Dry skin in acne patients may occur due to treatment such as topical retinoids, alpha and beta hydroxy acids, benzoyl peroxide, skincare products, procedures, or lightening creams. Skin dryness and irritation are particularly problematic ins SOC as it appears as an ashy discoloration and can increase the risk for PIH, respectively.8 When using topical therapies in SOC patients, irritation (eg, retinoid dermatitis) can result in pigmentary sequelae. More tolerable formulations such as creams, lotions, and aqueous gels with hydrating ingredients may decrease the risk of dry skin and irritation. Adjunctive skincare is needed to minimize dryness, peeling, irritation due to topical treatment such as with retinoids.64 Applying a non-comedogenic moisturizer after the prescription topical is one strategy for reducing dryness, while the less frequent prescription application can reduce erythema, stinging, or burning.
Statement 3: Decreased ceramide levels have been demonstrated in the skin of African Americans.
Although evidence is scarce, researchers are increasingly interested in epithelial barrier dysfunction in acne patients, which directly affects comedogenesis and inflammation.18 For SOC patients with acne, there are only a few small studies. An older Japanese study examined sebum secretion, stratum corneum (SC) lipids, transepidermal water loss (TEWL), and conductance within the SC of male patients with mild-to-moderate acne (n=36), age range 14 to 26 years, and age-matched male control subjects (n=29).19 They found that acne patients exhibited markedly higher sebum secretion and greater TEWL and decreased SC hydration which was more significant in those with moderate compared to mild acne and normal control subjects. Acne patients had significantly reduced free sphingosine and total ceramides in their SC.19
Another small study evaluated skin barrier properties in adolescent males (n=7) with moderate acne vulgaris with ten subjects without acne for 12 months.20 SC lipids were sampled from the cheek in each season using tape stripping. Acne-affected skin showed lower levels of ceramides with more profound reductions in the winter months than those without acne, which partially improved in the summer.20
Studies investigating differences in Black versus White skin have yielded variable results. Five studies found that TEWL is greater in Black skin than White skin,21-25 seven found no difference,26-32 and two reported decreased TEWL in Black patients.33,34 There has been no difference demonstrated in TEWL between Hispanic and White skin22,31; however, the diversity of Fitzpatrick skin types and ancestral heritage of the Hispanic population contributes to the complexity of interpreting such studies.
Controversial findings have been reported regarding the lipid levels found in the SC of varying ethnic groups. Although greater overall lipid content has been reported in Black SC, subsequent studies have shown that ceramide levels were lowest in Black skin. Sugino et al found ceramide levels existed in decreasing order in Hispanic and Asian, White, and Black skin. Ceramide levels were inversely correlated with transepidermal water loss (TEWL). Additionally, the ceramide levels directly correlated with water content of the SC.23 This was again demonstrated by Hellemans et al, who quantified ceramide levels using hydrolysis and found the lowest lipid level in the SC in Black skin.35 Another study found African Americans to have significantly fewer ceramides compared to Caucasian and Asian American subjects.33
More recently, high-performance thin-layer chromatography has evaluated SC lipid profiles in Asian, Black, and White subjects. The highest ceramide/cholesterol ratio was seen in the Asian group, while the lowest ratio was observed in Africans. However, no significant differences were found in the ceramide subgroups.36
To what extent the data mentioned above has implications for SOC patients with acne is to be further examined.
Statement 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.
PIH results from the overproduction of melanin after cutaneous inflammation. Although the exact mechanism is unknown, there is an increase in melanocyte activity, stimulated by prostanoids, cytokines, chemokines, and other inflammatory mediators and reactive oxygen species that are released during the inflammatory process.37 Also, common acne treatments can be drying and contribute to PIH if the patient develops significant irritation.38,39
Retinoids are recommended as a first-line treatment in acne guidelines40-47 and are particularly useful in the management of acne in SOC due to their dual effects on PIH resolution as well as acne. For all patients, including SOC patients, retinoid use should be titrated to decrease irritation and maximize efficacy.
