Prepubertal acne: a cutaneous marker of androgen excess?

Pathologic acne in pre-pubertal children: A case series and review on when to refer to pediatric endocrinology

Acne vulgaris is an extremely common chronic disease of the pilosebaceous unit. Despite its ubiquity, acne in the childhood years of approximately ages 1-6 years is exceedingly rare. Physicians should be suspicious of underlying systemic disease processes in patients of this age who present with onset of acne lesions, as pre-pubertal acne in childhood has a distinctly different pathology than that of other age groups. Through a case series, we highlight the importance of a thorough work-up and provide a review on when to refer to pediatric endocrinology to rule out precocious puberty and tumors as the cause of pre-pubertal acne.

Fermented Cosmetics and Metabolites of Skin Microbiota—A New Approach to Skin Health

The skin covers our entire body and is said to be the “largest organ of the human body”. It has many health-maintaining functions, such as protecting the body from ultraviolet rays and dryness and maintaining body temperature through energy metabolism. However, the number of patients suffering from skin diseases, including atopic dermatitis, is increasing due to strong irritation of the skin caused by detergents that are spread by the development of the chemical industry. The skin is inhabited by about 102–107 cells/cm2 and 1000 species of commensal bacteria, fungi, viruses, and other microorganisms. In particular, metabolites such as fatty acids and glycerol released by indigenous skin bacteria have been reported to have functional properties for the health of the skin. Therefore, skin-domesticating bacteria and the metabolites derived from those bacteria are used in many skincare product ingredients and function as probiotic cosmetics. Japanese traditional fermented stuff, used as foods in Japan for over 1300 years, are now being applied as fermented cosmetics. Fermented cosmetics are expected to have multifaceted health functionality and continue to grow as products in the natural skincare product market. In this review, we consider approaches to skin health using fermented cosmetics and modulation of skin microflora metabolites.

Comparison of guidelines and consensus articles on the management of patients with acne with oral isotretinoin

Guidelines and consensus on the management of patients with acne aim to give evidence-based, expert-group recommendations. This review compares current guidelines and consensus articles to provide a compilation of recommendations on the treatment of acne with oral isotretinoin. Ten common, relevant, clinical questions are addressed, based on published recommendations, including the indications of isotretinoin, the proposed daily dose, the cumulative isotretinoin dose and the laboratory monitoring needed. Recommendations on special considerations are also addressed, including the timing of procedures and the question of an association of depression or inflammatory bowel disease with isotretinoin. A major limitation is the use of different classification systems for acne across guidelines. The recommended daily dose ranges from 0.3 to 0.5 mg/kg in the European guidelines to up to 1 mg/kg in the US guidelines. A specific duration of treatment of at least 6 months is only recommended in the European guidelines. All guidelines report the need of strict pregnancy prevention measures. The European, French and US guidelines recommend to monitor for symptoms of depression. Important clinical questions that are inconsistently addressed in guidelines include the age indication, the recommendation for a cumulative dose, the timing of procedures, the association of isotretinoin with IBD, the recommendation for preventing acne flares and for appropriate laboratory monitoring. These topics should be clearly included in the recommendations of guidelines as they are often raised in everyday clinical practice.

Acne vulgaris in preadolescent children: recommendations for evaluation

Acne vulgaris in infants and children often triggers extensive laboratory evaluation out of concern about associated endocrinopathy. Clinical parameters to help guide evaluation of these children have not been defined. This was a retrospective chart review of 24 preadolescent patients with acne and a review of related medical literature. Two age-related subsets were identified: 12 patients who developed acne before the age of 15 months, 75% male, with comedonal and inflammatory lesions; and 12 patients who developed acne between the ages of 2 and 7 years, 75% female, with primarily comedonal lesions. Laboratory evaluation in 13 of the patients was unremarkable. Bone age was advanced in 1 of the 11 children imaged. Premature adrenarche was diagnosed in four patients; all four had additional clinical signs of puberty and growth parameters >90th percentile. None required additional treatment. Our cohort of preadolescent children presenting with acne included an equal number of patients in two distinct subsets: infantile and childhood-onset acne. Literature review identified a rare third subset presenting with acne, signs of advanced puberty, and associated endocrinopathy. There was no evidence of endocrinopathy in our patients with infantile acne. Two-thirds of our patients with childhood-onset acne had no additional clinical signs of puberty and no evidence of endocrinopathy. A focused history and physical examination is sufficient to evaluate the majority of infants and children with acne. Hand X-ray for bone age is a useful screening test. Further evaluation and endocrinology referral are warranted in preadolescents with acne and advanced bone age or additional clinical evidence of early puberty.

