Get to the Roots of Pediatric Acne

Health care providers asked Dermatology Times® for resources to help answer questions like these and address their young patients’ needs for fast, effective, and safe skin clearance as well as improved quality of life (QOL). In response, Dermatology Times® collaborated with 2 sister brands, Contemporary Pediatrics® and Psychiat- ric TimesTM, to fill the information gap. This trio of MJH Life SciencesTM franchises brought together a multidisciplinary panel of renowned experts to share their insights on how to develop success- ful, comprehensive acne treatment regimens that deliver body/mind wellness; the resulting webinar, “Getting to the Roots of Childhood Acne,” was held December 15, 2021.

Hilary Baldwin, MD, medical director of the Acne Treatment and Research Center in Brooklyn, New York; clinical associate professor of dermatology at Rutgers Robert Wood Johnson Medical Center in New Brunswick, New Jersey; and past president of the American Acne and Rosacea Society, moderated the hour-long webinar. The event featured experts across 3 specialties who discussed detailed strategies for addressing acne’s psychological and mental health challenges from their unique perspectives.

Panelists for this exclusive presentation, supported by Sun Pharmaceutical Industries, were:

• Bernard A, Cohen, MD, a professor of pediatrics and dermatology and former director of the pediatric dermatology and laser program at Johns Hopkins University School of Medicine in Baltimore, Maryland, who has extensive knowledge of cutaneous laser surgery;
• Raegan Hunt, MD, PhD, division chief, pediatric dermatology, Texas Children’s Hospital in Houston, Texas, and vice chair for pediatric dermatology and assistant professor of dermatology and pediatrics at Baylor College of Medicine in Houston; and
• Sasha Jaquez, PhD, an assistant professor in the departments of psychiatry and behavioral sciences and pediatrics at Dell Medical School at The University of Texas at Austin, who works in the embedded dermatology clinic.

PATIENT ASSESSMENT: GET THE PATIENT’S HISTORY, THEN GET THEIR STORY

The initial visit with a pediatric or adolescent patient with acne and their parent or guardian goes beyond obtaining a detailed medical history. The conversation needs to address a broad range of acne’s physical symptoms and psychological effects on the patient and their family. The pan- elists offered best practices on how to drill down for that information within the time and scope limitations each doctor faces.

1. Identify the type of lesion—white head, blackhead, papule, pustule, node, or cyst—then use the explanation of its pre- senting characteristics to open a dialogue about what the patient is experiencing.

“Informing the patient about the type of lesion they have is important to the assessment,” Cohen said. “Patients and their families need to understand why, even if acne seems relatively mild, it may warrant some kind of therapy. I also make a point of finding out what sorts of treatments they’ve tried. I may see a patient who has what I would consider to be stage 0 to 1 acne, but I have to understand that they wouldn’t be in the office with a chief complaint of acne if it wasn’t a concern. Share statistics on how widespread this disease is, how ‘normal’ it is, and assure them that, although some past treatments may have failed, there are treatments that can work.”

2. Ask the patient how severe they feel the acne is.

“Acne may look mild to the clinician, but it may be severe in the eyes of the patient,” Hunt said. “There may also be a disconnect between the way parents and patients perceive this disease. That communication can be a little tricky to navigate, so have a plan ready to bring these views into a common perspective. Use various graphic or numeric rating tools that give the patient some strategy for rating how acne affects them, from pain levels to mental health issues.”

3. Evaluate whether to talk separately with patients and parents.

“Sometimes it’s a plus to have patients and parents together in a conversation about acne, but other times it makes the conversation more difficult. The patient may be telling the dermatologist that their acne is not bothering them that much, yet they’ve been complaining to the parent about it prompting the appointment. You can often see from a glance or body language that you are not getting the whole picture,” Hunt noted. She advised that if an adolescent patient seems embarrassed to talk about their acne in front of their family, the provider should ask the parent or parents to leave the exam room. “There are privacy issues to consider,” Cohen noted. Seeing parents alone also has benefits, said the panelists, especially if they feel guilty about waiting to schedule a medical visit to treat their child’s acne or have concerns about the disease’s mental and physical effects on that child.

4. Include questions on mental health.

“Patients and their families may be coming totheir pediatrician or dermatologist for acne treatment, but that physician may be the first or only medical provider that can screen for related mental health concerns such as anxiety and depression,” Jaquez said. “Ask open-ended questions— so, don’t ask, ‘Are you being bullied?’ Ask, ‘Is anybody picking on you [because of your acne]? Does anybody say anything about your skin, or do they say mean things? And do they make fun of you because of your skin?’ Dermatologists and pediatricians also need to speak with the parent to see if there are any significant changes in the patient’s behavior, such as poorer grades, mood shifts, or increased anxiety. “Often, slipping grades are the first thing we notice, and could constitute a mental health referral.,” Jaquez said.

DIAGNOSTIC PEARLS: WHAT TO LOOK FOR IN CHILDREN, TEENS

Like any skin condition, acne can be challenging to diagnose properly. Even when the lesions are textbook examples of one type of the disease, the physician needs to look beyond the obvious symptoms to get a clear, full picture of this disease’s impact on the patient.

