Increasing number of early onset acne before obvious signs of puberty is a recognized phenomenon associated more with pubertal development than with age. There is apparently a genetic predisposition.
Pubertal development has two components, normal adrenarche related to maturation of adrenal glands and true puberty because of maturation of testis and ovary mediated by the hypothalamic-pituitary axis.
Adrenarche presents with high levels of DHEA and DHEAS that start rising at 6-7 years in girls and 7-8 years in boys and follow increasing during mid puberty. Excessive androgen production may result due to adrenal hyperandrogenism (exaggerated adrenarche, exuberant production of adrenal androgens relative to cortisol), congenital adrenal hyperplasia, Cushing's disease, 21-hyroxy-lase deficiency, and more rarely androgen producing tumors. Ovarian contribution to androgens can be through tumors (malignant and benign), but most commonly due to polycystic ovarian disease associated very often with obesity, persistent or resistant acne and insulin resistance [3, 12].
Acne could be the first sign of pubertal maturation and associated with increase in sebum and urinary excretion of androgenic steroids. A high frequency of acne was found in a longitudinal study of adolescent boys, where the prevalence and severity of acne correlated well with advanced pubertal maturation . A similar study of the same authors in early adolescent girls concluded that acne can be the first sign of pubertal maturation; significant elevations of DHEAS correlated well in girls with come-donal and inflammatory acne. The most common locations of acne in this group were the midforehead, nose and chin .
In a longitudinal study of acne and hormonal analysis, Stewart et al.  concluded that girls with severe acne present a statistically significantly earlier menarche (12.2 years) compared to those with moderate and mild disease (12.4 and 12.7 years). They also concluded that the number of comedones were predictive for the severity of late inflammatory acne. Mid-pubertal girls with severe come-donal acne showed more comedones even three years before menarche. This group also showed higher levels of DHEAS early in life. A correlation between DHEAS, sebum production and free testosterone was found in severe comedonal acne .
Lucky et al.  in a 5-year longitudinal cohort study of 871 girls stated clearly the predictor factors of an acne vulgaris study. They evaluated acne versus hormone levels at various ages before and after menarche. They were able to conclude that there were no ethnic differences in acne or hormone levels in the groups studied that included black and white girls. A progressive increase in number of acne lesions with age and maturation was found. The most common acne was comedonal; girls with severe acne at the end of the study had more comedones and inflammatory lesions by the age of 10 years and 2.5 years before menarche. The onset of menarche was also earlier in cases with severe acne and associated to higher levels of serum DHEAS and total and free testosterone compared to girls with mild-to-moderate disease. Early development of comedonal acne, DHEAS, free and total testosterone were good predictors for severe comedonal acne or a long-term disease .
The differential diagnosis is essentially similar to mid-chilhood acne. Adverse effects of certain drugs (cortico-steroids, anticonvulsants, etc.) and sporadic cases of pre-pubertal hydradenitis suppurative must be considered .
The therapy of acne at this age is similar to that reported before. Topical retinoids, benzoyl peroxide, antibiotics are appropiate in mild-to-moderate comedonal and inflammatory acne. In more severe cases, especially in risk of scarring, the use of oral antibiotics and oral iso-tretinoin may be necessary. Resistant, persistent and cases of acne appearing at unusual ages need hormonal evaluation and proper treatment. Adrenal problems may need low doses of oral corticosteroids; polycystic ovarian disease can be treated with oral contraceptives that include antiandrogens such as cyproterone acetate or the new low androgenic progestins. Spironolactone can also be considered .
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