What are the treatment options for an 11-year-old with small papules on bilateral arms?

Treatment Options for Small Papules on Bilateral Arms in an 11-Year-Old

For an 11-year-old with small papules on bilateral arms, the recommended first-line treatment is a combination of topical benzoyl peroxide and a mild topical retinoid, as these target the underlying causes of acne with minimal side effects. 1

Diagnostic Considerations

Before initiating treatment, consider these common causes of papular eruptions on arms in children:

• Acne vulgaris - most likely diagnosis given age and presentation 1
• Keratosis pilaris - common in this age group, presenting as small rough papules 2
• Papulosquamous disorders - including psoriasis or lichen planus 3
• Friction-related acne - from tight clothing or sports equipment 2

First-Line Treatment Options

Topical Therapies (Preferred Initial Approach)

• Benzoyl peroxide (2.5-5%) - Apply once daily to affected areas

  • Effective antimicrobial agent that reduces P. acnes and inflammation 1
  • Start with lower concentrations to minimize irritation 1

• Topical retinoids - Apply thinly at night

  • Normalizes follicular keratinization and has anti-inflammatory properties 1
  • Start with adapalene 0.1% which is less irritating than other retinoids 1

• Combination therapy is more effective than monotherapy

  • Use both benzoyl peroxide and retinoid (applied at different times of day) 1
  • Avoid topical antibiotic monotherapy due to resistance concerns 1

Skin Care Recommendations

• Gentle cleansing with mild, non-soap cleansers 1
• Avoid frequent washing with hot water which can worsen acne 1
• Use alcohol-free moisturizers if skin becomes dry 1
• Avoid skin irritants such as harsh soaps or over-the-counter anti-acne products not prescribed by a dermatologist 2
• Wear loose-fitting, breathable clothing to reduce friction 2

Second-Line Treatment Options

If first-line treatments fail after 4-6 weeks:

• Topical antibiotics (always combined with benzoyl peroxide to prevent resistance)

  • Clindamycin 1% or erythromycin 2% solution/gel 1
  • Apply once daily to affected areas 1

• Topical calcineurin inhibitors for sensitive areas if needed

  • Tacrolimus 0.1% ointment can be used off-label for facial involvement 1
  • Particularly useful for facial or intertriginous areas 1

Special Considerations for Pediatric Patients

• Avoid high-potency topical corticosteroids on large body surface areas in children due to risk of HPA axis suppression 1, 4
• Limit use of hydrocortisone to short courses (less than 7 days) for inflammatory lesions 4
• Monitor for skin irritation - pediatric skin may be more sensitive to topical treatments 1
• Treatment adherence may be challenging - simple regimens with once-daily applications are preferred 1

When to Consider Referral

• No improvement after 8-12 weeks of appropriate therapy 1
• Severe or extensive disease 1
• Presence of scarring or significant psychological impact 1
• Suspicion of alternative diagnoses requiring specialized treatment 3, 5

Common Pitfalls to Avoid

• Overtreatment leading to excessive dryness and irritation 1
• Inconsistent application of medications reducing efficacy 1
• Failure to recognize alternative diagnoses such as fungal infections or other dermatoses 5, 6
• Using adult-strength preparations that may be too harsh for pediatric skin 4
• Expecting immediate results - most treatments require 6-8 weeks for noticeable improvement 1