Chapter 54 Adolescents with Known Conditions
ACNE
ETIOLOGY
What Causes Acne?
Adolescent acne is caused by obstruction of the sebaceous follicles located primarily on the face and trunk. This process is activated by androgens and aggravated by Propionibacterium acnes. Acne can begin as early as age 8 years and affects as many as 85% of individuals between the ages of 12 and 25 years. Acne can be aggravated or induced by friction, oil-based cosmetics, and drugs that elevate plasma testosterone levels.
EVALUATION
How Does Acne Appear Clinically?
Depending on the interaction of the causative processes and the host response, acne may appear as open comedones (“blackheads”), closed comedones (“whiteheads”), or inflammatory papules, pustules, or cysts. Severity is determined by the extensiveness of the affected skin and by the types of lesions, with pustular and cystic lesions representing more serious involvement.
TREATMENT
What Are Treatment Choices for Acne?
Topical retinoids are the first choice for acne treatment. They relieve follicular obstruction and reduce inflammation. Retinoids can be combined with topical antimicrobial agents (e.g., benzoyl peroxide, erythromycin, or clindamycin). Systemic antibiotics such as erythromycin, tetracycline, doxycycline, and minocycline may also be needed in more severe inflammatory acne. Oral contraceptives with an estrogenic effect and a weak androgenic effect may also be useful in the treatment of acne in adolescent girls. Isotretinoin (Accutane) should be used only under the direction of a dermatologist. It is an oral retinoid that is effective for severe cystic acne. Food and Drug Administration (FDA) regulations mandate that all adolescents who are candidates for isotretinoin treatment must be counseled about the teratogenic effects of the drug and monitored for possible psychiatric effects. Girls must use effective oral and barrier methods of contraception, and must be followed regularly with pregnancy tests (see www.fda.gov/cder/drug/infopage/accutane/default.htm).
EATING DISORDERS
ETIOLOGY
How Common Are Eating Disorders?
Approximately 0.5% to 1% of adolescent girls develop anorexia nervosa, which makes this disorder the third most common chronic condition among adolescent girls after obesity and asthma. Up to 5% of older adolescents and young adult women develop bulimia nervosa. Prevalence rates for bulimia nervosa among high school students are generally lower than those among college-age women. Although their behaviors do not meet the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for bulimia nervosa, as many as 10% to 50% of adolescent women report occasional self-induced vomiting or binge eating.
Can Boys Develop Eating Disorders?
Recent studies suggest that up to one in six individuals with an eating disorder are male. In general, adolescent boys are shape-oriented, tend to be dissatisfied about their appearance from the waist up, and almost always diet for specific personal reasons. Males commonly diet to improve athletic performance, avoid being teased for being fat, avoid developing medical diseases associated with men in the family, or improve a gay relationship.
What Causes Eating Disorders?
Eating disorders are characterized by the misuse of eating in an attempt to solve other life problems. The etiologies of anorexia nervosa and bulimia nervosa are complex and multifactorial. A combination of biologic, psychologic, and societal factors contributes to the predisposition and perpetuation of eating disorders. Difficulty with the developmental transition from childhood to adulthood has been associated with eating disorders. Depression and sexual trauma are two psychological factors that have been associated with bulimia nervosa.
EVALUATION
What Are the DSM-IV Criteria for Eating Disorders?
Anorexia nervosa diagnostic criteria include persistent and severe restriction of energy intake, often combined with compulsive exercise in the pursuit of thinness. This drive for thinness is relentless. Patients who have anorexia nervosa may be subdivided into a restrictive type or a binge eating–purging type.
Bulimia nervosa criteria include binge eating followed by some compensatory behavior to rid the body of ingested calories. The most common type of purging behavior in adolescents is self-induced vomiting. Adolescents with bulimia nervosa are usually of average to above average weight for height. They often engage in impulsive behaviors such as substance abuse, self-mutilation, self-harm, or sexual promiscuity.
What Are the Signs and Symptoms of Eating Disorders?
