Acne in infants, young children, and preadolescents

INTRODUCTION — Acne vulgaris affects up to 95 percent of teenagers and young adults but can begin in infancy and early childhood [1]. This topic will discuss the pathogenesis, diagnosis, and management of acne in infants and children younger than 12 years. Neonatal acne, a common acneiform eruption occurring in the first months of life, is discussed elsewhere. Acne in adolescents and adults is also discussed separately.

●(See "Skin lesions in the newborn and infant".)

●(See "Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris".)

●(See "Acne vulgaris: Overview of management".)

●(See "Postadolescent acne in women".)

CLASSIFICATION — Acne in childhood is divided into three groups, based on age at presentation, differences in clinical presentations, associated conditions, and pathogenetic factors [1,2]:

●Infantile acne – Infantile acne typically occurs at the age of 6 to 16 months (median 9 months) and lasts for up to two years [3]. It is most often due to temporary, physiologic imbalances in androgen production.

●Mid-childhood acne – Mid-childhood acne has onset between one to seven years of age, a time when androgen levels should be at their nadir. Acne in this age group may reflect an increased androgen production, most often due to premature adrenarche. (See 'Pathogenesis' below.)

●Preadolescent acne – Preadolescent acne is defined as acne occurring with the early rise in adrenal androgens between 7 to 12 years, heralding the start of puberty.

EPIDEMIOLOGY — Acne in children and preadolescents is uncommon. In an analysis of the National Ambulatory Medical Care Survey looking at all physician office visits for acne (1993 through 2009), 4.8 percent were for preadolescent acne, 0.9 percent were for mid-childhood acne, and 3 percent were for neonatal or infantile acne [4]. Approximately 91 percent of visits were for adolescent acne.

Infantile acne occurs more frequently in males than in females, while mid-childhood and preadolescent acne affects females more commonly than males [3,5,6].

In a retrospective, population-based study, the age- and sex-adjusted annual incidence rate of acne in children aged 7 to 12 years was 58 per 10,000 person-years [6]. Incidence was higher in females than in males (89 versus 28 per 10,000 person-years). The median age- and sex-specific body mass index (BMI) percentile was higher for children with acne compared with controls (median 75, interquartile range 51 to 91; and 65, interquartile range 36 to 87).

PATHOGENESIS — Infants often have physiologic, transient increased levels of adrenal androgens. At birth, the immature adrenal gland can produce elevated levels of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS), which typically normalize by six months of age [7]. In babies with acne, these adrenal androgen elevations may be prolonged [8]. Additionally, in infants 6 to 12 months of age, there is an increased production of luteinizing hormone at pubertal levels ("mini-puberty"), which in male infants results in additional production of gonadal testosterone, further contributing to acnegenesis [8,9]. These hormonal imbalances are typically transient, and acne will improve as the hormone levels normalize. Genetic factors likely influence acnegenesis as well, as approximately 50 percent of babies with infantile acne have a sibling with infantile acne and a positive family history of severe, adolescent acne [5,10].

Mid-childhood acne is, in most cases, associated with increased androgen production due to premature adrenarche or, more rarely, to other disorders associated with hyperandrogenism, such as nonclassic (late-onset) congenital adrenal hyperplasia, gonadal or adrenal tumors [11,12], or conditions associated with precocious puberty. Premature adrenarche (often presenting with early acne) has been associated with low birth weight, due to hormonal stressors, and potential increased risk for polycystic ovarian syndrome (PCOS) and metabolic syndrome [13]. Exogenous exposure to testosterone gel and other androgens has also resulted in virilization with associated acne [14]. (See "Premature adrenarche" and "Definition, etiology, and evaluation of precocious puberty" and "Genetics and clinical presentation of nonclassic (late-onset) congenital adrenal hyperplasia due to 21-hydroxylase deficiency" and "Adrenal hyperandrogenism".)

CLINICAL MANIFESTATIONS — The clinical manifestations of acne in children vary depending on age.

Infantile acne — Infantile acne typically occurs at the age of 6 to 16 months (median 9 months) with typical acne lesions distributed over the cheeks (picture 1A-B) [5]. Mixed, inflammatory papules and pustules and comedones are common, with nodular lesions being infrequently seen in this age group. In most cases, babies with infantile acne do not have other signs or symptoms of hyperandrogenism [3,5]. The eruption is usually self-limited and generally resolves spontaneously by the end of the first year of life but may persist until two years of age. Scarring, presenting as typically small, atrophic pits, may result in up to 50 percent of affected infants [10].

