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ORIGINAL ARTICLE
Year : 2022  |  Volume : 67  |  Issue : 6  |  Page : 645-650
An observational study of clinical, metabolic and hormonal profile of pediatric acne


1 Department of Dermatology and STD, VMMC and SJH, New Delhi, India
2 Department of Paediatrics, VMMC and SJH, New Delhi, India
3 Department of Pathology, VMMC and SJH, New Delhi, India

Date of Web Publication23-Feb-2023

Correspondence Address:
Vipul Pareek
Ward No. 16, Near Civil Court, Suratgarh, District- Shri Ganganagar, Rajasthan - 335 804
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_537_20

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   Abstract 


Objectives: To study the biochemical, metabolic and hormonal profile among children presenting with acne and to determine the correlation of these parameters with acne grading. Methods: The observational cross-sectional study was conducted for a duration of 18 months on a total of 50 children between 1 and 12 years of age with clinical features of acne. The detailed information regarding the type of acne, biochemical profile (lipid profile, blood sugar levels), hormonal profile and associated illnesses were recorded. Spearman's rank correlation coefficient was used to find out the correlation of acne grading with hormonal and metabolic changes. Results: The mean age of the children was 11.4 years. Among the various lesions, comedones were seen in 98% cases, papules in 94.00% cases, a scar in 14.00% and pustule in 4.00% cases. As compared to children of age 1-7 years, those in age group 8-12 years had significantly more comedones (48 vs 1, P = 0.04), significantly fewer pustules (0.00% vs 100.00%, P = 0.001), and a comparable number of papules and scars. Most of the children (88.00%) had acne vulgaris grade 1. There was a significant negative correlation of Blood sugar-fasting (r = -0.312, P = 0.0275) and a significant positive correlation of HDL (r = 0.28, P = 0.0491) with acne grading. Conclusion: Comedones and papules are the commonest and the earliest forms of pediatric acne. Severe forms of acne are rarely seen below 12 years, age group. Preadolescent acne is commoner than mid-childhood acne, with no difference between male and females. Blood sugar levels and lipid profile derangements have a weak correlation with acne grading.


Keywords: Acne, hormonal, metabolic, pediatric


How to cite this article:
Pareek V, Khunger N, Sharma S, Dhawan I. An observational study of clinical, metabolic and hormonal profile of pediatric acne. Indian J Dermatol 2022;67:645-50

How to cite this URL:
Pareek V, Khunger N, Sharma S, Dhawan I. An observational study of clinical, metabolic and hormonal profile of pediatric acne. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 31];67:645-50. Available from: https://www.e-ijd.org/text.asp?2022/67/6/645/370316





   Introduction Top


Acne vulgaris is a ubiquitous disease of a pilosebaceous unit with a prevalence rate of 95% in the adolescent population (>12 years of age). Though the term “Vulgaris” suggests common, its occurrence is much less among toddlers and preadolescents.[1]

The occurrence of acne can be linked to the changing hormonal aspects of normal physiology during the lifetime of an individual. It has been seen that the initial 6-12 months of life are characterized by the production of high levels of dehydroepiandrosterone (DHEA) and its sulfated form (DHEAS) (with more LH and testosterone in males); with decreasing hormonal production after infancy due to progressive involution of the fetal adrenal glands. Then around seven years of age (adrenarche), DHEAS levels increase again, leading to the emergence of preadolescent acne.[2],[3] Accordingly, infantile acne (<1 year) is the commonest with 20% prevalence – usually self-limiting, mid-childhood acne (1-7 years) should alert the treating doctor about hyperandrogenemia requiring detailed hormonal investigations, and prepubertal acne (7-12 years) require pediatric endocrinologist follow-up for any abnormality and recalcitrant acne cases.[4]

Lesions of pediatric acne are polymorphic, consisting of comedones, papules, pustules, nodules, and sometimes scarring. Their diagnosis may not be straightforward as it may be the result of underlying diseases like Cushing's, congenital adrenal hyperplasia, polycystic ovarian syndrome, metabolic syndrome, premature adrenarche, and gonadal/adrenal/ovarian tumours.[1] Recently, the link of skin signs of hyperandrogenemia (acne vulgaris, hirsutism and androgenetic alopecia) with obesity and/or metabolic syndrome in the pediatric age group has been explored; however, it needs further biochemical evidence.[5] Mehta-Ambalal S[6] found a very high prevalence of altered biochemical, metabolic and hormonal status among female adults with acne. In addition, the polymorphic presentations, biochemical/hormonal evaluations and treatment differ among the various age groups of children.[7]

The available literature on the relative association of pediatric acne with the biochemical and hormonal profile of children is sparse. Thus, we conducted this study to know the biochemical, metabolic and hormonal profile among children presenting with acne.


