The treatment and management of acne and rosacea in patients with skin of color can be tricky and it behooves the astute clinician to be wary of the pitfalls and challenges associated with treatment.
Andrew F. Alexis, M.D.The treatment and management of acne and rosacea in patients with skin of color is associated with a unique set of challenges. Post-inflammatory hyperpigmentation (PIH) in particular remains one of the most challenging aspects of treatment. One key to optimal treatment is understanding how to best avoid this unwanted sequelae, according to Andrew F. Alexis, M.D., department of dermatology, Icahn School of Medicine at Mount Sinai, New York, NY.
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“The main challenge when treating patients with skin of color is PIH,” he says. “Particularly for acne vulgaris itself, PIH is a very common feature or sequela of the condition and it is often the driving force for the patient to go and see the dermatologist. It is my impression that the PIH is of equal and sometimes greater concern to the patient than the acne itself. Therefore as dermatologists, it is necessary to address both conditions when we interact with our patients.”
It is now widely accepted that inflammation and subclinical inflammation play a significant role in the development of lesions. Clinically, even non-inflamed lesions such as comedones still have inflammation that is subclinical. As such, Dr. Alexis says that there is a need to aggressively and effectively control the inflammatory component of the acne.
Topical retinoids are particularly useful in patients with skin of color, due to the combined effect of comedolysis and reducing hyperpigmentation, Dr. Alexis says. Some retinoids demonstrate anti-inflammatory effects, such as adapalene. Dr. Alexis also uses benzoyl peroxide (BPO) in his therapeutic regimen because it can inhibit the P. acnes that drives a lot of the inflammatory component of acne. It indirectly reduces inflammation.
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Other agents that can be used to reduce the inflammatory component include topical dapsone 5% gel and azaleic acid, the latter of which can also help address the PIH.
“There are a range of treatment options and the key is to come up with a regimen that is tolerable. Not only should it be efficacious and have strong anti-inflammatory and comedolytic effects, but it also has to be well-tolerated. If we induce irritation with our regimen, then we can also cause more pigment alteration, leading to disgruntled patients,” Dr. Alexis says.
Choosing the appropriate vehicle and concentration of the agent used, especially when considering BPO and the retinoids, is also key in achieving positive clinical outcomes, Dr. Alexis says. The availability of new vehicles and formulations has very much helped in this regard.
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Aqueous gels in particular, which are the basis of most branded products, are preferable to the ethanolic gel formulations of some generic products.
Dr. Alexis will also often use combination therapies to target as many pathogenic factors of acne at once, as well as to address hyperpigmentation. This could be a topical retinoid and topical BPO/clindamycin formulation, with or without an oral antibiotic, depending on the severity of symptoms. Adjunctive use of superficial chemical peels and bleaching agents can be considered for more severe cases.
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Patients with skin of color generally have a lower awareness of rosacea being a possibility, as most information suggests that one would expect to see rosacea in people of Northern European ancestry with fair skin. The perception that rosacea does not affect darker skin types is simply untrue, Dr. Alexis says. Rosacea in patients with skin of color can often be difficult to diagnose and may be under-recognized due to the challenges in detecting the erythema.
Patients will usually suspect that they have acne but upon closer inspection, one sees an absence of comedones and maybe some degree of erythema. The distribution of the papules and pustules is typical for rosacea on the central medial cheeks on the face and forehead, and the patients usually report the usual triggers for rosacea for flares.
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“Clinicians should be wary to have an index of suspicion for rosacea even in darker skin patients because it is under recognized. In addition, the history can be helpful as well as a close inspection for the characteristic signs for rosacea will help home in on the accurate diagnosis,” Dr. Alexis says.
Disclosure: Dr. Alexis reports no relevant disclosures.