Mid-childhood acne — Mid-childhood acne presents in children of one to seven years of age with comedones and inflammatory lesions typically distributed over the forehead, cheeks, and nose. Because children aged one to seven years do not produce significant amounts of androgens, acne in this age group suggests an endocrine abnormality that warrants evaluation by a pediatric endocrinologist. (See 'Indications for pediatric endocrinology referral' below.)

Preadolescent acne — Preadolescent acne usually presents in children aged 7 to 12 years, predominantly with mild to moderate numbers of comedones in the T-zone (ie, forehead, nose, and chin (picture 2)) and, less frequently, with papules, pustules, and nodules [15,16].

DIAGNOSIS

History and physical examination — The diagnosis of acne in any age group is made clinically in most cases, based on history and recognition of classic skin lesions (ie, open and closed comedones, inflammatory papules and pustules, nodules). Resultant postinflammatory erythema or hyperpigmentation, as well as scarring, should be noted (see "Pathogenesis, clinical manifestations, and diagnosis of acne vulgaris"):

●History – Relevant history includes age of onset; history of acne in parents and siblings; and medical and medication history, including use of oral, inhaled, or topical corticosteroids and other agents that may elicit acneiform drug eruptions (eg, cyclosporine, chemotherapy agents). Accidental exposure to exogenous androgens (eg, androgen-containing topical preparations or supplements used by parents or caregivers) should also be investigated.

●Physical examination – All children with acne should undergo a comprehensive physical examination for signs of androgen excess and advanced Tanner stage (table 1).

Children with premature adrenarche and subsequent pubarche will exhibit pubic hair and adult-type body odor without other signs of secondary sex development. The presence of additional secondary sexual characteristics, such as breast development, testicular enlargement, atypical genitalia, accelerated growth, and muscular habitus, raise suspicion of disorders associated with precocious puberty or other causes of hyperandrogenism, such as nonclassic (late-onset) congenital adrenal hyperplasia, androgen-secreting tumors, or exposure to exogenous androgens. (See "Premature adrenarche" and "Definition, etiology, and evaluation of precocious puberty" and "Genetics and clinical presentation of nonclassic (late-onset) congenital adrenal hyperplasia due to 21-hydroxylase deficiency".)

Initial workup — Following clinical examination and Tanner staging, the initial workup for suspected hyperandrogenism includes obtaining a bone age radiograph [5,13]. If bone age is advanced compared with chronologic and height age, referral to pediatric endocrinology is recommended to guide further workup and laboratory testing. (See 'Indications for pediatric endocrinology referral' below and "Premature adrenarche", section on 'Bone age radiograph'.)

Indications for pediatric endocrinology referral — Referral to pediatric endocrinology for evaluation and workup is warranted for children with acne and who present signs of [5,13]:

●Premature adrenarche and/or premature pubarche – Presence of sexual pubic or axillary hair before age eight years in females and age nine years in males and advanced bone age (see "Premature adrenarche", section on 'Further evaluation for children with advanced bone age')

●Adrenal hyperandrogenism – Increased height velocity, development of male secondary sexual characteristics in prepubertal males, hirsutism and clitoromegaly in prepubertal females (see "Diagnosis and treatment of nonclassic (late-onset) congenital adrenal hyperplasia due to 21-hydroxylase deficiency")

●Precocious puberty – Appearance of secondary sex characteristics, such as breast development before age eight years in females and testicular enlargement before age nine years in males (see "Definition, etiology, and evaluation of precocious puberty")

Skin biopsy and histopathology — Histopathology is rarely required to make a diagnosis of acne. In atypical cases where the diagnosis is unclear, a small 2 to 3 mm punch biopsy of a characteristic lesion in the least aesthetically sensitive area (away from the central face and cheeks) is recommended.

On histopathology, comedones will demonstrate an open or closed, follicular orifice with a keratinaceous plug and mild, perifollicular inflammation. With follicle wall rupture, bacteria and mixed inflammation (neutrophils, lymphocytes, histiocytes) surround the pilosebaceous unit. Foreign body type multinuclear giant cells and granulomatous inflammation may be seen. Fibrosis and scarring are seen in later lesions.

