As with the general population, acne is one of the most common dermatologic disorders among people with skin of color in the United States.1 Although there is a paucity of research regarding this topic, a study analyzed photographs of 2,895 women and found higher prevalence rates of acne among Black (37%) and Hispanic (32%) women compared with Asian (30%), White (24%), and Continental Indian (23%) women.2
The standard range of acne therapies is used in patients of various racial and ethnic backgrounds, with studies demonstrating similar efficacy across groups. However, there is a heightened risk for dyspigmentation in patients with darker vs lighter skin types. In a paper published in 2018, Alexis et al stated that post-inflammatory hyperpigmentation (PIH) and scarring are more common in patients with skin of color and may cause more distress than the acne.1
Higher melanin levels confer a “far higher risk for hyperpigmentation when there is any inflammation or damage to the skin,” explained Angela J. Lamb, MD, associate professor in the department of dermatology at the Icahn School of Medicine at Mount Sinai in New York. “For this reason, physicians must treat acne earlier and a bit more aggressively to prevent this side effect in patients with skin of color.”
Acne treatment strategies must be balanced with efforts to reduce and prevent hyperpigmentation inthis patient population. Topical retinoids represent the first-line choice of therapy and are often effective in reducing both acne lesions and PIH. In a study of 74 patients with Fitzpatrick skin types III–VI, for example, tazarotene 0.1% cream led to significant PIH reductions compared with vehicle (P <.05).3
Another study reported greater improvements in acne and PIH with tazarotene 0.1% cream compared with adapalene 0.3% gel, with a mean reduction of 48.9% vs 4.8% in patients treated with tazarotene vs adapalene (P =.017). Combination therapies including clindamycin 1.2%/tretinoin 0.025% and hydroquinone 4%/retinol 0.15% have shown improvements in hyperpigmentation severity, intensity, counts, and size.3
Other data support the efficacy of topical antibiotics (clindamycin 1.2%/BPO 3.75% gel) and topical dapsone 5% and 7.5% for the treatment of acne in patients with skin of color, and a small pilot study demonstrated improvements in acne and PIH with the use of azelaic acid 15% gel twice daily.1
To minimize irritation, patients should be advised to apply moisturizer following retinoid application – or before application for those with sensitive skin. Emerging findings suggest that the newer lotion-based retinoid formulations may be preferable for skin of color, as these therapies may result in less irritation that can exacerbate hyperpigmentation. Patients should also refrain from using drying toners and astringents as well as hair and skin products that may contribute to acne or irritate the skin.3
When hydroquinone is used to treat PIH, application should be limited to the affected areas to avoid unwanted lightening of the surrounding skin. For lesions smaller than 4 mm and thus not as amenable to spot application, Alexis et al recommend consideration of topical retinoids or azelaic acid. Superficial chemical peels may further improve the results of PIH treatment. Clinicians should also emphasize the importance of daily sunscreen use to prevent exacerbation of PIH.1
Among remaining gaps in acne care, Dr Lamb noted the ongoing need for novel treatment strategies. “Many acne treatments fall into a few categories, and it would be nice to have some other options,” she said. “We also need additional research into hormonal impact and dietary effects on acne.”
To learn more about acne and PIH in skin of color, we interviewed Janiene Luke, MD, FAAD, board-certified dermatologist, associate professor and residency program director in the department of dermatology at Loma Linda University in California, and chair of the Skin of Color Society Technology and Media Committee.
What are some of the differences in the risk and presentation of acne in patients with skin of color compared with White patients?
Acne is among the top 5 dermatologic disorders in all racial and ethnic groups.4Although the lesions seen in acne are similar in both lighter- and darker-skinned patients, PIH more often occurs in patients with skin of color. This can sometimes be extensive, is often distressing to patients, and is thought to be related to increased lability of melanocytes in people with darker skin.5
Patients of color may also exhibit hypertrophic or keloidal scarring in areas of the face, neck, chest or back. Black patients and patients of Latin descent are more likely to experience these complications.
What are the key prevention and treatment strategies for acne in patients with skin of color?
It is important to aggressively treat acne, as lesions that appear mild clinically can be highly inflammatory in patients of color. Therefore, it is important to initiate therapy early on to effectively treat existing lesions and prevent new lesions from forming.
With respect to prevention, it is imperative that patients of color wear sunscreen, since PIH can last for several months and is worsened with sun exposure.
What is known about the social and psychological impacts of acne in these populations?
Acne tends to have a negative psychological impact on patients and has been associated with anxiety, depression, social isolation, and lower self-esteem. In addition, it has been well documented that acne can negatively impact patients’ quality of life.6,7
What are the top remaining needs in this area in terms of research and patient education?
Although acne pathogenesis and treatment are generally well understood, research and development is needed in the treatment of PIH. Hydroquinone tends to be the gold standard lightening agent, and given some concerns over its use, other effective ingredients could be developed and utilized.
In patients with skin of color, patient education around sunscreen use is always needed since many patients with skin of color either believe they do not need to wear sunscreen or opt not to use it given the lack of options and difficulty finding formulations that are cosmetically acceptable on darker skin types.
1. Alexis AF, Harper JC, Stein Gold LF, Tan JKL. Treating acne in patients with skin of color. Semin Cutan Med Surg. 2018;37(3S):S71-S73. doi:10.12788/j.sder.2018.027
2. Perkins AC, Cheng CE, Hillebrand GG, Miyamoto K, Kimball AB. Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian and African American women. J Eur Acad Dermatol Venereol. 2011;25(9):1054-1060. doi:10.1111/j.1468-3083.2010.03919.x
3. Callender VD, Baldwin H, Cook-Bolden FE, Alexis AF, Stein Gold L, Guenin E. Effects of topical retinoids on acne and post-inflammatory hyperpigmentation in patients with skin of color: a clinical review and implications for practice. Published online November 9, 2021. Am J Clin Dermatol. doi:10.1007/s40257-021-00643-2
4. Davis SA, Narahari S, Feldman SR, Huang W, Pichardo-Geisinger RO, McMichael AJ. Top dermatologic conditions in patients of color: an analysis of nationally representative data. J Drugs Dermatol. 2012;11(4):466-473. PMID:22453583
5. Alexis AF. Lasers and light-based therapies in ethnic skin: treatment options and recommendations for Fitzpatrick skin types V and VI. Br J Dermatol. 2013;169(Suppl 3):91-97. doi:10.1111/bjd.12526
6. Kohn AH, Pourali SP, Rajkumar JR, Hekmatjah J, Armstrong AW. Mental health outcomes and their association to race and ethnicity in acne patients: A population-based study. Published online June 30, 2021. J Am Acad Dermatol. doi:10.1016/j.jaad.2021.06.866
7. Hosthota A, Bondade S, Basavaraja V. Impact of acne vulgaris on quality of life and self-esteem. Cutis. 2016;98(2):121-124. PMID: 27622255.