SEATTLE The treatment of acne in adolescents should be tailored to the type and severity of lesions and the adolescent's age, according to Dr. Annette Wagner.
Fully 80% of teenagers develop acne, noted Dr. Wagner, a pediatric dermatologist at Northwestern University in Chicago. "But the age of onset is really young now that puberty is starting earlier," she commented. "I see comedones on many 8-year-olds in my clinic."
Myths abound when it comes to the cause of acne, she said at a meeting sponsored by the American Academy of Pediatrics. Chocolate, fatty foods, poor eating habits, and lack of cleanliness have all been wrongly accused. The real culprit is an inherited genetic predisposition to form comedones, or pores plugged by keratin behind which oil and bacteria can accumulate.
"This is familial," she stressed. "That's the No. 1 big thing, and I tell that to every adolescent in the room in front of the parent, because parents can make their kids feel responsible for their acne," nagging them about diet, not washing their face, and such.
Myths are equally common when it comes to treating acne. Removing oil is ineffective because oil itself is not to blame, she said. And although most teenagers believe otherwise, sunlight does not improve acne; in fact, because it stimulates T cells in the skin, sun exposure causes the condition to flare.
As long as cosmetics are labeled noncomedogenic or nonacneogenicand most today arethey neither cause nor worsen acne, according to Dr. Wagner. Facials promote desquamation of the skin, but this process is not impaired in adolescence, and facials can do more harm than good. "Don't let cosmetologists manipulate the faces of your adolescents," she recommended. "That's not an appropriate treatment for acne."
Perhaps the most important myth of all is that acne is harmless, she commented. "Not only does it cause scarring, it does so much to make adolescents feel bad about themselves," she observed. "If you can offer treatment that will help, you are doing the right thing."
Moreover, "acne should be treated at any agedon't wait for these children to be adolescents or high school students," Dr. Wagner commented, offering some rules of thumb as to when treatment is appropriate. "I always treat it when any patient requests it, even if it's minor acne," she said, and all adolescents with lesions should be offered treatment. Systemic treatment is also warranted if acne is visible from across the examination room or if it has caused any scarring.
As far as skin care basics, Dr. Wagner recommended that young people with acne be advised to wash their skin gently. "Tell them, use your handsnot washcloths, not buff puffs, not exfoliants. Those make acne worse." They should also use a mild soap, preferably a liquid one, and apply sunscreen daily.
Excessive washing, application of petroleum jelly, and manipulation should be avoided. "I tell kids, if you squeeze a zit, you are going to be looking at it for about a month; if you don't squeeze it, it will dry up in about 10 days," she said.
Topical steroids used to treat seborrheic dermatitis also will worsen acne, she noted, so other agents should be selected for managing scale around the nose and scalp, or in the skin creases. Friction and sweating under clothing, as occur especially in young athletes, and exposure to aerosolized fat, as occurs in teenagers who work over deep fryers, also are exacerbating factors.
"But probably the thing that worsens acne more than anything else is working too hard to get rid of it," Dr. Wagner commented. "So less is better in this particular case."
Adolescents with relatively mild acne should be started on benzoyl peroxide, Dr. Wagner advised. "I like to put it in a wash form," she noted. "I tell them, wash your face with it in the morning and at night. That prevents them from using cleansers that aren't right."
In addition, they also should be prescribed a topical retinoid and, if they have inflammatory lesions, a topical antibiotic. Because retinoids can cause peeling, they should initially be used every other day and applied in a very small amounta quarter of the size of a peaonly to the area affected by comedones, with a gradual increase in frequency and amount.
Importantly, Dr. Wagner noted, adolescents should be counseled about a realistic time frame for seeing improvement. "It takes 3 months to get a comedone out of your skin with appropriate treatment, and it sometimes takes a month and half to even be able to use the retinoid every night," she said. "So this is not going to happen for this weekend's dance, and you have got to tell them that because that is their expectation."