What is the most appropriate initial treatment for a 6-month-old boy with mild acne characterized by open and closed comedones?

Management of Infantile Acne with Comedones

For a 6-month-old boy with mild acne characterized by open and closed comedones on the cheeks and chest without inflammatory lesions, topical benzoyl peroxide gel is the most appropriate initial treatment option. 1

Understanding Infantile Acne

Infantile acne typically presents between 3-16 months of age and is characterized by:

• Open and closed comedones (blackheads and whiteheads)
• May include inflammatory papules and pustules in more severe cases
• Usually affects the face, particularly cheeks and forehead
• May occasionally affect the chest, as in this case

Treatment Approach for Infantile Comedonal Acne

First-line Treatment

• Topical benzoyl peroxide (2.5-5%) is the preferred initial treatment for comedonal acne in infants 1
  • Provides antimicrobial activity against Cutibacterium acnes
  • Helps prevent bacterial resistance
  • Effective for comedonal lesions
  • Use lower concentrations (2.5%) initially to minimize irritation

Why Benzoyl Peroxide Over Other Options:

1. Topical erythromycin (Option A) is not recommended as first-line therapy for purely comedonal acne:

   • Antibiotics are more appropriate for inflammatory acne 2
   • Using antibiotics alone increases risk of bacterial resistance 2
   • Should be reserved for cases with inflammatory lesions

2. Curettage (Option C) is too invasive for first-line treatment of infantile acne:

   • Primarily used for treatment of acne scars rather than active comedonal acne 3
   • Unnecessarily aggressive for mild comedonal acne in an infant

3. DHEA and testosterone levels (Option D) are not indicated:

   • Hormonal evaluation is not necessary for typical infantile acne 4
   • Would be considered only with signs of precocious puberty, virilization, or unusually severe/persistent acne

Application Tips for Benzoyl Peroxide in Infants

• Start with a low concentration (2.5%) to minimize irritation
• Apply a thin layer to affected areas once daily initially
• Monitor for excessive dryness or irritation
• May gradually increase to twice daily if well tolerated
• Caution parents about potential bleaching of fabrics

Follow-up Recommendations

• Review after 4-6 weeks to assess response
• If inadequate improvement, consider adding a gentle topical retinoid or referral to pediatric dermatology
• If inflammatory lesions develop, reassess treatment approach

Important Considerations

• Infantile acne is typically self-limiting but may persist for months to years
• Severe cases may require more aggressive therapy and dermatology referral
• Parents should be counseled on gentle skin care practices
• Avoid harsh soaps and excessive washing that may worsen irritation

The American Academy of Dermatology guidelines support the use of benzoyl peroxide as a first-line agent for acne vulgaris, including comedonal presentations, making it the most appropriate choice for this infant 1.