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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.

What Lies Beneath: Taking a Deeper Look at Acne and Patient Care Strategies

To provide pediatricians and family practice physicians with up-to-date information on the diagnosis and treatment of acne.

This activity is designed for pediatricians and family practice physicians. No prerequisites required.

At the conclusion of this activity, the participant should be able to:

  • Recognize the prevalence and pathogenesis of acne to improve outcomes of treatment in the pediatric population.
  • Summarize the mechanisms of action and discuss the practical applications of the latest acne treatments.
  • Evaluate various treatment methods, with specific focus on pharmacologic agents to improve patient quality of life for those affected by acne.
  • Develop an individualized treatment plan depending on the patient’s age and severity of the patient’s condition.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 2 hours.

After reading this monograph, participants may receive credit by completing the CME test, evaluation, and receiving a score of 70% or higher.

Release date: March 15, 2008. Expiration date: March 15, 2010.

The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review
of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Dermik Laboratories, a business of sanofi-aventis U.S. LLC.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:


Bernard A. Cohen, MD, FAAP
Director of Pediatric Dermatology
Johns Hopkins Children’s Center
Professor, Dermatology and Pediatrics
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Cohen reports receiving grants/research support from Ortho-McNeil Pharmaceutical.


Adelaide Ann Hebert, MD, FAAD
Professor, Departments of Dermatology and Pediatrics
University of Texas–Houston Medical School
Houston, Texas
Dr Hebert reports receiving grants/research support from Galderma, Intendis, Medicis, Stiefel Laboratories, and Taro Pharmaceutical; serving as a consultant for Galderma, Intendis, Medicis, Stiefel Laboratories, and Taro Pharmaceutical; receiving honoraria from Galderma, Intendis, Medicis, Stiefel Laboratories, and Taro Pharmaceutical; and serving on the speakers’ bureau for Galderma, Intendis, Medicis, Stiefel Laboratories, and Taro Pharmaceutical.

Anthony J. Mancini, MD, FAAP
Head, Division of Pediatric Dermatology
Children’s Memorial Hospital
Associate Professor of Pediatrics and Dermatology
Northwestern University’s Feinberg School of Medicine
Chicago, Illinois
Dr Mancini reports serving as a consultant for Medicis and Stiefel Laboratories.

Notice: All faculty have indicated that they have not referenced unlabeled or unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

What Lies Beneath: Taking a Deeper Look at Acne and Patient Care Strategies
Bernard A. Cohen, MD, FAAP*

Acne is the most common skin disorder among adolescents, and is among the dermatologic conditions that are most frequently encountered by pediatricians.1,2 In addition to considerable physical discomfort, acne causes a great deal of emotional distress for many adolescents and young adults. By providing effective acne care, pediatricians help to relieve a considerable emotional burden for their patients, and also help to reduce the risk of permanent scarring.1

The pathophysiology of acne is complex, involving interactions among increasing hormone levels at the onset of puberty, altered responsiveness of sebaceous glands to androgens, abnormal keratinization and sebum production by sebaceous glands, proliferation of Propionibacterium acnes bacteria, the attraction of immune cells to developing lesions, the release of chemical mediators of inflammation, and the emergence of an inflammatory response.3 Several acne therapies are available to target these diverse pathophysiological processes, and clinical trials have helped to define the best ways to use these therapies for patients across the spectrum of acne severity. Although referral to a dermatologist may be required in some circumstances, most cases of acne can now be managed effectively by pediatricians and other primary healthcare providers using a combination of topical and systemic therapies.

Despite the range of effective treatment options, pediatricians often face significant challenges in the management of acne. Acne therapies may cause side effects that are difficult for patients to tolerate. Topical medications can produce significant skin irritation or drying, and oral antibiotics cause gastrointestinal disturbances and a range of other less common adverse events. Widespread use of antibiotics has also been associated with the spread of antibiotic-resistant strains of P acnes over the past several decades, resulting in the declining effectiveness of some antibiotics (eg, erythromycin). Drug-resistant forms of P acnes are capable of spreading from person to person, and have even been shown to propagate from Europe to North America.4 Oral isotretinoin is a powerful acne therapy that has produced dramatic clinical and emotional benefits for many patients with acne, yet is also associated with a substantial risk of serious birth defects, in addition to several other adverse effects.5,6

Difficulties associated with patient education and treatment adherence are also very common with acne therapy. Adolescents are often impatient with acne therapy, their adherence to therapy may be poor, and acne treatment often becomes a focus of disagreement or rebellion between patients and parents.7 Adolescent patients and their parents may have many misconceptions about the causes of acne or about how acne should be treated. Acne is often attributed to a wide range of dietary or behavioral causes, including chocolate, french fries, soda, or poor hygiene. Many patients with acne engage in behaviors that worsen the condition of the skin, including vigorous scrubbing or the use of abrasive cleansers. Effective education is therefore essential to help patients to understand the causes of acne, to avoid behaviors that may worsen acne severity, to establish realistic expectations about acne therapy, and to take acne medications as required to attain the best possible treatment outcomes. In addition, many adolescents say that they want more information about acne than they usually receive during a typical office visit with a primary care physician.8

