Acne is an equal-opportunity skin disorder. It occurs in people of all races and ethnicities. It has the same causes and follows a similar course in people with all shades of skin. However, there are some differences in the appearance and treatment of acne among different groups. I covers the methods to prevent and treat these distinctive issues as well as suggesting approaches for skin-care in darker skin populations.

Recognizing Diversity

Variations among skin tones all come down to melanin, which is responsible for absorbing sunlight and giving your skin its distinctive color. Melanin is produced in melanocytes (pigment-producing cells).

Everyone has the same number of melanocytes; however, in more darkly pigmented people, these pigment-producing factories create more melanin and are inclined to disperse it more widely in the epidermis.

There are important medical and cosmetic advantages to having dark skin. Darker skin is more resistant to sunburns, skin cancer, and wrinkles. As dark skin ages, the higher melanin content and facial oil cause the skin to age less rapidly than lighter skin.

However, dark skin does have disadvantages when it comes to dealing with acne — dark spots and scars are more likely to appear. Our world is host to great variability in skin color among people of all races. We’re all pretty much the same underneath where it counts, and making generalizations about acne and race or skin color is difficult.

But, the following are some of the features that are more likely to be seen in darker skin types:

• Dark spots are often the number one concern to the person with acne. Check out the next section that talks about how they form and what you can do about them.

• Inflammatory (red) acne lesions tend to be less visible. Lesions appear to be less common in very dark skin because the red color of inflammation is often well hidden by the surrounding darker skin.

• Sensitive skin known as eczema (atopic dermatitis) is more common in Asians, African-Americans, and Hispanics.

• Healing acne lesions tend to produce larger scars in Hispanics, Asians, and particularly African-Americans, as compared to Caucasians. The good news is that people of color are less likely to have severe nodular acne than are Caucasians.

Figuring Out Those Dark Spots!

People with white skin tend to complain about red marks that remain red or purplish in color. These spots are called macules in dermatologese. Like freckles and tattoos, they’re simply color changes of the skin (you can’t feel macules, and if you close your eyes, they don’t exist).

In black skin, those same red spots look much darker, even deep brown or black in color and many shades in between, particularly after they heal.

African-Americans are often more concerned about these dark acne-related macules than they are about the acne itself. The dark spots are known as postinflammatory hyperpigmentation or postinflammatory pigmentation — or PIP for short.

How dark spots are formed

PIP is limited to the sites of previous inflammation. Think of the spots as “footprints,” the aftermath or telltale signs that show where the original injury (inflammatory “battle”) took place. The original insult (and injury) that caused PIP can be a cut, a burn, a rash, or the after-effect from a healing acne lesion.

Often these “footprints” disappear over a period of time, but they always outlast the original inflammatory acne lesions themselves. In fact, they may take many months or even years to fade completely. There are actually two types of PIP.

Both start off when inflammation of the skin, such as acne, stimulates the melanocytes in your epidermis and causes them to step up the manufacturing of melanin.

The production of melanin (melanogenesis) increases in response to the tanning effect of sun, injuries to the skin such as burns, cuts, surgeries, as well as the inflammation caused by acne. The two different types of PIP are:

• Epidermal hypermelanosis: The busy melanocytes respond by handing off their melanin pigment in tiny granules to surrounding keratinocytes, your other epidermal cells. This increased stimulation and transfer of melanin granules results in epidermal hypermelanosis.

Your skin gets darker, but the pigment isn’t deep. The good news is that this type of PIP often responds to topical bleaching creams, which help to accelerate its disappearance. That’s because the majority of the melanin pigment is in the epidermis (the top layer of the skin) which allows it to be treated.

• Dermal melanosis: Dermal melanosis occurs when inflammation disrupts the basal cell layer, causing melanin pigment to be released and subsequently “dropped” more deeply into the dermis where it gets trapped by macrophages (scavenger white cells). This type of PIP is much harder to treat and may never fade away completely.

These spots are not scars, and some, if not all, of them will fade in time, or if necessary, they can be lightened with appropriate treatment (see tips for treating them later in this section). Unless the pigment is very deep, PIP will improve over time.

Be an extra patient patient! The dark spots take the longest to fade. The treatment of PIP tends to be a difficult and prolonged process that often takes 6 to 12 months to achieve the desired results of depigmentation.

Deterring the dark spots

Because these spots can take so long to disappear, it’s essential to prevent them from appearing in the first place. Early treatment and prevention of your acne can help put a stop to them. You should be aware of those things that put you at greater risk of developing PIP.