Eating disorders may present with any of the following:
Disturbed body image leading to an irrational interpretation of appearance
Disorganized eating patterns such as skipping meals on various pretenses, unusual or extreme food preferences (especially carbohydrate avoidance), hoarding of food, cooking for others, playing with food at meals, eating alone, refusing to eat with family or to eat a meal out, and feeling extreme bloating after eating
Changes in menstrual cycle or amenorrhea
Excessive and/or ritualistic exercise, especially sit-ups
• Abuse of laxatives, diet pills, diuretics, sugar-free gum (sorbitol), caffeine, and/or syrup of ipecac
Binge eating, especially of sweets, breads, and salty snack foods, secretive postprandial vomiting, stealing of food or money for food
Hair loss, cold hands and feet, syncopal episodes, constipation, calluses on dorsum of the fingers, parotid gland swelling, or dental enamel erosion
• Inability to recognize feelings or basic needs such as hunger or fatigue
Withdrawal from family and friends (for some adolescents, involvement in structured interactions, such as school organizations, may continue, although in a driven way)
Slowing of normative psychosocial development
Rigid adherence to a highly prescribed set of values, with a relative lack of curiosity and questioning
Compulsive neatness and orderliness
Change in mood such as increased irritability, increased anxiety, depression
Changes in school and/or work performance, especially regarding simultaneous striving for perfection while verbalizing a sense of ineffectiveness
Are Laboratory Tests Helpful?
The diagnosis of an eating disorder is clinical; there are no confirmatory laboratory tests. Information from the history and physical examination will help you choose laboratory tests to detect abnormalities that arise from weight control habits used by the adolescent and from malnutrition. Routine laboratory tests may include a complete blood count, erythrocyte sedimentation rate, and biochemical profile.
TREATMENT
How Are Eating Disorders Treated?
The successful treatment of eating disorders requires an interdisciplinary team. Medical monitoring, nutritional counseling, and individual and family counseling are the backbone of treatment. Family involvement is essential from the beginning. Establishment of a trusting relationship and the early restoration of the adolescent’s nutritional and physiologic state are the initial goals of treatment. Comorbidities such as depression also need to be treated. The successful treatment of an adolescent with an eating disorder may take months to years.
What Are the Complications of Eating Disorders?
Eating disorders are classified as psychiatric disorders, but they are associated with significant medical complications that must be treated to reduce likelihood of morbidity and mortality. Adolescents with eating disorders are at risk for significant growth retardation, pubertal delay, and reduction in bone mass. Medical complications generally reflect the weight control behavior used by the adolescent.
Caloric restriction causes decreased metabolic rate, easy fatigability, hypothermia, cold intolerance, and irregular menstrual cycles or amenorrhea. Patients may exhibit lanugo-type hair growth. Cardiovascular complications may include bradycardia and other dysrhythmias, orthostatic hypotension, and syncope.
Self-induced vomiting may result in dehydration, alkalosis, hypokalemia, esophagitis, salivary gland enlargement, dental enamel erosion, and subconjunctival hemorrhages.
Laxative use may lead to dehydration, malabsorption, and abdominal cramping.
DEPRESSION
ETIOLOGY
How Common Is Depression in Adolescents?
In the Centers for Disease Control and Prevention’s 2005 Youth Risk Behavior Survey, 28.5% of high school students reported feeling sad or hopeless, and 16.9% seriously considered attempting suicide, 13.0% made a suicide plan, and 8.4% had made a suicide attempt. Five percent to 9% of adolescents meet the DSM-IV criteria for major depressive disorder, and 3% to 8% meet the criteria for dysthymic disorder. Depressive disorders are diagnosed twice as often in adolescent women as in adolescent men.
EVALUATION
What Are the Diagnostic Criteria for Depression?
The DSM-IV outlines the diagnostic criteria for major depressive disorder and dysthymia. Major depressive disorder is usually associated with discrete episodes of more severe depression, which can be distinguished from the person’s usual level of functioning. Dysthymic disorder is primarily a chronic disturbance of mood, involving a depressed or irritable mood for most days for at least 1 year in adolescents.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