   Methods Top


The observational cross-sectional study was conducted at the outpatient department of Dermatology, Venereology and Leprosy and Regional STD Teaching, Training and Research Centre for a duration of 18 months. Ethical clearance was taken from the Institutional Ethics committee before conducting the study. All children between 1 and 12 years of age with clinical features of acne who attended skin OPD were included after written informed consent from their parents. Children taking systemic drugs and using topical medications causing acne were excluded from the study.

A total of 50 children were included in the study whose diagnosis of acne was made by clinical examination. Information regarding the type of acne (comedones, papules, pustules, nodules, cysts and scars), duration, onset and progression, site and mode of onset, the activity of lesion (stable/progressive), progression of the lesion (gradual and rapid); associated systemic illness; drug history; and menstrual history was taken and recorded in the predesigned proforma. The general examination included BP, pulse, weight, height and abdominal circumference measurements. The cutaneous signs of endocrine abnormalities examined were the presence of hirsutism, acanthosis nigricans, and patterned alopecia. Genitalia and systemic examination were also done.

For acne, the cutaneous examination included the type, site, number and dimensions of the lesion. Acne grading was done according to James & Tisserand Scale in Grade I, II, III and IV.[8]

Laboratory investigations included blood sugar levels, serum dehydroepiandrosterone sulfate (DHEAS), serum 17alpha-hydroxyprogesterone, serum cortisol; total testosterone, serum prolactin, serum T3, serum T4, serum TSH (thyroid-stimulating hormone), serum estradiol, serum luteinizing hormone (LH) and lipid profile. USG pelvis and abdomen for visualization of adrenal and ovary was also performed.

The criterion used for assessing pediatric metabolic syndrome (PMS) was International Diabetes Federation classification where a child was identified to be suffering from PMS when he/she, along with abdominal obesity, had any of the two following parameters[9]:

  1. Triglycerides (TG) ≥150 mg/dl
  2. High density lipoprotein (HDL) <40 mg/dL
  3. Fasting blood glucose ≥100 mg/dL
  4. High blood pressure with either systolic ≥130 or diastolic ≥85 mm of Hg.


The classification of pediatric acne as per the age was done according to Eichenfield et al.,[3] who divided acne into neonatal acne (from birth to 6 weeks), infantile acne (from 6 weeks to 1 year), mid-childhood acne (1-7 years), preadolescent (7-12 years or before menarche in girls) and adolescent (12-19 years or after the menarche in girls) acne.

To evaluate children's abdominal fat, the values above the 80th percentile were considered as abdominal obesity.[5],[6],[9] As for BMI, the World Health Organization (WHO) curves were used to identify a child's excess weight.[5],[6],[9]

Statistical analysis

The data were entered in MS Excel spreadsheet, and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. Categorical variables were presented in number and percentage (%), and continuous variables were presented as mean ± SD and median. Quantitative variables were compared using the Independent t-test/Mann Whitney test (when the data sets were not normally distributed) between the two groups. Qualitative variables were compared using the Chi-square test/Fisher's exact test. Spearman's rank correlation coefficient was used to find out the correlation of acne grading with hormonal and metabolic changes. A P value of <0.05 was considered statistically significant.


   Results Top


The mean age of the children was 11.4 years. The age distribution showed 48 (96%) children in the preadolescent age (7-12 years) and only 2 (4%) in the mid-childhood age (1-7 years). There were 29 (58%) males and 21 (42%) females. The mean age of onset in children was 10.3 years, with the mean duration of the acne in children being 0.78 years [Table 1].
Table 1: Demographic characteristics of study subjects

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The lesion type comprised of comedones in 98% cases, papules in 94.00% cases, scar in 14.00%, and pustule in 4.00% cases.

