Chapter 54 Adolescents with Known Conditions
ACNE
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
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
TREATMENT
What Are the Complications of Eating Disorders?
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.