*Marta Filo-Rogulska1, Dominika Wcisło-Dziadecka2, Ligia Brzezińska-Wcisło3
Neonatal and infantile acne – ethiopathogenesis, clinical presentation and treatment possibilities
Trądzik noworodkowy i niemowlęcy – etiopatogeneza, obraz kliniczny oraz możliwości terapeutyczne
1Dermatology Clinic, Regional Healthcare Centre for Mother, Child and Adolescent, Częstochowa
Head of Centre: Małgorzata Lemańska, MD
2Department of Skin Structural Studies, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia, Katowice
Head of Department: Krzysztof Jasik, assistant professor
3Department of Dermatology, School of Medicine in Katowice, Medical University of Silesia, Katowice
Head of Department: Professor Ligia Brzezińska-Wcisło, MD, PhD
Streszczenie
Trądzik noworodkowy i dziecięcy są stosunkowo rzadkimi chorobami wieku dziecięcego. W porównaniu z innymi rodzajami trądziku dysponujemy ograniczonymi danymi naukowymi dotyczącymi ich patogenezy i leczenia. Aktualne rekomendacje opierają się przede wszystkim na badaniach retrospektywnych i opisach serii przypadków. Uważa się, że przyczyną trądziku dziecięcego są zaburzenia równowagi hormonalnj wywołane androgennymi steroidami pochodzenia matczynego u noworodków i wydzielanymi endogennie u niemowląt. W przypadku współwystępowania trądziku z objawami wirylizacji, przedwczesnego dojrzewania płciowego lub zaburzeniami wzrostu konieczna jest pilna diagnostyka w kierunku możliwych poważniejszych zaburzeń endokrynologicznych.
Trądzik noworodkowy (występujący w czasie krótszym niż 4-6 tygodni po urodzeniu) przebiega zwykle łagodnie, ustępuje samoistnie i nie wymaga leczenia. Diagnoza różnicowa musi jednak obejmować inne choroby naśladujące trądzik, np. noworodkową krostkowicę głowy. Natomiast trądzik niemowlęcy może mieć ciężki przebieg, z pozostawieniem blizn, i wymaga leczenia typowymi lekami przeciwtrądzikowymi. Z wyjątkiem tetracyklin, które są przeciwwskazane u dzieci, prawie wszystkie inne leki, w tym izotretynoina, były stosowane z dobrymi efektami.
Niniejsza praca skupia się na patogenezie, objawach klinicznych i możliwościach terapeutycznych trądziku wczesnodziecięcego.
Summary
Neonatal and infantile acne are rare pediatric conditions. Compared to other types of acne there is a relative paucity of data on their pathogenesis and treatment. Current recommendations are mostly based on retrospective studies and case series. Androgen imbalance caused by maternal steroids in neonatal cases and endogenous secretion in infants is believed to be the primary cause of these forms of pediatric acne. Extensive workup for underlying endocrine causes is indicated in patients with symptoms of virilization, precocious puberty or growth disorders.
Neonatal acne (presenting at less than 4-6 weeks after birth) is usually a benign condition which resolves spontaneously and requires no treatment. However, differential diagnoses must include other acne-mimicking diseases e.g. neonatal cephalic pustulosis. Infantile acne on the other hand may have scarring potential and may require treatment with typical anti-acne drugs. Except for tetracyclines which are strongly contraindicated in pediatric patients almost all other medications including isotretinoin have been used with good effects.
This review focuses on the pathogenesis, clinical presentation and therapeutic possibilities of early childhood acne.
Introduction
Acne vulgaris occurs in 79-95% of adolescents and young adults (1). Often, however, it develops in infants and children before adolescence. Under certain circumstances, especially when the symptoms of premature puberty or virilization coexist, it must induce diagnostic work-up towards underlying endocrine disorders (2). Treatment of acne in neonates and infants should be adjusted to the severity of acne. Beside tetracyclines, which are absolutely contraindicated in this age group, medications used should be adapted to the type of acne lesions. Most anti-acne drugs are not registered in children under 12 years of age. According to pediatric acne treatment consensus they can be used in infants, but with extreme caution.
Neonatal and infantile acne are part of the spectrum of pediatric acne. Table 1 presents the current distinction between the five types of pediatric acne (3). This division is based on the child’s age at the development of the first acne lesions.
Tab. 1. Division of pediatric acne according to age at onset
| Neonatal acne | During first 6 weeks of life |
| Infantile acne | Between 6 weeks and 12 months |
| Mid-childhood acne | Between 1 and 6 years |
| Prepubertal acne | Between 7 and 12 years or until first menstruation in girls |
| Juvenile acne | Between 12 and 19 years |
Neonatal acne
Neonatal acne occurs in the first 6 weeks of life and affects about 20% of newborns (4). It usually manifests with small, closed comedones located on the forehead, nose and cheeks with frequently co-existing sebaceous gland hyperplasia (5).
The pathomechanism of acne formation in this age group has not been fully explained. It is believed that it is caused by the increased production of sebum in enlarged sebaceous glands under the influence of maternal androgens delivered through placenta and beta-hydroxysteroids produced in excess by the newborn’s adrenal cortex (dehydroepiandrosterone – DHEA, dehydroepiandrosterone sulfate – DHEA-S). Additionally, some of the affected male newborns may have elevated levels of testicular androgens, produced under the influence of luteinizing hormone (LH), levels of which in these children may reach puberty values (7). LH stimulates the synthesis of testosterone which leads to increased seborrhoea. This phenomenon may explain increased incidence of neonatal acne in boys (7, 8). Neonatal acne subsides spontaneously within 1 to 3 months and does not require pharmacological treatment (9).
Differential diagnosis should include viral, bacterial and fungal infections, neonatal milia, sebaceous gland hyperplasia, neonatal pustular melanosis and neonatal toxic erythema (10). Particularly frequently observed is the occurrence of neonatal cephalic pustulosis. In this case, skin lesions are acne-like without the presence of comedones. It is most likely caused by Malassezia yeasts colonizing the skin (11). In most cases, treatment is not required (12). In patients with severe changes, 2% ketoconazole creams (13) can be used.
Infantile acne
Infantile acne occurs primarily between 6 weeks and 12 months of age and similarly to neonatal acne male predominance is observed. Skin changes such as comedones and inflammatory lesions (papules, pustules, cysts) are located mainly on the cheeks. However, the lesions may have more severe character and may be more numerous in comparison with acne in newborns (14).
In most children acne remits before 4-5 years of age and only rarely persists until adolescence (15). Contrary to the neonatal acne, this form of acne can leave scars, which prompts early treatment, especially in more severe cases (14). Conglobate acne characterized by burrowing and interconnecting abscesses and irregular scars (both keloidal and atrophic) has been described in this age group but is very rare (16).
As with the neonatal acne, it is believed that the infantile acne is induced by androgens secreted by the adrenal cortex in both sexes (7). Elevated values of DHEA secreted by the adrenal cortex are observed up to 12 months of age. After this period there is a decrease in the secretion of DHEA, which results in a gradual remission of skin lesions (8). Higher prevalence of infantile acne in boys can also be explained by the increased secretion of LH which stimulates testicular androgen synthesis. This process is probably a result of the immaturity of the hormonal feedback mechanism between the gonads and the pituitary gland (14, 17).
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