Infantile acne is a rare occurrence. It Is more common in boys and predominately occurs on the cheeks in infants between the ages of 1 and 16 months. Clinically, the lesions range from comedones to inflammatory papulopustules to cysts. Successful therapies include topical tretinoin, benzoyi peroxide and topical and oral erythromycin. For more serious cases, oral isotretinoin (Accutane) has been reported to successfully treat recalcitrant infantile cystic acne. We describe two additional patients with infantile cystic acne treated successfully with oral isotretinoin.The dose of isotretinoin used ranged from 0.2 mg/kg/day to 1.5 mg/kg/day. The treatment duration varied from 5 to 14 months. Careful monthly monitoring is recommended because of the many side effects reported with isotretinoin. Practical tips for the administration of oral isotretinoin in infants are reviewed.
Infiinlile acne is often misdiagnosed because of its rare occurrence. Boys are more commonly affected, with ihe central cheeks being the most common localion. It typically begins after 3 months of age and resolves by age 4 or 5. generally without treatment. In infants requiting ireatnient. this usually consists of topical betizoyl peroxide, topical tretinoin, or topical or oral erythromycin. Infantile acne may be severe enough to lead to persistent nodules, cysts, and scarring. In severe cases, hormonal evaluation may be necessary lo rule out an underlying endocrinopathy and hyperandrogenism.
Oral isotretinoin has been used with success to treat resistant occurrences of infantile acne causing severe scarring and cosmetic sequelae (5-H). We report two young girls with severe nodulocystic acne treated successfully with oral isotretinoin.
A healthy 6-month-old girl presented with an acneifonn facial eruption consisting of several hundred open and closed comedones and a few inllammatory papules and small cysts. The comedonal component had been present since the age of I month and had been treated unsuccessfully with Neosporin and 1% hydrocortisone cream. The patient was prescribed oral erythromycin suspension 2OOmg/5 ml. 2 ml three times a day. She was also given tretinoin (Retin A Micro) gel 0.1% to be applied every other night and benzoyl peroxide 4% cream every morning. No improvement was noted after 9 months of conservative therapy. On follow-up she continued to worsen despite treatment, requiring repeated incision and drainage of several purulent, infected facial abscesses. General physical examination did not lind any overt signs of hypcrandrogenism, specifically because she was at Tanner stage 1 with no clitoromegaly or breast tissue and absent signs of secondary sexual characteristics. On cutaneous examination, she had severe papules, pustules, nodules and cysts with scarring. The patieni was sent for an endocrine work-up and was found to have nomial levels of free and total testosterone, androstenedione, sex honiione binding globulin and dehydroepiandrosterone sulfate (DHEAS).
Al 14 months of age she was started on oral isotretinoin at 0.2 mg/kg/day and was slowly increased to 1.5 mg/kg/day. She remained on isotretinoin for a totalof 14 months and received a total cumulative dose of 315 nig/kg. She had no major side effects, was monitored monthly, with a complete blood count, triglycerides.cholesterol, and liver function tests. Her triglycerides ranged from 117 to 2S6 mg/dl during treatment, while all other parameters remained nonnal. Her acne improvedgradually with this regimen. At age 5 she continues to have some comedones and infiammatory papules but is controlled on topical tretinoin.
A healthy 7-month-old girl presented to dermatology with an acneifomi eruption on her face. Her mother staled that she had erythematous papules since birth and had been tried on 1% hydrocortisone and 12% lactic acid lotion without relief. On her first visit she was noted to have open and closed comedones and inflammatory papules with yellow crusts. She had no signs of androgen excess or precocious puberty. She was prescribed tretinoin gel 0.1%. benzoyl peroxide wash4%, and cephelexin 125 mg/5 ml, I teaspoon three times a day for 2 weeks with no improvement. The patient continued on the topical tretinoin gel and was started onbenzoyl peroxide/erythromycin gel. Despite continuation of this regimen for 2 months, she progressed to have a nodulocytic component. Her endocrine work-up hadnormal findings. She was placed on erythromycin EES 200 mg/kg. 4 ml twice a day for I montb and continued tretinoin gel and benzoyl peroxide/erythromycin gelwithout improvement.
At 13 months of age she was begun on oral isotretinoin. She weighed 21 pounds and was placed on 10 mg every other day. She was monitored monthly for 5 months and continued on the same dose of oral isotretinoin without any major side effects. Her laboratory mnnitoring was all within normal limits. She had considerable improvement in her acneiform eruption, and the isotretinoin was discontinued after a 5-month course with a total cumulative dose of 90 mg/kg.
