Rosacea

SAN FRANCISCO — Children can get acne at any age, but what parents think is acne actually may be something else, Dr. Rebecca L. Smith said at a meeting sponsored by Skin Disease Education Foundation.

A good example is "neonatal acne." That's what this imposter used to be called, until it was recognized as a pustulosis process, not acne, she said. Now called neonatal cephalic pustulosis, it is a common, transient eruption in the first weeks of life that is localized to cheeks, chin, forehead, and eyelids. Lesions may develop on the chest, neck, and scalp as well.

"This takes some hand holding" to get parents through these weeks until the lesions resolve, said Dr. Smith, a dermatologist in Fort Mill, S.C. If a parent demands treatment, a bit of topical 2% ketoconazole cream usually clears the skin quickly.

The term neonatal acne may be a thing of the past, but "infants can get acne, and it can be very bad," she acknowledged. It's most common on the cheeks, and more likely in boys than in girls. "You can treat these children just like virtually any other acne patients, with topical and oral antibiotics and even topical tretinoin at times. Extreme cases can be treated with isotretinoin," she added.

The situation changes after the first year, however. Dr. Smith refers any child between 1 year of age and puberty who has bad acne to an endocrinologist. Neonatal adrenal glands produce only minimal androgen after 1 year of life, so acne in early childhood raises concern about underlying disease and hyperandrogenism. "I don't keep them. I send them off to my colleagues" in endocrinology, she said.

"We're seeing children younger and younger these days" with typically midfacial acne that's often the first sign of pubertal maturation, she said. These acne-prone children secrete sebum in the midfacial area earlier than do children without acne.

When it comes to management, Dr. Smith said she tries to translate the treatment strategy into terms children can understand, targeting as many age-appropriate factors as possible.

"We're going to treat your oil, treat your plugs, treat your bugs, and then treat your redness," she tells them. "A teenager can get that." That corresponds with treating sebum, faulty follicular keratinization, bacteria, and inflammation.

To avoid inducing drug resistance in Propionibacterium acnes, use the least aggressive treatment regimen that provides a sustained response, she advised. "I'm not worried about P. acnes resistance. [I'm] worried about P. acnes sharing that" resistance with other bacteria.

She said she always adds benzoyl peroxide to antibiotic therapy for acne because it increases antibiotic penetration and creates a tough environment for P. acnes. Some combination products are on the market. Patients should be told that these products can bleach clothing, pillowcases, carpet, and hair, but not skin, she said.

Retinoids are the foundation of maintenance therapy for acne. "I want everyone on retinoids eventually," she said. Many retinoid options are available. Get to know them, and choose the one that's right for each patient, she suggested.

Don't instruct children to use a pea-sized amount for the entire face, because that may not mean much to vegetable-averse children. "Tell them to use a chocolate chip-sized amount," and show them how to dot the face and rub the retinoid in, she said.

To increase children's ability to tolerate retinoid therapy, have them wash their faces with a gentle cleanser and apply an oil-free moisturizer before applying the retinoid. This may slightly decrease the effect of the retinoid, but increased adherence to therapy can provide better results than applying the retinoid alone, she said. Another strategy is to titrate dosing by starting applications every second or third night for the first week, and increasing frequency as tolerated.

Dr. Smith has been a speaker or adviser for, or has received funding from, companies that make retinoids, antibiotics, or tretinoin products for the treatment of acne. These companies include Allergan, CollaGenex, Dermik, Galderma, Medicis, SkinMedica, Stiefel, and Warner Chilcott.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Children can get acne at any age, but what parents think is acne actually may be something else, Dr. Rebecca L. Smith said at a meeting sponsored by Skin Disease Education Foundation.

A good example is "neonatal acne." That's what this imposter used to be called, until it was recognized as a pustulosis process, not acne, she said. Now called neonatal cephalic pustulosis, it is a common, transient eruption in the first weeks of life that is localized to cheeks, chin, forehead, and eyelids. Lesions may develop on the chest, neck, and scalp as well.

