Recent studies show that a diet high in refined sugar may cause and exacerbate acne in young children.

By Dr Lynn Chiam

What are the basic causes of acne in young children under 11 years old?

Acne vulgaris is a disorder of the hair follicle and the attached sebaceous gland (also known the pilo-sebaceous unit). Sebaceous glands are glands found in the skin which secrete an oily or waxy material to lubricate the skin.

Acne occurs when there is an increased production of androgen (naturally occurring steroid hormones found in both male and female) which causes abnormal shedding of the top most layer of the skin. This then leads to obstruction of the hair follicle.

Androgens also promote the sebaceous gland to secrete more sebum, causing the already obstructed follicles to be filled with lipid-rich material  called sebum. This forms a comedone, commonly referred to as whitehead or blackhead.

Whiteheads are often the first sign of acne in “prepubescent” children. These are small, skin-coloured, slightly raised bumps just beneath the skin surface. The openings of these follicles are usually tiny and don’t allow the contents to escape the surface.

A kind of bacteria, called Propionibacterium acnes then proliferates within the obstructed follicle. Propionibacterium acnes then releases chemicals that promote inflammation and leads to rupture of the comedone, finally forming a pimple or zit.

Several studies on pre-teens have shown that the prevalence and severity of acne correlates with advanced pubertal maturation. In the past two decades, children have been attaining puberty a few years earlier than before. This is likely related to better nutrition. As children reach puberty earlier, they will also tend to develop acne at a younger age.

During puberty, there is an increased production of androgens (steroid hormones) which leads to acne. Severe acne in teenagers is commonly seen in patients with significant numbers of whiteheads during the pre-pubertal years and is associated with higher levels of androgen hormones.

Increasing stress among pre-pubertal children has also been postulated as a trigger for acne.

Acne can uncommonly affect newborns up to two years of age. This is known as infantile acne. This type of acne usually settles spontaneously with little scarring.  The cause is thought to be related to hyperactivity of the sebaceous (oil) glands triggered by neonatal hormones.

Rarely, acne affecting  prepubertal children aged two to six is due to a higher level of androgen hormones than is expected for the age of the child. Hormonal imbalance may result in other signs like excessive body hair, abnormal growth, breast and genital development and body odour. In these cases, treatment for hormonal imbalance may be necessary.

To what extent does a child’s diet contribute to the incidence of acne?

The major factor for the development of acne in a child is pubertal maturation and the subsequent stimulation of sebaceous glands. Stress and more recently, diet, have been observed to affect acne to a certain extent. There are some studies in the recent years showing that a diet high in refined sugar may not be good for acne.

There is increasing evidence to suggest that decreasing the sugar load in the diet helps to control acne. A Korean study showed that by modifying the type and amount of carbohydrates consumed, improvement was seen in the severity of acne.  Low glycemic foods are noted to be good for those with acne and include barley, wholegrain breads, fruits, beans, vegetables and fish.

How many children under 11 years old with acne do you see in your practice? Is this trend on the hike?

The proportion of children under 11 with acne as compared with teenagers and adults still remains small. However, with more and more children reaching puberty earlier and with more awareness of the condition, I do see more young children coming to me with acne in the recent years.

To what extent can pre-adolescent acne be linked to genetics?

Pre-adolescent acne has many different factors, of which the main factor is genetics. However, it is likely that many different genes play a role in the pathogenesis of acne and more studies are needed fully understand the role of genetics in acne.

How and why do sugary foods exacerbate existing acne and even induce acne in young children?

Ingestion of sugary foods increase the blood sugar level. This in turn leads to more insulin being released. Insulin is a hormone which helps the body stores the sugar. High insulin levels then triggers more insulin-like growth factors and androgens to be released.

The insulin-like growth factor and androgens induce and exacerbate acne by causing obstruction of the hair follicles and inducing the sebaceous glands to be more active.

What is the best way to treat acne in children under 11 years old? How is this different from treating acne in adults?

Careful assessment of the lesions by a doctor is an important first step because the severity of the condition largely dictates the treatment approach.

Adults tend to get more inflamed pimples with pus while children tend to get more comedones (blackheads and whiteheads).

Most oral medicines can only be given after the child reaches a certain age. Children are more susceptible to adverse effects of medicines. Tetracyclines (a type of antibiotics) should not be used in those younger than eight years, as it can stain the teeth yellow. Hormonal therapy should also not be used in young children.

Therefore, topical creams are the mainstay of therapy for younger children

The main ingredients in topical creams for acne include the following:

Retinoids (a form of vitamin A)

Topical retinoids have multiple anti-acne actions, and should be primary treatment for most forms of acne vulgaris. It should be used early for best effects and are the mainstay for maintenance therapy. Retinoids can be combined with other types of creams like benzoyl peroxide and antibiotics.

Benzoyl peroxide

Benzoyl peroxide is safe to be used in any age group. It increases skin turnover, clears pores and reduces the amount of bacteria.

Most creams are approved for use on patients of 12 years and above. Epiduo, a combination of retinoids with benzoyl peroxide has been approved by the Health Sciences Authority (HSA) for patients aged nine years and above. This gives younger pre-pubertal children a safe option for the treatment of acne.


Antibiotics primarily affects the inflamed lesions and are less effective on comedones. Antibiotics should not be used as a monotherapy and can be combined with retinoids or benzoyl peroxide to enhance the efficacy.

Combination therapy

Combination therapy allows targeting of different causative factors and thus provides faster clearing and greater resolution of acne. Importantly, combination treatment also reduces the chances of antibiotic resistance.

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Dr Lynn ChiamDr. Lynn Chiam is an National University of Singapore (NUS) graduate and a specialist in dermatology. She is currently a Visiting Consultant at Kandang Kerbau Women’s and Children’s Hospital, Head of the Education Committee at the National Skin Centre, as well as the Medical Advisor to the Eczema Support Group (Singapore).