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Approach to pediatric acne treatment: an update.

By late adolescence, almost all individuals have experienced some degree of acne. A broad range of acne treatments has been shown to be safe and effective in adults. While still sparse, emerging data now also document similar safety and efficacy of these agents for children > 12 years of age. For younger children with preadolescent acne, where data are more limited or unavailable, it seems reasonable to extrapolate from the findings of studies involving older children >12 years of age. This article reviews the latest evidence and current expert opinions on acne therapies in the pediatric age group. Semin Cutan Med Surg 30:S16-S21

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Acne is a nearly universal phenomenon typically affecting American children between the ages of 12 and 17 years of age. (1) Given this high prevalence, it is not surprising then that the 2005 report on The Burden of Skin Diseases estimated that total direct costs associated with the treatment of ache vulgaris in the United States exceeded $2.2 billion, including the substantial costs of both over-the-counter and prescription products. (1)

Acne vulgaris is traditionally managed with a variety of topical and systemic medications (Table 1), as well as acne surgery techniques: Although the disease is commonly encountered by pediatric specialists, other primary care practitioners, and dermatologists, it is interesting to note that differences in prescribing practices have been described between different practitioners. In one analysis of nationally representative data regarding the prescribing patterns of pediatricians and dermatologists, Yentzer et al (2) found that dermatologists prescribe topical retinoids most, followed by topical clindamycin, oral minocycline, and topical benzoyl peroxide (BP) for the treatment of acne. Pediatricians rely on BP most, followed by topical clindamycin, topical tretinoin, and oral erythromycin (Table 2). There appears to be considerable overlap in terms of employment of retinoids, BP, topical clindamycin, as well as fixed combination topical products such as BP + clindamycin and BP + erythromycin. Both groups of practitioners utilize BP equally, with this agent representing about 11% of prescriptions for dermatologists and 17% for pediatricians.

However, there are some distinct differences in prescribing patterns. Although retinoids have demonstrated good efficacy for comedonal as well as mildly inflammatory acne and represent about 46% of prescribed acne products among dermatologists, retinoids represent only about 12% of pediatrician-prescribed agents. (2) Given that pediatricians likely manage a large cohort of patients with comedonal and mildly inflammatory acne, these data suggest that topical retinoids may be somewhat underutilized by pediatricians for acne management, The decreased rates of topical retinoid utilization among pediatricians have been attributed to a heightened sensitivity to potential adverse effects or less familiarity with topical retinoids.

In addition to the selection of appropriate therapeutic agents, the choice of vehicle is important because cosmetic tolerability favorably influences adherence (compliance) with treatment regimens. Ointments, creams, gels, and solutions have been among those most commonly employed; however, several new vehicle formulations as well as novel delivery options have been introduced and should be considered among the therapeutic options to individualize treatment and, thereby, optimize treatment outcomes.

A number of new topical products for ache treatment have been developed and introduced recently. These include products formulated with foam and hydrogel vehicles, novel fixed combinations of components, and a recently introduced topical gel formulation of the sulfone antibiotic/anti-inflammatory dapsone.

Foam and hydrogel vehicles have the advantage of easy spreadability with little residue. These vehicle formulations may be especially suited to treatment of hair-bearing areas (such as in male patients) or applied more easily over larger body surface areas such as on the chest and back. Clindamycin is available in a hydroethanolic foam, and a new tretinoin 0.025% + clindamycin 1.2% fixed combination product is available in a hydrogel formulation. Other novel fixed combinations include those containing antibiotic + BP, antibiotic + retinoid, and BP + retinoid (Table 3). Although use of the component agents separately may be more economical, fixed-combination products guarantee the stability of the components within these formulations and improve adherence to therapy because fewer applications are needed during the day.

