Dermatologic Therapy, Vol. 20, 2007, 122127
, 2007
Printed in the United States All rights reserved
Acne vulgaris in richly pigmented
Blackwell Publishing Inc
patients
Introduction
Acne vulgaris is one of the most common reasons
for dermatology visits. Because this is a disorder
of hair follicles, which may have some innate
ethnic differences, we asked our experts to describe
their preferences for treating the primary disease
as well as its sequela.
Question
Are there any differences between the clinical pre-
sentations of acne vulgaris in richly pigmented
patients? If so, what are they? (14)
Response
Dr. Quarles: Exclusive of the scarring, I dont think
there is much inter-ethnic difference in the clinical
presentation of acne. Richly pigmented patients
with even a few cysts frequently present with
postinflammatory hyperpigmented macules as well
as hypertrophic papular scarring predominantly
on the nose and chin. In patients with concomitant
sensitive skin, eczema, and/or seborrheic dermatitis,
the dermatologist must be careful when choosing
acne therapy taking into consideration that any
irritant could increase the risk of potential of
postinflammatory hyperpigmentation. Patients not
infrequently blame therapy for these dark spots.
Once the acne is controlled, the real work of
correcting post inflammatory hyperpigmentation
begins.
Dr. Johnson: In my experience, the only clinical
difference of significance is the often-missed
steroid-induced acneiform eruption that is pre-
valent in women born in West Africa or West India
who are using fading creams, which contain
steroids as unlabeled ingredients.
Dr. Badreshia: I think that the prevalence of
nodulocystic acne is lower in more fair-skinned
individuals. Pomade acne from oily products
used to moisturize hair in black patients is more
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DERMATOLOGIC THERAPY
ISSN 1396-0296
common in this patient group. The majority, if not
all, of my patients of color are most distressed
about the postinflammatory hyperpigmentation
(that they call scars) than the active acne
lesions. Scarring with keloid formation following
acne is more prevalent, especially on the chest,
back, and mandible.
Patients should be educated about skin care and
the use of appropriate oil-free noncomedogenic
skin, and hair care products. Gentle care (avoidance
of trauma) of their skin is important in preventing
progression of postinflammatory hyperpigmenta-
tion. My experience in treating South Asian skin
makes this point clearly. These patients tend to
over-wash, over-treat, and over-scrub based on the
belief that acne is caused by poor hygiene. Similarly,
patient perception that diet plays a significant
role in any skin condition, including acne, is not
uncommon in the South Asian population, as part
of their belief in holistic and complementary medi-
cine. In my experience, South Asians are less likely
to take oral medications as a result of these beliefs.
Dr. Vause: The primary difference is in the pre-
sence of inflammatory papular lesions on the face
and torso. Our ethnic patients are more often
distressed by the associated hyperpigmentation
than the active acne.
Dr. Brauner: No and yes, the pathophysiology of
acne is the same in all ethnic groups. Hyper-
pigmentation is more often present even in mild
acne in darkly pigmented patients. In my experi-
ence, forehead acne in deeply pigmented patients
is more common secondary to using greasy scalp
emollients or moisturizing shampoos and rinses.
Dr. Breadon: My experience with treating acne in
patients of color largely involves addressing the
patients concerns regarding the secondary and
prolonged dyschromia (generally hyperpigmenta-
tion) caused by their acne lesions. I take this
opportunity to educate the patient that manipula-
tion of their lesions can cause the pigmentation
to worsen and persist longer. The pigmentary

changes are far more disconcerting to these patients
than the active acne lesions. Unfortunately, the
dyschromia lasts so much longer than the original
acne lesions, even with intervention. This mottled,
leopard-like hyperpigmentation is cosmetically
unacceptable to patients.
Dr. Swinehart: Patients with pigmented skin and
acne vulgaris tend to develop postinflammatory
hyperpigmentation. This problem can be treated
with dry ice cryotherapy, comedone extraction,
and the use of tretinoin cream to gradually fade
the pigmentation.
