Effective acne management in skin of color requires a dual approach: treating the active lesions while simultaneously addressing post-inflammatory hyperpigmentation (PIH). Drawing from an expert, case-based session led by Dr. Hilary Baldwin and Dr. Andrew Alexis at the Skin of Color Update, this summary breaks down their practical strategies for managing this overlapping clinical challenge.
The faculty opened the session with a case involving a 14-year-old girl who presented with mild-to-moderate acne but severe pigmentary sequelae on the nose. Despite improvement in acne, treatment failed to meet the patient’s primary concern: post-inflammatory hyperpigmentation. Overly aggressive topical therapy also triggered irritation and iatrogenic hyperpigmentation, while the compulsive skin-picking behavior went unaddressed. Dr. Baldwin noted that this experience reshaped her approach to acne care, underscoring that focusing solely on clearing lesions is not enough when pigmentation is the key driver of distress.
Why Pigment Deserves Equal Attention in Acne Management
PIH disproportionately affects patients with darker skin phototypes. Survey data from acne patients show that noticeable PIH occurs in 65.3% of Black patients, 52.7% of Hispanic patients, and 47.4% of Asian patients and may persist for 6 to 12 months or longer. For many individuals with skin of color, pigmentary change, not the acne itself, is the primary concern and determinant of perceived treatment success.
Moreover, acne lesions typically improve much faster than pigmentation. Delaying targeted treatment for PIH can prolong recovery, diminish patient satisfaction, and contribute to early discontinuation.
Initiating Dual-Targeted Therapy: Acne and PIH Together
Drs. Baldwin and Alexis emphasized that topical therapies should be selected for their ability to address both inflammation and pigment simultaneously. Retinoids (tazarotene, adapalene, tretinoin, trifarotene) remain foundational due to their effects on keratinocyte turnover, inflammation, and melanin pathways. Azelaic acid contributes antioxidant, anti-inflammatory, and tyrosinase-inhibiting benefits, while salicylic acid adds keratolytic and sebum-reducing activity.
Because irritation itself can worsen hyperpigmentation, moisturization and barrier support are essential. Thiamidol, a human tyrosinase inhibitor and Melasyl, a tyrosine-precursor inhibitor, target melanogenesis without producing the “halo effect” sometimes associated with hydroquinone.
Behavioral contributors such as skin-picking must be identified early. Referral to mental health support may be appropriate when compulsive behaviors drive persistent trauma to the skin.
Evidence Update: Trifarotene for Pigmentary Sequelae and truncal acnea
A Phase IV study presented by Dr. Alexis directly evaluated trifarotene 0.005% cream in patients with skin of color. Significant improvements were demonstrated in the size, number, and intensity of hyperpigmented macules over 24 weeks compared with a vehicle, supporting its role as a strategic therapy when PIH is a dominant concern. Tazarotene 0.045% lotion was also noted as a well-tolerated option for pigmentation in sensitive skin.
For truncal involvement, where acne may behave differently, trifarotene remains the only topical retinoid with dedicated clinical data. Emerging support exists for clascoterone and sarecycline in truncal disease as well
Adjunctive Procedures and Antibiotic Use
Chemical peels, particularly salicylic acid 20–30% can be performed every 4–6 weeks to accelerate PIH clearance. The panel recommended pausing retinoids for seven days prior to peeling to reduce PIH risk from irritation.
When systemic therapy is needed, Dr. Alexis aims to discontinue oral antibiotics by 12 weeks and transition patients to topical maintenance regimens. Clindamycin monotherapy should be avoided due to resistance concerns.
Take Home Points
For patients with skin of color, successful acne management requires early, proactive attention to hyperpigmentation. Using melanin-conscious therapies, protecting the skin barrier, minimizing irritation, and addressing behavioral components can lead to more complete clinical improvement. A treatment plan that aligns with patient priorities from the start supports adherence, enhances outcomes, and builds trust.
References
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- Alexis AF, et al. Importance of treating acne sequelae in skin of color: 6-month phase IV study of trifarotene 0.005% cream. Int J Dermatol. 2024;63(6):806-815.
- Callender VD, et al. Postinflammatory hyperpigmentation in acne patients with skin of color. J Clin Aesthet Dermatol. 2011;4(7):20-31.
- Roggencamp D, et al. Thiamidol as a human tyrosinase inhibitor for hyperpigmentation. J Eur Acad Dermatol Venereol. 2019;33:2085-2091.
This summary was prepared by Dr. Courtney Hanna, Dermatology Resident, who attended the session. The content reflects the resident’s notes and interpretations, may contain errors, and is provided for educational purposes only. It does not constitute official faculty endorsement and should not replace original sources or clinical judgment.
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