DIFFERENTIAL DIAGNOSIS

Pseudoacne of the nasal crease — Pseudoacne of the nasal crease typically occurs in school-age children. Open and closed comedones and acneiform papules line up horizontally across the middle part of the nose at the developmental fault line, the transverse nasal crease [17,18]. Treatment with topical benzoyl peroxide and/or topical retinoids may improve lesions and prevent recurrence.

Idiopathic aseptic facial granuloma — Idiopathic aseptic facial granuloma is characterized by limited numbers of painless, inflammatory papules and nodules over the cheeks. The mean age of presentation is three years, but idiopathic aseptic facial granuloma has been described in a preadolescent as well [19-21]. The disorder is thought to be a childhood form of rosacea. Some children have a history of recurrent chalazions [22,23].

Ultrasound shows well-demarcated, hypoechoic nodules without calcification. Bacterial cultures are typically negative, but growth of Staphylococcus aureus, Streptococcus species, and Enterococcus faecalis has been reported in some cases [19]. Histopathology shows a mixed, inflammatory, granulomatous infiltrate with lymphocytes, histiocytes, neutrophils, and foreign body giant cells [24].

Antibiotic therapy is ineffective in most cases. Lesions typically resolve spontaneously, with a mean duration of 11 months (range 2 to 24 months) [19,20].

Keratosis pilaris — Keratosis pilaris appears in all age groups but is typically more prominent in younger children than in adults. Clinically, coarse, follicular papules associated with variable, underlying erythema are located on the cheeks, extensor aspect of the arms and upper thighs, and buttocks. Infants and toddlers may have a pronounced, papular variant with extensive involvement of cheeks, arms, and legs [25]. (See "Keratosis pilaris".)

Neonatal acne — Neonatal acne is a common eruption that typically arises in the first weeks of life and resolves spontaneously within a month or two. Small, inflammatory papules and pustules scattered over the face predominate (picture 3). Comedones are absent. Maternal hormones, elevated sebum excretion rates, and Malassezia species are implicated in the pathogenesis [26]. (See "Skin lesions in the newborn and infant".)

Neonatal cephalic pustulosis — Neonatal cephalic pustulosis is a self-resolving, papulopustular eruption observed in neonates. The rash is more widespread but similar to (if not a variant of) neonatal acne (picture 4). The face, upper trunk, and shoulders are affected. Malassezia species are thought to play a role in the pathogenesis [27]. (See "Vesicular, pustular, and bullous lesions in the newborn and infant", section on 'Neonatal cephalic pustulosis'.)

Demodicosis — Demodicosis is a disorder of the pilosebaceous unit caused by the human Demodex mites (Demodex folliculorum and Demodex brevis). It is uncommon in childhood. However, primary demodicosis has been described predominantly in immunosuppressed children, particularly those with Langerhans cell histiocytosis [28]. It has also been reported with topical corticosteroid use in an immunocompetent child [29]. Secondary demodicosis arises in conjunction with other facial inflammatory disorders, including periorificial dermatitis and rosacea. Treatment with topical ivermectin or permethrin significantly decreases the mite burden. Additional therapy to treat the underlying disorder in secondary demodicosis is still required. (See "Infectious folliculitis", section on 'Demodex folliculitis'.)

Acneiform drug eruptions — Acneiform drug eruptions in childhood have been reported with several medications, including cyclosporine and systemic, topical, and inhaled corticosteroids [30,31]. Chemotherapy with epidermal growth factor receptor (EGFR) inhibitors and mitogen-activated protein kinase kinase (MEK) inhibitors may also cause acneiform or keratosis pilaris-like eruptions (see "Acneiform eruption secondary to epidermal growth factor receptor (EGFR) and MEK inhibitors"). There are several reports of vitamin B12 supplementation also causing acneiform eruptions, including in a child [32].

TREATMENT — The principles of treating acne in infants and children are similar to those for treating adolescent acne and involve using combination therapy to target the multiple pathogenic factors in acne [1]. (See "Acne vulgaris: Overview of management", section on 'Treatment principles'.)

There are no large observational studies or randomized studies of acne treatment in infants and young children. The management of infantile and mid-childhood acne is primarily based on limited evidence from case reports and small case series and on clinical experience, as well as on evidence from studies in older patients.

Assessment of severity — Standardized acne assessments for childhood acne have not been established. The following five-point Investigator's Global Assessment (IGA) scale (used in a clinical trial for preadolescent acne [NCT02959970]) can be used:

●Clear (0) – No comedones. Papules or pustules, residual hyperpigmentation, and erythema may be present.

