Is topical therapy the best choice for this teenaged boy’s acne?

Case: This 14-year-old boy is brought for assessment and treatment of acne by his mother who is noted to have superficial acne scars. His 17-year-old brother has required systemic isotretinoin to control his acne, and the mother wishes to avoid any systemic therapy for her other son. He has been well and is not receiving any systemic medication. He has tried over-the-counter treatments, including low concentrations of benzoyl peroxide and numerous cosmeceuticals. His acne is limited to the face and consists of numerous central, open and closed comedones with more than 20 inflammatory papulopustular lesions. He has no nodules or cysts and no evidence of scarring. Although topical therapy would appease the mother, is it the best choice for this patient? (answer on next page)

Yes, topical retinoid therapy is the mainstay of all acne treatment.

This boy is an ideal candidate for topical therapy. He has no deep inflammatory acne lesions, no acne on his back or chest, and no scars from his acne are evident. He also appears to have significant motivation to treat himself as witnessed by his use of over-the-counter treatments, despite their apparent lack of effect. My only concern was his family history of scarring acne.

When deciding on an acne treatment, the most important physical sign to be aware of is that of scarring. Although scarring is most common in children with nodules and cysts, it can occur in the absence of such lesions. Thus, each child must be examined closely for this architectural defect. At the same time, skin “staining” of resolving acne can be misinterpreted as permanent scarring, and children should be made aware of the difference at the outset of their treatment program. When scarring is present, I prefer to use systemic therapy. However, when this is not possible, I always advise children and their parents that if I cannot gain control of the acne within the first 6 weeks of topical therapy that I will recommend systemic therapy.

In my opinion, the mainstay of all acne therapy is the use of a topical retinoid. This concept, first defined more than 30 years ago, remains the same today. Fortunately, thanks to changes in the retinoids and their formulations over time, these agents have improved effectiveness and tolerability. The addition of topical benzoyl peroxides and antibiotics to a retinoid-based regimen has an additive effect that accentuates the positive effects of each of the individual topical agents.

In my practice, retinoids (retinoic acid), chemicals with retinoid action (adapalene), antimicrobials (benzoyl peroxides), and topical antibiotics are the agents I rely on for topical anti-acne therapy. The combination of 2 of these agents into 1 product provides an additive therapeutic response and increased adherence to the treatment program.

I believe that nonpharmacological care of skin should be discussed with children and that this is of equal importance to specific pharmacotherapy in the optimal management of acne. I address skin cleaning and moisturizing and use of sunscreen products. I recommend that children use products labeled noncomedogenic, nonacneigenic, and water-based and that they question my staff or pharmacists about any uncertainties they may have. I also encourage searching the Internet for age-appropriate information on acne management, although most 14-year-olds already know what is available on the topic online.

The child’s lack of adherence can often frustrate the best treatment programs. This problem is the result of many factors and has no simple solutions. The lack of adherence to any form of therapy for all diseases is a frequent subject of research and is often cited as the most common cause of all treatment failures.

My strategy for maintaining adherence to topical acne therapy involves several steps: pay attention to the base of the topical agent to ensure tolerability; cite realistic expectations for response; ensure that the patient understands the difference between postinflammatory staining and true scarring; give the child control of his or her nonpharmaceutical treatment; and, wherever possible, primarily interview the child during visits.

This 14-year-old boy was treated with adapalene, applied to his entire face each morning, and clindamycin/ benzoyl peroxide, applied similarly in the evening. He chose his nonpharmaceutical skin care with caution and adjusted products depending on the weather and the degree of irritation. He attended all of his booked visits. He has had a very gratifying response after 6 months with topical therapy alone. I will continue to monitor him twice yearly because of his family history of scarring.