types. Dr. Ghali declared, “As soon as that kid quits football, the acne improves.” Athletic patients who are on isotretinoin may also need special care. Dr. Ghali pointed out that often the patient might need a lower dose of isotretinoin treatment over a longer period of time. Sometimes athletic patients complain about pain in the knees, hips, or back. Complaints are most common from patients who participate in soccer, cross country/track, volleyball, dance/aerobics, and sometimes football. Dr. Ghali mentioned that perhaps an athlete could take a lower dose of isotretinoin during peak season and increase dosage during the off-season.
Dr. Ghali also touched on acne association with anabolic steroids. He said, “These have not gone away. No matter what you hear, kids are dying to get an edge.” When patients present with increased mood swings it’s important to get psych involved and rule out substance abuse prior to therapy.
Overall, Dr. Ghali stressed that, “Acne is an art. What works for one patient may not work for another.”