Acne through the ages: case-based observations through childhood and adolescence

Acne vulgaris is a common disorder that affects more than 17 million individuals in the United States. Knowledge of the disease is an important part of clinical practice, particularly for the pediatric practitioner. Contrary to common belief, acne is not a disease limited to adolescents and young adults but can occur at any stage of life. This article is a case-based review of acne during childhood and adolescence. Workup is based on age and concurrent physical findings, whereas therapy depends on the type of skin lesions along with patient characteristics and preferences.

Infantile acne as the initial sign of an adrenocortical tumor

A 23-month-old boy with persistent acne since 6 months of age had signs of virilization and accelerated growth. Hormone evaluation indicated increased levels of dehydroepiandrosterone (DHEA) and testosterone. Ultrasound and abdominal computed tomographic scan revealed a large adrenal mass consistent with an adrenocortical tumor. The patient underwent surgical excision of the well-encapsulated tumor with normalization of his hormones and no subsequent recurrence. Although rare, childhood adrenocortical tumors have a poor prognosis, with the majority of tumors having regional and metastatic disease. Because early diagnosis and complete surgical excision improve prognosis, children with refractory infantile acne should be evaluated for signs of virilization and accelerated growth. Laboratory evaluation should include luteinizing hormone, follicle-stimulating hormone, total and free testosterone cortisol, DHEA, and its sulfate (DHEA-S). Elevated levels of DHEA and DHEA-S should prompt an aggressive diagnostic evaluation for an adrenocortical tumor.

Acne infantum as presenting symptom of congenital adrenal hyperplasia due to 11-beta-hydroxylase deficiency

Infantile acne is a rare condition which usually begins after the third month of life and appears mainly on the cheeks. Spontaneous healing typically occurs within 2 years. A 2-year-old boy developed acne infantum during the first days after birth; it failed to respond to topical treatment. Detailed physical examination and endocrinologic evaluation confirmed the presumed diagnosis of congenital adrenal hyperplasia (CAH), and showed it was caused by 11-beta-hydroxylase deficiency. CAH comprises a group of autosomal-recessively inherited disorders. These hereditary enzyme defects in steroid biosynthesis cause glucocorticoid deficiency and an overproduction of biosynthetic precursor steroids. Adrenal androgen biosynthesis is not impaired but shows a massive reactive overproduction due to the increased ACTH secretion within the up-regulated hypothalamo-pituitary-adrenal system. The characteristic features of CAH in male infants are demonstrated on the basis of this case report.

Akne im Kindesalter

Childhood acne has different clinical expressions which may be present from birth or manifest within the first weeks of life or after the third to sixth month of life. The condition may occur as a physiological phenomenon or may be pathological and require endocrinologic evaluation and treatment. It may be induced by drugs or ointments or due to intoxication. Severe courses with a tendency to scarring in childhood may be observed. Childhood acne may persist and develop into juvenile acne. It is likely that childhood acne may represent a risk factor for the development of severe acne in puberty.

A practical approach for the use of oral isotretinoin for infantile acne

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, benzoyl 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.

[Feminine acne: dermatologic disease or endocrine disease?]

Acne is a problem of the pilo-sebaceous follicle caused by the conjunction of three factors: seborrhea, follicle obstruction, and follicle inflammation. The key element, seborrhea, is under androgenic control. Acne in women is also influenced by developments and modifications in genital life, as well as by hormonal contraceptive and replacement therapies. Acne is rare prior to puberty, when it may indicate endocrine disease. At puberty, acne is quasi-physiological, because of the relative hyperandrogenism induced by the andrenarche preceding pubarche, as well as by the relative shortage of estrogens and progesterone during the first menstrual cycles. Other signs of hyperandrogenism, such as menstrual cycle difficulties and excess weight, which favor a hormonal origin, must be sought in cases of persistent or late-onset acne in adults. There is a mirror image of puberty during the peri-menopausal period, but with decreased seborrhea, so acne is rare. Finally, a tumoral origin must be sought in the rare cases of acne occurring after menopause. Hormonal investigation of acne should not be systematic, but is justified during prepuberty when other symptoms are associated with acne that resists well-conducted dermatological treatment. The therapeutic approach should be primarily dermatological, but hormone-oriented treatment should be considered when such therapy fails, or in the presence of other signs of hyperandrogenism. Sometimes the association of isotretinoin and an anti-androgen treatment are necessary to effectively treat such acne. Finally, particular attention must be paid to contraceptive therapies and hormone treatments, which can induce or aggravate acne, especially during the peri-menopausal period.