1. For patients aged 1 to 7, learn to recognize underlying diseases such as androgen secreting tumors and watch for signs of precocious puberty.

“Monitor their growth chart for a sudden linear acceleration. Assess any signs of early sexual development,” Hunt said. “These factors can be important clues that there is underlying disease that needs to be dealt with appropriately.” Cohen added, “In addition to assessing diet and DHEA [dehydroepiandrosterone], which I often leave to the endocrinologist, I get a quick bone age scan for these patients, with an x-ray of the left hand, fingers, and wrist. It’s an easy test that is a relatively reliable indicator of the markers for precocious puberty. It’s something I might do just as an exclusion even if the patient shows no physical signs of precocious puberty or adrenal hyperplasia.”

2. For older children and teens, conduct a thorough exam.

“Look for any signs or symptoms that seem unexpected, such as early signs of polycystic ovary syndrome,” Hunt said. “Don’t stop with an exam of the face. At least 50% of our older teen patients who have facial acne also have truncal acne.” However, most of those patients won’t bring it up, according to Baldwin: “They don’t want to talk about it, but the vast majority want to be treated,” she said. Since the patient often won’t acknowledge they have truncal acne, I just have to take a look. If the patient is uncomfortable taking their shirt off in front of their parent[s], I ask them to leave the room.” Missing this diagnosis could have serious repercussions, Hunt added. “We’re missing some of these patients early on and missing our window to prevent problems in the future. I see terrible hypertrophic scarring from acne on the trunk, mostly in teenage boys,” she said. “It’s just very unfortunate, because if we could capture those patients much earlier and be more aggressive with their treatment, we could help prevent lifelong scarring.”

PATIENT-CENTRIC REGIMENS:
BUILD THE PLAN AROUND INDIVIDUAL NEEDS, PREFERENCES

No medication will work if the patient does not ingest or apply it. Engaging the patient in developing the treatment can help increase adherence and improve outcomes.

1. Make the patient's lifestyle and personal preferences integral parts of the decision-making.

“Treatment plans are not one-size-fits-all; they are not recipes,” Baldwin said. “Ask the patient sitting in front of you about their lifestyle. Are they a morning or [an] evening person? Do they get up 2 minutes before they leave for school or do they have a longer morning routine? Can they come home after school or do they stay out for activities or work? It’s important to match the patient sitting in front of me with the appropriate regimen.” Hunt suggests: “Ask the patient about how these various treatments fit into their routine. Ask what barriers they anticipate. Ask the parents about challenges that you could problem solve before treatment begins.”

2. Determine how invested the patient is in clearing their skin.

“I have found it helpful to ask on a scale of 1 to 10—1 being ‘What acne?’ and 10 being ‘Get this off my face or I’m going to have a fit’—how committed that patient is [in] trying anything to get clear skin,” Baldwin said. “In my experience, the person down at 2 is unlikely to use medication, whereas that person up at 10 will do virtually anything that I ask of them. And sometimes the mom is at 10 and the kid is at 1. It’s important to know that you’ve got that gap. You cannot create a complex treatment plan for a patient who will not commit to [adherence].”

3. Create a reward system for younger patients and a hard-to-ignore protocol for teens.

“Very young patients can be difficult to deal with in terms of therapeutic timing. The simplest solution would be a once-a-day treatment or one that is split into a dose in the morning and another before bedtime,” Cohen said. “Parents can incentivize their children by creating a rewards chart with daily check marks showing adherence. If the plan is simple and routine, the chance of the child getting a reward on the chart is always pretty close to 100%—which sends a positive message about the child’s ability to succeed.”

4. Make sure parents of younger children understand their involvement.

“Parents of 8- or 9-year-olds cannot just give the child a tube with the topical medication and make the child responsible for adherence,” Hunt cautioned. “Preadolescents probably need some parental assistance to manage their care. Having a written plan can be very helpful. It can be a little overwhelming to try to remember all the details of an acne care plan.”

5. Counsel parents of teens that there is a fine line between reminding and nagging.

Jaquez suggested advising parents to put visual reminders about acne medications in obvious places—taped to the refrigerator door, attached to a gym bag, or in a text. “The message is ‘I’ve given you the tools you need to treat the acne; now you have the opportunity to take control of your care.’ Let them drive that,” she said

6. Suggest parents tie adherence to teen’s goals for clear skin and better QOL.

“Talk with the patient and, in some cases, the entire family to emphasize the importance of adherence. Make it clear you understand the medical... and psychological issues,” Jaquez said. “Essentially, you’re asking them to spend a few minutes a day on the treatment. In return, they’re going to be able to wear a football helmet without discomfort, be on Zoom without embarrassment, and interact with other kids without worrying about negative comments about their acne.”

7. Take photographs to chart progress.

“Sometimes patients don’t see that they’re getting better. Take photographs to show themthat they are,” Cohen said. This can be a valuable incentive for those who go off their medication. “The photos also show what happens when they don’t [adhere],” he added.

