Mary Scoviak

Thanks to more than 3 decades of robust growth, the body of literature on acne in skin of color has defined many of the obvious and subtle variations of this skin disorder in Fitzpatrick IV, V, and VI skin types and explored theories on treatments from physicians around the world. In this exclusive interview with 

, Adebola Dele-Michael, MD, medical director of Radiant Skin Dermatology and Laser and an assistant professor of dermatology at Mount Sinai, both in New York, New York, shared recommendations for putting basics and breakthroughs to work to help patients of color safely achieve and maintain clear skin.

The basics of diagnosis: Look for comedones.

“Diagnosing acne in skin of color can be tricky. It is not just about comedones,” Dele-Michael said. “The dermatologist has to be aware that the sequelae of acne, such as postinflammatory hyperpigmentation [PIH] and keloids or hypertrophic scarring, can distinguish acne on darker skin types.”

Because not all patients of color present with bumps, exams are more complex. “If the patient is wearing makeup, have them remove it,” Dele-Michael advised. “Then proceed with the exam. A dermatoscope can be helpful in identifying the difference between an open comedone, which is a blackhead, and an acne scar because it reveals more about the skin structure than the naked eye can see. The physician also has to feel the skin to discover any lesions beneath the surface. It is especially important to palpate the affected area when the patient has nodulocystic acne to make sure there are no keloids on top of nodules or cysts. Examining skin texture is important to avoid misdiagnosis with rosacea. Skin that has more sebaceous activity looks like an orange peel, and that can clue you in to the fact that there is underlying inflammation. Then, of course, the dermatologist needs to look for excoriation and cavitation. If they find a divot in the skin, they need to determine whether it is the result of a blemish or acne scarring and whether there has been loss in the dermis.”

Dele-Michael advised adding drill-down questions to the standard patient history to aid diagnosis for Fitzpatrick IV, V, and VI skin types. “For some very dark skin, it is hard to pick up on blushing and, even if that’s possible, to distinguish among blushing, redness, and background erythema,” she noted. “I ask my patients whether their cheeks feel very warm in certain circumstances, whether flares correlate with their menstrual cycle, and whether lesions are painful.”

The basics of treatment: Clear the lesions.

Recent study results showed that patients of color often rank PIH, discoloration, and scarring as their top concerns regarding acne treatment rather than just eliminating “bumps.”

 “Most of my patients are bothered most by discoloration, blemishes, or the PIH that results from acne,” Dele-Michael said. “If I just focus on clearing the lesions, I may not be meeting patients’ expectations.” Because acne can have long-term effects such as discoloration, keloid formation, and scarring, Dele-Michael urged dermatologists to be aggressive in treatment choices for patients of color.

“Consider oral medications such as isotretinoin—as long as the patient is not pregnant or planning on starting a family soon—spironolactone, doxycycline, and minocycline,” she said.

 “The goal is to curb the disease before scarring develops and before complications relating to PIH become more established and more challenging and expensive to treat.”

Once the oral regimen is completed, she suggested continuing the patient on topicals paired with “a very light peel.” “Peels can help address discoloration, but here is where you do not want to be aggressive. You don’t want to go too deeply into the skin,” she said. She prefers peels with lactic acid: “In these cases, those with salicylic acid can be a little too ‘spicy.’ I’m also combining chemical peels with new products such as Cyspera [Scientis], which addresses discoloration and hyperpigmentation without corticosteroids, retinoic acid, and hydroquinone. This combination approach helps shorten the treatment course.”

The basics: Lasers are useful to treat scarring.

“Lasers and energy devices have really changed the way I treat my patients with acne and acne scarring,” Dele-Michael said. She noted that in addition to a growing menu of lasers that safely treat skin of color, technologies such as radiofrequency devices combined with microneedling can provide options for treating scarring and PIH. Some that she has used to help restore collagen and elastin around scarring “without complications of discoloration” and that caused little or no thermal damage include Morpheus8 (InMode), which uses 4 different microneedling tips to penetrate up to 8 mm, and Genius (Lutronic), which has presets for all skin types and multiple body areas.

“As for lasers, sometimes I will use a Q [quality]–switched laser, which is something that can help with pigmentation and discoloration on skin of color. Generally, dermatologists should be looking for a laser treatment—perhaps a microsecond laser such as Neo Elite [Aerolase], which helps us stimulate collagen safely in skin of color and, for my patients, also works to treat acne and correct acne scarring.”