Question
How do you treat richly pigmented patients who
present with many (> 50) open and closed come-
dones, papules, and pustules affecting the facial skin?
Response
Dr. Quarles: I begin therapy by having patients
apply the least irritating topical retinoid at night.
Glycolic acid cleansers tend to be less irritating
than salicylic acid cleansers. In some patients
with sensitive skin, even very mild cleansers, such
as Cetaphil, may cause irritation. Clindamycin
solution or foam can be applied twice daily to
inflammatory lesions. Combination benzoyl per-
oxide 5%/clindamycin creams are well tolerated
when used daily. Most patients with very oily skin
tolerate combinations of retinoids at night and
benzoyl peroxide in the morning. Systemic anti-
biotics, usually tetracycline 500 mg twice daily as
needed, can be helpful.
Dr. Johnson: Comedones respond best to retinoids.
Azelex serves as an alternative hypopigment-
ing and anti-acne agent. Alternatively, a topical
retinoid or retinoid derivative could be beneficial
if the patient has very oily skin.
Dr. Badreshia: I begin with a discussion of past
treatments, hormonal flaring, as well as their
psychological scarring from postinflammatory
hyperpigmentation. If the patient has acne resistant
to several prescription formulations, I go straight
to isotretinoin. If they have not tried prescription
anti-acne drugs I use the following regimen:
am benzoyl peroxide 2.55% wash followed by
combination benzoyl peroxide antibiotic and a
noncomedogenic moisturizer in addition to doxy-
cycline 100 mg orally, pm I suggest a 5% glycolic
acid/2% salicylic acid wash followed by a topical
Introduction
retinoid (lower concentrations in cream formula-
tions for dry, sensitive skin) a noncomedogenic
moisturizer, and doxycycline 100 mg.
If the acne is cyclic and hormonal (evidence of
excess androgen production including irregular
menses, unwanted hair growth/hirsutism, deepen-
ing voice, and/or resistant acne) after screening
these patients for polycystic ovary syndrome
(PCOS) or ovarian tumors by checking free and
total testosterone, DHEA, LH/FSH levels, I would
consider oral contraceptives.
Education on the pathogenesis of acne and the
importance of following a comprehensive regimen
(explaining all of the prescribed products) including
gentle skin care and use of oil-free cosmetics is
essential to compliance.
At follow-up in 812 weeks, if they have been
compliant and have noted some improvement, I
consider changing their antibiotic and introduc-
ing adjunctive treatments including salicylic peels
and/or microdermabrasion in an attempt to help
their acne and postinflammatory hyperpigmenta-
tion. Alternatively, a series of light-based therapies
(blue light 2/weeks 8 treatments) or photody-
namic therapy sessions (four treatments every 24
weeks) can be beneficial. I introduce the Accutane
option if the patients disease remains refractory
after two courses of antibiotics in addition to the
above regimen. For postinflammatory hyperpig-
mentation, early use of skin lighteners is important.
I allow the patient to guide me as to how aggres-
sive I should be. Once the acne is under control, it
is crucial to treat postinflammatory hyperpigmen-
tation; this is usually their chief complaint.
Dr. Lupo: I do not perform any manipulation
(including extractions) until the patient has been
using retinoids for at least 24 weeks.
Dr. Vause: I begin with an acne face wash twice
daily, benzoyl peroxide/clindamycin combination,
azeleic acid, and sunblock plus a moisturizer as
needed. Later, Ill add a retinoid at bedtime. We
use oral antibiotics less often than in the past. It is
important to control the inflammation so well try
nicotinamide. Concurrently, gentle, yet progressively
stronger chemexfoliation and/or microdermabra-
sion augment the results.
Dr. Brauner: I dont treat them any differently
than more lightly pigmented patients: acne
cleansers, benzoyl peroxide, topical retinoids, and
oral minocycline or doxycycline to start. I also
perform acne surgery, comedone extraction as
necessary.