Systemic antibiotic therapy has been a mainstay of treatment for ache. These agents include primarily tetracycline derivatives in patients 8 years of age and older; the age restriction reflects concerns about dental enamel staining in individuals younger than 8 years of age. Data on prescribing patterns show that dermatologists tend to favor doxycycline and minocycline, whereas pediatricians frequently use tetracycline. (2) Tetracycline generally is less costly than the other derivatives, but the longer half-lives of doxycycline and minocycline permit once--or twice-daily dosing compared to the four-times-daily dosing typically required with tetracycline. Less frequent dosing of any medication is more likely to result in better treatment adherence. Moreover, data on antibiotic resistance patterns of Propionibacterium acnes indicate that the proportion of organisms resistant to doxycycline and minocycline are lower than with either erythromycin or tetracycline. Finally, photosensitivity and gastrointestinal side effects tend to be somewhat lower with doxycycline and minocycline compared to tetracycline.

Alternative agents have been used when traditional tetracycline derivative agents have proved insufficiently effective or in cases in which side effects preclude the use of antibiotics in the tetracycline class. Although randomized clinical trial data are not available for these alternative agents, case series have documented the efficacy and apparent tolerability of amoxicillin, (3) cephalexin, (4) trimethoprim and trimethoprim-sulfamethoxazole, (5) and azithromycin (6) for patients with acne who were either unable to take or had previously failed therapy with more conventional therapeutic agents.

The published data on amoxicillin are scant and involve assessments from retrospective chart reviews. (3) One large case series by Fenner and colleagues (4) reviewed the responses of 93 acne patients who received 98 courses of cephalexin. These investigators reported that only 22% of patients showed no response or worsened with therapy, whereas the remaining patients were either somewhat improved (29%), much improved (45%), or cleared (4%). Trimethoprim and trimethoprim-sulfamethoxazole have seen considerable pediatric usage for treatment of a variety of both cutaneous and extracutaneous infections, but the use of these agents in acne generally has been regarded as a third-line option. (5,7)

More extensive data are available regarding the use of azithromycin for ache. A review of the available literature reveals three randomized controlled trials (8-10) and one nonrandomized controlled trial (11) that demonstrated noninferiority of azithromycin to doxycycline; azithromycin also was not inferior to minocycline in one open-label study. (12) In addition, four open, noncontrolled studies (13-16) and one retrospective chart review (17) indicated that azithromycin improved ache. However, there is heterogeneity in study design as well as dosage regimens of the azithromycin and the control drug. Most of these studies acknowledged the long half-life of azithromycin and typically gave the drug as often as three to four times a week or as seldom as three times per month.

Erythromycin, an older macrolide derivative, is used less often now because of the emergence and establishment of antibiotic resistance among P. aches organisms. There is evidence [or significant antibiotic resistance among P. aches, and it is clear that erythromycin has been largely abandoned by both dermatologists (2.8%) and pediatricians (7.2%), (2) except perhaps for use in prepubertal children or pregnant females in whom alternative agents may be less appropriate. Clinicians have become increasingly aware of the impact of acne therapy on causing "ecological mischief." (18) Widespread use of antibiotics for ache has been presumed to be one possible driving force for the selection of antibiotic-resistant P. aches species. Studies looking at P. aches antibiotic resistance profiles have indicated increasing rates of antibiotic resistance over time. (19)

This provides a rationale for incorporation of BP into acne therapeutic regimens where possible, either as a separate agent or as part of a fixed combination, particularly when antibiotics are employed, as the use of BP has been associated with a reduction in development of antibiotic resistance among P. aches. Likewise, use of subantimicrobial doses of antibiotics has shown some limited benefit for patients with comedonal and inflammatory lesions, while at the same time not demonstrating a significant impact on altering native resident microbial flora. (20)

Preadolescent Acne

Data are limited on the use of acne medications in the preadolescent population (ie, patients [greater than or equal to] 7 to 11 years of age). A number of case series highlight the heterogeneous group of medications used for children with infantile acne. Two clinical trials have evaluated the use of tretinoin for preadolescent acne. In one open-label study involving 40 patients between 8 and 12 years of age, tretinoin 0.04% in a microsphere gel vehicle demonstrated good efficacy and safety, with patients showing both tolerability and also moderate improvement on the Evaluator's Global Severity Score. (21) The U.S. Food and Drug Administration granted an age indication of 10 years or older for tretinoin 0.05% gel, based on the trial data submitted. Otherwise, most acne medications are indicated for use in individuals 12 years of age or older (Table 4).

