At the 2021 Skin of Color Update virtual conference, Dr. Alexis highlighted key considerations when treating acne in patients with darker skin phototypes in addition to current and emerging strategies to improve treatment outcomes.
When treating acne patients with skin of color, it is important to consider the concomitant issue of post inflammatory hyperpigmentation (PIH). This PIH may be the driving force for the patient to come in for their visit and is a key treatment goal! Dr. Alexis shared that it is important to address this by incorporating agents that treat acne and PIH concurrently.
Leveraging the effects of retinoids is key. While retinoids are well known for their beneficial effects in acne, retinoids can also play a key role in the treatment of PIH through downregulation of tyrosinase and removal of excess epidermal melanin via exfoliation. Studies have shown improvement in acne and PIH with tretinoin 0.1% cream, adapalene, and indirect benefit has been seen with adapalene in combination with benzoyl peroxide.
Beyond retinoids, azelaic acid should be considered as an adjunct. While 20% is the approved strength for acne, dermatologists often use the 15% foam or gel for acne as well. In Dr. Alexis’ experience, he uses azelaic acid as an “add-on” as retinoids should be the mainstay of treatment. In a study of 20 patients with acne and PIH, 31% of patients who used azelaic acid 15% gel twice daily had no PIH at week 16.1
Dr. Alexis shared that he is frequently asked if hydroquinone is useful in treating PIH from acne. While he uses hydroquinone for many other causes of PIH, hydroquinone is difficult to use in patients with PIH from acne. The hyperpigmentation itself leads to smaller macules which are difficult to spot treat while avoiding lightening of non lesional skin. Dr. Alexis prefers full face treatments such as retinoids, azelaic acid, and chemical peels in addition to other adjunctive procedures.
Dr. Alexis shared that salicylic acid peels can be useful in both the treatment of acne and PIH, highlighting a case of significant improvement after 5 weeks of bi-weekly 30% salicylic acid peels.2 Glycolic acid peels are also helpful – a study of 30 South Asian patients with facial PIH evaluated treatment with topical bleaching agents alone vs topical bleaching agents combined with serial glycolic acid peels. Greater improvement in PIH was noted in patients treated with both topicals and peels vs topicals alone.3
The key to peels in skin of color is safety! It is imperative to avoid excessive injury which could lead to further PIH. Superficial peeling agents such as 20-30% salicylic acid, 30-50% glycolic acid, Jessner’s or modified Jessner’s peels are considered safe in this cohort. Dr. Alexis recommends stopping retinoids 1 week prior to peel, and to perform peels at 4-6 week intervals.
Beyond peels, there is emerging evidence in the use of lasers to treat PIH. Dr. Alexis highlights a recent retrospective review of patients with darker skin types and PIH improving with nonablative fractional laser (1927 nm).4 Dr. Alexis also shared a case of significant improvement of acne and PIH in one of his patients treated with just one session of 1927nm diode laser with Azelaic acid 15% foam.
Key take away – tell patients to hang in there! Treatment is a journey and may take several months at least. Give them a realistic roadmap and emphasize the need to stay on course with their treatment to “get the reward.”
Treat Early and Address Inflammation
Early and effective therapy is key in reducing long term sequelae. Treating acne comprehensively is important, as is treating subclinical inflammation. In a study of 30 African-American female patients with acne, even in clinically non inflamed lesions such as comedones, there was histologic evidence of inflammation. 5 Other studies have also identified sub-clinical histologic inflammation in non-lesional skin.6
How do we address subclinical inflammation? Thankfully, many of the treatments we use for acne have anti-inflammatory effects. Retinoids and antibiotics such as doxycycline, minocycline and sarecycline have anti-inflammatory effects. Benzoyl peroxide can decrease inflammation through inhibiting C. acnes. Topical dapsone and azelaic acid also have anti-inflammatory properties. Interestingly, anti-androgen therapies such as spironolactone and clascoterone also indirectly reduce inflammatory mediators. It is hypothesized that androgen receptor inhibition may reduce cytokine production by sebocytes.7 In in-vitro studies, the percent inhibition of inflammatory cytokines such as IL-8, IL-6 and IL-1B was greater with clascoterone compared to spironolactone.8
Combination Therapy is Key!