For example, you should avoid:

• Squeezing, rubbing, or picking your acne lesions

• Over-the-counter toners, witch hazel, and alcohol products as well as prescription acne products that may dry and irritate your skin and lead to PIP

• Harsh soaps and overwashing

• Scrubbing with loofahs and buff puffs Cosmetics that might aggravate your skin and make your acne look worse

I know, it’s tempting to think that squeezing spots will help them heal more quickly. In fact, squeezing actually makes them worse. Squeezing a spot carries a risk of scarring because the pus can burst inward into the skin rather than outward to the surface.

In fact, any situation where the skin can be irritated, be it squeezing blemishes, or plucking hair, can result in dark skin’s tendency to produce more melanin and create dark spots. Shaving the beard can also wreak havoc with acne and increase the possibility to develop PIP.

Keeping Acne and Dark Spots at Bay with OTC Medications

The same medications that are used to treat acne in Caucasian skin are also used to treat people of color; however, when there is a potential to develop PIP, you sometimes need to use the medications differently.

If after eight weeks of self-treatment, your acne and your dark spots persist, seek professional help from your healthcare provider or a dermatologist.

PIP may further darken with sun exposure, so to be truly effective, any therapy should include applying a sunblock over any acne or bleaching medications you use. Other measures to limit ultraviolet exposure (for example wearing hats, protective clothing, and — the best option — avoiding the sun altogether) should be part of your routine.

Benzoyl peroxide and salicylic acid

Over-the-counter (or OTC) medications such as benzoyl peroxide and salicylic acid may be an excellent approach if your acne is mild and you’re able to tolerate these products, but they can be quite irritating on some people’s skin. Begin with a benzoyl peroxide preparation.

If your skin is able to tolerate it and you see improvement of your acne, stick with it. If you want a further boost to your treatment, try adding an over-thecounter salicylic acid at another time of day or just apply it over the benzoyl peroxide. Apply a sunscreen over any medication(s) you are using.

Benzoyl peroxide and salicylic acid can be irritating and drying and produce whitish scales on dark skin. These scales are often referred to as looking “ashy.” The appearance of the scales is difficult for some people to tolerate. (Light skin or white skin gets ashy too; it’s just that you don’t see the contrast as well.)

If benzoyl peroxide or salicylic acid is producing ashiness and scales, apply a light non-oily moisturizer like Cetaphil Moisturizing Cream or Olay Active Hydrating Beauty Fluid. If you have dark spots, use a moisturizer that contains a sunscreen such as Purpose Moisturizer SPF 15 or Cetaphil Daily Facial Moisturizer SPF 15.

If you prefer, you may use a heavier, greasier moisturizer. If you have sensitive skin, be sure to use the lower strength (like 2.5 percent benzoyl peroxide water-based) products to start with. Start treatment every second night, then build up to once or twice daily, as you’re able to tolerate the product.

Similarly, if you get too ashy or irritated from salicylic acid products that have a mild peeling activity, try using the lower 1 percent concentration or try applying the medications on an alternate-day basis.

Over-the-counter bleaches

For the PIP spots, look for over-the-counter preparations that contain 1 to 2 percent hydroquinone, a chemical that’s traditionally been the main treatment for PIP. Companies that make over-thecounter hydroquinone-containing “fade” creams and gels include Ambi, Esoterica, Porcelana, and Black Opal.

These products are applied as a thin layer on the affected areas once or twice a day. You may experience a mild skin irritation or temporary skin darkening. If skin irritation or darkening persists, stop using them and seek professional help. If no improvement is seen after three months of treatment, their application should be discontinued.

Some of these agents contain a built-in sunscreen, however, sun exposure should be limited further by using an additional sunblocking agent or protective headgear to shade treated skin or lightened skin.

The over-the-counter products may be helpful, but if they aren’t strong enough, you may require one of the prescription strength medications.

There are over-the-counter products containing 10 percent hydroquinone or higher that are available in many other countries, particularly within Africa and Asia, and some of them have found their way (illegally) into “health” stores in the United States — mostly in ethnic neighborhoods within big cities. These high concentrations actually bring the risk of a darkening reaction known as ochronosis.

Getting Professional Help

Acne treatments are generally as safe and effective on dark skin as they are on light skin. And in most cases, the treatments are the same. In earlier articles, I outline the topical and oral approaches that dermatologists commonly suggest and that are also appropriate for people with darker skin.

The main difference in the professional treatment of darker skin is a deeper concern for skin discoloration or scars from acne. In this section, I fill you in on how treatments differ when used on darker skin, including aggressive treatments of the acne and the use of more potent skin lighteners for PIP.

When treating dark skin, a combination of topical creams and gels, chemical peels, and sunscreens may be necessary for significant improvement.

This combination of various topical therapeutic agents has been shown to be beneficial, especially on the face. Daily use of a broad-spectrum sunscreen (SPF 15 or greater) is an essential part of any therapeutic regimen.

