Pediatric Primary Care Case Studies (124 page)

Staging the severity of the condition is important to select the appropriate management strategy. Acne is sometimes graded as mild if there are less than 15 lesions and mostly comedones. It is considered moderate if there are 15 to 50 papules and pustules and rare cysts. Severe acne is defined as a predominance of nodules and cysts. Acne fulminans is an acute disorder that requires intensive treatment. It is rare but would present with ulcerative, nodular lesions on the face and upper trunk accompanied by fever, leukocytosis, elevated sedimentation rate, and polyarthritis (Paller & Mancini, 2006).

Other diagnoses to consider but that do not fit this picture include folliculitis, perioral dermatitis, rosacea, and seborrheic dermatitis (Roebuck, 2006).

Do you need to do anything to confirm the diagnosis, such as laboratory studies?

No laboratory studies are recommended in general management of acne. Endocrine studies would be needed if an endocrine evaluation was merited based upon the physical findings.

Management

Therapeutic plan: What will you do therapeutically?

The plan is determined by the type and severity of the acne and needs to be customized to improve the patient’s adherence to the plan. The goals are to:

•   Decrease excess sebum

•   Decrease the abnormal keratinization and desquamation in the pilose-baceous follicle

•   Decrease the colony count of
P. acnes

•   Decrease inflammation

•   Decrease the risks of scarring

Decreasing embarrassment and increasing self-esteem are also important goals.

Treatment Options

You need to understand the various treatment options before you can create an individualized plan for this Hispanic adolescent. “Topical therapy is the standard of care for acne” (Strauss et al., 2007, p. 653).

The mainstay and first treatment of acne is a topical retinoid. Topical retinoids are also a mainstay of maintenance therapy. Their primary mechanism of action is normalization of follicular keratinization and perhaps facilitation of follicular penetration of other agents. These products help prevent microcomedones, the precursor of all the other lesions of acne. Retinoids are drying and somewhat irritating to the skin. Application on alternate nights or just two to three times per week is sometimes needed at the beginning of therapy (Roebuck, 2006). Retinoids should be applied to very dry skin to avoid the irritating effects. Alternative choices are azelaic acid or salicylic acid preparations, but these are less effective agents (Strauss et al., 2007).

Benzoyl peroxide is the next therapeutic agent commonly used for acne management. It serves as an antibacterial, comedolytic agent and oxidizing agent. It is available in a variety of concentrations and vehicles though there is little evidence to evaluate the efficacy of these different formulations (Strauss et al., 2007). Gels, topical cleansers, pads, and creams are all available. Benzoyl peroxide is the most common ingredient in over-the-counter acne products (Institute for Clinical Systems Improvement, 2006).

Topical antibiotics are used for moderate and severe acne conditions.
Propionibacterium acnes
is an anaerobic bacterium present in pilosebaceous follicles. The antibiotics reduce colonization and may possess direct anti-inflammatory effects. A combination of erythromycin or clindamycin and a topical retinoid are more effective than either agent alone. Combining either of these agents with benzoyl peroxide decreases bacterial resistance and enhances efficacy and again, combining the products is more effective than using either product alone (Strauss et al., 2007).

Oral antibiotics are considered the standard of care for moderate and severe acne and treatment-resistant forms of inflammatory acne (Strauss et al., 2007). Doxycycline and minocycline are more effective than tetracycline; minocycline may be more effective than doxycycline. Erythromycin should be used only in those who cannot use the tetracyclines because bacterial resistance is common. Trimethoprim-sulfamethoxazole can be used when the other antibiotics cannot be used. Azithromycin has also been used. There are no studies that support use of ampicillin, amoxicillin, or cephalexin according to the expert panel of the American Academy of Dermatology (Strauss et al.). Because antibiotic resistance is increasing and there are some side effects of antibiotics, they should all be used for as short a time as possible. Vaginal candidiasis is a problem for female patients with all the antibiotics. Doxycycline is associated with photosensitivity. Minocycline may cause pigment deposition in skin, mucous membranes, and teeth. Pigmentation may occur in acne scars, anterior shins, and mucous membranes. Autoimmune hepatitis and serum sickness-like reactions are all rare occurrences with minocycline (Strauss et al.).

Hormonal agents may also be helpful in treatment of acne among women. These decrease androgen levels and thus the production of sebum. Oral contraceptives,
spironolactone, and cyproterone acetate are among these types of agents. Oral corticosteroids used in short courses of high dose may be beneficial in patients with highly inflammatory disease but are not considered mainstays of treatment (Strauss et al., 2007).

Oral isotretinoin, a vitamin-A derivative, is approved for treatment of severe acne. It can also be used in less severe cases where either physical or psychological scarring is occurring. It is a potent teratogen and has many other serious adverse effects so it should only be prescribed by physicians knowledgeable in its administration and monitoring. Female patients must participate in the iPLEDGE program (
http://www.ipledgeprogram.com
). Mood disorders, depression, and suicidal ideation have been reported in addition to other effects summarized in
Table 31-1
.

The summary of a plan for management of acne of different types and in different levels of severity is found in
Table 31-2
.

In José’s case, it would be appropriate to prescribe a topical retinoid, benzoyl peroxide, and a topical antibiotic. You choose adapalene 0.1% cream because it is effective and has fewer problems with burning and drying than other agents, and 1% clindamycin with 5% benzoyl peroxide (Duac gel), which should be easy for him to use. You prescribe the adapalene for use at night. The Duac can be applied after the adapalene. Use of an oral antibiotic such as doxycycline is also an option, but you choose to begin more conservatively and then see if it should be added to the regimen later.

Educational plan: What will you do to educate him and his mother about acne and its management?

Points to make through discussion include:

   Explain the diagnosis and its pathophysiology, chronic nature, and need for maintenance after it is brought under control.

   Explain the use of the various agents you are prescribing: adapalene 0.1% cream, 1% clindamycin with 5% benzoyl peroxide (Duac), and their side effects.

   Reassure them that acne is very treatable but results may not be apparent for 6 to 12 weeks. He will need to be patient until the improvements begin.

   Alert him that an increase in the number of lesions is common as all the developing ones in the skin layers emerge, but this effect will subside as the lesions are eliminated.