123
Introduction
FIG. 1. (a) Hispanic male with acne vulgaris. (b) African American female with post inflammatory hyperpigmentation
secondary to acne. (c) Hispanic female keloids secondary to acne vulgaris.
Dr. Breadon: My usual regimen for the acne of
patients of color starts with a nightly retinoid
(tretinoin for the open and closed comedones). If
the patient has oily skin, I include an at-home
mask, such as sulfacetamide or an amino fruit acid
exfoliating mask. Patients with numerous (> 20)
pustules and/or nodules are usually started on an
oral tetracycline derivative, which is tapered after
the patient becomes lesion-free for two consecu-
tive months. I like to initiate treatment for the real
reason the patient came to the office, the fading of
their hyperpigmented macules. Therefore, patients
are started on one of the newer combination of 4%
hydroquinone/retinoid/corticosteroid preparations
and instructed to apply nightly to the centers of
the dark macules, following nightly application of
the topical retinoid.
Question
What is your approach to the treatment of similar
lesions affecting the anterior and posterior chest?
124
Response
Dr. Quarles: In my practice, the treatment for
chest and back acne is the same as for disease
affecting the face.
Dr. Johnson: I dont think the color of the skin
matters in distinguishing management of chest
or back acne but, if the patient is hairy, I pre-
scribe antibiotic foam (they are, however, very
expensive).
Dr. Badreshia: I prescribe benzoyl peroxide wash
daily followed by topical antimicrobials in com-
bination with oral antibiotics like doxycycline for
812 weeks. The resulting postinflammatory hyper-
pigmentation can be treated with spot superficial
chemical peels, skin lighteners, or reassurance
depending on the patients level of psychological
scarring. Deeper chemical peels should be avoided
as the jawline, chest, and back have a higher
propensity to develop scars. I consider Accutane

for acne that is resistant to two different antibiotics.
Education is also important regarding proper
skin care and avoidance of excessive perspiring
from exercise/sports related activities or occlusive
sports gear when possible.
Dr. Vause: We treat the torso similar with the face
but in a more aggressive manner.
Dr. Breadon: Treatment of the chest and back
areas with similar lesions consists of the same
regimen I use for facial disease.
Question
Which therapies have you used for the post-
inflammatory hyperpigmented macules in this
patient group?
Response
Dr. Quarles: Four percent hydroquinone is the
work horse. I prefer it in combination with a
retinoid/corticosteroid, which is applied nightly.
On occasion, Ill have 6% hydroquinone com-
pounded with desonide lotion 0.05% and ascorbic
acid, which is applied to the dark spots in the
morning. Addition of ascorbic acid minimizes
oxidation of hydroquinone. The addition of salicylic
acid chemical peels and/or microdermabrasion
and glycolic cleansers is very helpful.
Dr. Brody: I like hydroquinone bleaches, includ-
ing Bleach Eze.
Dr. Johnson: Early postinflammatory hyper-
pigmentation is treated with: chemical peels,
microdermabrasion, and hydroquinones (as long
as the latter remains available). Azelex helps
when the pigmentation is secondary to acne. Its
very important to instruct patients not to aggra-
vate the problem by over-washing/scrubbing with
beads, particles, loofas, or cleansing cloths. Richly
pigmented individuals may need to be reminded
that sunscreens should be applied to all hyper-
pigmented areas before each sun exposure.
Dr. Badreshia: My aggressiveness is determined
by the patients level of psychological scarring.
I advise patience as the lightening agents will
help but the fading may take weeks to months.
For early localized disease, I give the patient the
option of using an over-the-counter hydroquinone
or a prescription-strength product. Postinflam-
matory hyperpigmentation.
Introduction
If the lesions are diffuse, I use the more aggres-
sive prescription combination hydroquinone; spot
chemical peels (every 2 weeks for 5 weeks) in
addition to glycolic peels. The patients main-
tenance regimen with evening retinoic acid will
help increase superficial exfoliation and melanin
dispersion. Azelaic acid can also be used as it
inhibits melanin synthesis.
