Acne vulgaris affects nearly 10 percent of the world-wide population.1 In a study by Perkins et al, acne was found to be more prevalent in African Americans (37%) and Hispanics (32%), followed by Asians (30%), Caucasians (24%), and Continental Indians (23%).2 This article highlights five considerations when treating acne in patients with skin of color.
1 EVALUATE TOPICAL RETINOID REGIMEN
Topical retinoids are the mainstay of acne treatment and exert their effects by minimizing active lesions and inhibiting microcomedone formation.3 Higher doses of retinoids can cause skin irritation, thus increasing the risk of postinflammatory hyperpigmentation (PIH). Common side effects of topical retinoids include erythema, dryness, peeling, and irritation. These side effects are most common during the first few weeks of treatment initiation.4 To improve tolerability and patient adherence, consider the following:
A. Retinoid concentration and vehicle formulation. Lower concentrations of topical retinoids have been shown to minimize the risk of PIH.5 Studies have shown that creams, microsphere, crystalline formulations, and aqueous gels are better tolerated in patients with skin of color.6
B. Short contact therapy. This method minimizes the length of exposure to the retinoid. Patients apply the topical retinoid for a specified amount of time (e.g., 30–60 minutes once daily) and then rinse it off their skin. In a study assessing tretinoin 0.05% cream applied in this manner for up to 32 weeks, results showed similar efficacy to its once-daily leave-on regimen, but with improved tolerability.7
C. Nondaily application. This method minimizes the frequency of exposure to the retinoid. Patients should apply the retinoid every other day. In a study comparing every other day tazarotene 0.1% gel to once-daily adapalene 0.1% gel, results showed that both formulations had similar efficacy and tolerability.8
2 TAKE A HISTORY OF SKINCARE REGIMEN
It is important to take a thorough history of a patient’s current skincare regimen. By doing so, you can learn if they are using products that may exacerbate potential side effects of a treatment regimen. Counsel patients to avoid toners and astringents, as they can excessively dry the skin and increase irritation.9 Recommend lipid-free cleansers, as they gently clean the skin and maintain epidermal integrity.10 Recommend noncomedogenic moisturizers as well. One study showed that adapalene used in combination with an anti-inflammatory moisturizer had greater efficacy and tolerability versus adapalene alone.11 Lastly, emphasize the importance of daily sunscreen use. Darker skin is naturally protected from ultraviolet B (UVB) light but susceptible to UVA and visible light. UVA has been shown to induce PIH in patients with acne.12 One study found that one of the most common reasons for sunscreen avoidance in skin of color populations was “dislike of greasiness;” thus, it is important to address this concern with patients and counsel them on the wide variety of sunscreen formulations available.13
3 INITIATE ISOTRETINOIN GRADUALLY
For patients who require isotretinoin, they should be started on a low dosage, which is then increased gradually, as isotretinoin initiation can cause an initial acne flare. This initial flare can lead to subsequent PIH. Patients may also experience ashen or grayish facial skin secondary to the drug’s xerotic effects.14
4 INQUIRE ABOUT HAIRCARE PRACTICES
Individuals of different ethnicities have varying haircare practices, and many frequently apply comedogenic oils to the hair and scalp. For example, a study by Nayak et al15 showed that Asian Indian male and female individuals applied coconut oil to the hair for moisturization. This practice often leads to pomade acne, which is characterized by numerous closed comedones over the forehead and temples.14 It is important to be aware of what products are being used on the hair so you can counsel patients appropriately.
5 DISCUSS PIH
Patients with skin of color are often equally or more bothered by PIH than active acne. Therefore, it is important to discuss how active acne leads to PIH and how a customized treatment plan treats both (e.g., consider treatment regimens that include topical retinoids and/or azelaic acid). Discuss with patients the anticipated timeline for improvement of both acne and PIH. Also, ask patients if they have treated their PIH in the past, and if so, with what products (e.g., hydroquinone, etc.).
By understanding some of the unique challenges that impact patients with skin of color who have acne, you will be better equipped to achieve shared treatment goals.
WAYS TO HELP MAUI FIRE VICTIMS.
HAWAI’I EMERGENCY MANAGEMENT AGENCY: Donations and volunteer support information at www.ready.hawaii.gov or 808-733-4300.
AMERICAN RED CROSS OF HAWAI’I: Monetary donations should include the designation “Hawaii (Maui) Wildfires.” www.redcross.org/hawaii.
MAUI UNITED WAY: The Fire Disaster Relief Fund is providing financial assistance through grants to nonprofits at the forefront of relief efforts and directly to households that have been deeply affected. www.mauiunitedway.org/disasterrelief.
