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
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 â€œuneven skin toneâ€ or â€œacne scars,â€ 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 â€œacne excoriÃ©e,â€ 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 â€œscarsâ€ 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