Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. On this episode, we’ll hear about acne management in pediatric patients from Dr. Peter Lio. Dr. Lio is a Clinical Assistant Professor of Dermatology and Pediatrics at Northwestern University Feinberg School of Medicine and a dermatologist at Medical Dermatology Associates of Chicago. Let’s hear from him now.
Dr. Lio:
So the treatment of acne is one of those things that has continued to be refined and has continued to get, in my opinion, much better than even just a few years ago. We now have multiple new combination agents that do a lot of the hard work for us and our patients, but we also have some totally new classes of therapy that are incredible. In general, I really like to refer back to the 2024 American Academy of Dermatology Acne Management guidelines. They’re very well written. The group of experts on there is not only incredibly accomplished and world renowned for their knowledge, but they’re real clinicians who are taking care of these patients, so it’s also very practical. And they break it down into both mild and then moderate-to-severe groups.
To me, the most important take-home point is that essentially everybody uses topicals, and that’s true for almost all of our patients. We’re not only going to start there, but even for patients that are going to require secondary things like systemic antibiotics, hormonal agents, or even isotretinoin, they’re all going to be on topicals in the beginning, and, generally speaking, concomitantly with their other therapies. So we think about it like this: we have the oldies but goodies, which are our topical benzoyl peroxide—that’s been around since the very beginning—and our topical antibiotics as well, things like clindamycin, which can be very helpful. And then we have our topical retinoids, so our legacy retinoids and even some newer ones that are better in some ways.
Of course, with that sometimes comes some more cost, but typically, we’re going to use some combination of those three things. And the general recommendation is not to use monotherapy. Just using one of those things alone is probably not a great choice for almost anybody; although, sometimes we can add them in one at a time if we’re worried about somebody being sensitive to them. The good thing is now we have a number of different fixed-dose combination products: sometimes topical antibiotic plus benzoyl, topical retinoid plus benzoyl, topical retinoid plus an antibiotic, and then even these triple agents, so we have all three together, which is pretty exciting. And of course, we have some of the other agents, like salicylic and azelaic acid, in addition to physical modalities.
When we’re talking to our patients, this has to be a shared decision-making process. Just the sheer number of different potential treatments and all their specifics means that we have to put together a regimen for patients that’s going to work for them. So especially for little kids, I’m a little bit more cautious with our retinoids. I think you can give essentially 100 percent of patients a topical antibiotic and not have to worry. Topical clindamycin lotion has been around for a long time. It’s extremely well tolerated. But the side effect profile is not zero. There are potential issues that can happen, including colitis. We know that it can actually cause a C. diff infection in some patients, although that seems fleetingly rare.
That being said, by itself it’s not very effective either. So you can have things that might be very easy to give but don’t do much, which means we often have to pair them. But a lot of my patients, for example, have atopic dermatitis concomitantly, and so I’m worried about starting a retinoid. I’ll need to either pick one that’s ultra gentle or give them lots of instructions about how to start that retinoid. I might say, “I want you to use it every other night or even just once or twice a week in the beginning.” Or the most extreme version of that would be doing what is called short contact therapy, where they put their retinoid on, leave it on just long enough to brush their teeth, then wash it off and moisturize, so they get just a tiny exposure in the beginning to slowly harden their skin or toughen it up to the retinoids. Mostly everybody, I think, can eventually use retinoids, but in the very beginning that could be trouble.
Of course, other things, even the over-the-counters like salicylic acid or benzoyl peroxide, can be extremely irritating and bothersome for some patients, and they can make things worse in some situations. And, of course, the topicals generally speaking are safer than our systemic therapies, so for antibiotics, we have to be very careful.
Announcer:
That was Dr. Peter Lio sharing strategies for managing pediatric patients with acne. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!