Acne is an extremely common condition, affecting up to 80% of adolescents. Many cases are mild and may be considered “physiological”, but others can be very severe and lead to permanent scarring. Paediatricians will frequently encounter acne in their practice, and have an important role in identifying and advising patients who require treatment.

This review focuses on the practical management of acne from a paediatric perspective, with an emphasis on relating treatment decisions to currently available evidence. Many clinical trials of acne treatment have been carried out in the last 25 years, but they are of variable quality. Hence, there are grey areas, where treatment has to be guided by consensus opinion or clinical experience until better evidence is available.

CLINICAL FEATURES AND AETIOLOGY

Acne is a disease of pilosebaceous follicles. Under the influence of androgens, usually around puberty, the sebaceous glands enlarge and produce excess sebum. At the same time, keratinocytes in the sebaceous duct proliferate and cause blockage. These events lead to comedone formation. As a secondary event, Propionibacterium acnes (P acnes) colonise the comedones causing inflammation, which leads to papules and pustules.

Clinically, acne usually affects the face first, with the back and chest affected in more severe cases. The lesions seen are blackheads (open comedones), whiteheads (closed comedones), papules, pustules and sometimes nodules, cysts, and scars.

TREATMENT

Treatment is influenced by the type of lesions, severity, sex and age of patient, psychological impact of the disease, and presence of scarring.

In exceptional circumstances where there is abnormal androgen production, or an external cause, treatment is directed to the underlying cause.

All acne treatments take up to 12 weeks to reach maximum benefit, and should usually be continued for several months. Education regarding the natural history of acne and expectations of treatment will improve compliance.

TREATMENT OF MILD ACNE

Case history A

Michael, who is 13, has been attending …