Management of acne in adolescent patients should consider more than what associated skin lesions look like and where they appear. Acne vulgaris is a very visual and apparent skin disorder, and when it occurs in the adolescent to teenage years, it coincides with a time period when individuals are extremely aware of their appearance and vulnerable to peer pressure. It should be noted that while concerns for self-image are stereotypically associated with females, males can be equally impacted by emotional and psychological sequelae.
A number of studies have described the impact of acne on quality of life, which, in this context, is meant to apply to a broad category of symptoms and manifestations. For example, surveys have identified lower self esteem in adolescents with acne compared to those with healthy skin1,2 that may result in adopting coping mechanisms, such as growing one’s hair to hide the face, avoiding eye contact, and wearing clothing that hides scarred skin areas.3-5 Such behaviors are concerning in their own right; on the more serious side, however, presence of acne scars has been associated with depression, anxiety, withdrawal, and low body image.6-8 Tragically, one study found that teenagers with acne were more likely to have suicidal ideation or to have attempted suicide.7 Unfortunately, the psychological burdens associated with acne are often exacerbated by teasing and bullying.9
What the above highlights is that there is urgent need to detect acne early in its life cycle and to work closely with patients to help them prevent and lessen the appearance of it. What it also suggests is that as treatment is applied to the skin, we are, in a way, helping to resolve more than what appears before our eyes.
Common Misconceptions and Barriers to Treatment
There are several long-standing misperceptions that remain prevalent and that may serve as a barrier for younger individuals to seek out a dermatologic consultation. For instance, in my own practice, I have heard many patients tell me that they have been told they do not clean their face enough or that they have a poor diet and that these are the reasons why they have acne scars. Unfortunately, the existence of these old wives’ tales only serves to confuse patients, further perpetuating the cycle of hard feelings and anxieties that acne may cause.
One issue that complicates the ability to identify the impact of acne on quality of life is that patients are often not forthcoming with how their skin appearance makes them feel. There may be clues in the patient’s appearance and demeanor—a hat pulled low, hair over the face, a slumped posture—but these are by no means definitive, nor are they necessarily associated with the presence of clinically severe acne. Instead, if the clinician suspects that a patient is being negatively and unduly affected by his or her acne, it may be worthwhile to direct the interview towards uncovering any symptoms. Asking open-ended questions in such situations tends to be more constructive, as patients may get defensive if confronted directly about whether their acne is bothering them.
Beyond detecting what can be very serious emotional and psychological effects of acne on the patient, the interview may also help unveil treatment goals. For instance, consider the female patient who reports that her acne causes her to wear makeup but that she would rather not have to hide. Relating to such a patient that treatment can alleviate that need might help increase compliance while also establishing a reasonable and attainable goal for therapy.
The presence of a parent in the room is sometimes helpful during the interview but it may also serve as an obstacle in some situations. It bears mentioning that our goal should be to deal with patients directly as much as possible and to empower them to be involved in the treatment process. Over the course of years of practice, I have learned that patients derive the greatest benefit when they feel we are working together as a team to address their problem.
Skin Hygiene and Treatment Considerations
Many of the psychological consequences that patients suffer from as a result of their acne are reversible with proper treatment. But simply applying medication to the affected area may be insufficient to achieve the results patients want. Proper skin care regimens can be additive to the treatment process as they help restore the skin barrier, thus ensuring that the products we use achieve good penetration without being overly irritating.
THE ADOLESCENT VISIT: UNCOVERING PATIENT CONCERNS
• Assess the patient’s appearance and demeanor
• Ask Open-ended questions about symptoms and impact of acne
• Deal with the patient directly and empower him/her
• Attempt to assess and establish treatment goals
• Associate severity of acne with severity of impact
• Directly question about the impact of acne on the patient
• Hesitate to ask to speak to the patient one-on-one if a parent seems to be an obstacle
Just as treatment of acne should be tailored to the needs of the individual, it is also advisable to adjust skin care recommendations accordingly. Gender may be an important factor to consider. For male patients, a lot of times the struggle is getting them to use any cleanser in the first place, whereas with young girls, there is often a need to educate them away from using too many products or overly harsh astringents and cleansers. In either case, it is best to keep things as simple as possible with recommendations so as not to overwhelm a patient who may already be anxious about his or her skin.
Education should also be provided as to how to use the products we recommend most effectively. I have observed three common mistakes among acne patients that can lead to frustrating results:
1. Use of too much product at one time;
2. Spot treatment; and
3. Giving up too soon on the treatment regimen.
There are a lot of very good and effective acne treatments available, but they take time to be fully effective. At the same time, introducing too much medication at one time can cause irritation (which may affect compliance) while treating just the active acne lesion and not the surrounding skin doesn’t help to prevent and control future acne.
While recent research has largely focused on the role of inflammation in acne formation and in exacerbating flare-ups, it is important to remember that inflammation is only one component. Treatment, then, should be directed at as many of the relevant targets as possible, while also balancing tolerability. Favorable tolerability profiles lead to improved adherence, increased satisfaction and overall improved clinical outcomes. Individual factors, such as a preference for oral versus topical medication or an inability to adhere to more than once-daily application, are also important.
