Acne vulgaris is a globally prevalent dermatological condition that poses challenges in treating individuals with skin of color. According to Fitzpatrick skin phototypes III-VI, people of African, Asian, Middle Eastern, and Hispanic ethnicity have Skin of Color (SOC). With the additional risk of post-inflammatory hyperpigmentation (PIH) as a consequence of inflammatory acne or its corresponding treatment, managing acne in this subpopulation is highly significant. PIH has a negative impact on self-esteem and quality of life and, thus, continues to be the treatment priority in the patient. 

Acne is treated similarly in patients of all skin types. However, some are more advantageous for individuals with SOC, especially by targeting both active acne lesions and PIH. A review of evidence on acne treatment revealed that treatments contained topical agents, like retinoids and azelaic acid, along with topical antibiotics and benzoyl peroxide. More recent formulations and blended regimens reported to be effective in diminishing lesions are less likely to cause PIH and may treat pre-existing PIH. Use of moisturizer, titrating doses, and patient education are techniques to minimize irritation and enhance compliance. Additionally, systemic therapies, like oral antibiotics, isotretinoin, oral contraceptives, and spironolactone, are deemed effective for refractory acne or more severe cases but clinical studies in SOC are scarce. Chemical peels tend to improve acne and target PIH directly. Overall, based on little evidence, topical and systemic therapies are well tolerated in the SOC population but effectiveness should be balanced with the threat of unfavorable effects. 

Key practice points are:

• Patients with SOC need appropriate regimens, prioritizing targeting inflammatory processes early to prevent PIH, decrease existing PIH, and have minimal treatment-related irritation to prevent causing new PIH.
• Routine moisturizer use can preserve the skin barrier and decrease irritant effects of topical therapies (e.g., retinoids) and prevent the flare-up of inflammatory lesions. Medication adherence may be improved, further enhancing overall outcomes.
• Sun protection, along with sun avoidance and sunscreen application, should be counseled to help prevent the evolution or aggravation of PIH.
• Patient education concerning the application (size, amount, technique) can decrease treatment-related adverse effects and enhance subsequent compliance and consequences.
• Proper use of topical retinoids, topical antibiotics, benzoyl peroxide (BPO), and azelaic acid, will lessen PIH and not exacerbate it further.
• Topical therapy combinations are more efficacious than monotherapy.
• Early aggressive treatments that are tolerable should be used to prevent PIH.
• Consider a lower treatment initiation threshold and start systemic treatment earlier on in patients with SOC since they have a higher risk for hyperpigmentation and keloid scarring.
• Avoid long-term oral antibiotics use, and during short-term use, BPO should be used concomitantly to decrease the risk of developing antibiotic resistance.
• Oral antibiotics combined with a topical retinoid with or without BPO should be employed during an inflammatory acne flare heeded by continued use of the topical retinoid as maintenance in patients with SOC.
• Isotretinoin is beneficial for treating nodulocystic acne, acne resistant to topical treatment or oral antibiotics, and can also improve PIH.
• Currently, three oral contraceptive pills have got approval for the treatment of acne vulgaris by the US Food and Drug Administration; Ortho Tri-Cyclen (norgestimate/ethinyloestradiol), Estrostep (norethindrone acetate/Ethinyl estradiol) and Yaz (drospirenone/Ethinyl estradiol).
• Spironolactone has demonstrated good efficacy in treating acne in adult women and can be used in combination with topical therapies, like retinoids, to prevent or treat PIH.
• Chemical peels have the potential to manage both acne and PIH simultaneously.

Source: Chiang C, Ward M, Gooderham M. Dermatology: how to manage acne in skin of colour. Drugs Context. 2022;11:2021-10-9.