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  • Mid-childhood acne warrants evaluation for various causes of hyperandrogenism.

  • Acne fulminans and isotretinoin-induced acne fulminans represent severe presentations of acne. Management should include both modified dosing of isotretinoin and systemic corticosteroids.

  • Acne conglobata is a severe, nodular form of acne that heals with extensive scarring.

  • Acne excoriee, or skin-picking disorder, is a psychological disorder, and patients should be comanaged with psychiatric providers.

  • Periorificial dermatitis is a common acneiform eruption often caused by topical or inhaled corticosteroids.



Neonatal acne can occur in up to 20% of healthy newborns. Lesions usually appear around 2 weeks of age and resolve spontaneously within 3 months. Typically, small, inflamed papules congregate over the nasal bridge and cheeks (Fig. 80-1). Because comedo formation is absent, the pathogenesis of neonatal acne may be different than acne vulgaris. It has been shown that sebum excretion rates in newborns are transiently elevated in the perinatal period.1 Additionally, Malassezia sympodialis, a normal commensal on human skin, may also play a role. Some reports have demonstrated positive cultures of the pustules with Malassezia spp. and improvement with ketoconazole cream.2 Although there appears to be a strong association between Malassezia spp. and neonatal acne, definite causality has not yet been proven.3 Neonatal cephalic pustulosis presents with similar but widespread papulopustular lesions over face, scalp, upper chest and back, and shoulders.

Figure 80-1

Neonatal acne. Small, erythematous papules and pustules over the face and chest in a newborn.


Infantile acne presents at 3 to 6 months of age classically with open and closed comedones over the cheeks and chin. (Fig. 80-2). Papules, pustules, and nodules can also present on the face. Pitted scarring may occur even with relatively mild disease. Infantile acne is caused in part by the transient elevation of dehydroepiandrosterone (DHEA) produced by the immature adrenal gland.4 Additionally, during the first 6 to 12 months of life, boys may also have an increased level of luteinizing hormone (LH) that stimulates testosterone production. Around 1 year of age, these hormone levels begin to stabilize until they surge again during adrenarche. As a result, infantile acne usually resolves around 1 to 2 years of age. Treatment generally consists of topical retinoids and benzoyl peroxide. Oral therapy with erythromycin, azithromycin, trimethoprim, or isotretinoin can be used in severe or refractory cases.

Figure 80-2

Infantile acne. Primarily open and closed comedones over the cheeks of a 5-month-old infant.


Mid-childhood acne is defined as appearing between 1 and 7 years of age.5 Typically, acne is very rare in this age group because the ...

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