Despite the limited data available for the use of these medications in infants and preadolescent patients, clinical judgment should be exercised to select appropriate therapies for children with acne. Topical BP, topical retinoids, and topical antibiotics have been used with some success in younger children with ache. (22) For those with more severe acne, systemic antibiotic therapy has included erythromycin and its derivatives, trimethoprim, and cephalexin; these have been used with success in cases in which tetracycline and its derivatives are less desirable, given their propensity for dental enamel staining. Tetracycline and doxycycline are generally recommended for children 8 years of age and older with severe acne; minocycline carries a recommendation for children 12 years of age and older with moderate-to-severe acne.

Combination oral contraceptives may be helpful for post-menarchal adolescents and adults. However, because of concerns about premature epiphyseal closure, their use in premenarchal patients generally is not advised except in consultation with an endocrinologist. Spironolactone and its analog, drospirenone, are sometimes used in the treatment of adults and some adolescents, but these agents do not currently play a significant role in preadolescent acne.

Improving Adherence in Pediatric Patients

A recent literature search using the key terms adherence, compliance, or concordance yielded a list of more than 168,000 articles. Although this is a highly heterogeneous group of articles, some key themes are highlighted in these references.

Simplify treatment regimens. Successful adherence is inversely related to the number of agents that must be taken or applied and the number of times each day that they must be taken or used. For patients who have difficulty with adequate compliance, fixed-combination products may improve adherence to the prescribed regimen. Interestingly, however, one multistep, multicomponent, over-the-counter acne product has generated a reported $830 million in sales worldwide, (23) attesting to the popularity of therapeutic rituals, particularly among adolescents.

Consider vehicle appropriateness. Adherence also depends on identifying patient preferences and matching vehicle selections to those preferences. For example, gels and foams are easier to spread on hairy areas such as the male chest. Other patients may prefer the tactile sensation of a cream over an ointment. Patients with oily skin may tolerate gels or solutions, whereas those with dry or combination skin may prefer lotions or creams.

Adjust regimens for tolerability. Side effects may arise with use of topical acne medications, particularly at the start of a new treatment. It is possible to mitigate these side effects by matching the vehicle to the patient's skin type, as mentioned above. Some patients who may have more sensitive skin may have concerns about tolerating topical retinoid therapy; these individuals may benefit from gradual escalation of the retinoid, initially applying the medication every other night for 1 to 2 weeks before advancing to every-night therapy. Alternatively, some patients prefer using medication every night by using short-contact applications for 30 to 60 minutes during the first 1 to 2 weeks before advancing to overnight therapy. Starting with lower-potency retinoids and advancing to higher-potency retinoids at follow-up visits may also improve efficacy while minimizing irritancy.

Provide written action plans, videos, text-messaging reminders. Written action plans, educational videos, and text-messaging reminders about using prescribed medications are among the various techniques advocated to reinforce treatment recommendations and improve adherence. "Cheerleading" by the clinician and staff who see signs of improvement can encourage patients to continue with their prescribed regimens.

Manage expectations. It is important to anticipate side effects and educate patients in advance that most side effects do not require stopping a medication but can be managed successfully with minor adjustments in the regimen. Pediatric and especially adolescent patients also benefit from understanding the definition of a "reasonable time frame" for seeing signs of improvement. These patients often have unrealistic expectations of seeing improvement in hours to days (often reinforced by what they see in advertisements for over-the-counter products that promise overnight results), whereas the typical improvement is measured in weeks to months.

Monitor for psychological comorbidities. The psychological impact of acne can be considerable. One study (24) affirmed that adolescent patients often have psychological and especially mood issues related to their acne in a severity-dependent fashion. The more severe the acne, the more severe and more prevalent were the mood disturbances that were noted. Clinicians who care for patients with acne should remain alert for the presence of depression or other emotional or social issues, and may provide encouragement for the patient and family to seek counseling or other therapy, as appropriate.

Consider cost issues. Medication costs can have a substantial impact on whether a prescription is filled and on whether a patient who begins using a medication remains adherent with the recommended regimen in the long term. Cost considerations should be taken into account when selecting appropriate medications.