As compared to children of age 1-7 years, those in age group 8-12 years had significantly more comedones (48 vs. 1, P = 0.04), significantly less pustules (0.00% vs 100.00%, P = 0.001), and comparable number of children with papules (93.75% vs. 100.00%, P = 1) and scar (14.58% vs. 0.00%, P = 1). In comparison to females, males had comparable number of comedones (96.55% vs. 100.00%, P = 1), papule (93.10% vs. 95.24%, P = 1), pustule (6.90% vs. 0.00%, P = 0.503) and scar (20.69% vs. 4.76%, P = 0.215) [Table 2].
Table 2: Association of age and gender with type of acne

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Most of the children (88.00%) had acne vulgaris grade 1, followed by grade 2 in 10.00%, and acne vulgaris grade 1 and truncal acne in 2.00% cases. There was no significant difference in the acne grading among different age groups and gender (P > 0.05) [Table 3].
Table 3: Association of age and gender with acne grading

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In this study, 15 (71.43%) females attained menarche. Out of these, 80.00% had a regular menstrual cycle. The mean age of onset of menstrual cycle was 10.84 years. Acanthosis nigricans was present in 3 (6.00%) children. There was no case of alopecia or hirsutism. Genitalia examination was also normal in all children.

Amongst the metabolic parameters, lipid profile showed the derangement in cholesterol, TG, HDL and Low-density lipoprotein (LDL) among 0, 7, 16 and 8 children; diabetic parameters showed the derangement in sugar fasting, PP and Insulin F and PP among 5, 1, 1 and 14 children; thyroid profile showed derangement in T3, T4, TSH among 5, 1 and 5 children; hormonal profile showed derangement in FSH, LH, Prolactin, estradiol, testosterone, DHEAS, 17-OH progesterone and cortisol in 0, 5, 2, 5, 17, 6, 0 and 1 children.

There was a significant negative moderate correlation of Blood sugar-fasting (r = -0.312, P = 0.0275). and a significant positive poor correlation of HDL (r = 0.28, P = 0.0491) with acne grading.

However, we found no correlation of 17alpha-hydroxyprogesterone (r = -0.227, P = 0.1132), Cortisol (r = -0.046, P = 0.751), Estradiol (r = -0.057, P = 0.6963), FSH (r = 0.127, P = 0.3777), LH (r = -0.237, P = 0.0975), Prolactin level (r = -0.156, P = 0.2804), DHEA sulphate (r = 0.12, P = 0.4046), T3 (r = 0.107, P = 0.4612), T4 (r = -0.135, P = 0.3505), Testosterone (r = -0.12, P = 0.4051), TSH (r = -0.23, P = 0.1076), Blood sugar-postprandial (r = -0.269, P = 0.0587), LDL (r = 0.198, P = 0.1677), Cholesterol (r = 0.195, P = 0.1754), Serum insulin- fasting (r = -0.113, P = 0.4338), Serum insulin-postprandial (r = -0.127, P = 0.3782), Total cholesterol HDL ratio (r = -0.099, P = 0.4927), and Triglyceride (r = -0.23, P = 0.1082) with acne grading [Table 4].
Table 4: Correlation of hormonal changes and metabolic changes with acne grading

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The photographs of few cases of paediatric acne have been shown in [Figure 1], [Figure 2], [Figure 3].
Figure 1: 4 years female presenting with papules and comedones on cheeks

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Figure 2: 12 year old female presenting with comedones and few papules present on forehead and nose

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Figure 3: 10 years old female presenting with (a) comedones on the forehead, nose and cheek; (b) acanthosis nigricans on the neck

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   Discussion Top


Acne is a problem is seen from the neonatal period up to adulthood, and very rarely a person achieves adulthood without having had some degree of acne. There are very few studies on pediatric acne in the Indian population.

Demographic characteristics

In the index study on 50 children with acne, the mean age was 11.04 ± 1.93 years. The cases of mid-childhood acne (1-7 years) were 2 (4%) and preadolescent acne (8-12 years) were 48 (96%). As compared, Lucky et al.[10] reported a mean age of 12.2 +- 1.4 years, with a range of 9 to 15 years. Half of the children were aged 9-12 years, and 43% were aged >12 to 15 years. In another study by Lucky AW et al.,[11] 871 girls with acne were studied for racial and ethnic differences, which included 439 black and 432 white children; the mean age of the patients was 12.5 years. The epidemiologic profile of preadolescent acne seems to evolve, and the current trend toward a decreasing age of onset of acne may be explained by the onset of early puberty.[10],[11]

There were 58% (29) males and 42% (21) females in our study. The gender distribution of acne in the pediatric age group was equal and did not favour either sex. A similar study on children between 9 and 14 years showed an equal distribution of acne among girls (50.8%) and boys (49.2%).[12] All girls in our study had preadolescent acne, whereas two boys had mid-childhood acne and 27 boys had preadolescent acne. It is known that neonatal and infantile acne is more common in boys, but in the later ages, there are no differences in the acne among males and females,[2] and this pattern of equal distribution of pediatric acne in both sexes was also observed in our study.

