TOW #43: Acne

So, this week, it’s time to talk about zits! Acne is a near ubiquitous experience of adolescence, and one of the more distressing aspects to teens. We are poised to really be in the frontline for helping teens dealing with acne and it’s important for us to really know causes and treatment. Materials for this week:

Take-home points for this week on acne:

  1. Epidemiology: Acne is the most common skin disorder in the United States, affecting approximately 85% of young people between 12 and 24 years of age. Adolescent acne usually begins with puberty onset, occurring earlier in girls than boys. Most people outgrow it, but 12% of women and 3% of men continue to have clinical acne until 44 years of age.
  2. Pathogenesis: Acne is chronic inflammation of the pilosebaceous unit, which consists of a hair, its associated sebaceous gland, and the opening to the skin surface known as the follicular ostium ("pore"). These are concentrated on the face, back and chest, where acne mostly occurs. Four interrelated processes contribute to acne development: 1) abnormal keratinization with obstruction of the follicle, 2) androgen stimulation and increased sebum production, 3) secondary inflammation, and 4) proliferation of bacteria. Genetics and environment influence these processes.
  3. Misconceptions of acne causes: For many years, avoiding foods such as chocolate, soft drinks, milk, fatty foods, and ice cream was recommended; however, the literature does not support these restrictions to decrease acne (though warranted for obesity). Dirt or poor hygiene do not cause acne, so frequent face washing does not improve acne and may worsen it through irritation.
  4. Knowing the acne severity grading can help with determining appropriate treatment strategies.

Acne severity grading

Lesion Type
Few to several comedones, few scattered papules
Less than 1/4 of the face, mostly T zone
Many papules and pustules, variable comedones, 1-2 nodules 
Roughly 1/2 face
Few, shallow
Numerous papules and pustules and nodules; variable comedones; sinus tracts and/or cysts
Face, back, and/or
Moderate to extensive, hypertrophic and/or deep


  1. Treatment: Topical agents treat the different causes: retinoids treat keratinization, benzoyl peroxide treats secondary inflammation and bacteria, and topical antibiotics also treat bacteria. Topical agents are first line for mild and moderate, while oral agents (antibiotics, oral tretinoin – Accutane, oral contraceptives) are used for severe. For mild acne, we often start with a single agent – either a retinoid or benzoyl peroxide (5% has been found as good as 10% with less side effects). For mild to moderate, combine agents that address different pathways (retinoid + BP or topical antibiotic). Anticipatory guidance is critical to adherence: topical medications are preventive and require 8 to 12 weeks to assess efficacy. The entire area affected must be treated, not just current lesions, and long-term therapy usually is required.

TOW #42: Travel preparedness

We have been seeing a lot of families at Harborview preparing to travel to visit relatives around the world this spring and summer, and we expect many of you have as well. This is a good time to review some of the key resources and recommendations for travel preparation visits.

Materials for this week:

Take-home points for travel preparedness with children:

  1. International travel among children is on the rise. In 2010, ~2.2 million US children aged ≤18 years traveled internationally. Children are less likely to get travel advice/visits compared to adults. In one review of children with post-travel illnesses evaluated at clinics, only 32% of the children visiting friends and relatives had received pre-travel medical advice, compared with 59% of adults.
  2. Most common illnesses encountered after travelling are diarrheal illnesses, skin conditions (including bites, cutaneous larva migrans, and sunburn), systemic febrile illnesses (especially malaria) and respiratory disorders. Injuries are also common, especially motor vehicle and water-related injuries. For food safety review: “Boil it, peel it, cook it, or forget it.”
  3. Vaccination review is key. Make sure children are up to date on common vaccines and then assess for travel-related vaccines. When indicated, we provide typhoid injection and yellow fever vaccines, and if given enough lead time, you can sometimes get it covered by insurance through a prior authorization. Some pharmacies provide these at reasonable costs-ask your clinic faculty.
  4. Counsel on the special risks of children who are visiting friends and relatives in developing countries. They will have increased risk of exposure to malaria, intestinal parasites, and tuberculosis. Review malaria prevention and provide malaria prophylaxis medications, as appropriate. Also remember assault and STI risk for teenagers who are travelling.
  5. Screen for tuberculosis after children return if they have visited an endemic country for a week or more. You can test as early as 10 weeks after they return (or you can wait until their annual well child exam).