"This takes some hand holding" to get parents through these weeks until the lesions resolve, said Dr. Smith, a dermatologist in Fort Mill, S.C. If a parent demands treatment, a bit of topical 2% ketoconazole cream usually clears the skin quickly.

The term neonatal acne may be a thing of the past, but "infants can get acne, and it can be very bad," she acknowledged. It's most common on the cheeks, and more likely in boys than in girls. "You can treat these children just like virtually any other acne patients, with topical and oral antibiotics and even topical tretinoin at times. Extreme cases can be treated with isotretinoin," she added.

The situation changes after the first year, however. Dr. Smith refers any child between 1 year of age and puberty who has bad acne to an endocrinologist. Neonatal adrenal glands produce only minimal androgen after 1 year of life, so acne in early childhood raises concern about underlying disease and hyperandrogenism. "I don't keep them. I send them off to my colleagues" in endocrinology, she said.

"We're seeing children younger and younger these days" with typically midfacial acne that's often the first sign of pubertal maturation, she said. These acne-prone children secrete sebum in the midfacial area earlier than do children without acne.

When it comes to management, Dr. Smith said she tries to translate the treatment strategy into terms children can understand, targeting as many age-appropriate factors as possible.

"We're going to treat your oil, treat your plugs, treat your bugs, and then treat your redness," she tells them. "A teenager can get that." That corresponds with treating sebum, faulty follicular keratinization, bacteria, and inflammation.

To avoid inducing drug resistance in Propionibacterium acnes, use the least aggressive treatment regimen that provides a sustained response, she advised. "I'm not worried about P. acnes resistance. [I'm] worried about P. acnes sharing that" resistance with other bacteria.

She said she always adds benzoyl peroxide to antibiotic therapy for acne because it increases antibiotic penetration and creates a tough environment for P. acnes. Some combination products are on the market. Patients should be told that these products can bleach clothing, pillowcases, carpet, and hair, but not skin, she said.

Retinoids are the foundation of maintenance therapy for acne. "I want everyone on retinoids eventually," she said. Many retinoid options are available. Get to know them, and choose the one that's right for each patient, she suggested.

Don't instruct children to use a pea-sized amount for the entire face, because that may not mean much to vegetable-averse children. "Tell them to use a chocolate chip-sized amount," and show them how to dot the face and rub the retinoid in, she said.

To increase children's ability to tolerate retinoid therapy, have them wash their faces with a gentle cleanser and apply an oil-free moisturizer before applying the retinoid. This may slightly decrease the effect of the retinoid, but increased adherence to therapy can provide better results than applying the retinoid alone, she said. Another strategy is to titrate dosing by starting applications every second or third night for the first week, and increasing frequency as tolerated.

Dr. Smith has been a speaker or adviser for, or has received funding from, companies that make retinoids, antibiotics, or tretinoin products for the treatment of acne. These companies include Allergan, CollaGenex, Dermik, Galderma, Medicis, SkinMedica, Stiefel, and Warner Chilcott.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — Children can get acne at any age, but what parents think is acne actually may be something else, Dr. Rebecca L. Smith said at a meeting sponsored by Skin Disease Education Foundation.

A good example is "neonatal acne." That's what this imposter used to be called, until it was recognized as a pustulosis process, not acne, she said. Now called neonatal cephalic pustulosis, it is a common, transient eruption in the first weeks of life that is localized to cheeks, chin, forehead, and eyelids. Lesions may develop on the chest, neck, and scalp as well.

"This takes some hand holding" to get parents through these weeks until the lesions resolve, said Dr. Smith, a dermatologist in Fort Mill, S.C. If a parent demands treatment, a bit of topical 2% ketoconazole cream usually clears the skin quickly.

The term neonatal acne may be a thing of the past, but "infants can get acne, and it can be very bad," she acknowledged. It's most common on the cheeks, and more likely in boys than in girls. "You can treat these children just like virtually any other acne patients, with topical and oral antibiotics and even topical tretinoin at times. Extreme cases can be treated with isotretinoin," she added.