Clinical characteristics

In this study, among various types of lesions, the majority, i.e., 49 (98%), had comedones, followed by 47 (94%) having papules, and 2 (4%) having pustules. Post-acne scars were present in 7 (14%) children. Around 49 (98%) had Grade 1 acne, with only 1 (2%) case having Grade 2 acne signifying that even mild acne can lead to scarring. Hence, early and appropriate treatment of pediatric acne is essential as the scars are permanent and impair the quality of life.

In our study, there was a significant association between comedones and pustules with the age distribution (P < 0.05). Comedones were seen more commonly in the preadolescent age group (p = 0.040), and pustules were more common in mid-childhood patients (p = 0.001). Bloch noted that comedones were a universal event, and they appeared at the earliest, as seen in our study.[13] Hinrichsen J et al.[14] also found increasing severity of acne with age. Children in the younger age group showed milder severity having predominant comedones, with few papules and pustules as compared to teenagers who had more pustules and nodules. Lucky et al.[11] also reported that comedones are the earliest lesions and the authors concluded that comedones are the precursors of inflammatory lesions (papules and pustules), and thus diagnosing acne itself may be the best predictor of future severe acne. The study by Napolitano also reported that the majority (88.5%, 207/234) of children aged between 9 and 14 years showed mild or almost clear disease state, that is GEA scale 1 or 2.98.[15]

We found no significant association of gender with a grade of acne. Cunliffe also reported a similar peak incidence of comedones and papules with no significant association of gender with type and severity of acne.[16] In contrast, Ahluwalia et al.[17] reported that mild acne occurs in prepubertal females with an average age of 10 years. Lucky et al.[11] showed a strong correlation between comedones and premenarchal age. They reported that a premenarcheal girl with comedones acne has a higher risk of having later, severe acne (papules and pustules) than a girl who first has mild acne later in adolescence: thus recommending the role of early intervention to prevent later scarring. In our study, there were no cases of severe acne. However, to confirm if early-onset acne is a predictor of severe acne later on in life, future prospective studies are recommended.

Association of acne with obesity, metabolic syndrome and hormonal changes

Pediatric overweight and obesity is an emerging public health priority as rates have rapidly increased worldwide. Obesity is often grouped with other metabolic abnormalities, including hypertension, dyslipidemia, and insulin resistance, leading to an increased risk of cardiovascular disease. This group of risk factors, termed metabolic syndrome, has traditionally been reported in adults.[18] With the increased prevalence of pediatric obesity, metabolic syndrome is now also evident in children and adolescents.[19] Coviello et al.[20] reported the association of metabolic syndrome and PCOS in adolescent girls. Gupta et al.[21] reported a prevalence of 3.3% PMS among the 2100 school-age children of 10–16 years of age.

In the index study, out of 50 patients, 19 (36%) patients had derangement of lipid profile and 18 (36%) patients had derangement of the glycemic profile; however, on complete biochemical testing and hormonal evaluation, none of the cases met the diagnostic criteria for metabolic syndrome, CAH, Cushing's Syndrome, adrenal or gonadal androgen-secreting tumours and PCOS. On correlation analysis, a significant correlation was shown only by Fasting blood sugar and HDL with acne grading.

In this study, there was no significant association of age, gender, acne type and grading with the hormonal profile of the patients. Similarly, In a study by Iftikhar et al.,[22] on 350 patients of all age groups, the level of androgens were not directly correlated with acne severity. In contrast, Lucky AW et al.,[11] (1997) and Stewart ME et al.,[23] found that DHEAS, testosterone and free testosterone levels significantly affected the severity of acne: with significantly higher levels in severe acne as compared to mild or moderate acne. It was proposed that the role of DHEAS is predominant among the androgens (compared to testosterone or androstenedione), which are responsible for sebaceous gland activation in the preadolescent age,[11] but it is the balance among all the biochemical and hormonal variables that predicts the onset and severity of acne.[24]

Limitations of the study

  1. This study served from the limitation in the number of cases of different acne grades especially Grade 2 and further. Most of the cases in our study belonged to Grade 1 acne, and thus a conclusive association of acne grading with hormonal parameters could not be drawn.
  2. Lack of control population and long-term follow-up data further posed limitations in studying the relationship between acne grading and hormonal distribution.
  3. The treatment and the outcome follow-up of the patients were not studied.



