Nuances for Treating Acne in SOC Patients

Andrew Alexis, MD, MPH, vice chair for diversity and inclusion, department of dermatology, Weill Cornell Medicine, New York, New York, and Dermatology Times® board member, highlighted the key considerations when treating acne in patients with skin of color (SOC) specifically those with darker Fitzpatrick skin types, while also discussing the current strategies to treat them.¹

Alexis began with explaining how post inflammatory hyperpigmentation (PIH) is one of the most prominent issues in SOC patients with acne and sometimes may be the symptom that patients are most bothered by.

With COVID-19 requiring people to utilize face masks, Alexis said the number of patients with acne and PIH issues has gone up significantly. He recommends that physicians use agents that treat active acne and PIH at the same time to tackle this issue. It is important that this treatment combination can be sustained until both issues are cleared, in which Alexis recommends retinoids to accomplish this.

Alexis also mentioned that the effects of retinoids go beyond just treating acne, as it can also treat PIH. He said there are many mechanisms of retinoids that can treat PIH, such as the down regulation of tyrosinase and the removal of excess epidermal melanin. Other treatments for PIH include tyrosinase inhibitors and melanosome transfer blockers (niacinamide and protease inhibitors).

Newer retinoid options include:

• Tretinoin gel microsphere 0.04%, 0.06%, 0.08% and 0.1%
• Tretinoin 0.05% lotion
• Trifarotene 0.005% cream
• Tazarotene 0.045% lotion
• Tazarotene 0.1% foam

There is also azelaic acid, Alexis said, that can be used as an adjunct, and currently the 20% dose is approved to treat acne. He said that the 15% dose is what is ideal for combination therapies but is off label.

Alexis said that hydroquinone spot treatment is often not practical as a treatment option. “While I use hydroquinone for so many other disorders and other causes of PIH, when it comes to acne specifically, because of the nature of the acne hyperpigmented macule… it becomes very difficult to treat just the acne and not the normal-non lesioned skin,” Alexis said. Lightening of the non-PIH skin can occur if the treatment is misplaced.

Alexis mentioned that chemical peels can also be useful for treating both PIH and acne, but to be mindful of safety because it can cause injury and worsen PIH. He recommends limiting the patient to superficial peeling agents, stopping topical retinoids 1 week before administering peels, and always start low and work up the chemical peel slowly. A nonablative fractional laser (NALF) can also be used for PIH treatment with azelaic acid 15% foam. Patients need to be aware that treatment can take months to work, according to Alexis, so telling them when to expect results is needed.

He then moved to his second point was that early and effective therapy is key to reducing long-term sequelae. Alexis warned that physicians need to be cautious of subclinical inflammation, but it can be targeted. He said that retinoids, antibiotics, benzoyl peroxide, dapsone, azelaic acid, intralesional corticosteroids, spironolactone, and clascoterone, can all be used to address this issue. Clascoterone, which is not yet available according to Alexis, is a new treatment that works by inhibiting the androgen receptor and may reduce cytokine production by the sebocytes.

Alexis emphasized that combination is key when addressing inflammation because it addresses multiple pathogenic factors. Alexis presented research² that showed that black patients with acne had statistically significantly lower odds of receiving isotretinoin, adapalene, tazarotene, and dapsone than white patients, which works against his recommendation of combination treatment. He said it is important to make sure that this population of patients is not being under treated.

The third point was to maximize tolerability and avoid irritation. “If we induce irritation from the treatments that we recommend, we now can cause more pigmentary alteration,” Alexis said. Skin care such as a hydrating cleanser, moisturizer, a post topical medication can all be used to help the tolerability of treatment. Some of the newer formulations, like micronized tretinoin, can be less harsh, but there are availability issues according to Alexis.

He ended the presentation by repeating the 3 main points:

1. Align treatment endpoints with patient goals while giving them realistic timelines. This includes not only the acne, but any PIH or other issues that might arise.
2. Do not undertreat the patient and start combination therapy early.
3. Maximize the tolerability of the treatment by adding adjunctive skin care, carefully select the vehicle, and pay close attention to dosing regimens.

Disclosures:

Grants: Leo Pharma, Novartis, Almirall, Bristol-Meyers-Squibb, Amgen, Menlo, Galderma, Valeant (Bausch Health), Cara, Arcutis.

Advisory board/Consulting: Leo Pharma, Galderma, Pfizer, Sanofi-Regeneron, Dermavant, Beiersdorf, Valeant, L’Oreal, BMS, Bausch health, UCB, Vyne, Arcutis, Janssen, Allergan, Almirall, AbbVie, Sol-Gel, Amgen.

Speaker: Regeneron, SANOFI-Genzyme, Pfizer, Astra Zeneca.

Royalties: Springer, Wiley-Blackwell, Wolters Kluwer Health.

Reference:

1. A. Alexis. Acne Vulgaris: Nuances in the Approach to Treatment in Patients with Skin of Color. Presented at the: Skin of Color Update; September 10, 2021; Virtual.
2. Bell MA, Whang KA, Thomas J, Aguh C, Kwatra SG. Racial and ethnic disparities in access to emerging and frontline therapies in common dermatological conditions: a cross-sectional study. J Natl Med Assoc. 2020;112(6):650-653. doi:10.1016/j.jnma.2020.06.009