Conclusion

A wide range of acne therapies are available for pediatric use Although most of these are indicated for use in patients [greater than or equal to] 12 years of age, judicious use of these medications in an off-label fashion for children with preadolescent acne is reasonable until more research is available regarding use of these agents in the preadolescent population.

Most children with mild acne will tolerate topical agents such as BP, topical retinoids, and topical antibiotics, either as single agents or in fixed combinations, especially if the dosing of these agents is escalated gradually, using some of the techniques discussed. Those with moderate-to-severe acne may require systemic therapy. Children 8 years of age and older should be able to tolerate tetracycline derivatives, including doxycycline and minocycline, which have more favorable antibiotic-resistance profiles and dosing schedules than does tetracycline. When possible, BP should be incorporated into topical regimens in an effort to reduce the potential for "ecological mischief" and the risk of altering, native resident microbial flora. When effective, subantimicrobial doses of antibiotics are preferable to higher doses, although many patients with moderate-to-severe acne may require antimicrobial doses to control their disease.

Ultimately: optimal outcomes require not only selection of appropriate pharmacotherapy, but also an understanding about factors that may affect compliance with recommended therapeutic regimens.

References

(1.) The Lewin Group. The Burden of Skin Diseases 2005. Available at: http://www.lewin.com/content/publications/april2005skindisease.pdf. Accessed May 10, 2011

(2.) Yentzer BA, Irby CE, Fleischer AB Jr, Feldman SR: Differences in ache treatment prescribing patterns of pediatricians and dermatologists: An analysis of nationally representative data. Pediatr Dermatol 25:635-639, 2008

(3.) Turowski CB, James WD: The efficacy and safety of amoxicillin, trimethoprim sulfamethoxazole, and spironolactone for treatment-resistant acne vulgaris. Adv Dermatol 23:155-163, 2007

(4.) Fenner JA, Wiss K, Levin NA: Oral cephalexin for acre vulgaris: Clinical experience with 93 patients. Pediatr Dermatol 25:179-183, 2008

(5.) Bhambri S, Del Rosso JQ, Desai A: Oral trimethoprim/sulfamethoxazole in the treatment of acne vulgaris. Cutis 79:430-434, 2007

(6.) Rafiei R, Yaghoobi R. Azithromycin versus tetracycline in the treatment of acne vulgaris. J Drugs Dermatol 17:217-221, 2006

(7.) Cunliffe WJ, Aldana OL, Goulden V: Oral trimethoprim: A relatively safe and successful third-line treatment for acne vulgaris. Br J Dermatol 141:757-758, 1999

(8.) Maleszka R, Turek-Urasinska K, Oremus M, Vukovic J, Basic B: Pulsed azithromycin treatment is as effective and safe as 2-week-longer daily doxycycline treatment of acne vulgaris: A randomized, double-blind, noninferiority study. Skinmed 9:86-94, 2011

(9.) Parsad D, Pandhi R, Nagpal R, Negi KS: Azithromycin monthly pulse vs daily doxycycline in the treatment of acne vulgaris. J Dermatol 28:1-4, 2001

(10.) Kus S, Yucelten D, Aytug A: Comparison o f efficacy of azithromycin vs. doxycycline in the treatment of acne vulgaris. Clin Exp Dermatol 30: 215-220, 2005

(11.) Singhi MK, Ghiya BC, Dhabhai RK: Comparison of oral azithromycin pulse with daily doxycycline in the treatment of acRe vulgaris. Indian J Dermatol Venereol Leprol 69:274-276, 2003

(12.) Gruber F, Grubisic-Greblo H, Kastelan M, Brajac I, Lenkovic M, Zamolo G: Azithromycin compared with minocycline in the treatment of ache comedonica and papulo-pustulosa. J Chemother 10:469-473, 1998

(13.) Antonio JR, Pegas JR, Cestari TF, DoNascimento LV: Azithromycin pulses in the treatment of inflammatory and pustular acne: Efficacy, tolerability, and safety. J Dermatolog Treat 19:210-215, 2008

(14.) Innocenzi D, Skroza N, Ruggiero A, Concetta Potenza M, Proietti I: Moderate ache vulgaris: Efficacy, tolerance and compliance of oral azithromycin thrice weekly. Acta Dermatovenerol Croat 16:13-18, 2008

