BNF for Children 2011-2012

574 13.6 Acne and rosacea BNFC 2011–201213 Skintreatment if eczema worsens or if no improvementafter 2 weeks); reduce to once daily or switch to0.03% ointment if clinical condition allowsPrevention of flares in children with moderateto severe atopic eczema and 4 or more flares ayear, who have responded to initial treatmentwith topical tacrolimusChild 2–16 years apply 0.03% ointment thinlytwice weekly (with an interval of 2–3 days betweenapplications); use short-term treatment regimenduring an acute flare; interrupt preventative therapyafter 1 year to reassess conditionChild 16–18 years apply 0.1% ointment thinlytwice weekly (with an interval of 2–3 days betweenapplications); use short-term treatment regimenduring an acute flare; review need for preventativetherapy after 1 yearOther indications section 8.2.2Protopic c (Astellas) AOintment, tacrolimus (as monohydrate) 0.03%, netprice 30 g = £19.44, 60 g = £35.46; 0.1%, 30 g =£21.60, 60 g = £39.40. Label: 4, 11, 28Excipients include beeswaxCytokine modulatorsETANERCEPTCautions section 10.1.3Contra-indications section 10.1.3Hepatic impairment section 10.1.3Pregnancy section 10.1.3Breast-feeding section 10.1.3Side-effects section 10.1.3Indication and doseSevere plaque psoriasis. By subcutaneous injectionChild 8–18 years 800 micrograms/kg (max.50 mg) once weekly; max. treatment duration 24weeks; discontinue if no response after 12 weeksPolyarticular-course juvenile idiopathic arthritissection 10.1.3whether the acne is predominantly inflammatory orcomedonal.Mild to moderate acne is generally treated with topicalpreparations, such as benzoyl peroxide, azelaic acid, andretinoids, (section 13.6.1).For moderate to severe inflammatory acne or wheretopical preparations are not tolerated or are ineffectiveor where application to the site is difficult, systemictreatment (section 13.6.2) with oral antibacterials maybe effective. Co-cyprindiol (cyproterone acetate withethinylestradiol) has anti-androgenic properties andmay be useful in young women with acne refractoryto other treatments.Severe acne, acne unresponsive to prolonged courses oforal antibacterials, acne with scarring, or acne associatedwith psychological problems calls for early referralto a consultant dermatologist who may prescribeoral isotretinoin (section 13.6.2).Neonatal and infantile acne Inflammatory papules,pustules, and occasionally comedones may develop atbirth or within the first month; most neonates with acnedo not require treatment. Acne developing at 3–6months of age may be more severe and persistent;lesions are usually confined to the face. Topical preparationscontaining benzoyl peroxide (at the loweststrength possible to avoid irritation), adapalene, ortretinoin may be used if treatment for infantile acne isnecessary. In infants with inflammatory acne, oralerythromycin (section 5.1.5) is used because topicalpreparations for acne are not well tolerated. In cases oferythromycin-resistant acne, oral isotretinoin (section13.6.2) can be given on the advice of a consultantdermatologist.Rosacea The adult form of rosacea rarely occurs inchildren. Persistent or repeated use of potent topicalcorticosteroids may cause periorificial rosacea (steroidacne). The pustules and papules of rosacea may betreated for at least 6 weeks with a topical metronidazolepreparation (section 13.10.1.2), or a systemicantibacterial such as erythromycin (section 5.1.5), orfor a child over 12 years, oxytetracycline (section5.1.3). Tetracyclines are contra-indicated in childrenunder 12 years of age.PreparationsSection 10.1.313.6.1 Topical preparations foracne13.6 Acne and rosacea13.6.1 Topical preparations for acne13.6.2 Oral preparations for acneAcne vulgaris Acne vulgaris commonly affects childrenaround puberty and occasionally affects infants.Treatment of acne should be commenced early toprevent scarring; lesions may worsen before improving.The choice of treatment depends on age, severity, andIn mild to moderate acne, comedones and inflamedlesions respond well to benzoyl peroxide (see below)or topical retinoids (see p. 576). Alternatively, topicalapplication of an antibacterial such as erythromycin orclindamycin may be effective for inflammatory acne.However, topical antibacterials are probably no moreeffective than benzoyl peroxide and may promote theemergence of resistant organisms. If topical preparationsprove inadequate oral preparations may be needed(section 13.6.2). The choice of product and formulation(gel, solution, lotion, or cream) is largely determined byskin type, patient preference, and previous usage ofacne products.