HAWAI’I COMMUNITY FOUNDATION’S MAUI STRONG FUND: Providing resources for disaster recovery, 100% of funds will go to the community. No fees will be taken. www.hawaiicommunityfoundation.org/maui-strong
HAWAI’I SALVATION ARMY: They will be providing meals in Maui emergency shelters. hawaii.salvationarmy.org/
KĀKO’O MAUI FUND: Funds will go to help Maui families and businesses. Donations up to $100,000 will be matched. www.memberplanet.com/campaign/cnhamembers/kakoomaui
MAUI MUTUAL AID FUND: Volunteers are raising money to get support to vulnerable residents like kūpuna, those with physical disabilities, and those without insurance. https://www.paypal.com/donate?hosted_button_id=Y7J26SYUJFQU8
REFERENCES
- Heng AHS, Chew FT. Systematic review of the epidemiology of acne vulgaris. Sci Rep. 2020;10(1):5754. doi: 10.1038/s41598-020-62715-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Perkins AC, Cheng CE, Hillebrand GG et al. 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. doi: 10.1111/j.1468-3083.2010.03919.x. [DOI] [PubMed] [Google Scholar]
- Thielitz A, Abdel-Naser MB, Fluhr JW et al. Topical retinoids in acne—an evidence-based overview. J Dtsch Dermatol Ges. 2008;6(12):1023–1031. doi: 10.1111/j.1610-0387.2008.06741.x. [DOI] [PubMed] [Google Scholar]
- Culp L, Moradi Tuchayi S, Alinia H, Feldman SR. Tolerability of topical retinoids: are there clinically meaningful differences among topical retinoids? J Cutan Med Surg. 2015;19(6):530–538. doi: 10.1177/1203475415591117. [DOI] [PubMed] [Google Scholar]
- Alexis AF, Woolery-Lloyd H, Williams K et al. Racial/ethnic variations in acne: implications for treatment and skin care recommendations for acne patients with skin of color. J Drugs Dermatol. 2021;20(7):716–725. doi: 10.36849/JDD.6169. [DOI] [PubMed] [Google Scholar]
- Alexis AF, Barbosa VH. Skin of Color: A Practical Guide to Dermatologic Diagnosis and Treatment. 2012. Springer.
- Veraldi S, Barbareschi M, Benardon S, Schianchi R. Short contact therapy of acne with tretinoin. J Dermatolog Treat. 2013;24(5):374–376. doi: 10.3109/09546634.2012.751085. [DOI] [PubMed] [Google Scholar]
- Leyden J, Lowe N, Kakita L, Draelos Z. Comparison of treatment of acne vulgaris with alternate-day applications of tazarotene 0.1% gel and once-daily applications of adapalene 0.1% gel: a randomized trial. Cutis. 2001;67(6 Suppl):10–16. [PubMed] [Google Scholar]
- Callender VD, Baldwin H, Cook-Bolden FE et al. Effects of topical retinoids on acne and post-inflammatory hyperpigmentation in patients with skin of color: a clinical review and implications for practice. Am J Clin Dermatol. 2022;23(1):69–81. doi: 10.1007/s40257-021-00643-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Levin J. The relationship of proper skin cleansing to pathophysiology, clinical benefits, and the concomitant use of prescription topical therapies in patients with acne vulgaris. Dermatol Clin. 2016;34(2):133–145. doi: 10.1016/j.det.2015.11.001. [DOI] [PubMed] [Google Scholar]
- Chularojanamontri L, Tuchinda P, Kulthanan K et al. A double-blinded, randomized, vehicle-controlled study to access skin tolerability and efficacy of an anti-inflammatory moisturizer in treatment of acne with 0.1% adapalene gel. J Dermatolog Treat. 2016;27(2):140–145. doi: 10.3109/09546634.2015.1079298. [DOI] [PubMed] [Google Scholar]
- Poli F. Acne on pigmented skin. Int J Dermatol. 2007;46(Suppl 1):39–41. doi: 10.1111/j.1365-4632.2007.03463.x. [DOI] [PubMed] [Google Scholar]
- Mahler HIM. Reasons for using and failing to use sunscreen: comparison among Whites, Hispanics, and Asian/Pacific Islanders in Southern California. JAMA Dermatol. 2014;150(1):90–91. doi: 10.1001/jamadermatol.2013.4992. [DOI] [PubMed] [Google Scholar]
- 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. [PMC free article] [PubMed] [Google Scholar]
- Nayak BS, Ann CY, Azhar AB et al. A study on scalp hair health and hair care practices among Malaysian medical students. Int J Trichology. 2017;9(2):58–62. doi: 10.4103/ijt.ijt_76_16. [DOI] [PMC free article] [PubMed] [Google Scholar]