Addressing Hyperpigmentation in Skin of Color

Skin of color (SOC) — categorized as Fitzpatrick skin types IV to VI — requires different approaches to avoid the lasting effects of hyperpigmentation that linger after acne inflammation has gone.¹ One of the most underappreciated facets of dermatology in treating patients with SOC is that post-inflammatory hyperpigmentation (PIH) can be just as bothersome as acne itself.¹ In a survey of 100 women with SOC, 86% rated dark spots and 80% blotchy, uneven skin as their primary cosmetic concern.¹

Ethnic and Racial Subtypes of Acne

In a multinational study of 2835 women with acne, black and Latino women had more dyspigmentation, PIH, and atrophic scars than women in other ethnic and racial groups (65% and 48%, respectively; P <.05).² Acne subtype could play a role in the resulting PIH, as black and Asian women in the study had the highest percentage of inflammatory acne — 19% and 20%, respectively.² Moreover, black women in the study had 60% to 70% more lipid content in their hair follicles vs white women, which could account for acne severity.²

Men with SOC have equally troubling concerns, albeit in different areas of the body.³ One of the most vexing dermatologic annoyances for men, pseudofolliculitis barbae (PFB), also known as ingrown hairs or razor bumps, is prevalent in 45% to 83% of black men.³ PIH occurs in up to 90% of men with PFB.³ Black and other dark-skinned men, more than women with SOC, are also prone to acne keloidalis nuchae (AKN), or folliculitis keloidalis nuchae, which appear as dome-shaped papules at the back of the neck and near the scalp line.³ Treatment involves avoiding shaving for a month and eflornithine hydrochloride cream for recalcitrant cases.³

Treatment Considerations for SOC

One of the ways to mitigate PIH is to treat acne early and aggressively without using high doses of topical agents or high-intensity lasers, which might worsen the pigmentation.¹ The appropriate choice of topical medication is essential because irritating agents could exacerbate PIH.¹

The first-line treatment for acne, regardless of Fitzpatrick skin type, is topical retinoids, which should be gradually titrated to avoid irriration.¹ Oral agents include antibiotics, retinoids, and hormonal modulators.¹ Patients with nodulocystic acne may be prescribed isotretinoin to mitigate potential PIH.¹

Unfortunately, many clinicians still think that “topical retinoids should not be used as first-line therapy due to the risk of hyperpigmentation,” said Valerie D. Callender, MD, FAAD, medical director of the Callender Dermatology & Cosmetic Center in

Glenn Dale, Maryland. “This is certainly not the case. [However,] clinicians can use them safely by implementing maneuvers to decrease cutaneous irritation such as the use of gentle cleansers, dilute the topical retinoid with a moisturizer, start with lower concentrations of the retinoid and titrate up to higher concentrations as tolerated, and lastly, apply the topical retinoid every other night and gradually apply every night if tolerated.”

Reducing hyperpigmentation involves avoiding sun exposure, inhibiting tyrosinase, which is responsible for melanin production, inhibiting the melanosome from transferring to the keratinocyte, exfoliation to remove excess melanin, and removing melanin in the epidermis.¹ The tyrosinase inhibitor hydroquinone is the first-line therapy for skin lightening and is frequently combined with tretinoin and fluocinolone.¹

Many clinicians use topical retinoids for 6 to 8 weeks before comedone extraction and corticosteroid injection to decrease any potential for PIH in SOC.¹ Other modalities to treat PIH include chemical peels and surgical procedures to reduce scarring. The preferred laser treatment in SOC is fractional photothermolysis because it does not involve melanin.¹

Clinicians need to be mindful of certain treatments that might be counterproductive, and counsel patients about gentle skin care and to use sunscreen daily. Also important in patients with SOC are the types of skin and hair products they use, including skin lightening creams and potentially irritating cosmetics.¹

Scarring

Aside from PIH, scarring — which occurs in up to 95% of acne cases — is challenging to address.⁴ Only 2 of the 7 current validated scarring scales used in clinical trials consider discoloration of lesions.⁴ There is no standard scale that captures all elements of scarring, including lesion depth, number, color, and distribution.

“As the populations in both research studies and the general public are becoming more diverse, we are seeing that the older instruments were not typically developed in the setting of the diversity that we see today,” said Raja Sivamani, MD, MS, associate professor of clinical dermatology and director of the clinical research and clinical trials unit at the University of California, Davis. “While hyperpigmentation and hypopigmentation do not necessarily have a skin texture or contour change associated with it, we are realizing that there is a large psychological burden and it does count as a type of acne ‘scar’ that should be addressed. In many cases, the dyspigmentation is more distressing than the acne itself.” 

Overall, clinicians need to recognize the increased risk for hyperpigmentation in patients with SOC and be prepared to make treatment decisions that take into consideration the prolonged effects of acne not just on skin appearance, but on general quality of life.  

References

1. Callender VD, Barbosa V, Burgess CM, et al. Approach to treatment of medical and cosmetic facial concerns in skin of color patients. Cutis. 2017;100(6):375-380.
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.
3. Awosika O, Burgess CM, Grimes PE. Considerations when treating cosmetic concerns in men of color. Dermatol Surg. 2017;43(suppl 2):S140-S150.
4. Clark AK, Saric S, Sivamani RK. Acne scars: how do we grade them? [published online September 11, 2017]. Am J Clin Dermatol. doi:10.1007/s40257-017-0321-x