Incorporating New Medications into Acne Treatment - Episode 6
An overview of common sequelae and potential complications of acne, including physiological and psychological scaring.
Hilary E. Baldwin, MD: Another thing that’s different about the face and the chest are the common sequelae that can occur after the acne lesions have resolved. Fran, what kind of stuff do you see in your practice? Is there a difference between the trunk and the face in terms of scarring, hyperpigmentation, and the like?
Fran E. Cook-Bolden, MD: Hilary, in my practice, I see about 60% of patients with skin of color. I would say that the most common sequelae that I see is post-inflammatory hyperpigmentation: the dark spots that we see on the skin. In my fairer patients, I see post-inflammatory erythema, pretty commonly. In terms of distinguishing the face from the trunk, truncal acne is likely to scar. I would say that I see much earlier scarring with truncal lesions, which is why I want to make sure that I look for it and diagnose it instead of waiting for the patient to complain about it. Some won’t complain about it because it’s covered up, and they’ll wait until it gets bad and start to scar before they bring it to my attention. I want to make sure that I capture that from the very beginning of the lesions.
One of the sequelae that I want to talk about, going in another direction, that Julie talked about already. Something we don’t think about when we talk about sequelae of acne, is that psychological sequelae: embarrassment, impaired self-image, low self-esteem, frustration, or even anger. They get mad at us because it’s not clearing up quickly enough. They are also angry at themselves. They don’t understand, or their parent doesn’t understand why they’re having this acne.
In addition to physical sequelae, which are commonly post-inflammatory erythema, post-inflammatory hyperpigmentation especially in darker skin, and scarring that we can see in anyone, I always think about that psychological sequelae that Julie talked about earlier when I’m treating patients.
James Q. Del Rosso, DO: On the physical side, there’s a type of scarring on the trunk with little white atrophic scars that I’ve never seen on the face. I think they are called albopapuloids; there’s a term for them, and I don’t think I’m remembering correctly. I’ve seen it in the book Plewig and Kligman’s Acne and Rosacea. You see it every once in a while, and I have found nothing that helps that.
I’ll also ask all of you. This is certainly going back to what Fran mentioned: I find that a lot of my patients with darker skin, especially Black females, will tell me that, “I know the acne is going to go away, but it’s these dark spots that bother me the most.” As we know, those are very challenging. On the psychological side, that bugs them because they hang around for months.
Fran E. Cook-Bolden, MD: Forever.
Hilary E. Baldwin, MD: Alison Layton, [MB, ChB,] wrote an interesting article several years ago now that was called, “Scarred for Life,” and it was about exactly your point, Julie and Fran. The point was that, even once the acne is gone, and even if there are no physical scars, the psychological scarring of having had acne in the patient’s earlier life stays with them forever, and it sometimes changes the paths that they take in life. It’s certainly nothing to be sneezed at.