Adolescent Acne By Lisa Kimmey-Walker, MSN, RN, CPNP, Pediatric Nurse Practitioner, Memorial Hermann Health Centers for Schools and member of the Center for Technical Assistance and Training Advisory Panel
Pimples! Why me? Since about 80% of teens get acne vulgaris to some degree and all acne is hormonal, chances are you will have the opportunity to help a student with this problem. Lets start with an anatomy review. The high levels of hormones in teens lead to an increase in sebum(oil) production, which can clog hair follicles (pores) and lead to pimple formation. This occurs usually about one to two years prior to the onset of puberty so the “tweens” (pre-teens) may also be affected. The sebum can combine with dead skin cells and dirt on the skin. Pimples may become infected and lead to pustules. The bacteria are propionibacterium acnes. “Blackheads” have oxidized melanin that lead to the darker color. Stressful events can worsen acne and genetics certainly contribute to likelihood and degree of acne. Providers should also incorporate assessment for creatine or anabolic steroid use in students with a history of severe acne.
Education is key in the management of this condition. Reassurance that acne is not diet related and is manageable is important in preserving or restoring self-esteem. Affected areas of the face, back, or chest should be washed two or more times daily to remove the excess sebum. Soap and water or OTC Salicylic acid acne washes can be used. To minimize scarring, the teen should not traumatize the lesions in any way, including the use of adhesive strips to clean out pores.
Patience is not typically associated with adolescents, but help them “hang in there” since improvement takes months, not days. And the bad news…. Once initiating treatment, the acne frequently gets worse before it gets better, resulting in premature cessation of therapy and failure to keep follow-up appointments. Adolescents need a good support system and regular feedback. Serial photographs help document progress whether by the student or clinician.
There are many medications available for the treatment of acne in various presentations. Benzoyl peroxide (BPO) has antimicrobial activity against propionibacterium. acnes and is available in 2.5%, 5% and 10% strengths OTC. It is very effective with mild acne and as a combination therapy for moderate acne. The American Academy of Pediatrics recommends starting with the lowest doses for initial management of acne. There are a variety of prescription medications for acne available including topical and systemic antibiotics. A topical agents like Tretinoin (Retin A) is used with mild to moderate acne. Retin A cream should be the initial therapy with progression to the gel if needed. The newer micro gel is less irritating. Moderate to severe acne may be treated with Benzamycin (BPO + erythromycin) and Benzaclin (BPO + clindamycin) alternating with Retin A to avoid systemic antibiotics. Benzamycin must be refrigerated. Erythromycin gel is an inexpensive topical solution option for mild to moderate acne.
Systemic or oral antibiotics used to treat moderate to severe acne are tetracycline, erythromycin, minocycline, clindamycin, trimethoprim/sulfamethoxazole (Bactrim), and isotretinoin (Accutane). The pros and cons of each drug should be discussed with both the student and family. For example, Minocycline can cause a lupus- like skin reaction, Tetracycline and Accutane are teratogenic (harm fetuses) and Bactrim can cause a severe allergic reaction (Stevens-Johnson). A depression assessment is needed prior to initiation of Accutane. Oral contraceptives must be free of norgestrel, norethindrone and norethindrone acetate as these hormones exacerbate acne.
NASBHC ● 666 11th St., NW Suite 73 5, Washington, DC 20001 202-638-5872 ● www.nasbhc.org
Whatever the treatment plan, the adolescent needs education, ongoing support and reassurance. Initial and ongoing assessment of self-esteem, coping and perceptions of progress are key components of acne management. The school-based health center team is in the optimal position to provide education, support, many of the treatments and coordination of care with dermatologists and primary care physicians.
Acne Web-Based Resources Teen education on acne and treatments at: www.coolnurse.com/acne.htm
Teen education and Acne Quiz at: www.kidshealth.org/teen/diseases_conditions/skin/acne.html
Lisa Kimmey-Walker, MSN, RN, CPNPPediatric Nurse Practitioner/ManagerMemorial Hermann Health Centers for Schools-Lamar ClinicRosenberg, Texas NASBHC ● 666 11th St., NW Suite 73 5, Washington, DC 20001 202-638-5872 ● www.nasbhc.org
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