TREATMENT CHOICES: OPTIMIZE OPPOR- TUNITIES PRESENTED BY NEW OPTIONS
A robust pipeline and new FDA approvals give physicians more ways to customize treatment.

1. Explore the topicals that form a more powerful and versatile part of the acne armamentarium.

Little to no systemic absorption has long made topicals a go-to for mild or moderate acne, but previous generations were limited in the body sites and severity they could treat. Now, significant innovations address those constraints. Some use a novel mechanism of action. “Clascoterone 1% cream [Winlevi; Sun Pharma] is something I am very excited about for both moderate to severe facial and truncal acne,” Cohen said. “The data on efficacy and safety are amazing.” Watch for more new topicals, some of which may be approved for children as young as 9. Cohen added that cost remains the biggest obstacle to prescribing the new treatments. “Some of our insurers will cover it, but many will not. I think over the next year we will see a dramatic improve- ment in access to this and other new treatments,” he said.

2. Avoid treatments that list irritation as an adverse effect, especially in younger patients.

“I find that if patients experience irritation with the first treatment you prescribe, it is very difficult to get them back into the office and started on a correct regimen,” Baldwin said. Advances in vehicles have vastly reduced irritation and improved tolerability for topicals, she added.

3. Classify acne before making treatment decisions, keeping in mind important exceptions for pediatric patients.

After ruling out underlying health issues, Cohen said, the next step is classifying the acne. Once that is decided, the treatment approaches don’t look categorically different for younger patients than adults, but there are extremely important exceptions. "Tetracycline derivatives are not indicated for patients younger than 8, as they can damage bone development and stain teeth,” Hunt said. She added that for acne that is mostly comedonal, she would likely use benzoyl peroxide and/or a topical retinoid; if it is mostly inflammatory, she would likely add topical or oral antibiotics.

4. When consideringisotretinoin, schedule time for a detailed conversation about its safety and efficacy.

Cohen advised starting with the basics: a complete understanding of the patient’s health issues and a detailed look at the medication’s risks and benefits. “Expect this to be a longer visit, in person or virtual, because it is important to sit down and go over everything,” he added. If the patient could become pregnant, the provider needs to detail the iPLEDGE Risk Evaluation Mitigation and Strategy program during that initial conversation, Cohen said.

He also cautioned against overlooking the possibility of other rare but less serious adverse effects: “We’ve had a couple of patients develop acne fulminans as a reaction to isotretinoin, but most patients, I’d say 90% to 95%, do well on it.” Jaquez added that dermatologists and pedi- atricians also need to be prepared to answer questions about the drug’s mental health effects. She advised doctors to not only lay out the con- cerns but also let patients know that they can have a referral to a mental health professional if they feel it is warranted.

PSYCHOLOGICAL WELL-BEING: LIFT ACNE’S BURDEN ON QOL
Any treatment plan needs to acknowledge the very real impact of acne on a patient’s self-esteem and life quality. But don’t forget the family members who experience pain or heartache alongside a young patient with this sometimes devastating disease.

1. Make it clear to patients that the practice’s medical team recognizes and acknowledges acne’s psychological toll.

“My team did a small survey looking at [QOL] issues in children with common dermatologic disorders and compared [them with] some significant nonneurologic issues in the literature. We found that dermatologic issues such as acne, psoriasis, and eczema scored as high in terms of negative impact on [QOL] as seizure disorders, asthma, and similar conditions,” Jaquez said.

2. Set aside at least a few minutes during each visit to talk with parents separately about acne’s impact on the entire family.

“Although the treatment plan is about the patient, don’t forget about the parents. They feel their child’s pain,” Baldwin said. She pointed to results from a 2021 survey, sponsored by Sun Pharma in collaboration with the American Acne and Rosacea Society, on how a teen’s moderate to severe acne affects their families and that more than 90% of parents who participated were “very worried” about the harmful impact of the skin disease on their adolescent’s physical, mental, and social wellness.¹ They also shared feelings of guilt about waiting too long to seek treatment, concerns about long-term scarring, and worries about their children’s mental health. “One of the most important things the physician can do is validate what the patient and parents are experiencing,” Jaquez said. “It may help to make a plan for going forward so that they stop feeling guilty and start working toward better dermatologic and mental health.”

3. Develop a network of collaborative psychologists or psychiatrists.

“Most dermatologists have experienced situations in which they are asking the patient questions about how acne impacts them and, suddenly, the emotional floodgates open,” Baldwin said. “Both pediatricians and dermatologists need to have a psychologist or psychiatrist on call to both help pediatric patients through a critical moment and provide ongoing care.”

Disclosures:

Baldwin is a consultant for Sun Pharma. Cohen, Hunt, and Jaquez reported no conflicts relevant to this event. Sun Pharma sponsored this webinar.

Reference:

1. Parents are very worried about the effects of severe acne on their teenage chil- dren as reported in a new survey. Sun Pharmaceuticals in collaboration with the American Acne and Rosacea Society. News release. Sun Pharma. April 7, 2021. Accessed January 14, 2022. https://www.sunpharmaderm.com/pdf/Sun_ Pharma_Acne_Survey_Press_Release.pdf