●Almost clear (1) – Rare comedones. No more than a few small papules and pustules.

●Mild (2) – Easily recognizable comedones in limited numbers, with or without the presence of small papules and pustules.

●Moderate (3) – Many comedones with or without easily recognizable, small and medium-sized papules. No nodules or cysts.

●Severe (4) – Widespread and numerous comedones. Many small, medium-sized, and large papules and pustules; nodules or cysts may or may not be present.

Infants and children <7 years

Mild acne — Mild infantile and mid-childhood acne can be managed with topical treatments. A low-strength topical retinoid (tretinoin 0.025% cream or adapalene 0.1% gel) or benzoyl peroxide 2.5% cream applied once daily are typically used. Because benzoyl peroxide can inactivate topical generic tretinoin formulations, the two should not be applied concurrently. Benzoyl peroxide washes should be avoided, or used with caution, to prevent eye irritation or accidental ingestion.

Alternatively, and particularly if scarring is noted, a fixed combination product (adapalene 0.1%/benzoyl peroxide 2.5% gel) applied once daily can be used.

For infantile acne, treatments should be continued for at least three to four months and continued until the acne is clear and the baby is out of the typical window period, approximately two years of age. For mid-childhood acne, treatments may need to be continued throughout adolescence.

In an open-label study, 12 infants with mild to moderate acne were treated with adapalene 0.1% gel once daily, with a median clearance time of 3.4 months [33]. Erythema, burning, and pruritus were noted in up to one-third of patients, but none discontinued therapy.

Moderate to severe acne — For children with moderate acne or more pronounced, inflammatory papules, systemic antibiotic therapy may be required in addition to topical retinoid and benzoyl peroxide therapy as described for mild acne (see 'Mild acne' above). Antibiotic monotherapy is not recommended.

While data in childhood acne are lacking, in general, any use of topical or systemic antibiotics in acne should be combined with topical benzoyl peroxide to prevent microbial resistance when possible [34]:

●Choice of oral antibiotic – Macrolides (erythromycin, azithromycin) are the antibiotics of choice for children younger than eight years [1]. Although tetracyclines are the preferred antibiotics for the treatment of moderate to severe acne in adolescents and adults, they should not be given to children younger than eight years of age.

Successful use of trimethoprim 100 mg twice daily has been reported in an infant with erythromycin-resistant acne [3].

●Dosing – Dosing regimens for erythromycin and azithromycin in children are based on body weight:

•Erythromycin suspension (base, ethylsuccinate, stearate; 200 mg/5 mL) 10 mg/kg/dose, one to two times daily. Common adverse effects include nausea, vomiting, and diarrhea. Serious side effects include altered cardiac conduction (prolonged QT interval), liver toxicity, and hypertrophic pyloric stenosis in infants.

•Azithromycin suspension (200 mg/5 mL) 5 mg/kg once daily (maximum dose 250 mg/day). Common side effects include nausea and diarrhea. Serious side effects include altered cardiac conduction (prolonged QT interval, ventricular tachycardia), Clostridium difficile colitis, drug hypersensitivity reactions, liver toxicity, and ototoxicity.

●Duration of treatment – Oral antibiotics are usually given for three months. To reduce the risk for antibiotic resistance and potential adverse effects, the need for continued antibiotic use beyond three months is reassessed in the individual patient [35]. (See "Acne vulgaris: Management of moderate to severe acne in adolescents and adults", section on 'Oral antibiotics' and "Acne vulgaris: Management of moderate to severe acne in adolescents and adults", section on 'Appropriate use'.)

Severe acne — For severe, nodular acne and acne not responsive to systemic antibiotics, oral isotretinoin can be used. In the United States, oral isotretinoin is used off label for the treatment of acne in children younger than 12 years:

●Dosing – Standard dosing in infants and children is 0.5 to 1 mg/kg/day (same as for adolescent acne). Cumulative dosing has not been established in infantile acne. Reported duration of treatments range from 4 to 14 months [36,37].

●Administration – Tips for the administration of isotretinoin to young children or those who cannot swallow capsules are summarized in the table (table 2) [38,39].

●Adverse effects and monitoring – Reported adverse effects of isotretinoin in infants include diarrhea, perioral rash, lip desquamation, transaminitis, umbilical granulation tissue, eczema, reduced hair growth, and mood changes [37]. Laboratory monitoring (ie, lipids and liver function tests) should be done at baseline and once the therapeutic dose has been established (typically in one to two months). While premature closure of growth plates is a serious concern with systemic isotretinoin in children, it has typically been reported with higher doses of isotretinoin (above 1 mg/kg/day) and for longer durations of treatment (four to six years) [39].