A polymeric lotion containing tretinoin 0.05% effectively and safely treated moderate-to-severe acne in all skin types improving patients' quality of life (QoL) scores, although racial and gender differences exist. This study also demonstrated beneficial effects on PIH in those patients most at risk.48 A further study evaluated the efficacy, tolerability, and safety of tretinoin 0.05% lotion in moderate-to-severe acne in an Asian population.49 A post hoc analysis of two phase III studies showed that the treatment
Statement 3: Decreased ceramide levels have been demonstrated in the skin of African Americans.
Although evidence is scarce, researchers are increasingly interested in epithelial barrier dysfunction in acne patients, which directly affects comedogenesis and inflammation.18 For SOC patients with acne, there are only a few small studies. An older Japanese study examined sebum secretion, stratum corneum (SC) lipids, transepidermal water loss (TEWL), and conductance within the SC of male patients with mild-to-moderate acne (n=36), age range 14 to 26 years, and age-matched male control subjects (n=29).19 They found that acne patients exhibited markedly higher sebum secretion and greater TEWL and decreased SC hydration which was more significant in those with moderate compared to mild acne and normal control subjects. Acne patients had significantly reduced free sphingosine and total ceramides in their SC.19
Another small study evaluated skin barrier properties in adolescent males (n=7) with moderate acne vulgaris with ten subjects without acne for 12 months.20 SC lipids were sampled from the cheek in each season using tape stripping. Acne-affected skin showed lower levels of ceramides with more profound reductions in the winter months than those without acne, which partially improved in the summer.20
Studies investigating differences in Black versus White skin have yielded variable results. Five studies found that TEWL is greater in Black skin than White skin,21-25 seven found no difference,26-32 and two reported decreased TEWL in Black patients.33,34 There has been no difference demonstrated in TEWL between Hispanic and White skin22,31; however, the diversity of Fitzpatrick skin types and ancestral heritage of the Hispanic population contributes to the complexity of interpreting such studies.
Controversial findings have been reported regarding the lipid levels found in the SC of varying ethnic groups. Although greater overall lipid content has been reported in Black SC, subsequent studies have shown that ceramide levels were lowest in Black skin. Sugino et al found ceramide levels existed in decreasing order in Hispanic and Asian, White, and Black skin. Ceramide levels were inversely correlated with transepidermal water loss (TEWL). Additionally, the ceramide levels directly correlated with water content of the SC.23 This was again demonstrated by Hellemans et al, who quantified ceramide levels using hydrolysis and found the lowest lipid level in the SC in Black skin.35 Another study found African Americans to have significantly fewer ceramides compared to Caucasian and Asian American subjects.33
More recently, high-performance thin-layer chromatography has evaluated SC lipid profiles in Asian, Black, and White subjects. The highest ceramide/cholesterol ratio was seen in the Asian group, while the lowest ratio was observed in Africans. However, no significant differences were found in the ceramide subgroups.36
To what extent the data mentioned above has implications for SOC patients with acne is to be further examined.
Statement 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.
PIH results from the overproduction of melanin after cutaneous inflammation. Although the exact mechanism is unknown, there is an increase in melanocyte activity, stimulated by prostanoids, cytokines, chemokines, and other inflammatory mediators and reactive oxygen species that are released during the inflammatory process.37 Also, common acne treatments can be drying and contribute to PIH if the patient develops significant irritation.38,39
Retinoids are recommended as a first-line treatment in acne guidelines40-47 and are particularly useful in the management of acne in SOC due to their dual effects on PIH resolution as well as acne. For all patients, including SOC patients, retinoid use should be titrated to decrease irritation and maximize efficacy.
A polymeric lotion containing tretinoin 0.05% effectively and safely treated moderate-to-severe acne in all skin types improving patients' quality of life (QoL) scores, although racial and gender differences exist. This study also demonstrated beneficial effects on PIH in those patients most at risk.48 A further study evaluated the efficacy, tolerability, and safety of tretinoin 0.05% lotion in moderate-to-severe acne in an Asian population.49 A post hoc analysis of two phase III studies showed that the treatment