The situation changes after the first year, however. Dr. Smith refers any child between 1 year of age and puberty who has bad acne to an endocrinologist. Neonatal adrenal glands produce only minimal androgen after 1 year of life, so acne in early childhood raises concern about underlying disease and hyperandrogenism. "I don't keep them. I send them off to my colleagues" in endocrinology, she said.

"We're seeing children younger and younger these days" with typically midfacial acne that's often the first sign of pubertal maturation, she said. These acne-prone children secrete sebum in the midfacial area earlier than do children without acne.

When it comes to management, Dr. Smith said she tries to translate the treatment strategy into terms children can understand, targeting as many age-appropriate factors as possible.

"We're going to treat your oil, treat your plugs, treat your bugs, and then treat your redness," she tells them. "A teenager can get that." That corresponds with treating sebum, faulty follicular keratinization, bacteria, and inflammation.

To avoid inducing drug resistance in Propionibacterium acnes, use the least aggressive treatment regimen that provides a sustained response, she advised. "I'm not worried about P. acnes resistance. [I'm] worried about P. acnes sharing that" resistance with other bacteria.

She said she always adds benzoyl peroxide to antibiotic therapy for acne because it increases antibiotic penetration and creates a tough environment for P. acnes. Some combination products are on the market. Patients should be told that these products can bleach clothing, pillowcases, carpet, and hair, but not skin, she said.

Retinoids are the foundation of maintenance therapy for acne. "I want everyone on retinoids eventually," she said. Many retinoid options are available. Get to know them, and choose the one that's right for each patient, she suggested.

Don't instruct children to use a pea-sized amount for the entire face, because that may not mean much to vegetable-averse children. "Tell them to use a chocolate chip-sized amount," and show them how to dot the face and rub the retinoid in, she said.

To increase children's ability to tolerate retinoid therapy, have them wash their faces with a gentle cleanser and apply an oil-free moisturizer before applying the retinoid. This may slightly decrease the effect of the retinoid, but increased adherence to therapy can provide better results than applying the retinoid alone, she said. Another strategy is to titrate dosing by starting applications every second or third night for the first week, and increasing frequency as tolerated.

Dr. Smith has been a speaker or adviser for, or has received funding from, companies that make retinoids, antibiotics, or tretinoin products for the treatment of acne. These companies include Allergan, CollaGenex, Dermik, Galderma, Medicis, SkinMedica, Stiefel, and Warner Chilcott.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

MIAMI — Nonablative fractional resurfacing with an erbium-doped 1,550-nm laser device can safely and effectively improve acne scarring among patients with skin types IV-VI, Dr. Wendy E. Roberts said at an international symposium sponsored by L'Oréal Institute for Ethnic Hair and Skin Research.

"Treatment of acne scars with ablative lasers in skin types IV-VI has been limited because of hypopigmentation and depigmentation risks," she said. This significant risk of hypopigmentation, in particular, has limited laser resurfacing for distensible and nondistensible acne scars in skin types other than I-III.

In search of better results, researchers assessed nonablative fractional photothermolysis in 40 patients with skin types IV through VI. Dr. Roberts presented the findings on behalf of the lead investigator, Dr. Vic A. Narurkar, a dermatologist in San Francisco who was unable to attend the meeting.

"This study was motivated by the fact that most laser and light-based technologies are risky in skin types IV-VI, especially for hypopigmentation. And if they are safe, they are generally ineffective," Dr. Narurkar said in a follow-up interview.

Dr. Narurkar and his associates, Dr. Joely Kaufman and Dr. Zakia Rahman, enrolled patients with moderate to severe acne scarring from three clinical sites. Presentations included distensible, nondistensible, ice pick, and box-type scars. Participants were treated with an erbium-doped 1,550-nm Fraxel laser (Reliant Technologies) at 4- to 6-week intervals.

"Resurfacing, particularly for acne scars, has, until the development of the Fraxel laser, not been a viable option for darker skin with traditional lasers," said Dr. Narurkar, who is a consultant for Reliant. Dr. Roberts reported no conflict of interest related to the company.