In most cases, it is necessary to use a combination of products to target the characteristic follicular hyperkeratinization, inflammation, excess sebum, and Propionibacterium acnes proliferation that combine to cause acne. In appropriate patients, the additional of hormonal therapy should be considered, as it is one of the most effective way to control excessive sebum production. Reticence to recommend oral contraceptives is certainly understandable, but we may also be doing patients a disservice by dismissing them as an option without good reason.
I believe there is strong rationale to be aggressive with treatment. While topical retinoids are an appropriate starting point for therapy in many patients, adding additional medications will help increase efficacy. A limited course of topical or oral antibiotics may be necessary for more severe presentations (with the caveat that a benzoyl peroxide formulation should be used as well to reduce the potential for resistance). As a last line of defense, isotretinoin is a powerful agent that in many cases eliminates the need for multiple courses of antibiotics while achieving high remission rates.
A candidate topical agent in the pipeline offers to add yet another treatment option to consider. SB204 (Novan, Inc.) is a nitric oxide releasing topical drug candidate that appears to have activity against all multiple pathogenic targets relevant to acne. Its primary mechanism of action is to inhibit the NLRP3 inflammasome, thereby decreasing the downstream release of IL-1β and IL-17; yet, it is also an effective antimicrobial with demonstrated ability to kill P. acnes.
In two recent Phase 3 studies, a subset of 905 adolescents aged nine to 17 years with moderate to severe acne were randomized 1:1 to SB204 4% or vehicle used once daily, SB204 showed a statistically significant reduction in inflammatory, non-inflammatory and total lesions while maintaining a good safety and tolerability profile in adolescents. SB204 demonstrated favorable levels of tolerability with respect to burning and stinging, dryness, erythema, pruritus, and scaling.10 Notably, the percentage of patients reporting no tolerability issues with the active treatment was evident as early as week 2 of the study and stayed consistent throughout (Table 1).
A Sense of Optimism
There is growing awareness that adolescents with acne may suffer from emotional and psychological consequences as a result of their skin disorder. Discovering those symptoms is often complicated, as young patients may be unwilling to discuss these issues. However, it is nonetheless important to stay attuned to how patients behave and what they say in order to direct the interview appropriately.
Fortunately for our patients, there are several treatment options and more potentially moving through the pipeline. It may be necessary to use a combination of topical medications and/or oral medications to achieve the full clearance of lesions that patients desire. The treatment approach should target as many of the pathogenic factors involved in acne formation as possible. It is also advisable to pair treatment with an appropriate skin care regimen and to arm patients with proper education for how to use the products we recommend.
Above and beyond what we can offer patients in terms of treatment is a sense of optimism and hope that they can achieve clearance of troublesome acne, and that they are not alone in their struggle to treat their skin disorder.
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2. Fried RG, Weschler A. Psychological problems in the acne patient. Dermatol Ther. 2006;19(4):237-240.
3. Tedeschi A, Dall’Oglio F, Micali G, Schwartz RA, Janniger CK. Corrective camouflage in pediatric dermatology. Cutis. 2007;79(2):110-112.
4. Tasoula E, Gregoriou S, Chalikias J, et al. The impact of acne vulgaris on quality of life and psychic health in young adolescents in Greece: results of a population survey. An Bras Dermatol. 2012;87(6):862-869.
5. Mallon E, Newton JN, Klassen A, Stewart-Brown SL, Ryan TJ, Finlay AY. The quality of life in acne: a comparison with general medical conditions using generic questionnaires. Br J Dermatol. 1999;140(4):672-676.
6. Kilkenny M, Stathakis V, Hibbert ME, Patton G, Caust J, Bowes G. Acne in Victorian adolescents: associations with age, gender, puberty and psychiatric symptoms. J Paediatr Child Health. 1997;33(5):430-433.
7. Purvis D, Robinson E, Merry S, Watson P. Acne, anxiety, depression and suicide in teenagers: a cross-sectional survey of New Zealand secondary school students. J Paediatr Child Health. 2006;42(12):793-796.
8. Halvorsen JA, Dalgard F, Thoresen M, Bjertness E, Lien L. Is the association between acne and mental distress influenced by diet? Results from a cross-sectional population study among 3775 late adolescents in Oslo, Norway. BMC Public Health. 2009; 9:340.
9. Magin P, Adams J, Heading G, Pond D, Smith W. The causes of acne: a qualitative study of patient perceptions of acne causation and their implications for acne care. Dermatol Nurs. 2006; 18(4):344-349,370.
10. Thiboutot D, Zaenglein A, Hebert, A, Eichenfeld, l. Assessment of pharmacokinetics and safety of investigational nitric oxide-releasing SB204 gel in adolescents with acne vulgaris. Poster presented at: World Congress of Pediatric Dermatology Annual Meeting; 2017 July 06-09; Chicago, IL