been associated with pomade acne.11 This variant of acne is
less common today than when it was first described over 4
decades ago due to shifts in consumer preferences toward
lighter, less greasy hair products. However, it can still be observed
and, when it is identified, patients should be counseled
on using alternative hair products that are less likely to cause
acne, such as silicone-based hair serums (containing cyclomethicone
or dimethicone).9,12
The use of over-the-counter topical skin lightening or skin
bleaching creams is not uncommon among patients with skin
of color, many of whom try such products as a treatment of PIH and other dyschromias before seeking a dermatology consultation.
9 In addition to hydroquinone-based products, some
skin lightening creams sold at ethnic beauty supply stores and
via the internet illegally contain prescription-strength corticosteroids,
such as clobetasol and bethamethasone valerate.13 As
such, steroid acne can be seen in this context. Clinical clues to
this diagnosis include an acute flare of acne with monomorphous
inflamed papules and pustules in association with facial
hypopigmentation and atrophy. Patients are generally unaware
that such bleaching creams may contain potent corticosteroids
and often do not consider mentioning these products to their
physician unless asked directly. Therefore, the diagnosis rests
on the dermatologist having a clinical suspicion when presented
with the aforementioned signs and symptoms. Requesting
that the patient bring in all their skin care products is a useful
way to detect the inadvertent long-term use of corticosteroids
on the face, or other products that may contribute to acne.
The Role of Inflammation
It has been well established that inflammation plays an integral
role in the pathogenesis of acne, particularly in the context of
papules, pustules, nodules, and "cysts." However, only recently
has the role of inflammation as an early and subclinical event
in the development of acne been elucidated.
In a 1996 study, Halder et al14 examined 30 black females with
acne, obtaining punch biopsies of lesional skin. Histopathological
signs of inflammation were found to be out of proportion
to clinical inflammation and extended beyond the boundaries
of clinically inflamed lesions. Moreover, even clinically
non-inflamed lesions (ie, comedones) exhibited inflammation
histopathologically. This subclinical inflammation likely contributes
to the high propensity toward PIH in acne patients with
darker skin (including those with mild to moderate acne).
