Racial and Ethnic Variation in Acne

An article posted in the Journal of Drugs in Dermatology examined the implications for treatment and skin care recommendations for skin of color (SOC) patients with acne.¹

A panel of 6 SOC dermatologists used a modified Delphi process to answer the following questions:

• Are there racial/ethnic differences in the clinical presentation and sequela of acne?
• Are there racial/ethnic differences in the therapeutic endpoint of acne treatment and patient expectations?
• Is there a need for specialized approaches to therapeutic options and skincare in acne patients with SOC?

After looking over 26 clinical studies, 7 epidemiological studies, and 27 reviews, the panel developed 6 consensus statements.

1. Post-inflammatory hyperpigmentation (PIH) is a common sequela of acne in SOC but can also occur due to irritation from topical acne treatments or procedural therapies. Given that PIH can occur as a sequela of acne or as a complication of treatment, regimens must be aggressive enough to reduce inflammation from acne and well-tolerated to avoid irritation from treatment. Therefore, when considering treatment and skin care regimens for SOC patients with acne, an individualized selection of a topical regimen to minimize irritation should consider tolerability characteristics of the active ingredients and vehicle.

Acne is the most commonly diagnosed condition in Black, Asian, and Hispanic patients and PIH was reported in about 2/3 of Black women. PIH can be epidermal or dermal and can be caused by an increase in production and transfer of melanosomes induced by inflammatory cytokines. Sub clinical inflammation was evident in clinical noninflammatory lesions and the degree of histopathologic inflammation in Black patients with acne was out of proportion to their clinical appearance. 

Asian patients are more susceptible to skin irritation of topical treatments, cleansers, and skin care with a high predisposition to PIH. One study reported 90.8% of Japanese patients with acne had some acne scarring and another study reported 58.2% of 342 patients had PIH.

Prolonged inflammation that is also recurring can make PIH worse and lead to hypertrophic and keloidal scarring, which have higher prevalence in SOC patients. Topical treatment, according to the panel, needs to be thoughtful when choosing the active agent, concentration, vehicle, dosing regimen, and adjunctive skin care. 

The topical treatments mentioned as being safe and effective in acne patients with Fitzpatrick skin types IV-VI are benzoyl peroxide (BPO) 2.5%-5.5%, retinoids, dapsone, azelaic acid, and fixed combination products. 

2. Dry skin is a common concern among patients with SOC and may be more visible or stigmatizing in richly pigmented skin.

Dry skin can be caused by acne treatments and can be problematic as it can present as an ashy discoloration and an increase risk for PIH. Also, when using topical treatments, irritation can result in pigmentary sequela. Formulas with hydrating ingredients may decrease the risk of both dry skin and irritation.

3. Decreased ceramide levels have been demonstration in the skin of Black patients—noted specifically in documentation as African American.

There is little evidence on epithelial barrier dysfunction in acne patients that directly affects comedogenesis and inflammation. There is even less evidence in SOC. 

A study from Japan investigated sebum secretion, stratum corneum (SC) lipids, transepidermal water loss (TEWL), and conductance within the SC of male patients with mild to moderate acne, ages 14 to 26 years. It was found that acne patients exhibited higher sebum secretion and greater TEWL, as well as decreased SC hydration which was more significant in patients with acne than those without.²

Another study examined the skin barrier properties in adolescent males, the mean age being 7, with moderate acne vulgaris with patients with clear skin for 1 year. The SC lipids were sampled using tape stripping from the cheek. Acne-affected skin showed lower levels of ceramides with greater reductions in the winter months than those without acne.³ 

Studies that investigate the differences in Black skin vs White skin have yielded variable results. There were 5 trials that found greater TEWL in Black skin than White skin, 7 found no difference in TEWL level, and 2 reported decreased TEWL in Black patients. No difference has been demonstrated in TEWL between Hispanic and White skin.

There have been controversial findings regarding the lipid levels found in the SC of different ethnic groups, but greater lipid content has been reported in Black SC and other studies have demonstrated that ceramide levels were lowest in Black skin.

Recently, high-performance thin-layer chromatography has evaluated SC lipids data patients who are Asian, Black, and White. The highest ceramide/cholesterol ration was seen in the Asian patients and the lowest was observed in Black patients.⁴ 

More research is needed for the implications of the aforementioned data.

4. Acne-related PIH in the SOC individual can be as bothersome as the acne lesions themselves. Thus, the therapeutic endpoint of acne treatment in SOC patients includes the resolution of PIH and long-term control of underlying acne vulgaris.

“Retinoids are recommended as a first-line treatment in acne guidelines and are particularly useful in the management of acne in SOC due to their dual effects on PIH resolution as well as acne,” wrote the authors.

