Dr. Andrew Alexis discusses how acne and rosacea differ in darker skin types, including how to optimally manage both.
Andrew Alexis, MD, MPH, Professor of Clinical Dermatology, Weill Cornell Medical College, New York City
“Acne is among the leading skin disorders for which patients with skin of color see a dermatologist. There are data that show that acne is actually the number one diagnosis among African Americans, Asians, and Hispanic or Latino populations,” said Dr. Andrew Alexis, MD, who presented “Managing Acne and Rosacea in Patients with Skin of Color,” during the Controversies in Acne and Rosacea session at the American Academy of Dermatology (AAD) Annual Meeting 2023 in New Orleans.
One of the clearest differences between acne in darker skin versus lighter skin phototypes is a tendency for richly pigmented patients to develop post inflammatory hyperpigmentation, said Dr. Alexis.
“This post inflammatory hyperpigmentation is often the driving force for a patient with skin of color to even seek treatment for acne. A study we published a number of years ago showed that approximately 42% of nonwhite women with acne reported that post inflammatory hyperpigmentation (PIH) clearance was the most important aspect of their treatment,1 which emphasizes the need to treat both the acne and the hyperpigmentation in this scenario.”
According to Dr. Alexis, it’s important for dermatologists to emphasize to these patients that the treatment goals are clearance of the papules, pustules, and comedones, as well as discoloration, and to include realistic timelines and committment to treating both issues to complete clearance, said Dr. Alexis.
“For treatment of the acne, we might give the patient 3 to 4 months to see significant clearance. But the clearance for the pigmentation we might need a longer period of time—6 months, 8 months sometimes.”
Treatment Options
Topical retinoids are a convenient foundation for treating acne in skin of color, said Dr. Alexis.
“… we can leverage [their] effect on hyperpigmentation. It has been shown for many years that retinoids can improve hyperpigmentation, including in the landmark study from decades ago using tretinoin cream. More recent experience has shown improvements in hyperpigmentation with newer retinoids. One of the newer retinoids, a fourth generation topical retinoid, trifarotene (Aklief, Galderma), is undergoing a phase 4 study as a treatment for post inflammatory hyperpigmentation. We look forward to seeing data on that in the future.”
Adjunctive treatment options include superficial chemical peels containing salicylic acid or glycolic acid in low concentrations or a Jessner’s peel. These can further improve hyperpigmentation, said Dr. Alexis.
“It has been shown that one concept that is very important to consider in acne patients with skin of color is that there is not only clinical inflammation that you can see but also subclinical inflammation.”
Dr. Alexis cited an early landmark study by Halder et al., which found that facial biopsies of acne in African American female subjects demonstrated marked inflammation histopathologically, even in “non-inflammatory lesions,” such as comedones.2
“When it comes to treatment, we want to put together a well-rounded therapeutic regimen that addresses the multiple pathogenic factors of acne and effectively controls the inflammation clinically and sub-clinically. There are many ways to do that.”
A more recent addition to the armamentarium is using a medication that targets the sebaceous gland, said Dr. Alexis.
“In the recent past, we’ve seen the approval of a topical antiandrogen drug called clascoterone (Winlevi, Sun Pharmaceutical) which inhibits androgen receptors on the sebaceous gland resulting in reduction in inflammatory cytokines and improvements in acne.”
Another option is to use devices, he said.
“There are two devices that have been developed that target the sebaceous gland. The wavelength of these lasers that target the sebaceous gland is 1726 nm. We’re seeing so far with the data that are available that patients with skin of color can be treated safely with these modalities, which are agnostic of skin pigmentation.”
If the patient’s acne is moderate to severe, the treating dermatologist should have a low threshold for oral therapy. This includes narrow spectrum oral tetracycline antibiotics, like sarecycline and oral isotretinoin, said Dr. Alexis.
“Oral isotretinoin is largely underutilized in patients of color. Unfortunately, there have been disparities reported in a number of articles, including an article by John Barbieri in JAMA Dermatology, which showed that non-Hispanic Blacks are less likely to receive a prescription for isotretinoin than white patients.”3
Similar disparities exist in the use of oral antibiotics and spironolactone in skin of color patients, said Dr. Alexis.
“It’s important not to underutilize oral therapies when they’re warranted in patients with moderate to severe acne, especially when one considers the sequelae of hyperpigmentation and even hypertrophic scars and keloidal scarring, particularly when acne is on the trunk.”
Rosacea
There are interesting clinical features of rosacea in skin of color—most notably erythema may be more subtle in very richly pigmented skin, said Dr. Alexis.
“One has to keep an open mind to the diagnosis of rosacea whenever presented with a patient who has acneiform papules in the central part of the face with concomitant symptoms of burning, stinging and sensitivities to many topical agents. Self-reported very sensitive skin is often a common finding among rosacea patients. Patients might describe a sense of warmth to describe the flushing sensation in the central face.”
Dermatologists should look carefully to see if there’s an absence of comedones to differentiate acne vulgaris from rosacea, which is important in the overall management, he said.
“There are reports that show rosacea does affect individuals with the whole spectrum of skin phototypes and can certainly affect patients with skin of color; however, this is very much underreported and underrecognized.”
There are no significant variations in treatment of rosacea in skin of color versus lighter skin phototypes with the exception of using lasers and energy-based devices, said Dr. Alexis.
“Devices, such as pulsed dye laser and intense pulse light, would be limited to lighter skin phototypes and may not be suitable for skin types 5 and 6. However, other modalities such as the microsecond pulse 1064 Nd:YAG can be used as a laser light-based technology for treatment of rosacea as an alternative or adjunct to medical therapy.”
References:
- Callender VD, Baldwin H, Cook-Bolden FE, et al. Effects of Topical Retinoids on Acne and Post-inflammatory Hyperpigmentation in Patients with Skin of Color: A Clinical Review and Implications for Practice. Am J Clin Dermatol. 2022 Jan;23(1):69-81. doi: 10.1007/s40257-021-00643-2. Epub 2021 Nov 9. PMID: 34751927; PMCID: PMC8776661.
- Halder RM, Holmes YC, Bridgeman-Shah S, et al. A clinicohistopathologic study of acne vulgaris in black females (abstract). J Invest Dermatol. 1996;106:888.
- Barbieri JS, Shin DB, Wang S, et al. Association of Race/Ethnicity and Sex With Differences in Health Care Use and Treatment for Acne. JAMA Dermatol. 2020;156(3):312-319. doi:10.1001/jamadermatol.2019.4818
Disclosures: Dr. Alexis has ties, including advisory board, consulting, and research ties, to AbbVie, Aerolase, Allergan, Almirall, Amgen, Arcutis Biotherapeutics, Arcutis, Inc., Bausch Health, Beiersdorf, Bristol-Myers Squibb, Cara Therapeutics, Castle Biosciences, Covington & Burling LLP, Cutera, Dermavant Sciences, Eli Lilly, EPI Health, Galderma Laboratories, Janssen Pharmaceuticals, L’Oreal USA, Leo Pharma Novartis, Pfizer, Regeneron, Sanofi Genzyme, Sanofi/Regeneron, Sanova Works, Sol-Gel Technologies, UCB, and VYNE Therapeutics.