Acne in Skin of Color: It’s All About PIH

Unlike Caucasian patients who are primarily concerned about the acne itself, skin of color patients prioritize postinflammatory hyperpigmentation.

Patients with skin of color (SOC) often worry more about postinflammatory hyperpigmentation (PIH) and scarring than acne itself, and recent data suggest that antibiotic resistance patterns may differ between racial and ethnic groups.

“Dermatologists need to show empathy and understand the negative impact that PIH has on patients’ quality of life,” said Valerie D. Callender, MD, at the Fall Clinical Dermatology Conference, held October 21 to 24, in Las Vegas, Nevada, and virtual.1 She is a professor of dermatology at Howard University College of Medicine in Washington, DC.

Because PIH can be emotionally devastating for patients with SOC, she said, clinicians must not only provide prompt, potent treatment, but they must also appreciate acne’s psychosocial total. Here, listening goes a long way. “They’ll say, ‘I want to get rid of these scars.’ But most of the time they’re hyperpigmented macules, not scar tissue.”2 Patients also may call PIH a blemish, said Callender, which is another emotionally loaded term.

“They may have a lot of makeup on to camouflage and cover up. And PIH is difficult to camouflage. PIH is aesthetically unpleasing to them, and they’re most likely emotionally concerned about it.” A study of adult female acne revealed that whereas the chief complaint of Caucasian patients is typically the acne itself, nonwhite patients prioritize PIH.3

“Early intervention and aggressive acne treatment are important in patients with SOC to treat as well as prevent acne-related PIH. Initiate topical retinoids and antibiotics—everything you can do—to get the acne under control to prevent further PIH.”

Regarding antibiotic resistance in patients with SOC, 2 studies show that Black patients are less likely to receive oral acne therapy than Caucasians.4,5 “These findings suggest that antibiotic resistance may be lower in patients with SOC because they are prescribed antibiotics less often.”

Treatment preferences also differ among racial groups. In 1 study, East and South Asian patients were less likely than Caucasians to see health care practitioners for acne. Additionally, Asian and Black patients preferred over-the-counter acne cleansers and washes over prescription treatments.4

Similarly, vehicle choices assume extra importance for patients with SOC. With aggressive acne treatments, tolerability is a concern. “Dosing is always important—start low, then go high, maybe every other day,” she said. Topical retinoids in lotion formulations are very well tolerated by patients with SOC, Callender added, and maintenance regimens can help prevent future PIH.

“I basically let patients know we’re clearing up the acne and PIH at the same time,” Callender explained. “Acne is the cause, so we have to go after that aggressively, but the PIH will improve with time. It doesn’t happen overnight.” For stubborn PIH, she typically prescribes topical hydroquinone on a patient’s second or third visit.

Regarding skin care, Callender recommended gentle, nonirritating cleansers, noncomedogenic moisturizers, and sunscreens. Although pomade acne is becoming less common, she added, some patients require discussion of hair care. Comedogenic oils used to manage curly hair may drip onto the forehead, she explained, causing comedones along the hairline.

“You’ve got to talk about everything, not just prescription medications,” she said. “You really have to know what your patients are using.”

References:

  1. Callender VD. Management of acne in skin of color patients. Fall Clinical Dermatology Conference; October 21-24; Las Vegas.
  2. Davis EC, Callender VD. A review of acne in ethnic skin: pathogenesis, clinical manifestations, and management strategies. J Clin Aesthet Dermatol. 2010;3(4):24-38.
  3. Callender VD, Alexis AF, Daniels SR, et al. Racial differences in clinical characteristics, perceptions and behaviors, and psychosocial impact of adult female acne. J Clin Aesthet Dermatol. 2014;7(7):19-31.
  4. Mehta M, Kundu RV. Racial differences in treatment preferences of acne vulgaris: a cross-sectional study. J Drugs Dermatol. 2020;19(12):802. doi:10.36849/JDD.2020.5488
  5. Barbieri JS, Shin DB, Wang S, et al. Association of race/ethnicity and sex with differences in health care use and treatment for acne. JAMA Dermatol. 2020;156(3):312-319. doi:10.1001/jamadermatol.2019.4818

Disclosures:

Callender has been a clinical researcher, advisory board member, consultant, and/or speaker for Acne Store, Aerolase, AbbVie/Allergan, Beiersdorf, Eli Lilly, Galderma, Incyte, L’Oreal, Ortho Dermatologics, Pfizer, Revance, Skinbetter Science, UCB, SkinCeuticals, UCB, and VYNE Therapeutics.