(15.) Kapadia N, Talib A: Acne treated successfully with azithromycin. Int J Dermatol 43: 766-767, 2004

(16.) Gruber F, Grubisic-Greblo H, Kastelan M, Brajac I, Lenkovic M, Zamolo G: Azithromycin compared with minocycline in the treatment of ache comedonica and papulo-pustulosa. J Chemother 10:469-473, 1998

(17.) Fernandez-Obregon AC: Azithromycin for the treatment of ache. Int J Dermatol 39:45-50, 2000

(18.) Leyden JJ, Del Rosso JQ, Webster GF: Clinical considerations in the treatment of acne vulgaris and other inflammatory skin disorders: A status report. Dermatol Clin 27:1-15, 2009

(19.) Eady AE, Cove JH, Layton AM: Is antibiotic resistance in cutaneous propionibacteria clinically relevant? Implications of resistance for ache patients and prescribers. Am J Clin Dermatol 4:813-831, 2003

(20.) Skidmore R, Kovach R, Walker C, et al: Effects of subantimicrobialdose doxycycline in the treatment of moderate acne. Arch Dermatol 139:459-464, 2003

(21.) Eichenfield L, Matiz C, Funk A, Dill SW: Study of the efficacy and tolerability of 0.04% tretinoin microsphere gel for preadolescent ache. Pediatrics 125:1316-1323, 2010

(22.) Cunliffe WJ, Baron SE, Coulson 1H: A clinical and therapeutic study of 29 patients with infantile ache. Br J Dermatol 145:463-466, 2001

(23.) Katz S: Online exclusive: Proactive reformulates packaging. Available at: http://www.beautypackaging.com/articles/2010/01/online-exclusive-proactiv- reformulates-packaging. Accessed July 19, 2011.

(24.) Dalgard F, Gieler U, Holm JO, Bjertness E, Hauser S: Self-esteem and body satisfaction among late adolescdents with ache: Results from a population survey. J Am Acad Dermatol 59:46-51, 2008

Albert C. Yan, MD, * Hilary E. Baldwin, MD, ([dagger]) Lawrence F. Eichenfield, MD, ([double dagger]) Sheila Fallon Friedlander, MD, ([section]) and Anthony J. Mancini, MD ([paragrasph]|)

* Chief, Pediatric Dermatology, Children's Hospital of Philadelphia. Associate Professor. Pediatrics and Dermatology Perelman School of Medicine at the University of Pennsylvania. Philadelphia. PA

([dagger]) Associate Professor and Vice Chair. Department of Dermatology, SUNY Downstate, Brooklyn, NY

([double dagger]) Clinical Professor of Pediatrics and Medicine (Dermatology), Chief. Pediatric and Adolescent Dermatology. Children's Hospital San Diego, University of California San Diego School of Medicine. San Diego. CA

([section]) Clinical Professor of Pediatrics and Medicine, Dermatology, University of California. San Diego, Rady Childrens Hospital, San Diego, CA

([paragraph]) Professor of Pediatrics and Dermatology, Northwestern University's Feinberg School of Medicine. Head. Division o f Pediatric Dermatology, Children's Memorial Hospital, Chicago, IL

Publication of this CME article was jointly sponsored by the University of Louisville Continuing Health Sciences Education and Skin Disease Education Foundation and supported by an educational grant from Johnson & Johnson Consumer & Personal Products Worldwide Division of Johnson & Johnson Consumer Companies, Inc.

Albert C. Yan MD. has no relevant financial relationships with any commercial interests.

Hilary E. Baldwin MD. has served as a consultant and speaker for Allergan, Galderma, Medicis. and Onset She has also been a speaker for GlaxoSmithKline and Ortho Dermatologics.

Lawrence F. Eichenfield, MD. has served as an investigator for Galderma, GlaxoSmithKline, Johnson & Johnson, Neutrogena, and Stiefel. He has also been consultant and/or served on the advisory board for Coria and Galderma, GlaxoSmithKline. Intendis, Medicis, Ortho Dermatologics, Stiefel and Valeant.

