EXPERT ANALYSIS FROM AAD 17
ORLANDO (FRONTLINE MEDICAL NEWS) – Postinflammatory hyperpigmentation is a common consequence of acne in Latino skin, and aggressive medical treatments or procedures can aggravate the problem.
In fact, the hyperpigmentation that remains after acne is treated can be even more upsetting than the acne itself, according to Mercedes Florez-White, MD.
“Most of the time, the postinflammatory hyperpigmentation [PIH] has much more impact on the patient’s quality of life even than the disease itself, so you need to be very careful when treating these patients,” said Dr. Florez-White of Florida International University, Miami.
Every Fitzpatrick phototype can be observed in the Latino population, but one feature seems to link them: inflammation linked with all types of acne, even comedonal. “Even patients with very pale skin can show, at the periphery of the comedone, a little darkness signaling inflammation. The skin of a mestizo [a person of mixed Spanish/Native American ancestry] is especially prone to this,” she said at the annual meeting of the American Academy of Dermatology.
There is a paucity of research on the treatment of acne in people with skin of color, Dr. Florez-White said. Even the most recent acne treatment guidelines, published in 2016 by the AAD, acknowledge the area as a “research gap” that needs to be addressed.
In the meantime, she offered what she called “pearls of acne wisdom” gleaned from 35 years of treating Latino patients in South America and the United States.
Overview and diagnosis
Nodulocystic acne is the most common type in this population, followed by comedonal acne. Although the comedonal type is not generally considered inflammatory acne, it should be in Latino patients, given their sensitivity to skin inflammation and its outcome. “There is inflammation there from the beginning – treat it as an inflammatory disease for the best results.”
• Acne in Latino patients occurs most commonly, but not exclusively, on the lower face. “We have also seen this on the neck and chest,” she noted.
• A thorough history – including a rundown of hair and skin products the patient is using – is critical. “You never know when something you think is acne is really something else,” like an allergic reaction, she said.
Treatment
There are no AAD-generated treatment guidelines for acne in Latino patients. Dr. Florez-White manages her patients according to a treatment algorithm published by the Ibero-Latin American College of Dermatology and a paper published in the Journal of Dermatologic Treatment (2010 May;21[3]:206-11), as well as her own clinical experience.
Topical therapy
• Start topical retinoids at a lower concentration, two to three times a week, and gradually increase the dose and frequency until the desired effect is reached. Also, start benzoyl peroxide at lower doses.
• For a patient with very proinflammatory cystic acne, initiate a short course of corticosteroids to decrease inflammation – this will reduce the risk of PIH.
• Add azelaic acid in a 20% cream or 15% gel. “It’s an anti-inflammatory and antibacterial, and it really does help reduce the chance of PIH. This is used all over Latin American and Asia, but it is an off-label use in the U.S.” she said.
• For adult women, consider 5% dapsone gel, but not in combination with benzoyl peroxide.
Oral therapy
• Doxycycline is first-line treatment for moderate to severe papulopustular or nodulocystic acne. Other primary agents could be minocycline or tetracycline. Second-line antibiotic choices include erythromycin, azithromycin, and sulfamethoxazole/trimethoprim. Antibiotics should be given with benzoyl peroxide to reduce the chance of bacterial resistance.
• For nonresponsive cases, use oral isotretinoin, started at half the recommended dose. Increase gradually to treatment response.
For women with hormonally mediated acne, give a trial of oral contraceptives with antiandrogen properties, or spironolactone. “I like to combine oral contraceptive pills with isotretinoin. You can give this because the absorption of isotretinoin is very superficial. You won’t have any problems with that,” she noted.
Skin care
Good skin care will help promote healing and generally increase patient compliance with medication, Dr. Florez-White said.
• A noncomedogenic broad-spectrum sunscreen should be used daily. Consider one with mineral oxides, especially iron oxide, as only these preparations scatter both visible light and infrared radiation, which both increase the risk of PIH.
• Cleanse with a synthetic detergent or lipid-free cleanser.
• Recommend daily use of a salicylic, lactic, or glycolic acid.
Camouflage is very important for some patients, especially teens. “I always recommend a noncomedogenic fluid makeup,” she said.
Procedures
• Comedo extraction is an essential part of a comprehensive acne treatment program, but hold off until after a month of retinoid treatment. Removing the lesions significantly decreases the chance of PIH.
• Very superficial chemical peels with salicylic acid alone, or in combination with mandelic acid, may improve outcome faster and decrease PIH that already exists. These can be used in conjunction with oral agents, including isotretinoin.
Dr. Florez-White had no financial disclosures.
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