A polymeric lotion containing tretinoin 0.05% is safe and effective for treatment for moderate to severe acne in all skin types for quality of life (QOL) scores, but there are differences based on gender and race. This study also reported beneficial effects on PIH in patients most at risk.⁵

A post hoc analysis of 2 phase 3 studies demonstrated that 0.05% tretinoin lotion treatment reduced noninflammatory acne lesions and was well-tolerated in the Asian population with no reported skin dryness, irritation, or PIH.⁶ Another study in Hispanic acne patients diagnosed with moderate to severe acne using that same lotion achieved positive efficacy and safety results.⁷ 

A subgroup analysis of Black patients from 3 studies worth of data demonstrated adapalene (ADAP) 0.3%/benzoyl peroxide (BPO) 2.5% gel was safe and more effective than vehicle in reducing both inflammatory and noninflammatory acne lesions.⁸

Topical antibiotics in combination with BP or a retinoid have been effective and safe for SOC patients with acne and acne caused PIH. Also, topical dapsone 5% and 7.5% gel are effective and safe in treating moderate acne in SOC patients and may be an option in inflammatory and noninflammatory lesions.

A post hoc analysis of data from 2 phase 3 studies that included White, Black, Hispanic, and non-Hispanic self-identified patients analyzed tazarotene 0.045% lotion was effective, safe, and well-tolerated in all groups and resulted in a decreased in incidence of PIH in Black patients.⁹

5. Adjunctive skin care can play an essential role in preventing, treating, and maintaining acne. When selecting a cleanser and moisturizer for acne and acne-prone skin, individual and/or cultural variations in skin care preferences should be considered. Some skin care and hair care products that are commonly used in communities of color, such as cocoa butter and petrolatum, may exacerbate acne. 

Right now, there are no distinguishing between phototypes or ethnic groups in US and Europe acne guidelines.

“Daily application of fragrance-free, non‐irritating, and non‐comedogenic cleansers, moisturizers, and sunscreen may reduce adverse events such as dryness, erythema, photosensitivity, and PIH resulting from topical drugs,” wrote the authors. “Special consideration should be applied to SOC patients prone to PIH. Using the appropriate skin care is prudent in this population to minimize irritation.”

Also, over the counter (OTC) skin lightening products used by specific subpopulations with SOC can cause occult steroid acne. 

6. Special considerations when treating SOC individuals with acne:

• Dry skin and irritation commonly result from topical acne treatment or systemic retinoid therapy.
• Non-comedogenic cleansers and moisturizers can improve dryness and irritation resulting from acne treatment. Favor aqueous gels, lotion, or cream vehicles.
• Acne-affected skin has shown lower levels of ceramides, with profound reductions compared to health individuals of all ethnicities. Ceramide-containing moisturizers may enhance adherence and complement existing acne therapies.

These statements will help patient education and will manage expectations and adherence. Also, this will give the clinician a better picture on what products the patient is currently using that may be causing the irritation. 

OTC products that are cosmetically elegant, nonirritating, well tolerated, anti-inflammatory, and restores skin barrier function are recommended for use.

Skin care is a necessary part of acne treatment as it can prevent, treat, and maintain care. The skin care treatment should be chosen by each patients diagnosed acne and personal history. 

There were limitations in the number, size, and methodologies of studies, and the available data to suggest strategies to improve outcomes in acne patients with SOC. 

Disclosure:

The authors disclosed receipt of an unrestricted educational grant from CeraVe USA for support with the research of this work and also received consultancy fees for their work on this project. 

All authors contributed to the development and review of this work and agree with the content.

Reference:

1. Draft- Racial and Ethnic Variations in Acne Article. JDDonline - Journal of Drugs in Dermatology. Accessed July 8, 2021. https://jddonline.com/articles
2. Yamamoto A, Takenouchi K, Ito M. Impaired water barrier function in acne vulgaris. Arch Dermatol Res. 1995;287(2):214-218. doi:10.1007/BF01262335
3. Pappas A, Kendall AC, Brownbridge LC, Batchvarova N, Nicolaou A. Seasonal changes in epidermal ceramides are linked to impaired barrier function in acne patients. Exp Dermatol. 2018;27(8):833-836. doi:10.1111/exd.13499
4. Jungersted JM, Høgh JK, Hellgren LI, Jemec GBE, Agner T. Ethnicity and stratum corneum ceramides. Br J Dermatol. 2010;163(6):1169-1173. doi:10.1111/j.1365-2133.2010.10080.x
5. Tretinoin 0. 05% lotion for the once-daily treatment of moderate-to-severe acne vulgaris: impact of gender and race on efficacy and safety | cochrane library. doi:10.1002/central/CN-02007393
6. Han G, Armstrong AW, Desai SR, Guenin E. Novel tretinoin 0. 05% lotion for the once-daily treatment of moderate-to-severe acne vulgaris in an asian population. J Drugs Dermatol. 2019;18(9):910-916.
7. Cook-Bolden FE, Weinkle SH, Guenin E, Bhatt V. Novel tretinoin 0. 05% lotion for once-daily treatment of moderate-to-severe acne vulgaris in a hispanic population. J Drugs Dermatol. 2019;18(1):32-38.
8. 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;13(2):170-174.
9. Bhatia N, Weiss JS, Sadick N, et al. Novel polymeric tazarotene 0. 045% lotion for moderate-to-severe acne: pooled phase 3 analysis by race/ethnicity. J Drugs Dermatol. 2020;19(7):727-734. doi:10.36849/JDD.2020.5125