Preadolescents (children 7 to 12 years) — For preadolescent acne, the treatment principles are the same as for adolescent acne. Our approach to the treatment of acne in preadolescent and adolescent children is illustrated in the algorithm (algorithm 1).

It should be noted that hormonal therapies (ie, combined oral contraceptives, spironolactone) are not indicated for preadolescent acne. (See "Acne vulgaris: Overview of management" and "Acne vulgaris: Management of moderate to severe acne in adolescents and adults".)

Mild acne — Monotherapy with topical tretinoin 0.025% cream or adapalene 0.1% gel or combination therapy with benzoyl peroxide 2.5% gel plus tretinoin 0.025% cream or adapalene 0.1% gel can be used for mild acne in preadolescents. Simplifying routines in this age group is especially important to encourage better adherence [1,40]. For combination therapy, once-daily routines (eg, benzoyl peroxide wash with adapalene 0.1% gel) or fixed combination products (eg, adapalene-benzoyl peroxide 0.1%/2.5% gel) may ease compliance.

Topical dapsone is a second-line topical treatment for mild, inflammatory acne for children ≥9 years [41]. Dapsone gel 7.5% is applied once daily. Dapsone should not be applied at the same time as benzoyl peroxide, as they can cause a temporary orange discoloration of skin and hair [42].

Topical therapies for preadolescent acne have been evaluated in several randomized trials:

●Adapalene-benzoyl peroxide – In a randomized trial that included 285 children aged 9 to 11 years with moderate acne treated with adapalene-benzoyl peroxide 0.1%/2.5% gel or vehicle, the percent reduction in lesion count at 12 weeks was greater in the active treatment group than in the vehicle group (69 versus 19 percent) [43].

●Tretinoin – In a randomized trial with 110 children aged 9 to 11 years, treatment with topical tretinoin 0.04% microsphere gel (55 patients) induced a statistically significant greater mean reduction in noninflammatory lesions compared with vehicle (-19.9 versus -9.7, respectively) at 12 weeks [44].

A post-hoc analysis of two multicenter, phase 3, randomized trials of tretinoin 0.05% lotion versus vehicle in 154 children aged 9 to 13 years with moderate to severe acne found a mean percent reduction in inflammatory and noninflammatory lesion counts of 50 and 44 percent, respectively, in the tretinoin group compared with 31 and 19 percent, respectively, in the vehicle group at 12 weeks [45].

●Topical dapsone – Dapsone 7.5% gel was evaluated in a phase 4, open-label, multicenter study in 100 patients 9 to 11 years of age. At 12 weeks of treatment, total lesion counts decreased by 24, with a mean percentage reduction of 51.9 percent [46].

Moderate to severe acne — Oral antibiotics, while maintaining topical treatments, are the first-line therapy for preadolescents with moderate to severe acne. Doxycycline is approved for children ≥8 years of age and should not be used in younger children due to the potential for yellow staining of teeth.

For children ≥8 years of age, the recommended dose of doxycycline is 50 to 100 mg once or twice daily or 150 mg once daily [1]. For children unable to swallow pills, doxycycline is commercially available in liquid suspension 25 mg/5 mL or syrup 50 mg/5 mL. Doxycycline may be given with food to minimize gastrointestinal upset.

Erythromycin (10 mg/kg/dose, one to two times daily) or azithromycin (5 mg/kg once daily, maximum daily dose 250 mg) are alternative antibiotics for children <8 years of age.

Systemic antibiotic therapy should be limited to three months and then discontinued, while topical therapy with a retinoid with or without benzoyl peroxide is maintained.

Severe acne — For severe, nodular acne and acne not responsive to systemic antibiotics, isotretinoin may be used. Dosing is the same as for adolescent acne (0.5 to 1 mg/kg/day for 20 weeks), with a cumulative dose of 120 to 150 mg/kg.

Adverse effects of isotretinoin and laboratory monitoring during therapy are discussed in detail separately. (See "Oral isotretinoin therapy for acne vulgaris".)

FOLLOW-UP — Regular interval monitoring for treatment tolerability and response is recommended. In general, acne treatments can take 8 to 12 weeks to take effect. For any patient on isotretinoin, regardless of age, monthly appointments for counseling are required by iPLEDGE (the US Food and Drug Administration-mandated risk management program).