Unfortunately, despite benefits of combination therapy, several studies have shown lower rates of prescribing topical therapies and oral isotretinoin in Black patients in the United States. It is especially important to consider the curbing of long-term development of scarring and hyperpigmentation in patients with darker skin tones. Dr. Alexis shared a case of a patient he treated with Adapalene-benzoyl peroxide gel at night, dapsone gel in the morning, oral doxycycline, spironolactone and intralesional triamcinolone with promising results.
There is a constant balance between efficacy and tolerability, as irritation can lead to further dyspigmentation. Hydrating cleansers, moisturizers, and application of moisturizers pre- or post- prescription therapy can help prevent irritation. Newer formulations such as tretinoin lotion with hyaluronic acid and glycerin have been studied with benefit. If unable to obtain coverage for the newer therapies, it is possible to leverage adjunctive skin care to maximize tolerability.
Take home messages – align treatment endpoints with patient goals and provide realistic timelines. Initiate efficacious combination therapy early – do not undertreat! Maximize tolerability – adjunctive skin care, careful selection of vehicle/actives, and dosing regimens are important. Doing all of the above can lead to wonderful outcomes that align with patients’ goals.
- Kircik LH. Efficacy and safety of azelaic acid (AzA) gel 15% in the treatment of post-inflammatory hyperpigmentation and acne: a 16-week, baseline-controlled study. J Drugs Dermatol. 2011;10(6):586-590.
- Lee HS, Kim IH. Salicylic acid peels for the treatment of acne vulgaris in Asian patients. Dermatol Surg. 2003;29(12):1196-1199. doi:10.1111/j.1524-4725.2003.29384.x
- Sarkar R, Parmar NV, Kapoor S. Treatment of Postinflammatory Hyperpigmentation With a Combination of Glycolic Acid Peels and a Topical Regimen in Dark-Skinned Patients: A Comparative Study. Dermatol Surg. 2017;43(4):566-573. doi:10.1097/DSS.0000000000001007
- Bae YC, Rettig S, Weiss E, Bernstein L, Geronemus R. Treatment of Post-Inflammatory Hyperpigmentation in Patients With Darker Skin Types Using a Low Energy 1,927 nm Non-Ablative Fractional Laser: A Retrospective Photographic Review Analysis. Lasers Surg Med. 2020;52(1):7-12. doi:10.1002/lsm.23173
- Halder RM et al. A clinicohistopathological study of acne vulgaris in black females. J Invest Dermatol 1996; 106:888
- Jeremy AH, Holland DB, Roberts SG, Thomson KF, Cunliffe WJ. Inflammatory events are involved in acne lesion initiation. J Invest Dermatol. 2003;121(1):20-27. doi:10.1046/j.1523-1747.2003.12321.x
- Hebert A, Thiboutot D, Stein Gold L, et al. Efficacy and Safety of Topical Clascoterone Cream, 1%, for Treatment in Patients With Facial Acne: Two Phase 3 Randomized Clinical Trials. JAMA Dermatol. 2020;156(6):621-630. doi:1001/jamadermatol.2020.0465
- Rosette C, Agan FJ, Mazzetti A, Moro L, Gerloni M. Cortexolone 17α-propionate (Clascoterone) Is a Novel Androgen Receptor Antagonist that Inhibits Production of Lipids and Inflammatory Cytokines from Sebocytes In Vitro. J Drugs Dermatol. 2019;18(5):412-418.
- Elbuluk N, Grimes P, Chien A, Hamzavi I, Alexis A, Taylor S, Gonzalez N, Weiss J, Desai SR, Kang S. The Pathogenesis and Management of Acne-Induced Post-inflammatory Hyperpigmentation. Am J Clin Dermatol. 2021 Nov;22(6):829-836. doi: 10.1007/s40257-021-00633-4. Epub 2021 Sep 1. PMID: 34468934.
This information was presented by Dr. Andrew Alexis at the 2021 Skin of Color Update virtual conference held on September 10-12-2021. The above highlights from his lecture were written and compiled by Dr. Blair Allais.
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