Aftercare plays a big role in the success of chemical peels or light/energy treatments. It all comes down to hydration. “Currently, I’m getting good outcomes with CO2Lift [Lumisque] masks based on carboxytherapy [carbon dioxide therapy] that help bring more oxygen to the face and seal in hydration. They’ve been reducing treatment and recovery time for my patients,” she said.

For at-home use, in addition to her proprietary product, she recommends products such as those from La Roche-Posay, CeraVe (L’Oréal Groupe), and Neutrogena (Johnson & Johnson). “I advise patients to stay away from prod- ucts that have benzoyl peroxide or salicylic acid for home use because sometimes they can be a bit too much. They can actually damage the skin microbiome,” she said.

Manage lifestyle issues in acne care plans

Addressing the underlying physical causes of acne and treating key issues for patients of color—discoloration, hyperpigmentation, and hypopigmentation—and minimizing scarring are essential aspects of any care plan, but lifestyle and psychological factors need to be considered, according to Dele-Michael. Her talking points include the following:

How much stress is the patient experiencing? “With all the pressures people are under, this is a big contributor to acne,” she said.

What are the staples in the patient’s diet? “Hormonal acne is on the rise in people of color,” she said. “I’m not claiming that any one diet will eliminate acne, but we do know that the very high sugar intake in some people’s diets can lead to insulin resistance, which can affect their hormone profile. That, in turn, can cause a form of polycystic ovarian syndrome, which is associated with insulin resistance. If a patient’s acne is driven by what they eat, it can be difficult to get hormonal acne under control unless they’re willing to change their diet dramatically.”

How much does acne affect the patient’s quality of life? “This is important to ask,” she noted. “On the indices, the patient’s case may be mild, but for that person, it could seem severe. My practice is in Manhattan. I have a lot of patients who are actors. For them, having 1 acne cyst on their face may seem severe. Meanwhile, a teenager may not be really bothered by flares because most of their classmates have acne as well. When we’re coming up with our treatment regimen, understanding how that person experiences acne can really help treat them correctly. I may actually upgrade patients from mild to severe because of the weight of their perception.”

Add this question to standard histories for patients of color

“I want to know the vitamin D intake of my patients of color,” Dele-Michael said. “I especially want to look at the results of the 25-hydroxy vitamin D test to get an accurate profile of any deficiency.”

The darker the skin, the higher the risk of deficiency: “Vitamin D is connected with autoimmunity, and patients may develop autoimmune diseases if their vitamin D levels are low. Since the start of the pandemic, there’s been a very high risk and very high rate of incidence of people walking around with single-digit vitamin D levels, which is actually dangerous.”

Vitamin D levels of less than 30 nmol/L, Dele-Michael said, could make the body resist treatment, whether for acne and hidradenitis suppurativa or psoriasis: “Conditions such as hair loss also become more difficult to treat.”

Deficiency is higher in skin of color because the melanin in darker skin types blocks the skin’s ability to process and synthesize vitamin D, Dele-Michael pointed out. That’s becoming more of a problem with urban patients of color spending more hours working indoors, she said.

“The other key connection here is that cow’s milk is a source of vitamin D, but a lot of people of color are lactose intolerant,” she pointed out. “So, we have a situation where the melanin in darker skin is block- ing vitamin D synthesis. People of color have been spending more time indoors—first because of the pandemic and now because of work demands—so we’re not getting enough sun to synthesize vitamin D in our skin. We’re not able to drink milk because we’re not able to process it properly...so our diet is vitamin D deficient. The net result is that these deficiencies can lead to really challenging skin conditions that are not improving with optimal treatments.”

Dele-Michael’s repletion recommendations: “The body of recent research has shown that daily supple- mentation is better than bolus supplementation,” she said. “But if someone is deeply deficient, just give them the prescription-strength bolus. I usually start patients whose vitamin D levels are less than 30 [nmol/L] on 50,000 international units [IU] once a week. Once they are replete, I would recommend that they go on 2000 to 5000 IU daily. I always tell my patients, jokingly, that they have to continue vitamin D supplementation unless they move to the beach.”

This article was originally published by sister publication Dermatollogy Times.

1. Callender VD. Management of acne in skin of color patients. Presented at: Fall Clinical Dermatology Conference; October 21-24, 2021; Las Vegas, NV.

