Treatment of an infantile acne with oral isotretinoin

ARTICLE

Auteur(s) : F. SARAZIN¹, A. DOMPMARTIN¹, S. NIVOT², D. LETESSIER¹, D. LEROY¹

¹ Departments of Dermatology ² Pediatrics, Centre Hospitalier Universitaire, 14033 Caen Cedex, France

Article accepted on 14/10/2003

Infantile acne is an uncommon disorder especially in female infants. When topical therapies and oral antibiotics do not clear the acne, oral retinoids can be used. We report the case of nodulocystic acne in a 20 month-old-female infant who was treated with oral isotretinoin usually used in teenagers.

Case report

A young girl developed acne at 20 months of age. There was no family history of acne. She had mediofacial seborrhea with mixed-type lesions. Papules, nodules, pustules and comedones were present on both cheeks and also microcysts on the nose (Fig. 1). There was no raucity of the voice, no clitoris hypertrophy, no hyperpilosity. Screening evaluation searching for an endocrinopathy was negative: bone age, total and free testosterone, and its sulfate (DHEAS), 17α-hydroxyprogesterone, delta-4-androstenedione, gonadotropins (FSH, LH) and prolactin. Blood count, liver tests, ion-concentration, serum iron, zinc and immunoglobulins were normal.
She had a prophylactic treatment of vitamin D2 2000 UI/day (Stérogyl^®, Aventis), sodium fluorure 0.25 mg/day (Zymafluor^®, Novartis). To clean her face, her mother had applied almond oil every day for one year. She had been previously treated with topical fusidic acid (Fucidine^® cream, Leo) during one month with no improvement of the acne lesions. When she first reported to the Dermatology department, sodium fluorure and almond oil were discontinued. Topical erythromycin (Eryfluid^®, Pierre Fabre), and oral pristinamycin 50 mg/kg/day (Pyostacine^®, Aventis) during 2 months then amoxicillin clavulanic acid 60 mg/kg/day (Augmentin^®, GlaxoSmithKline) during 6 weeks were inefficacious on the inflammatory lesions. Two pustular nodules had to be surgically incised under local anaesthesia. After 6 months of oral antibiotics she was started on isotretinoin (Roaccutane^®, Roche), 0.5 mg/kg/day (5 mg/day). Serum cholesterol, triglycerides, liver enzymes were checked every two months. Two months later, the tolerance was excellent and the isotretinoin dosage was increased to 0.6 mg/kg/day. Pustules, comedones and inflammatory lesions disappeared and the acne was significantly improved by 7 months with a cumulative dose of 120 mg/kg. Six months after the withdrawal of the drug, the acne relapsed in the same place with nodules, microcysts on the cheeks, chin and nose. The lesions were far less inflammatory. She had episodic courses of topical erythromycin and tretinoin (Erilyk^®, Biorga). Serum hormones were still normal although there was a non-significant elevation of DHEAS up to 200 ng/ml (10 < N < 140 ng/ml). At 5 years of age all the lesions disappeared with no relapse and no growth retardation (Fig. 2).

Discussion

This young girl presented with an infantile acne which is different from acne neonatorum and prepubertal acne [1]. The age of onset of infantile acne is between 6 and 16 months [2] with a male predominance. In female infants, like our patient, acne is an uncommon disorder, which starts later at a mean age of 14 months. Occasionally there is a family history of acne. The lesions are usually confined to the cheeks like our little girl, rarely on the chin, the forehead, or the back. On presentation the acne lesions are polymorphous with comedones, inflammatory papules and pustules, rarely nodules or cysts. The lesions last for a few years, and some remain into puberty [3]. Atrophic scars can persist.
Before any therapeutic approach, a iatrogenic acne must be eliminated. One must exclude the acneiform lesions following the administration of lithium and phenytoin during pregnancy, or the administration of steroids, anticonvulsant drugs and halogenids. The withdrawal of sodium fluoride did not improve our patient's acne. An accidental exposition to dioxin and the use of comedogenic topical products are also capable of producing an acneiform reaction. Infantile acne may also be a marker of precocious puberty [4]. Clinical examination must search for signs of hyper androgenemia, virilization or hypercorticism. The main clinical signs are pubic or axillar hair, seborrhea, vibex, accelerated growth, clitoris or penis hypertrophy, maturation of the testis. The best physiologic measurement of androgenicity is the bone age. The main aetiology of precocious puberty is congenital adrenal hyperplasia.
The duration of treatment of infantile acne is long, around 18 months [2]. Infants with mild disease respond well to topical treatments. The molecules used are erythromycin, benzoylperoxide, tretinoin. Similarly to the adults, they produce side effects of mild irritant dermatitis easily controlled by adjusting the frequency of the applications. The inflammatory nodulocystic lesions require oral antibiotics. Oral tetracycline should not be used in children below 8 years in order to avoid tooth discoloration. 84% of English dermatologists chose erythromycin as the first line treatment [5]. The daily dose was 125 mg twice a day during 4 months but the dose can be increased if the lesions are resistant [2]. When the patients fail to respond to erythromycin, trimethoprim is an alternative option [2, 5, 6]. On isolated occasions, persistent inflammatory nodules can be treated with cryotherapy [2] or intralesional steroids under general anesthesia [5].
If some children develop severe nodular acne, or fail to respond to numerous courses of oral antibiotics, they may need to be treated with oral isotretinoin. There are a few reported cases of the use of oral isotretinoin in infantile acne with good results [5]. Four clinical cases are well documented [2, 7-9]. The children had been treated between 12 and 29 months of age. The mean daily dose is 0.65 mg/kg/day (0.3-1.0 mg/kg/day) which is the same as the adult dose. During the treatment, the dosage was increased in two cases with a minimal toxicity [7, 8]. The mean duration of treatment was 5-7 months with mean cumulative doses of 85 mg/kg (61-100 mg/kg). There were no clinical or biological side effects and especially no growth retardation was observed in this indication. Cheilitis is as important as with adults. One infant treated with 1 mg/kg/day of 13-cis-retinoic acid developed mood change associated with hair-growth retardation and increase of lactic deshydrogenase levels [7]. A mild elevation of liver transaminases has also been noted [8]. Treatment was not discontinued because of these side effects. For one patient, acne relapsed after discontinuation of the treatment but the lesions were less inflammatory than previously observed [9]. This patient underwent two isotretinoin regimens until the cumulative dose was 100 mg/kg.
Oral isotretinoin may be necessary in a small number of infants to reduce the inflammatory lesions and the risk of scarring. To facilitate oral administration, 5 mg and 10 mg capsules are opened in a dark environment and the contents smeared on a spoon full of hot milk. Lipids increase digestive absorption. It is a well-tolerated treatment with good therapeutic results but relapse is frequent, with less inflammatory lesions that can be controlled with topical treatments. n

References

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