As a consequence of the complex pathophysiology of acne, current guidelines for acne management generally emphasize the use of combination treatment strategies that may include topical benzoyl peroxide, antibiotics, or retinoids.3,9 Randomized clinical trials have demonstrated that combination therapies produce more rapid and more complete resolution of acne lesions than monotherapy.10-12 Combining antibiotic therapy with topical benzoyl peroxide has also been shown to reduce the risk of antibiotic resistance and improve the response to acne therapy.12,13

This issue of Johns Hopkins Advanced Studies in Medicine provides an overview and update on acne care for pediatricians. Anthony J. Mancini, MD, FAAP, reviews the prevalence, pathogenesis, clinical presentation, and psychological impact of acne. Dr Mancini also discusses recent studies that have examined the relationship between acne and diet.

An understanding of acne pathogenesis provides the basis for the second article, an overview of acne treatment options by Adelaide Ann Hebert, MD, FAAD. Dr Hebert describes the wide variety of acne therapies that are available, the efficacy and principal adverse effects of these therapies, and the importance of combination therapy for acne treatment.

Bernard A. Cohen, MD, FAAP, discusses 3 case studies that illustrate specific diagnostic or management issues that are common in pediatric dermatology. These cases describe the management of acne in an otherwise healthy infant, and in an adolescent male with darkly pigmented skin. A third case study describes the recognition and management of periorificial dermatitis, an uncommon pediatric form of rosacea that is sometimes mistaken for acne.

This monograph concludes with highlights from a question-and-answer session in which the authors discussed several challenging issues in acne management.


1.    Krowchuk DP. Managing acne in adolescents. Pediatr Clin North Am. 2000;47:841-857.
2.    Fleischer AB Jr, Herbert CR, Feldman SR, O’Brien F. Diagnosis of skin disease by nondermatologists. Am J Manag Care. 2000;6:1149-1156.
3.    Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003;49(1 suppl):S1-S37.
4.    Ross JI, Snelling AM, Eady EA, et al. Phenotypic and genotypic characterization of antibiotic-resistant Propionibacterium acnes isolated from acne patients attending dermatology clinics in Europe, the USA, Japan, and Australia. Br J Dermatol. 2001;144:339-346.
5.    Abroms L, Maibach E, Lyon-Daniel K, Feldman SR. What is the best approach to reducing birth defects associated with isotretinoin? PLoS Med. 2006;3:e483.
6.    McLane J. Analysis of common side effects of isotretinoin. J Am Acad Dermatol. 2001;45:S188-S194.
7.    Webster GF. Acne vulgaris and rosacea: evaluation and management. Clin Cornerstone. 2001;4:15-22.
8.    Malus M, LaChance PA, Lamy L, et al. Priorities in adolescent health care: the teenager’s viewpoint. J Fam Pract. 1987;25:159-162.
9.    Strauss JS, Krowchuk DP, Leyden JJ, et al. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. 2007;56:651-663.
10.    Wolf JE Jr, Kaplan D, Kraus SJ, et al. Efficacy and tolerability of combined topical treatment of acne vulgaris with adapalene and clindamycin: a multicenter, randomized, investigator-blinded study. J Am Acad Dermatol. 2003;49(3 suppl):S211-S217.
11.    Cunliffe WJ, Meynadier J, Alirezai M, et al. Is combined oral and topical therapy better than oral therapy alone in patients with moderate to moderately severe acne vulgaris? A comparison of the efficacy and safety of lymecycline plus adapalene gel 0.1% versus lymecycline plus gel vehicle. J Am Acad Dermatol. 2003;49(3 suppl):S218-S226.
12.    Lookingbill DP, Chalker DK, Lindholm JS, et al. Treatment of acne with a combination clindamycin/benzoyl peroxide gel compared with clindamycin gel, benzoyl peroxide gel, and vehicle gel: combined results of two double-blind investigations. J Am Acad Dermatol. 1997;37:590-595.
13.    Leyden J, Levy S. The development of antibiotic resistance in Propionibacterium acnes. Cutis. 2001;67(2 suppl):21-24.

*Director of Pediatric Dermatology, Johns Hopkins Children’s Center, Professor, Dermatology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: Bernard A. Cohen, MD, FAAP, Professor, Dermatology and Pediatrics, Johns Hopkins University School of Medicine, East Baltimore Campus, 208 Brady–Pediatric Dermatology, 600 North Wolfe Street, Baltimore, MD 21287. E-mail:

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.

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