A nontreating physician scored photographs taken at baseline and at 6 months or longer after completion of the three to five treatment sessions. Every participant showed some improvement, so there were no patients classified as grade 0 (no improvement). Six percent were grade 1 (up to 25% improvement); 34% were grade 2 (26%-50%); 42% were grade 3 (51%-75%); and 18% were grade 4 (76% or greater).

"The majority of patients showed a 50% or greater improvement in acne scars," said Dr. Roberts, a dermatologist in Rancho Mirage, Calif., who also is with the department of medicine at Loma Linda (Calif.) University Medical Center.

Because of the risk of adverse events, use of nonablative fractional resurfacing can be more challenging for patients with ethnic skin. "You really have to not know what you are doing with this to cause any damage in skin types I-III. But it does get tricky in skin types IV-VI. If your laser settings are not conservative, you can get edema and postinflammatory hyperpigmentation," Dr. Roberts said at the meeting, which was also sponsored by Howard University.

In the study, 22% of patients experienced transient postinflammatory hyperpigmentation (PIH) and 28% had acne flares. "We can work through the flares and treat the PIH," Dr. Roberts said. "There was no hypopigmentation, which is quite remarkable."

"We were most impressed with the fact that there were no permanent adverse effects, and even the postinflammatory hyperpigmentation eventually resolved," Dr. Narurkar said. "Future studies include the use of pre- and posttreatment regimens for Fraxel to speed up the recovery and reduce both PIH and acne flares."

A patient is shown at baseline (left) and after undergoing five treatments with an erbium-doped 1,550-nm laser. Photos courtesy Dr. Zakia Rahman

MIAMI — Nonablative fractional resurfacing with an erbium-doped 1,550-nm laser device can safely and effectively improve acne scarring among patients with skin types IV-VI, Dr. Wendy E. Roberts said at an international symposium sponsored by L'Oréal Institute for Ethnic Hair and Skin Research.

"Treatment of acne scars with ablative lasers in skin types IV-VI has been limited because of hypopigmentation and depigmentation risks," she said. This significant risk of hypopigmentation, in particular, has limited laser resurfacing for distensible and nondistensible acne scars in skin types other than I-III.

In search of better results, researchers assessed nonablative fractional photothermolysis in 40 patients with skin types IV through VI. Dr. Roberts presented the findings on behalf of the lead investigator, Dr. Vic A. Narurkar, a dermatologist in San Francisco who was unable to attend the meeting.

"This study was motivated by the fact that most laser and light-based technologies are risky in skin types IV-VI, especially for hypopigmentation. And if they are safe, they are generally ineffective," Dr. Narurkar said in a follow-up interview.

Dr. Narurkar and his associates, Dr. Joely Kaufman and Dr. Zakia Rahman, enrolled patients with moderate to severe acne scarring from three clinical sites. Presentations included distensible, nondistensible, ice pick, and box-type scars. Participants were treated with an erbium-doped 1,550-nm Fraxel laser (Reliant Technologies) at 4- to 6-week intervals.

"Resurfacing, particularly for acne scars, has, until the development of the Fraxel laser, not been a viable option for darker skin with traditional lasers," said Dr. Narurkar, who is a consultant for Reliant. Dr. Roberts reported no conflict of interest related to the company.

A nontreating physician scored photographs taken at baseline and at 6 months or longer after completion of the three to five treatment sessions. Every participant showed some improvement, so there were no patients classified as grade 0 (no improvement). Six percent were grade 1 (up to 25% improvement); 34% were grade 2 (26%-50%); 42% were grade 3 (51%-75%); and 18% were grade 4 (76% or greater).

"The majority of patients showed a 50% or greater improvement in acne scars," said Dr. Roberts, a dermatologist in Rancho Mirage, Calif., who also is with the department of medicine at Loma Linda (Calif.) University Medical Center.

Because of the risk of adverse events, use of nonablative fractional resurfacing can be more challenging for patients with ethnic skin. "You really have to not know what you are doing with this to cause any damage in skin types I-III. But it does get tricky in skin types IV-VI. If your laser settings are not conservative, you can get edema and postinflammatory hyperpigmentation," Dr. Roberts said at the meeting, which was also sponsored by Howard University.