   Conclusion Top


Comedones and papules are the commonest and the earliest forms of pediatric acne. Most of the pediatric population suffers from Grade 1 acne, and the more severe forms of acne are rarely seen below 12 years, age group. Preadolescent acne is commoner than mid-childhood acne, and there is no difference in incidence between male and females. A weak correlation exists between fasting blood sugar and HDL with acne grading.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Krakowski AC, Eichenfield LF. Pediatric acne: Clinical presentations, evaluation and management. J Drug Dermatol 2007;6:589-93.  Back to cited text no. 1
    
2.
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3.
Eichenfield LF, Krakowski AC, Piggott C, Del Rosso J, Baldwin H, Friedlander SF, et al. Evidence-based recommendations for the diagnosis and treatment of pediatric acne. Am Acne Rosacea Soc Pediatrics 2013;131:163-86.  Back to cited text no. 3
    
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Schnopp C, Mempel M. Acne vulgaris in children and adolescents. Minerva Pediatr 2011;63:293-304.  Back to cited text no. 4
    
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Holzer G, Volc-Platzer B. Chapter 72: Skin manifestations of paediatric metabolic syndrome. Harper's Textbook of Pediatric Dermatology. Wiley online Library, United Kingdom (U.K) 2019. p. 841-58.  Back to cited text no. 5
    
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Mehta-Ambalal S. Clinical, biochemical, and hormonal associations in female patients with acne: A study and literature review. J Clin Aesthet Dermatol 2017;10:18-24.  Back to cited text no. 6
    
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Alberti G, Zimmet P, Kaufman F, Tajima N, Silink M, Arslanian S, et al. The IDF consensus definition of the metabolic syndrome in children and adolescents. Pediatr Diabetes 2007;8:299-306.  Back to cited text no. 9
    
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Bloch B. Metabolism, endocrine glands and skin-diseases, with special reference to acne vulgaris and xanthoma. Br J Dermatol 1931;43:61-87.  Back to cited text no. 13
    
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Hinrichsen J, Ivy AC. Incidence in the Chicago region of acne vulgaris. Arch Dermatol Syphilol 1938;37:975-82.  Back to cited text no. 14
    
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Napolitano M, Ruggiero G, Monfrecola G, Megna M. Acne prevalence in 9 to14-year-old old patients attending pediatric ambulatory clinics in Italy. Int J Dermatol 2018;57:1320-3.  Back to cited text no. 15
    
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Cunliffe WJ. Acne. Chicago. Year Book Medical Publishers Inc; 1989. p. 2-10.  Back to cited text no. 16
    
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Ahluwalia J. The microbiome in preadolescent acne: Assessment and prospective analysis of the influence of benzoyl peroxide. Pediatric Dermatol 2019;36:200-6.  Back to cited text no. 17
    
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Emiroğlu N, Cengiz F, Kemeriz F. Insulin resistance in severe acne vulgaris. Postep Derm Alergol 2015;XXXII: 281-5.  Back to cited text no. 18
    
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Higgins V, Adeli K. Pediatric metabolic syndrome: Pathophysiology and laboratory assessment. EJIFCC 2017;28:25-42.  Back to cited text no. 19
    
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Coviello AD, Legro RS, Dunaif A. Adolescent girls with polycystic ovary syndrome have an increased risk of the metabolic syndrome associated with increasing androgen levels independent of obesity and insulin resistance. J Clin Endocrinol Metab 2006;91:492-7.  Back to cited text no. 20
    
21.
Gupta A, Sachdeva A, Mahajan N, Gupta A, Sareen N, Pandey RM, et al. Prevalence of pediatric metabolic syndrome and associated risk factors among schoolage children of 10–16 years living in District Shimla, Himachal Pradesh, India. Indian J Endocrinol Metab 2018;22:373-8.  Back to cited text no. 21
    
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Iftikhar U, Choudhry N. Serum levels of androgens in acne & their role in acne severity. Pak J Med Sci 2019;35:146-50.  Back to cited text no. 22
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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