In patients who use skin lightening products (a practice that can lead to inadvertent exposure to potent corticosteroids), steroid acne may occur. These patients will tend to have an acute flare of monomorphous papules and pustules after a period of extended use of topical corticosteroid-containing skin lightening products. Observing a lightened facial skin complexion should raise clinical suspicion for this variant of acne.12
SOC patients with acne frequently present with dyspigmentation.7,9,11,13,16,25,26 Hypertrophic scars and keloids from acne can also be observed in this population. Although the exact mechanisms have not been completely elucidated, there is an increase in melanocyte activity, stimulated by prostanoids, cytokines, chemokines, and other inflammatory mediators as well as reactive oxygen species that are released during the inflammatory process.9,11 PIH can occur as a sequela of the acne itself or as a complication of treatment and can worsen with persistent and recurring inflammation.9,11,13-16 Common acne treatments can be drying and contribute to PIH if the patient develops significant irritation.9,11,13-16
Education of Healthcare Providers and SOC Patients With Acne
The specific features of SOC patients with acne require tailored long-term management. Before recommending treatment, the physician should first determine the skin type (normal, oily, dry, or combined) and the predominant type of acne lesion(s) present.13-16,25-27 Patient education about skin irritation and PIH is integral to treating acne to manage expectations and improve adherence.13-16,25-28 It is important to obtain a detailed history of personal care products used by SOC patients with acne as some products such as toners, scrubs, and astringents, as well as devices, can be irritating.13-16,25-28 A tailored selection of prescription therapies and adjuvant skin care should minimize irritation in all patients with acne.16,25,26
Nonprescription products and skincare products include skin cleansers, topical sebum‑controllers, anti‑inflammatory agents, moisturizers, sunscreens, and camouflage products.13-16,25-28 Appropriate use of these products may help augment the benefit of acne treatment and minimize side effects.28
Healthcare professionals and patients should be educated on the varied uses of nonprescription products and skin care using cleansers and moisturizers for acne-prone skin.16 Educated healthcare professionals may be more likely to recommend these products to patients who have been prescribed acne treatments known to be irritating.12-16,28 This approach may help mitigate side effects, improve treatment compliance and improve the effectiveness of prescription medications.12-16,28 Conversely, efforts to directly educate the general population on the proper use of adjunctive nonprescription products and skin care may be particularly important, as many people who suffer from acne self-manage their condition and do not consult with healthcare professionals.12,16
The Algorithm
Skincare and complementary procedures
The first section of the algorithm addresses skin care, sunscreen, and complementary procedures. Various topical acne treatments have been associated with adverse events such as skin dryness, erythema, scaling, stinging, burning, and pruritus.12-16,25,26,28
As an adjunct to acne treatment, skin care may reduce dryness or irritation, particularly important in SOC patients with acne.16 Skin xerosis may be more visible in richly pigmented skin, impacting QoL.16 Xerosis can also increase the irritation potential of topical therapy, which could lead to iatrogenic PIH.
Various guidelines and algorithms for prevention, treatment, and maintenance recommend nonprescription acne products and skin care as adjuncts to medical acne treatment and maintenance.27,29-38 Guidelines from the US and Europe do not include specific considerations for SOC patients.29-31 Canadian acne guidelines recommend considering skin type and tolerance and applying creams and lotions for sensitive skin versus gels that may be more suited for oily skin.32 The Japanese acne guidelines recommend preventing skin irritation and carefully choosing lowâ€Âirritant and non-comedogenic products