This step is very important to prevent the pigmentation from becoming darker or allowing the already lightened skin to repigment. The treatment of PIP tends to be a difficult and prolonged process and may not work at all. When it does work, it often takes 6 to 12 months to achieve cosmetically acceptable depigmentation.

Treating your acne and PIP with topical drugs

A variety of topical treatments have been used to treat epidermal PIP, with varying degrees of success. These agents include chemical peels, retinoids, azelaic acid, and hydroquinone.

Lightening of dark areas may be achieved with one of these topical measures. Each of these treatment options potentially improves epidermal hypermelanosis, but none are proven effective with dermal hypermelanosis.

Bleaching with prescription-strength hydroquinone

Hydroquinone is the cornerstone agent in the treatment of PIP. It’s a topical bleaching agent that suppresses the melanocytes from producing melanin. Hydroquinone-containing combination products such as EpiQuin Micro, Glyquin XM, Lustra-AF, and Triluma are available by prescription only.

Some of these agents contain their own sunscreens. In addition, some contain vitamin E, vitamin C, retinol, or glycolic acid. There are unsubstantiated claims that some of these chemicals have “age-defying,” sun-blocking, wrinkle-preventing properties when mixed with the hydroquinone.

I really can’t give you any opinion on those claims because with such a mixture of ingredients, it’s hard to tell what each one does. Hydroquinone may be prescribed along with azelaic acid (described later in the next section) to lighten the dark areas more quickly.

Preparations that contain hydroquinone are applied twice a day to the dark spots. Allergic reactions to them are rare. Hydroquinone combination products are very expensive and are almost never covered by prescription plans because hyperpigmentation is considered a “cosmetic problem” for which treatment is “not medically necessary.”

I tell you this so you don’t suffer “sticker shock” when you go to the pharmacy. Some dermatologists will ask that a more concentrated prescription (up to 8 percent hydroquinone, instead of the usual 3 to 4 percent) be mixed (compounded) for you if you don’t respond to the lower strength treatments.

Applying azelaic acid

Some products actually treat acne and bleach PIP, saving you money and valuable application time. Azelaic acid, a prescription product known as Azelex or Finerin, is an inhibitor of melanin synthesis.

It can treat your acne and lighten the dark spots at the same time. Apply a small amount once or twice a day to all acneprone areas including the dark spots.

Acne tends to respond to azelaic acid in six to eight weeks; however, the PIP spots may take many months to lighten. Because azelaic acid decreases pigmentation, it can temporarily lighten areas that aren’t targets of your treatment. It can also be irritating.

Relying on retinoids

Topical retinoids can also perform a double duty. In addition to the beneficial actions of the retinoids in treating and preventing both comedonal and inflammatory acne, they also may have a lightening effect on PIP. Adaplene (Differin), tazarotene (Tazorac), Avita, and tretinoin (Retin-A) are all prescription retinoids.

Retinoids are known to hasten the rate of turnover (get rid of dead cells, in plain English) of epidermal keratinocytes (the majority of the cells that make up the epidermis) and they also seem to assist in the normalization of pigmentation as well.

Furthermore, by causing the skin to peel, they enhance the penetration of the other bleaching medications into the epidermis. Creams are the least irritating, so you probably should start out with a cream-based retinoid instead of a gel.

If you have oily skin or have a low risk for irritation, you may be prescribed a gel formulation with a higher concentration of retinoid in it. Topical retinoids can be effective; however, they can be a “doubleedged sword” if you have very sensitive skin. These products may result in more irritation that may ultimately cause more PIP.

Peeling the pigment away

It’s possible to actually remove some layers of skin over time to remove layers of the pigment. The following procedures should be approached with great caution and performed only by a professional with a lot of experience in their use. The risk of worsening the PIP is always present with all of these procedures.

Chemical peels

Glycolic or salicylic acid peels can be effective treatments of PIP in dark-complexioned individuals. These are superficial peels that don’t penetrate below the upper layers of skin, and they can sometimes help to even irregular skin tones and lighten PIP.

Matching the strength of a peel to an individual’s skin type and scarring history is critical to avoiding complications. Salicylic and glycolic acids may be applied by an experienced dermatologist or cosmetic surgeon. They may need to perform the peel multiple times in order to see improvement.

Depending on the strength of the acid peel, you may be asked to discontinue applying some or all of the topical agents that are described in the previous sections for a few days before the peel, and resume using them several weeks after the peel, to maintain the results.

These procedures need to be approached cautiously as the risk of peel-induced PIP is well known, as well as the risk of hypertrophic scarring and keloid formation that tends to occur to the more darkly complexioned individual.

Lasers

Certain lasers are now being used to treat PIP, but should only be used by experienced medical professionals. People with dark skin have been told in the past that laser treatments aren’t safe for them.