PROGNOSIS — With appropriate treatment, childhood acne has an excellent prognosis. Early recognition and prompt initiation of appropriate therapy will prevent potential scarring.

Early-onset acne may be a harbinger of more severe, adolescent acne, and parents/caregivers should be counseled to seek dermatologic care if their child's acne recurs (in the case of resolved, infantile acne) or if acne worsens (for mid-childhood and preadolescent patients).

Mid-childhood or preadolescent acne associated with premature adrenarche may be associated with the later development of polycystic ovarian syndrome (PCOS), and children should be clinically followed accordingly. (See "Premature adrenarche" and "Etiology and pathophysiology of polycystic ovary syndrome in adolescents" and "Diagnostic evaluation of polycystic ovary syndrome in adolescents".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acne vulgaris".)

SUMMARY AND RECOMMENDATIONS

●Classification of pediatric acne – Based on age at presentation and pathogenetic factors, pediatric acne is classified into three groups (see 'Classification' above and 'Pathogenesis' above):

•Infantile acne – Infantile acne typically occurs at the age of 6 to 16 months (median 9 months), is associated with transient physiologic imbalance in androgen production in most cases, and lasts for up to two years.

•Mid-childhood acne – Mid-childhood acne occurs between one to seven years of age and is, in most cases, associated with premature adrenarche.

•Preadolescent acne – Preadolescent acne occurs between 7 to 12 years of age and is associated with the early rise in adrenal androgens, heralding the start of puberty.

●Clinical presentation – Infantile acne presents with typical acne lesions (inflammatory papules and pustules and comedones) distributed over the cheeks (picture 1A-B). In mid-childhood acne, comedones and inflammatory lesions are distributed over the forehead, cheeks, and nose. Preadolescents most often present with comedones in the T-zone of the face (forehead, nose, chin) and, less frequently, with papules, pustules, and nodules. (See 'Clinical manifestations' above.)

●Diagnosis – The diagnosis of acne is clinical, based on history and recognition of classic skin lesions. Referral to pediatric endocrinology for evaluation and workup is warranted for children with acne and who present signs of premature adrenarche and/or premature pubarche, adrenal hyperandrogenism, or precocious puberty. (See 'Diagnosis' above and 'Indications for pediatric endocrinology referral' above.)

●Treatment:

•Infants and children <7 years:

-Mild acne – Mild infantile and mid-childhood acne is managed with topical treatments. We suggest a low-strength topical retinoid (eg, tretinoin 0.025% cream, adapalene 0.1% gel) or benzoyl peroxide 2.5% cream rather than a combination of the two as initial therapy (Grade 2C). They are applied once daily. A fixed combination product (adapalene 0.1%/benzoyl peroxide 2.5% gel) can be an alternative therapy, especially if scarring is noted. (See 'Mild acne' above.)

-Moderate acne – For children with moderate acne or more pronounced, inflammatory papules, we suggest systemic antibiotic therapy with erythromycin or azithromycin in addition to topical therapy as described for mild acne (Grade 2C). Oral erythromycin is given at the dose of 10 mg/kg/dose one to two times per day and continued for three months. (See 'Moderate to severe acne' above.)

-Severe acne – For severe, nodular acne that does not respond to systemic antibiotic therapy, oral isotretinoin is a therapeutic option. In the United States, oral isotretinoin is used off label for the treatment of acne in children younger than 12 years. (See 'Severe acne' above.)

•Children 7 to 12 years – For preadolescent children, the acne treatment principles are the same as for adolescents (algorithm 1):

-Mild acne – For preadolescent children with mild acne, we suggest topical retinoids or benzoyl peroxide or a combination of the two rather than other topical agents as initial therapy (Grade 2C). (See 'Mild acne' above.)

-Moderate to severe acne – We suggest oral antibiotic therapy in addition to topical therapy for preadolescents with moderate to severe acne (Grade 2C). We typically use erythromycin in children younger than eight years and doxycycline in children ≥8 years of age for three months while maintaining topical therapy. (See 'Moderate to severe acne' above.)

-Severe acne – For severe, nodular acne and acne not responsive to systemic antibiotics, isotretinoin is a therapeutic option. In the United States, oral isotretinoin is used off label for the treatment of acne in children younger than 12 years. (See 'Severe acne' above.)