Sheila F. Friedlander, MD. has served on an advisory board for Galderma and Onset.

Anthony J. Mancini, MD, FAAP, has served as a consultant for Galderma. Medicis, and Stiefel. He has also been a speaker for Galderma.

Corresponding author: Albert C. Yan, MD, Chief. Pediatric Dermatology, Children's Hospital of Philadelphia. Associate Professor. Pediatrics and Dermatology Perelman School of Medicine at the University of Pennsylvania. Philadelphia. PA. E-mail: yana@email.chop.edu
Table 1. Acne Medications Currently Available

Topical Agents, by class

* Retinoid agents

--Adapalene

--Tazarotene

--Tretinoin

* Benzoyl peroxide formulations
(numerous over-the-counter and prescription products)

* Antibiotics

--Clindamycin

--Erythromycin

--Sodium sulfacetamide

--Sulfur

* Combination products

--Antibiotic-benzoyl peroxide fixed combinations

--Antibiotic-retinoid fixed combinations

--Benzoyl peroxide-retinoid fixed combinations

* Keratolytic agents (eg, salicylic acid)

* Anti-inflammatory agents (eg, dapsone)

Systemic Agents, by class

* Oral antibiotics

--Tetracycline derivatives

* Doxycycline

* Minocycline

* Tetracycline

--Macrolide derivatives

* Azithromycin

* Erythromycin

--Cephalosporins

* Cephalexin

--Penicillins

* Amoxicillin

--Trirnethoprim-sulfamethoxazole

* Combination oral contraceptives

--Drospirenone

--Drospirenone/levomefolate

--Ethinyl estradiol/norethindrone

--Ethinyl estradiol/norgestimate

* Hormonal agents

--Spironolactone

* Systemic retinoids

--Isotretinoin

Table 2. Most Frequently Prescribed Medications by Specialty

Pediatricians                      Dermatologists

Benzoyl peroxide                   Adapalene

Clindamycin                        Tretinoin

Tretinoin                          Clindamycin

Erythromycin                       Minocycline

Clindamycin 1%/                    Benzoyl peroxide
benzoyl peroxide 5% topical gel

Erythromycin 3%/                   Doxycycline
benzoyl peroxide 5% topical gel

Adapalene                          Erythromycin 3%/
                                   benzoyl peroxide 5% topical gel

Doxycyline                         Tetracycline

Tetracycline                       Clindamycin 1%/
                                   benzoyl peroxide 5% topical gel

Minocycline                        Erythromycin

Source: Adapted from Yentzer BA, Irby CE, Fleischer AB Jr, Feldman
SR. Pediatr Dermatol. 25:635-639, 2008.

Table 3. Novel Therapeutic Options

Novel Agent

* Dapsone

Novel Combinations of Components

* Antibiotic/benzoyl peroxide fixed combinations

* Antibiotic/retinoid fixed combinations

* Benzoyl peroxide/retinoid fixed combinations

Table 4. FDA Approvals and Pediatric Age Indications for Medications
Commonly Employed for Acne

Drug                           Common Brand       Date of Earliest
Category      Active Drug      Names              FDA Approval

Topical       Tretinoin        Retin-A 0.025%,    October 1971
retinoid                         0.05%, 0.1 %
                               Avita 0.025%       January 1997
                               Atralin 0.05%      July 2007

              Adapalene        Differin 0.1 %,    May 1996
                                 0.3%
              Tazarotene       Tazorac 0.05%,     June 1997
                                 0.1%

Topical       Erythromycin     Akne-Mycin,        January 1985
antibiotic                       Erygel, Emgel

              Clindamycin      Cleocin T          July 1980
                               Evoclin            October 2004

Topical       Dapsone          Aczone             July 2005
antiinflam-
matory

Fixed
combination
product

BP+Abx        BP+erythromycin  Benzamycin         October 1984

              BP+clindamycin   Benzaclin          December 2000
                               Duac               August 2002
                               Acanya             October 2008

BP+retinoid   BP+tretinoin     Epiduo             December 2008

Retinoid+Abx  Tretinoin+       Ziana              November 2006
              clindamycin      Veltin             July 2010