But experts using the lower powered treatments at very specific wavelengths that are now available can help you avoid complications, such as exacerbating PIP or producing scars.

Microdermabrasion

This procedure is a superficial exfoliation that may not be suitable for skin of color, but it is sometimes used to treat PIP and smooth skin texture. It can be effective in reducing superficial hyperpigmentation; however, pigmentary streaking and worsening of PIP may occur in people with dark skin types.

Managing the scars

Acne scars can form after cysts and nodules heal. Even minor outbreaks of inflammatory acne can result in significant scarring if you’re predisposed to form larger scars as is the case in many African-Americans. Acne scars are difficult to treat, and keloids, large scars that grow way beyond the bounds of normal scars, are particularly difficult to deal with.

Intralesional cortisone injections, though, are particularly effective for patients of color. As with inflammatory nodules and cysts, cortisone injections are sometimes injected directly into the scars to help shrink them.

In these instances, higher concentrations than are used to treat active acne lesions are used. Other procedures, such as soft tissue fillers, scar revision, and laser surgery, may also be considered. Caution must be used with all of these procedures because of the risk of creating further scarring and PIP.

Therefore, only an experienced dermatologist or other cosmetic surgeon who is knowledgeable about skin of color should perform these corrective procedures.

The method known as dermabrasion, used to remove deep scars, can sometimes be too risky to use on people with dark skin because it has a likelihood that it will make scarring and PIP worse.

The newest treatment of keloids and hypertrophic scars is to have them shaved flat or excised (cut out) by a dermatologist or plastic surgeon. After the procedure is done, the patient applies topical imiquimod (Aldara) cream for at least 8 weeks. There have been optimistic reports that there are fewer recurrences with this method.

Oral acne therapy to prevent scars and PIP

The use of oral therapy doesn’t differ much according to the relative lightness or darkness of one’s skin. But sometimes a more aggressive approach with oral antibiotics such as one of the oral tetracyclines will get the less visible, “under-theskin” papules and nodules under control and prevent the more obvious postinflammatory hyperpigmentation (PIP) and the more complicated hypertrophic scars and keloids that can result from them.

Looking at Pomade Acne

African-Americans and other individuals who have tight curly hair frequently use pomades (oils and greasy ointments) to style or improve their hair’s manageability.

Some people believe that pomade acne is caused by the pomade’s blockage of pores and that as a result, many pomade users develop blackheads and whiteheads, with perhaps a few papules and pustules on the forehead and/or temples — places where the pomade comes into contact with their skin.

Pomades can also contribute to an inflammation or infection of the scalp, called folliculitis, in which pustules and redness develop around the hairs. This type of folliculitis can cause hair loss and scarring of the scalp. My best advice to you is to stop using pomades. If your acne persists after stopping, be sure to see a dermatologist.

However, if you feel your life or hairstyle can’t be complete without pomade, you still have a couple options to reduce potential problems:

• If you’re using pomade to deal with a dry scalp, try applying the pomade 1 inch behind your hairline.

• If you’re using it to style or make your hair more manageable, try applying the pomade to the ends of your hair only, to avoid contact with your scalp and hairline.

Cosmetics for Women of Various Ethnic Groups

Dark-complexioned women tend to be more concerned about skin tone and having a clear, even complexion than they are about wrinkles and fine lines. Until recently, most skin-care companies have neglected African-Americans and other ethnic consumers.

Ethnic cosmetic brands were available, but their products were far fewer than those in Caucasian makeup lines. In the past decade, things have markedly improved and there are now many companies that offer skin-care products for women of color.

The color spectrum has broadened to include a wider variety of darker color shades for you to match your skin tones and conceal your acne while not irritating or worsening it.

Products for Asian women are still few in number; however, Shiseido now offers a full line of products for the Asian woman. Your dermatologist may be able to recommend cosmetic measures to make the PIP spots less apparent until they resolve.

You may have a problem in choosing the right cosmetic if you have uneven skin tones that represent an uneven distribution of your pigmentation, such as appears in PIP. Some areas are darker while some appear lighter. In such cases, you should match your foundation to the most predominant color, or find one with a shade in between the two.

Experiment and sample before you buy. Pigmented makeup creams have also been successfully used to camouflage hyperpigmented skin to a shade similar to that of the surrounding unaffected skin. Some companies can custom-blend foundation colors, but this may be very expensive; Dermablend and Covermark are two such products.

They’re available in many shades that can be easily blended to match any skin tone. In fact, they can be used for people of all skin colors. Besides acne spots, they can be used to conceal skin imperfections such as birthmarks, burns, and discolorations from surgery.

These products can be found in makeup counters in some department stores and also can be obtained online. Of course, PIP occurs just as often in males; however, most males would not use camouflaging methods as readily as females to try to hide it.