INTRODUCTION
Epidemiology
Published practice and community-based survey studies
have reported that acne is the most frequent dermatologic
condition in populations with skin of color, including
blacks (in New York, NY;1 Washington, DC;2 and London,
UK3), Latinos (in New York, NY),4 Arab-Americans (in Southeast
Michigan),5 and South-Asian Americans (in New York, NY).6 In a
global study, unilateral facial photographs of 2,835 females (10
to 70 years of age) from 4 cities (Los Angeles, USA; London,
UK; Akita, Japan; and Rome, Italy) were examined for clinical
features of acne. The prevalence of acne was found to be
37%, 32%, 30%, 24%, and 23% in African Americans, Hispanics,
Asians, Caucasians, and Continental Indians, respectively.7
Clinical Nuances
Increased constitutive pigmentation and labile melanocyte responses
to inflammation are key characteristics of skin of color.
As a result, inflammatory disorders of the skin, such as acne,
are typically complicated by the presence of postinflammatory
hyperpigmentation (PIH). Acne-associated PIH is characterized
by hyperpigmented macules typically ranging from 2 mm to 4
mm in size arising at sites of resolved or resolving acne lesions
(Figure 1). Although spontaneous remission is expected, PIH
generally lasts from several weeks to several months after an
acne lesion has resolved, depending on the severity.
Patients frequently refer to PIH as “uneven skin tone†or “acne
scars,†and may have the misconception that the lesions
are permanent if left untreated. In many instances, PIH is of
greater concern to the patient than the acne itself; it is often
the driving force for acne patients with skin of color to seek
a dermatologist consultation. In the setting of excoriation or
other traumatic manipulation of acne lesions by the patient,
PIH tends to be more severe and longer lasting (Figure 2). A
harsh skin care regimen (eg, vigorous scrubbing, or excessive use of exfoliating products, strong toners, or astringents, etc)
can also contribute to PIH. In cases of severe excoriation or
“acne excoriée,†hypopigmented macules with angulated hyperpigmented
borders can be observed (Figure 3).
Populations with skin of color (especially those of sub-Saharan
African ancestry) have a higher prevalence of keloids
and hypertrophic scars.8 This is due to a genetic predisposition
toward heightened fibroblast responses to injury and
inflammation. Inflammation from acne, particularly in cases
of severe truncal involvement, can therefore lead to the formation
of keloids in individuals who are so predisposed. As
such, moderate to severe acne in populations with skin of
color is associated with a higher risk of disfiguring and persistent
raised scars, which are most frequently observed on
the chest, upper back, and jawline.
There are a number of cultural skin and hair care practices that
can in some instances exacerbate acne.9 One example is the
more frequent use of cocoa butter lotions and creams among
African Americans.10 This is due to a widely held perception in
this population that cocoa butter helps to even skin tone and
improve scars. Therefore, in an effort to reduce the hyperpigmentation
and perceived “scars†of PIH, many patients with
skin of color (particularly African Americans) may apply cocoa
butter liberally to the face. This in turn can exacerbate acne
due to its comedogenicity.
Another cultural practice that can contribute to worsening
acne is the frequent use of thick, oil-based hair products
among populations of African ancestry with afro-textured hair.
In this population, the application of hair products designed
to add sheen, prevent dryness, and improve manageability
is a common practice. Historically, thicker products containing
petrolatum or mineral oil have been used and these have