TOW #41: Firearm screening and safety

Following up the theme of child abuse prevention month, we have another topic that focuses on injury prevention, specifically looking at firearm safety storage and preventing unintentional injuries (the second leading cause of death among teenagers). We have many resources locally including the incredible Dr. Fred Rivara, a nationally-renowned researcher on firearm injuries and prevention. In addition, the Seattle Children's community benefit team and REACH pathway residents (Corinne, Bo and Quynh) have worked to develop local resources and events. A big thank you to R2 Dr. Quynh Nguyen who developed the helpful teaching points below.

Materials for this week:

Take-home points for firearm safety:

  1. Statistics: 1 in 3 homes have guns, many not locked. 80% of unintentional firearm deaths of kids under 15 occur in a home. Consider counseling parents to ask other parents about guns in their home before sending over their child to play.
  2. Many depressed teens die from suicide by firearms. If you are crunched for time and cannot screen for firearms in every clinic wellness visit, be sure to do this for visits with depressed teenagers. Come up with a safety plan for gun storage with the parents, and offer resources such as 1-800-273-TALK from the suicide prevention lifeline.
  3. What to offer for gun safety? There are 5 main types of locking devices: lock box, gun vault or safe, cable lock, trigger lock, and personalized lock. Visit  64,000 adults in King County with a loaded gun in or around their homes reported storing their gun(s) loaded and unlocked, so please help advise that the safest way to store guns is unloaded, locked, and out of reach of young children and teenagers! Avoid devices that use keys. Of course, the safest thing is not have a gun in your home, as a gun in the home is 43 times more likely to be used to kill a family member or friend rather than be used in self-defense.
  4. Does counseling work? A standard screening question followed by a 20 second firearm storage safety message led to counseled families being 2.2 times more likely to practice safe firearm storage techniques. Consider this statement: Having a loaded or unlocked gun in your house increases the risk of injury or death to family members, whether by accident or on purpose. I urge you to store your unloaded guns in a locked drawer or cabinet, out of reach of children.

TOW #40: Child abuse recognition & management

April is child abuse prevention month, so we are going to discuss this always challenging but critical topic in our field. We owe gratitude to the SCAN and CPS teams who work so hard to help evaluate and keep children safe. Our role in primary care encompasses strategies to build resilience, promote strong relationships/bonds, link families to resources, and screen and refer for concerns.

Materials for this week:

Take-home points for child abuse recognition:

  1. We are mandated reporters for suspected child abuse and neglect and any allegations of sexual abuse. We are likely to encounter child maltreatment in our practices: a recent study found 1 in 8 children between 0-18 years in the U.S. have some form of substantiated maltreatment. A meta-analysis of 22 US studies suggested that 30 – 40% of girls and 13% of boys experience sexual abuse during childhood.
  2. Neglect is the most common form of child maltreatment, accounting for ~60% of cases. Neglect is failure to meet the basic emotional, physical, medical or educational needs of a child. It includes lack of adequate nutrition, hygiene, shelter, and safety.
  3. Corporal punishment is not recommended in any form by the AAP. Spanking (i.e., using “an open hand on the buttocks or extremities with the intention of modifying behavior without causing physical injury”) is the least objectionable, but is considered maltreatment if it is done so hard as to leave a bruise.
  4. Children of all SES levels are at risk for child abuse. In ~80% of cases, parents are perpetrators of child maltreatment. Some specific parent-level risk factors for child abuse include parent poverty, parent of multiple children under 5, history of substance use or mental illness (including current depression), teenage parents, cognitive deficits, single parents, history of child maltreatment or intimate partner violence, failure to empathize with children, or inappropriate expectations for child development. Child-level risk factors include physical, emotional, or behavioral disability; result of undesired pregnancy; or multiple gestation pregnancy.
  5. Bruising is the most overlooked form of abuse. The TEN-4 rule is a helpful guide to remember patterns of bruising more associated with child abuse. TEN = Torso, Ears, Neck bruising and 4 = any bruise on a 4 month old or younger – those bruises should prompt more work-up and a referral to CPS.

Thanks for your work to help protect children.