Testosterone 5alpha-reductase inhibitor bisnaphthoquinone derivative from Impatiens balsamina

The 35% EtOH extract of aerial parts of Impatiens balsamina L. has been investigated for activity against testosterone 5alpha-reductase. Activity-guided fractionation led to the identification of the bisnaphthquione derivative named impatienol (1), 3-hydroxy-2-¿[3-hydroxy-1,4-dioxo (2-naphthyl)] ethyl¿ naphthalene-1, 4-dione, which exhibited significant testosterone 5alpha-reductase inhibitory activity. This 5alpha-reductase inhibitory compound has been previously synthesized, but this is the first report of its isolation from a natural source.

Acne neonatorum: a study of 22 cases

BACKGROUND

Acne is not uncommon in the neonatal period. Acne neonatorum is characterized by a mainly facial eruption of inflammatory and noninflammatory lesions. It is most commonly mild and transient. Hyperactivity of sebaceous glands, stimulated by neonatal androgens, has been implicated as the underlying pathogenetic mechanism.

MATERIALS AND METHODS

All patients diagnosed with acne neonatorum in "A. Sygros" Hospital, Athens, Greece, during the years 1993-1996, were evaluated clinically and epidemiologically. Histologic examination and smears for Propionibacterium acnes and Pityrosporum ovale were performed in selected cases.

RESULTS

Of the 22 patients studied, 18 were male (81.8%) and 4 were female. The mean age at onset was 3 weeks and the mean duration of the disease was 4 months. Papules and pustules were the most frequent types of lesions (72.7%), followed by comedones only (22.7%). The cheeks were the most common site of predilection (81.8%). A family history of acne was reported in only three patients. Histologic examination showed hyperplastic sebaceous glands with keratin-plugged orifices. Smears for P. ovale were negative.

CONCLUSIONS

Our findings are consistent with previous experience, although inflammatory lesions were encountered more often than previously reported. Hereditary factors did not seem to play a significant role in our series. Topical treatment hastened the resolution of this self-limited condition. Recalcitrant cases warrant investigation for underlying androgen excess.

Treatment of androgen excess in females: yesterday, today and tomorrow

Hirsutism, acne and androgenic alopecia represent, in females, some of the manifestations of the clinical spectrum of hyperandrogenism. These pictures represent not only cosmetic damage, but also a source of remarkable psychological distress. Often hirsutism is regarded as presumptive evidence of a lack of femininity. The major diagnostic concern is to exclude an ovarian or adrenal androgen-secreting tumor, a congenital hyperplasia or polycystic ovary disease. Ethnic background should be taken into account together with the progression of the symptoms. Following the etiology, surgery and exogenous glucocorticoids or inhibition of gonadotropin secretion have to be carefully chosen in the management of different kinds of hyperandrogenism. Several pharmacologic agents have recently shown the ability to block the androgen receptors at target organ sites, thus allowing a specific antiandrogenic treatment. In some cases cosmetic measures could be of great value. Obesity accompanied by hyperinsulinemia can represent the main cause of ovary androgen hypersecretion; therefore a reduced body weight and muscle activity represent the basis of any treatment. Some other drugs, such as long-acting analogs of somatostatin, could be considered among possible drugs for the future. The aim of this article is to provide an appraisal of what is presently known about the regulation of hair growth, the various causes of excessive androgen secretion and the current methods to solve, safely, this important feminine clinical problem.

[Treatment of acne]

The treatment of acne is based upon simple pathogenic arguments, but needs to be adapted to the type of acne. Patients must always be informed that it is long and difficult and that no significant response will be expected before 2 to 3 months of regular treatment. The authors present the different therapeutic agents and strategies. Isotretinoin should be used only in severe acne after failure of at least 3 months of a well conducted classical treatment and in nodulo-cystic acne; because of its major side effect of teratogenicity its use in adolescent girl's requires pregnancy testings before and during treatment and an effective contraception.

Acne. An overview of clinical research findings

Although acne represents the most common chronic skin condition seen by dermatologists, there are still many unanswered questions regarding its pathophysiology, and patients are still in need of more effective therapies, particularly those aimed at the hormonal aspects of acne. Recent clinical research has led to advances in our understanding of factors such as cytokines in follicular hyperkeratinization and the role of androgens in acne, the emergence and significance of antibiotic resistance of P. acnes, the long-term safety and efficacy of isotretinoin, and the safety and efficacy of new topical retinoids, such as tazarotene and adapalene. Fruitful interactions between basic scientists and clinical researchers within medicine and the pharmaceutical industry will, it is hoped, provide for future advances in this area.

Pathogenesis and treatment of acne in childhood

Acne occurs more frequently in newborns and infants than one would gather from written accounts. Acne neonatorum tends to be overlooked because it is usually minor and transient. In contrast, acne infantum, which generally does not make its appearance until after 3 months of life, is more serious. Even acne conglobata may develop in infants. There are many other types of acne in childhood reflecting different pathogenetic mechanisms; included in this group are acne venenata infantum, steroid acne, hormonal disturbances, and toxic reactions.