In the study, 22% of patients experienced transient postinflammatory hyperpigmentation (PIH) and 28% had acne flares. "We can work through the flares and treat the PIH," Dr. Roberts said. "There was no hypopigmentation, which is quite remarkable."

"We were most impressed with the fact that there were no permanent adverse effects, and even the postinflammatory hyperpigmentation eventually resolved," Dr. Narurkar said. "Future studies include the use of pre- and posttreatment regimens for Fraxel to speed up the recovery and reduce both PIH and acne flares."

A patient is shown at baseline (left) and after undergoing five treatments with an erbium-doped 1,550-nm laser. Photos courtesy Dr. Zakia Rahman

MIAMI — Nonablative fractional resurfacing with an erbium-doped 1,550-nm laser device can safely and effectively improve acne scarring among patients with skin types IV-VI, Dr. Wendy E. Roberts said at an international symposium sponsored by L'Oréal Institute for Ethnic Hair and Skin Research.

"Treatment of acne scars with ablative lasers in skin types IV-VI has been limited because of hypopigmentation and depigmentation risks," she said. This significant risk of hypopigmentation, in particular, has limited laser resurfacing for distensible and nondistensible acne scars in skin types other than I-III.

In search of better results, researchers assessed nonablative fractional photothermolysis in 40 patients with skin types IV through VI. Dr. Roberts presented the findings on behalf of the lead investigator, Dr. Vic A. Narurkar, a dermatologist in San Francisco who was unable to attend the meeting.

"This study was motivated by the fact that most laser and light-based technologies are risky in skin types IV-VI, especially for hypopigmentation. And if they are safe, they are generally ineffective," Dr. Narurkar said in a follow-up interview.

Dr. Narurkar and his associates, Dr. Joely Kaufman and Dr. Zakia Rahman, enrolled patients with moderate to severe acne scarring from three clinical sites. Presentations included distensible, nondistensible, ice pick, and box-type scars. Participants were treated with an erbium-doped 1,550-nm Fraxel laser (Reliant Technologies) at 4- to 6-week intervals.

"Resurfacing, particularly for acne scars, has, until the development of the Fraxel laser, not been a viable option for darker skin with traditional lasers," said Dr. Narurkar, who is a consultant for Reliant. Dr. Roberts reported no conflict of interest related to the company.

A nontreating physician scored photographs taken at baseline and at 6 months or longer after completion of the three to five treatment sessions. Every participant showed some improvement, so there were no patients classified as grade 0 (no improvement). Six percent were grade 1 (up to 25% improvement); 34% were grade 2 (26%-50%); 42% were grade 3 (51%-75%); and 18% were grade 4 (76% or greater).

"The majority of patients showed a 50% or greater improvement in acne scars," said Dr. Roberts, a dermatologist in Rancho Mirage, Calif., who also is with the department of medicine at Loma Linda (Calif.) University Medical Center.

Because of the risk of adverse events, use of nonablative fractional resurfacing can be more challenging for patients with ethnic skin. "You really have to not know what you are doing with this to cause any damage in skin types I-III. But it does get tricky in skin types IV-VI. If your laser settings are not conservative, you can get edema and postinflammatory hyperpigmentation," Dr. Roberts said at the meeting, which was also sponsored by Howard University.

In the study, 22% of patients experienced transient postinflammatory hyperpigmentation (PIH) and 28% had acne flares. "We can work through the flares and treat the PIH," Dr. Roberts said. "There was no hypopigmentation, which is quite remarkable."

"We were most impressed with the fact that there were no permanent adverse effects, and even the postinflammatory hyperpigmentation eventually resolved," Dr. Narurkar said. "Future studies include the use of pre- and posttreatment regimens for Fraxel to speed up the recovery and reduce both PIH and acne flares."

A patient is shown at baseline (left) and after undergoing five treatments with an erbium-doped 1,550-nm laser. Photos courtesy Dr. Zakia Rahman