Oral          Erythromycin     EES, Eryped,       April 1965
antibiotic                       Ery-tab

              Tetracycline     Sumycin and        September 1954
                                 others

              Doxycycline      Vibramycin,        December 1967
                                 Doryx and
                                 Adoxa

              Minocycline      Dynacin, Minocin,  August 1982
                                 and others
                               Solodyn            May 2006

              Trimethoprim-    Bactrim, Septra    July 1973
              sulfametho-
              xazole

              Amoxicillin      Amoxil             November 1979

              Cephalexin       Keflex             January 1971

              Azithromycin     Zithromax          November 1991

Systemic      Isotretinoin     Accutane           May 1982
retinoid                       Amnesteem          November 2002
                               Sotret             December 2002
                               Claravis           April 2003

Drug                           Common Brand
Category      Active Drug      Names              Age Indication

Topical       Tretinoin        Retin-A 0.025%,    [greater than or
retinoid                         0.05%, 0.1 %       equal to] 12 years
                               Avita 0.025%       [greater than or
                                                    equal to] 12 years
                               Atralin 0.05%      [greater than or
                                                    equal to] 10 years

              Adapalene        Differin 0.1 %,    [greater than or
                                 0.3%               equal to] 12 years
              Tazarotene       Tazorac 0.05%,     [greater than or
                                 0.1%               equal to] 12 years

Topical       Erythromycin     Akne-Mycin,        Indicated for
antibiotic                       Erygel, Emgel    pediatric use; no
                                                  specific age
                                                  restrictions

              Clindamycin      Cleocin T          [greater than or
                                                    equal to] 12 years

                               Evoclin            [greater than or
                                                    equal to] 12 years

Topical       Dapsone          Aczone             [greater than or
antiinflam-                                         equal to] 12 years
matory

Fixed
combination
product

BP+Abx        BP+erythromycin  Benzamycin         [greater than or
                                                    equal to] 12 years

              BP+clindamycin   Benzaclin          [greater than or
                                                    equal to] 12 years
                               Duac               [greater than or
                                                    equal to] 12 years
                               Acanya             [greater than or
                                                    equal to] 12 years

BP+retinoid   BP+tretinoin     Epiduo             [greater than or
                                                    equal to] 12 year

Retinoid+Abx  Tretinoin+       Ziana              [greater than or
              clindamycin                           equal to] 12 years
                               Veltin             [greater than or
                                                    equal to] 12 years

Oral          Erythromycin     EES, Eryped,       Indicated for
antibiotic                       Ery-tab          pediatric use; no
                                                  specific age
                                                  restrictions

              Tetracycline     Sumycin and        [greater than or
                                 others             equal to] 8 years

              Doxycycline      Vibramycin,        [greater than or
                                 Doryx and          equal to] 8 years
                                 Adoxa

              Minocycline      Dynacin, Minocin,  [greater than or
                                 and others         equal to] 12 years
                               Solodyn            [greater than or
                                                    equal to] 12 years
              Trimethoprim-    Bactrim, Septra    2 months
              sulfametho-
              xazole

              Amoxicillin      Amoxil             Indicated for
                                                  pediatric use;
                                                  no specific age
                                                  restrictions

              Cephalexin       Keflex             Indicated for
                                                  pediatric use;
                                                  no specific age
                                                  restrictions

              Azithromycin     Zithromax          [greater than or
                                                    equal to] 6 months

Systemic      Isotretinoin     Accutane           [greater than or
retinoid                                            equal to] 12 years
                               Amnesteem          [greater than or
                                                    equal to] 12 years
                               Sotret             [greater than or
                                                    equal to] 12 years
                               Claravis           [greater than or
                                                    equal to] 12 years

Abx=antibiotics; BP=benzoyl peroxide. Source: Drugs@FDA
(http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm).
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Title Annotation:Pediatric Acne Management: Optimizing Outcomes
Author:Yan, Albert C.; Baldwin, Hilary E.; Eichenfield, Lawrence F.; Friedlander, Sheila Fallon; Mancini, A
Publication:Pediatric News
Date:Oct 1, 2011
Words:4154
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