Used in combination, the synergy between
over-the-counter products, prescription products,
and chemical peels are more effective. Daily
broad-spectrum sunscreen use with micronized
titanium or zinc oxide is cosmetically pleasing
and mandatory to prevent worsening. Cosmetic
camouflage is important to many of my patients
during the healing stages.
Dr. Lupo: In general, I find that richly pigmented
skin has more dermal pigment, especially after
picking and damaging the pilosebaceous unit. The
deeper the pigment, the darker it appears and the
harder it is to get it to fade. I believe strongly in
topical and oral retinoids. Isotretinoin is a favorite
because I think it helps the postinflammatory
hyperpigmentation the fastest. I use hydroquinone
only after the active acne is under control and
usually I do not need it unless the patient is very
impatient. I use microdermabrasion and salicylic
acid peels. Laser can be great for acne, scars,
and postinflammatory hyperpigmentation. Its
important to avoid irritation, which could
increase pigmentation.
Dr. Vause: We explain that treatment of post-
inflammatory hyperpigmentation requires patience
and compliance. We like to avoid the spotted
halos often seen with higher concentrations of
hydroquinones. We are able to achieve a more
uniform correction (the goal) with combinations
of chemexfoliation with salicylic, glycolic, and
trichloroacetic acids plus home treatments with
kojic, lactic, and azeleic acids. Finally, sunblock,
sunblock, and sunblock!
Dr. Brauner: I prescribe hydroquinone solution
first as initial therapy. If the response is less than
ideal, I switch the patient to one of the variations
on Dr. Kligmans formula. For minimal acne and
minimal dyschromia I may use only azelaic acid.
Dr. Breadon: In-office series of mild lipophilic
chemical peels such as Jessners solution and the
beta-hydroxy acid peels are helpful in exfoliating
the superficial pigmentation, as well as penetrat-
ing the acne lesions. These are applied every 24
125
Introduction
weeks, according to the patients needs, in con-
junction with the acne regimen. Milder acids, such
as the amino fruit acids, or lower concentrations
of beta-hydroxy acids can be applied to the chest
and back, at less frequent intervals.
Question
When do you consider using chemical peels as part
of your anti-acne armamentarium in richly pig-
mented patients?
Response
Dr. Badreshia: After at least 4 weeks of acne regi-
men and giving adequate time to adjust to these
medicines I described consider, I give patients the
option of salicylic acid or glycolic acid (every 2
4 weeks) to improve active acne as well as any
residual postinflammatory hyperpigmentation
peels. The key is to perform staged peels starting
with safe superficial peels at low concentrations
and individualized to skin type/color. Spot peeling
is another great approach to improve postinflam-
matory hyperpigmentation. I am more cautious of
using glycolic acid peels in skin types VVI because
of the higher propensity to hyperpigment from
irritant contact dermatitis. A test spot is preformed.
Glycolic acid is a humectant and works best for
dry skin, whereas salicylic acid is lipophilic and
works best for oily, acne-prone skin. After treating
active acne and postinflammatory hyperpigmen-
tation, superficial acne scarring can be improved
with glycolic acid (used in all skin colors) or
Jessners/trichloroacetic acid peel (only in type IV
with test spots done initially). I do not use
medium-depth peels in types VVI.
Dr. Vause: We always employ chemexfoliation
and/or microdermabrasion in the management of
acne and its sequela.
Dr. Brauner: I perform Jessners peels predomi-
nantly for resistant comedones.
Dr. Breadon: In my clinical experience, ice-pick
acne scarring is more common in patients of
color having grades III and IV acne. Treatment of
these scars is difficult in general, but particularly
so when dyschromia from the correction of the
scarring is factored in. Application of 100%
trichloroacetic acid into the depth of the scar
only is achieved by applying perilesional petrola-
tum to the surrounding normal skin. Healing from
this intentional wound takes approximately 23
126
weeks. Hyper or hypopigmentaion can be treated
with intralesional hydroquinone.