2. Draghici CC, Miulescu RG, Petca RC, Petca A, DumitraŞcu MC, Şandru F. Teratogenic effect of isotretinoin in both fertile females and males (review). Exp Ther Med. 2021;21(5):534. doi:10.3892/etm.2021.9966

Articles

A clinician updates the conventional wisdom on acne’s variations in patients of color, offering pearls from her practice and practical takeaways from recent research.

Pearls for acne in skin of color

Sunscreen is a useful, ubiquitous product. As a daily staple in patients’ lives, it might not be the first product that would be expected to cause controversy. However, research over the last few years has raised safety concerns on a number of fronts, including systemic absorption of UV agents, possible environmental damage, and links to frontal fibrosing alopecia (FFA).

In a presentation at the 17th Annual Skin of Color Society Scientific Symposium,

 Steven Wang, MD, head of dermatology section and director of dermatologic surgery and dermatology at Memorial Sloan Kettering Cancer Center in Basking Ridge, New Jersey, outlined three current controversies and delved into the research behind them.

 show that six active ingredients in sunscreen are absorbed into the bloodstream, even after just one day of use. In 2019, the agency issued a proposed rule3 that would divide UV agents into one of three categories: safe and effective, not safe and effective, and those for which more safety information is needed.

Only two UV agents, titanium dioxide and zinc oxide (which are physical, as opposed to chemical, sunscreens) are considered safe and effective. Aminobenzoic acid (PABA) and trolamine salicylate are not considered safe and effective. The remaining 12 active ingredients, including the six in the aforementioned study, need further safety data.

Wang pointed out that the data from these studies reflect laboratory conditions, not real-life use, as the investigators applied the products at the maximum recommended level and reapplied four times a day, which Wang said would not typically happen in normal use.

He also said titanium dioxide and zinc oxide don’t provide a full toolkit of options. “Titanium dioxide and zinc oxide are safe and effective, but they are still difficult to use in very high SPF and are too white to blend into Fitzpatrick skin types IV to VI.”

He stated the same reservation about environmental concerns surrounding oxybenzone and its toxicity to coral reefs. “Controversy mainly started from the laboratory study where the investigator placed oxybenzone in a sort of a tank, and in really high concentration levels, about 2.2 parts per billion to 228 parts per million….[At] that concentration…you can actually kill the coral reef and deform the DNA in the larval stage of the coral reef. Just to put things in perspective, the oxybenzone concentration in the Hawaiian ocean in the coral reef was about 0.8 to 19 parts per billion. In the Virgin Islands, this is about 75 parts per trillion and 1.5 parts per billion.”

He said he feels that oxybenzone has been unfairly a target of criticism when global warming is doing most of the damage to coral reefs.

The last controversy Wang addressed is the connection between sunscreen and FFA. “The only thing the research shows is that people with FFA tend to use a lot of sunscreen,” he said. He added that concerns about free radicals causing FFA don’t hold true anymore, as the titanium dioxide and zinc oxide in most modern sunscreens has an aluminum shell to prevent the release of free radicals.

He also noted that the studies on which these findings were based were questionnaires, and that recall bias and temporal ambiguity affect findings from such research, as does the number of inactive ingredients in sunscreen.

, Wang and his coauthors declared the evidence for a link between sunscreen use and FFA insufficient.

Wang reported no relevant or financial interests.

This article was originally published on Dermatology Times.

1. Wang S. Controversies in sunscreen. Presented at: 17th Annual Skin of Color Society Scientific Symposium; March 13, 2021; virtual.

2. Matta MK, Florian J, Zusterzeel R, et al. Effect of sunscreen application on plasma concentration of sunscreen active ingredients: a randomized clinical Trial. 

. 2020;323(3):256-267. doi:10.1001/jama.2019.20747

3. FDA advances new proposed regulation to make sure that sunscreens are safe and effective. News release. Food and Drug Administration. February 21, 2019. Accessed April 14, 2021. 

https://www.fda.gov/news-events/press-announcements/fda-advances-new-proposed-regulation-make-sure-sunscreens-are-safe-and-effective

4. Robinson G, McMichael A, Wang SQ, Lim HW. Sunscreen and frontal fibrosing alopecia: a review. 

. 2020;82(3):723-728. doi:10.1016/j.jaad.2019.09.085

Sunscreen is a necessary preventive tool. However, there are concerns about UV agent absorption, environmental impact, and possible correlations with frontal fibrosing alopecia (FFA). Here is a look at whether those worries are justified by research. 

Mary Scoviak

Articles

Pearls for acne in skin of color

Addressing sunscreen controversies