Treating acne vulgaris in skin of color

The clinical presentation of acne vulgaris in darker-skinned individuals differs in many ways from the white population, including some specific exacerbating factors that are due to cultural skin and hair-care practices.

“The best treatment outcomes are achieved by aggressively controlling the inflammation and addressing the hyperpigmentation that can result from acne,” says Andrew Alexis, M.D., chair of the Department of Dermatology at Mount Sinai St. Luke’s and Mount Sinai West in New York City.

Patients with skin of color are likely to be equally or more concerned by the dark spots caused by acne than they are by the acne itself. “This has been shown in a number of studies,” Dr. Alexis says.

For example, Dr. Alexis was co-author of a study that appeared in the Journal of Clinical and Aesthetic Dermatology in 2014 that found that among adult women with acne, postinflammatory hyperpigmentation was reported as the most troublesome sign in over 25% of non-white patients compared to only 2.8% of white patients.

“Therefore, it is important to address both the acne and the hyperpigmentation when treating skin of color,” Dr. Alexis tells Dermatology Times.

In fact, the same study concluded that clearance of the postinflammatory hyperpigmentation was the top treatment priority of non-white patients: 42% compared to 8.4% of Caucasians.

The desired treatment endpoint for a patient of darker skin is resolution of not just the active acne lesions, but clearance of the dark spots.

Other sequelae that are often more frequent in darker skin with acne are keloids and hypertropic scars, especially from severe truncal acne.

“Hence, undertreatment must be avoided in these instances,” Dr. Alexis says. “By controlling the underlying disease of acne, you can reduce the risk of long-term sequelae, such as hyperpigmentation, and keloids and hypertropic scars in more severe cases.”  

Products like cocoa butter on the face are frequently used by African Americans, “based on a widely held belief that it helps to even the skin tone or treat hyperpigmentation,” says Dr. Alexis, who spoke on acne vulgaris at the Skin of Color Seminar Series (SOCSS) in New York City in May. “However, cocoa butter has a tendency to be comedogenic, thus a tendency to worsen acne.”

In addition, many women of African ancestry apply petrolatum-based and other potentially comedogenic oily products to their hair, which, when spread close to the forehead and frontal hairline, “can lead to an outbreak of pomade acne,” Dr. Alexis said. “Therefore, you should advise these patients to avoid application of thicker hair products close to the forehead and temples. Switching to lighter, less comedogenic hair products is advisable, such as those containing cyclomethicone or cyclodimenthicone, which are silicone-based hair serums.”

Alternatively, oil-based hair products can be continued, “as long as they are applied at least 1 inch from the frontotemporal hair line,” Dr. Alexis says.

There are also instances of patients of color inadvertently using steroid-containing creams to lighten or even the skin.

“Patients can get their hands on creams that are marketed as fade creams or skin lightening creams or spot removers,” Dr. Alexis says. Ingredients include prescription-strength corticosteroids such as clobetasol propionate. “These creams are sold without a prescription illegally, without the patient knowing that they are applying a prescription-strength corticosteroid to face or body,” he says.

The long-term use of a potent topical corticosteroid on the face may lead to steroid acne.

When treating acne, subclinical inflammation can be detected histopathologically. An abstract published in 1996 in the Journal of Investigative Dermatology biopsied African-American women with acne and found evidence of microscopic inflammation, even in areas that were not clinically inflamed.

A more recent 2003 study from the same journal detected evidence of subclinical inflammation by taking biopsies from skin that was not actively involved with acne, specifically perifollicular uninvolved skin. “The investigators found increased expression of T lymphocytes and interleukin-1,” Dr. Alexis says. “The implications in darker skin are that this subclinical inflammation can contribute to increased risk of postinflammatory hyperpigmentation.”

The expanded list of agents with anti-inflammatory effects includes topical retinoids like adapalene; tetracycline antibiotics such as doxycyline and minocycline; topical dapsone; azelaic acid; and intralesional corticosteroids. Topical benzoyl peroxide indirectly reduces inflammation by inhibiting P.acnes – a key driver of inflammation in acne.

When putting together a topical regimen for patients of color with acne, consideration should be given to both maximizing efficacy and tolerability because “we can induce pigmentary abnormalities if we  inflame the skin as a complication from our topical treatment regimen,” says Dr. Alexis, director of the Skin of Color Center at Mount Sinai St. Luke’s and Mount Sinai West.

The vehicle, the actual active ingredient, the frequency and the quantity of topicals all need to be managed in such a way that the patient achieves a high degree of tolerability, without any irritation; otherwise, “irritation itself can induce more pigmentary abnormalities,” Dr. Alexis says.

A number of recent studies of available agents have shown safety and efficacy in darker skin patients with acne.

A study presented at the 2017 SOSCC found that the retinoid benzoyl peroxide combination Epiduo Forte (Galderma), which contains adapalene 0.3% and benzyl peroxide 2.5%, provided a high degree of tolerability in lighter skin types as well as in darker skin types, along with low incidences of redness, scaling, dryness and stinging/burning in both populations.

There are also studies among Hispanics that show that topical Onexton, containing clindamycin and benzoyl peroxide, is effective for acne.

Furthermore, studies of topical Aczone (dapsone) 7.5% gel for acne, including a study in the Journal of Drugs and Dermatology in 2016, for which Dr. Alexis was a co-author, found comparable safety and efficacy in lighter skin and darker skin.

Topical retinoids can be used as a treatment for postinflammatory hyperpigmentation associated with acne. A study in the New England Journal of Medicine from 1993 found that by applying tretinoin 1% cream over 40 weeks, there was a significant improvement in postinflammatory hyperpigmentation, secondary to acne (however, 50% of patients experienced irritation).

Another study appeared in the journal Cutis in 2006, which found that the retinoid tazarotene 0.1% cream in darker skin also resulted in significant improvement in hyperpigmentation from acne.

In addition, using adapalene in African patients showed improvement in hyperpigmentation, according to a study from the Journal of the European Academy of Dermatology and Venereology in 2011.

“The key step to successful outcomes for acne in darker skin is to initiate a combination treatment regimen that targets the inflammatory component, as well as reduces hyperpigmentation,” Dr. Alexis says. “It is also critical to minimize irritation from topical therapies, as this can induce more pigmentary changes.”

Setting realistic timeline expectations for patients is also paramount and leads to better outcomes, according to Dr. Alexis. “Clearance of the active acne usually occurs within the first 3 months of treatment,” he says. “This is followed by clearance of the dark spots caused by the acne, which may take an additional 3 to 6 months of treatment.”

Disclosure: Dr. Alexis serves on the advisory board of Allergan, Galderma, Foamix Pharmaceuticals and Valeant Pharmaceuticals. He is also an investigator for Allergan, Novan and BioPharmX, and a consultant to BioPharmX and La Roche-Posay.