Acne is generally thought to be a disease of adolescence, affecting 90% of teenagers. However, acne is seen in neonates, infants, and small children. Acne rieonatorum is defined as acne present at birth or occurring during the lirsl four weeks of life. It has been esliniated that 20% of newboms can be affected. Most of these occurrences consist of mild, inflammatory, facial lesions that run a selflimited course. Boys are more likely to be affected, and the cheeks are the most prominently involved area.
The most widely accepled cause of acne neonatorum is hyperactive sebaceous glands stimulated by neonatal androgens. The differential diagnosis consists ofmiliaria, transienl neonatal pustular melanosis, erythema toxicum neonatomm, neonatal sebaceous ghuid hyperpiasia, cephalic pustulosis, acneform drug eruptions, and infections caused by viruses, bacteria, or fungus.
Some confusion exists as to vv-hether neonatal acne truly exists or if the term neonatal cephalic pustulosis is a more accurate description. Neonatal acne has beendeiined as inllanimatory papules and pustules scattered over the cheeks without comedones. Many studies and reports have claimed that neonatal acne is an inflammatory response to Fityrosporiim species, it is probable, however, that some of what is termed neonatal acne is an early presentation of comedonal acne (as inpatient 1) and not a response to Maiassczia. More studies are needed to define the clinical characteri.stics and pathogenesis of both neonatal cephalic pustuiosis andneonatal acne.
Infantile acne is much less common and is defined as acne with an onset occurring from 1 to 16 months of age. It is also more common in boys and the cheeks arethe most predominant area affected. Clinically, inflammatory papules, pustules, and comedones are typically seen. In severe cases, cysts can occur, and may lead tosubsequent scarring.
Lisunily, both acne neonatorum and infantile acne arc miki and have a self-limited course. If treatment is needed, topical benzoyl peroxide creams and washes,topical irelinoin. and topical and oral erythromycin are commonly used. Isotretinoin has been used with success in recalcitrant infantile cystic acne. Four published patients were treated successfully with doses of isotretinoin ranging from 0.5 to 2 mg/kg/day for 4 to 6 months. No major side effects were describetl.
Isotretinoin is FDA approved for children 12 years and older for the treatment of nodulocystic acne. The dosing regimen is typically 0.5-1.0 mg/kg/day for a period of 20 weeks. Some clinicians prefer to prescribe isotretinoin until a cumulative dose of 120 mg/kg is reached. Total doses lower then this have been associated with higher relapse rates. The ideal cumulative isotretinoin dose for infantile acne is not known. Our palients required 315 mg/kg and 90 mg/kg, respeciiveiy, for clearance of their acne.
Adverse skeletal effects reported with oral retinoids are numerous and include calcitication of ligaments and tendons, cortical hyperostosis, periosteal thickening,premature epiphyseal closure, and possible osteoporosis. These side effects are extremely rare at lypical doses used for acne treatment. On the other hand, longterm high dose (2-5 mg/kg/day) retinoid treatment of ichthyosis or xerodeniia pigmentosum may pose a greater risk for bony and mu.sculoskeletal changes.
Caution should be used when treating infantile acne so that the average dose of isotretinoin ranges between 0.5 iuid 1.5 mg/kg/day. The recommended dosing schedule for isotretinoin is iwice daily and with food or milk to enhance oral absorption. Administration in young children and infants is complicated by the fact thai this drug is not available in a liquid suspension, and is highly light and oxygen labile. Isotretinoin is available in 10, 20, and 40 mg soft gelatin capsules. In order to administer dosages inthe 0.3-2 mg/kg/day range, it may be necessary to split capsules in half. Unfortunately, isotrelinoin is extremely sensitive to light and oxygen and will degrade shortly after exposure.
Roche Pharmaceuticals recommends piercing Accutane capsules with a large bore needle and squeezing the contenis of the capsule into soft food like cottage cheese,ice cream, pudding, oatmeal, or butter. This leads to drug wastage and concern over stability ofthe drug alter exposure to light and oxygen. The soft gelatin capsuleis filled wiih a mixture of an unpalatable, oily inactive vehicle and active drug. We found this method of delivery inadequate because of the taste of the oily vehicle (even when concealed in food), concerns over the amount of drug versus vehicle delivered as a result of incomplete evacuation of the capsule, and drug instability followingexposure to light and oxygen.
An alternative method of drug delivery involves freezing the isotretinoin capsules to a solid consistency. This allows one to cut the capsule in half or in quarters to deliver the desired dose. The capsule can then be concealed in a palatable food such as a candy biir. This method prevents wasting of the drug, tninimizes exposure ofthe active ingredient to lighl and oxygen atid masks the poor taste of the vehicle.
Our two young patients further demonstrate that oral isotretinoin can be used safely and is quite effeclive in infants with severe nodulocystic acne that is unresponsive to conventional therapies.