Dr. Swinehart: Chemical peels are more effective
for wrinkles and, in my opinion, have a limited
benefit in acne pigmentation. However, dry-ice
cryotherapy has been used for many decades to
treat this problem.
Question
In your experience, are there differences in the
development of acne scars (or types of acne scars)
in these patients? If so, how do you treat them?
Response
Dr. Quarles: Hypertrophic papular scarring on the
nose and chin, similar to rhinophyma, is not rare
in this patient group. If recognized during the
early inflammatory stage then intralesional triam-
cinolone 5 mg/cc is helpful. Once the scarring has
occurred, I find very little if anything will reduce
the scarring. If the patient does not keloid, then
perhaps dermabrasion will be helpful; however,
proceed with caution!
Dr. Brody: Postinflammatory hyperpigmentation
is not an acne scar.
Dr. Johnson: I think scarring isnt that different
except that it is riskier to use some modalities
such as fractional laser, dermabrasion, and deeper
peels in pigmented patients.
Dr. Badreshia: Patients whose chief complaint is
to treat acne scars are usually concerned about
postinflammatory hyperpigmentation. In superfi-
cial acne scarring, I perform a series of superficial
chemical peels and microdermabrasion. Although
dermabrasion and laser treatments have good
results, significant adverse effects limit their use.
The newer nonablative treatments may be associ-
ated with less side effects but are also less effec-
tive. The literature is scant with short follow-up
times to make any definitive conclusions with
these new modalities. The 1450-nm diode laser
over four to six treatment sessions and fractional
resurfacing to promote collagen remodeling
has been attempted in skin of color with some
success.
Dr. Brauner: I dont think there are any differences
in scarring the difference is in dyschromia, which
is as or more visible than a scar contour shadow.

Dr. Breadon: Punch grafting, followed by regional
diamond-fraise dermabrasion, or ultrapulsed car-
bon dioxide laser resurfacing every 46 weeks after
skin grafting gives excellent results. Again, possible
dyschromia postresurfacing is a possibility but
in my experience can be resolved nicely with the
new hydroquinone preparations.
Dr. Swinehart: Acne scarring can, of course, be
treated with punch grafting, punch elevation,
dermal grafting, and wire brush dermabrasion.
Summary
Our experts feel that the most significant differences
in acne vulgaris in richly pigmented patients are
(1) the development of postacne hyperpigmenta-
tion and (2) pomade acne, which occurs secondary
to applying very oily hair preparations to the scalp.
This is the case whether the disease is confined
to the face or additionally involves the chest. A
combination of retinoids, benzoyl peroxide with or
without topical antibiotics varying the presence of
pustular disease seems to be an effective regimen.
Irritating topicals should be avoided as they
Introduction
can precipitate or exacerbate hyperpigmentation
(creams and lotions are preferred to gels and solu-
tions). Hyperpigmentation, the most distressing
aspect of disorder responds to: kojic and lactic
acids, hydroquinone, microdermabrasion, super-
ficial chemical peels (beta-hydroxyacids for oily
skin, alpha-hydroxy acids for dry skin), and Jessners.
Nodulocystic acne may be less prevalent in this
patient group. Scarring in these patients can be
treated with dermabrasion and grafting. In South
Asian patients who may be using alternative skin
products, it is important to get a good medical
history. The rare keloid responds to intralesional
or topical steroids.
References
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2. Callender VD. Considerations for treating acne in ethnic
skin. Cutis 2005: 76 (2 Suppl.): 1923.
3. Mosam A, Vawda NB, Gordhan AH, Nkwanyana N,
Aboobaker J. Quality of life issues for South Africans with
acne vulgaris. Clin Exp Dermatol 2005: 30: 6 9.
4. Alakloby OM. Pattern of skin diseases in Eastern Saudi.
Arabia Saudi Med J 2005: 26: 16071610.
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