While acne is the most common dermatologic condition across all skin types, its treatment varies significantly from patient to patient. There are many factors that can influence which treatment is the most effective for a patient, including treatment goals and areas of concern. At the GW Advances in Acne Conference, Andrew Alexis, MD, discussed treating acne and postinflammatory hyperpigmentation (PIH) in skin of color (SOC).
“The key is maximizing efficacy and tolerability, while setting resolution of both acne and PIH as the treatment target,” he recommended. He shared his tips for improving both acne and PIH in an interview with The Dermatologist. Dr Alexis is a professor and chair of dermatology at Mount Sinai West and Mount Sinai Morningside, and the director of the Skin of Color Center in New York City.
The Dermatologist: As you mentioned in your presentation, PIH is considered more bothersome by patients with darker phototypes. What are some of the challenges of treating acne and PIH?
Dr Alexis: The key challenges are:
- Treating the underlying acne that caused and can, in turn, cause more PIH if uncontrolled;
- Avoiding irritant dermatitis-induced PIH from the topical regimen being used to treat the acne; and
- Treating the PIH induced by acne.
The first challenge is addressed by designing a comprehensive treatment regimen that targets multiple pathogenic factors. The second challenge is addressed by carefully selecting active ingredients, concentrations, vehicles, and dosing frequency that are appropriate for a given patient from a tolerability standpoint. The third challenge is addressed by leveraging the effects of topical retinoids (on both acne and PIH) and using PIH-directed therapies, such as chemical peels, nonablative fractional lasers, or skin lightening agents when warranted.
The Dermatologist: What other considerations should dermatologists keep in mind when treating patients with darker phototypes and acne?
Dr Alexis: Avoid undertreatment in an effort to minimize risk of sequelae, such as PIH and scarring. Scarring, in particular, can be more challenging to treat in SOC due to the higher risk of pigmentary sequelae from most therapies used to treat acne scarring.
The Dermatologist: What treatment options are available for PIH and scars caused by acne?
Dr Alexis: The following options are effective for PIH or scars caused by acne:
- Topical skin lightening agents (eg, hydroquinone, azelaic acid, over the counter/cosmeceuticals)
- Superficial chemical peels
- Nonablative fractional resurfacing
- Submillisecond 1064nm Nd:YAG laser
The Dermatologist: What additional research is needed to improve the treatment of acne in patients with darker phototypes? What ways can clinical trials improve their recruitment of patients from racial minority groups?
Dr Alexis: Some areas where we need more research include conducting SOC population-specific acne studies to assess the safety, tolerability, and efficacy of therapies, with PIH resolution included as a secondary endpoint. Recruitment of SOC populations can be improved by carefully selecting investigators/clinical trials sites that collectively can enroll a diverse and representative patient population.
The Dermatologist: What key takeaways would you like to leave with dermatologists?
Dr Alexis: The treatment of acne for patients with SOC can be extremely rewarding given the potentially transformative outcomes that can be achieved with a well-rounded regimen. I recommend these takeaways:
- Unless contraindicated, a topical retinoid should be included in the topical regimen for acne treatment in patients with SOC (given the dual benefits on acne and PIH).
- Tolerability can be maximized through adjunctive skin care, as well as selection of prescription acne medications with well-formulated vehicles.
Alexis A. Management considerations for skin of color patients with acne. Presented at: GW Virtual Appraisal of Advances in Acne Conference; July 30, 2020; virtual.