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Acne nuances in patients with skin of color


Acne presents with certain nuances in darker skin patients. Exacerbating factors, treatment approaches and desired treatment outcomes may differ from lighter skin patients.

Dermatologists seeing acne patients with Fitzpatrick skin types IV, V and VI find nuances in acne presentation, exacerbating factors, treatment approaches and desired treatment outcomes among darker-skin versus lighter skin patients.

Dr. AlexisAndrew F. Alexis, M.D., M.P.H., chairman of dermatology at Mount Sinai St. Luke's and Mount Sinai West and director of the Skin of Color Center at Mount Sinai Health System, New York, N.Y., presented on the topic of acne in skin of color at The Skin of Color Seminar Series, held April 30 and May 1 in New York City.

He says that among the more important nuances of acne in darker skin patients is that many get post-inflammatory hyperpigmentation, as a result of the acne.

“These dark spots from post-inflammatory hyperpigmentation typically last several weeks to several months longer than the acne, itself, and can very frequently be more troublesome to the patient than the acne,” Dr. Alexis says.

Dr. Alexis authored a study published in 2014 that showed roughly a quarter of women of color with acne reported that hyperpigmentation was the most troublesome sign of their acne — more troublesome than the bumps or the pustules or any of the other features of acne.1

Differences in exacerbating factors

There also are potential differences in the exacerbating factors of acne in skin of color patients. Among those, there are subgroups within skin of color that have cultural skin and hair care practices that predispose them to acne. Specific practices among African Americans include more frequent use of products such as cocoa butter- or Shea butter-containing creams, which can be comedogenic and exacerbate acne.

“Hair products, such as products that contain petrolatum, mineral oil or other comedogenic oils that are used for the scalp frequently among African American female patients, can lead to a variant acne called pomade acne,” Dr. Alexis says. “Pomade acne is characterized by mostly comedones, with some papules, on the forehead and temples, close to the hairline. It’s due to the comedogenic hair products seeping down onto the forehead and temples….”

Yet another example of cultural practices that can lead to acne flares is use of some bleaching creams that include illegal doses of corticosteroids. Patients often purchase these creams with corticosteroids, unknowingly, at ethnic beauty supply stores, according to Dr. Alexis.

“Some of these bleaching creams can contain clobetasol, betamethasone valerate, both of which are corticosteroids. And, if used long term on the face, it can actually produce a variant of acne called steroid acne,” Dr. Alexis says.

Providers treating patients might not know about this phenomenon, according to Dr. Alexis.

“In order to make the diagnosis, it’s really the dermatologist who has to have the index of suspicion because the patient doesn’t make the link between the bleaching cream and the acne,” he says.

Signs of bleaching cream use include the presence of irregular patches of hypopigmentation and a monomorphic eruption of papules on the face.

“The patient often reports a sudden flare of their acne, and that’s characteristic of steroid acne,” Dr. Alexis says. “Once the doctor has that suspicion by seeing potential signs of long-term steroid use on the face, I advise dermatologists to ask the patients to bring in all the products they’ve used over the past six to 12 months. On the followup visit, you may uncover bleaching creams that have the corticosteroid.”

NEXT: Treatment nuances


Treatment nuances

Treating skin of color patients with steroid acne means taking them off the offending cream. They may experience a flare initially after stopping the cream, Dr. Alexis says. Step two is instituting an effective and aggressive topical and or oral acne regimen.

Treating acne aggressively in skin of color patients is among the nuances of treatment, according to Dr. Alexis. Dermatologists should try to control the inflammatory component of the disorder because of the higher risk of hyperpigmentation, as a result of the inflammation. There’s an added incentive to get rid of the acne, he says. In more severe acne cases, especially acne involving the trunk, the risk of keloids and hypertropic scarring goes up in skin of color patients.

“So, it’s important not to undertreat the acne,” he says. “At the same time, we can’t aggressively treat at the expense of tolerability. We have to maximize tolerability because of the potential risk of irritation from any of the topical products we prescribe to produce more pigment abnormalities.”

The bottom line, according to Dr. Alexis, tailor the regimen for the individual patient.

Dermatologists can do that with a combination of topical retinoids, topical benzoyl peroxide and topical antiinflammatory formulations, like dapsone, used in concentrations and dose frequencies that the individual patient can tolerate.

There are studies in Fitzpatrick IV, V and VI patients using azelaic acid, benzoyl peroxide, dapsone, adapalene, tretinoin, tazarotene, adapalene-benzoyl peroxide, clindamycin-benzoyl peroxide and clindamycin-tretinoin.

In most studies, safety and efficacy of the acne treatments was comparable among black and non-black patients, alike, according to Dr. Alexis.

“We anticipate more studies in patients of color with some of the newer agents that have been approved over the past year, including a higher strength adapaline.3%-benzyl peroxide 2.5% formulation gel, which is currently on the market, and a recently approved higher strength dapsone product, dapsone 7.5% cream. We don’t have any published studies on those at this time,” he says.

More resources

Dr. Alexis recommends these resources for more on skin of color acne studies:

Topical dapsone gel 5% for the treatment of women of color with acne. Alexis AF, Burgess C, Callender VD, Herzog JL, Roberts WE, Schweiger ES, Stockton TC, Gallagher CJ. The Efficacy and Safety of Topical Dapsone Gel, 5% for the Treatment of Acne Vulgaris in Adult Females With Skin of Color. J Drugs Dermatol. 2016 Feb 1;15(2):197-204. https://www.ncbi.nlm.nih.gov/pubmed/26885788

Nuances and optimizing treatment outcomes in acne among skin of color patients. Alexis AF. Acne vulgaris in skin of color: understanding nuances and optimizing treatment outcomes. J Drugs Dermatol. 2014 Jun;13(6):s61-5. https://www.ncbi.nlm.nih.gov/pubmed/24918573

Adapalene-benzoyl peroxide topical gel in black patients with acne. Alexis AF, Johnson LA, Kerrouche N, Callender VD. A subgroup analysis to evaluate the efficacy and safety of adapalene-benzoyl peroxide topical gel in black subjects with moderate acne. J Drugs Dermatol. 2014 Feb;13(2):170-4. https://www.ncbi.nlm.nih.gov/pubmed/24509968


Callender VD, Alexis AF, Daniels SR, Kawata AK, Burk CT, Wilcox TK, Taylor SC. Racial differences in clinical characteristics, perceptions and behaviors, and psychosocial impact of adult female acne. J Clin Aesthet Dermatol. 2014 Jul;7(7):19-31.https://www.ncbi.nlm.nih.gov/pubmed/25053980

Disclosure: Dr. Alexis has been an investigator for Allergan and Novan, as well as a consultant for Allergan, Galderma and Novan.

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