TOPICS

Racial Differences in Clinical Characteristics, Perceptions and Behaviors, and Psychosocial Impact of Adult Female Acne

Valerie D. Callender, MD; Andrew F. Alexis, MD, MPH;
Selena R. Daniels, PharmD, MS; Ariane K. Kawata, PhD;
Caroline T. Burk, PharmD, MS; Teresa K. Wilcox, PhD; Susan C. Taylor, MD

Callender Dermatology & Cosmetic Center, Glenn Dale, Maryland; Skin of Color Center, Department of Dermatology,
St. Luke’s-Roosevelt Hospital Center, New York, New York; Allergan, Inc., Irvine, California; Evidera, Bethesda, Maryland;
Health Outcomes Consultant, Laguna Beach, California; Society Hill Dermatology, Philadelphia, Pennsylvania

Abstract
Objective: Limited data are available on racial differences in clinical characteristics and burden in adult female acne. The objective was to describe racial differences in clinical characteristics, psychosocial impact, perceptions, behaviors, and treatment satisfaction in facial adult female acne. Design: Cross-sectional, web-based survey. Setting: Diverse sample of United States women. Participants: Women between the ages of 25 and 45 years with facial acne (?25 visible lesions). Measurements: Outcomes included sociodemographic characteristics, psychosocial impacts, perceptions, behaviors, and treatment satisfaction. Racial differences were evaluated using descriptive statistics and t-test/chi-square analyses. Results: 208 females participated (mean age 35±6 years); 51.4 percent were White/Caucasian and 48.6 percent were non-White/Caucasian women [Black/African American (n=51); Hispanic/Latina (n=23); Asian (n=16); Other (n=11)]. Age of acne onset (mean 14.8±5 vs. 17.0±8 years, p<0.05) and acne concern occurred earlier (16.6±7 vs. 19.3±9 years, p<0.05) in White/Caucasian than non-White/Caucasian subjects. Facial acne primarily presented on chin (28.0%) and cheeks (30.8%) for White/Caucasian women versus cheeks (58.4%) for non-White/Caucasian women. Non-White/Caucasian women experienced more postinflammatory hyperpigmentation than White/Caucasian women (p<0.0001). Facial acne negatively affected quality of life (QoL) in both groups, and most participants (>70%) reported some depression/anxiety symptoms. More White/Caucasian than non-White/Caucasian women were troubled by facial acne (88.8% vs. 76.2%, p<0.05). Lesion clearance was most important to White/Caucasian women (57.9 vs. non-White/Caucasian 31.7%, p<0.001); non-White/Caucasian females focused on postinflammatory hyperpigmentation clearance (41.6% vs. Caucasian 8.4%, p<0.0001). Conclusion: Results highlight racial differences in participant-reported clinical characteristics, attitudes, behaviors, and treatment satisfaction. These findings may inform clinicians about racial differences in facial adult female acne and guide treatment recommendations toward improving care.  (J Clin Aesthet Dermatol. 2014;7(7):19–31.)

Acne vulgaris (hereafter referred to as acne) is one of the most frequently encountered externally visible skin diseases in dermatology for individuals 15 to 40 years of age in the United States.[1] Acne has typically been regarded as an adolescent condition, but recent research and clinical practice experience have shown that it is also common in the adult population.[1–4] Among adult cases of acne, women are affected more frequently than men; approximately 12 to 22 percent of US women have adult acne,[2–4] compared to three percent of men.[2] Despite the higher prevalence of adult female acne (AFA), there has been limited research investigating the epidemiology, clinical presentation, and symptom burden in women, and more specifically potential racial differences that may exist.
Facial acne is a multifactorial disease with respect to its pathophysiology as well as its impact on daily functioning.[5–6] A variety of factors have been connected with AFA, including hormones, genetics, cosmetics, diet, tobacco use, and stress.[7–8] This condition has also been associated with substantial burden and impairments in health-related quality of life (QoL).[9] Previous studies have demonstrated that facial acne can impair self-image, psychological well-being, and the ability to develop social relationships.[5,10–13]
Acne is the most common dermatological diagnosis in non-Caucasian patients.[14–19] In a community-based photographic study, clinical acne was found to be highly revalent in Black/African American (37%), Hispanic/Latina (32%), and Asian (30%) women, more so than in Continental Indian (23%) and White/Caucasian (24%) women.[20]
Acne characteristics may also vary across racial and ethnic backgrounds in women. A common facial location in Black/African American women is the hairline, which may be impacted by hair grooming products used to prevent dryness of the hair.[19] Furthermore, over two-thirds of Black/African American women with acne experience postinflammatory hyperpigmentation (PIH), a darkening of the skin pigment due to increased amounts of melanin that usually occurs during the healing process after acne treatment.[5,20] PIH can worsen with persistent and recurring inflammation.[21–22] Keloidal scars are also a more common potential sequela in non-White/Caucasian populations, presenting frequently along the jawline and trunk and often associated with greater acne severity.[19,22,23]
Traditionally, acne has been treated homogenously across all skin types, but special risks in darker skin types, particularly for development of PIH and keloids, must be considered.[5,24] Strategies to minimize the risk of pigmentary abnormalities and keloid scarring in skin of color include the following: avoiding irritation associated with topical acne therapies, and aggressively reducing acne-associated inflammation by employing topical and/or oral agents with anti-inflammatory effects.[24] Concurrent management of PIH is also a nuance to treating acne in non-White/Caucasian skin types.[25]
There has been limited research comparing the characteristics of acne among different racial and ethnic groups, particularly in AFA. However, there is growing recognition of the nuances and unique challenges of treating AFA, particularly in darker skin types.[20] A broader understanding of racial/ethnic variations in clinical presentation, patient perceptions, and psychosocial impact of acne in women will help to improve treatment outcomes in this increasingly diverse patient population.
The objective of this study was to describe if there are racial differences in facial AFA. Variation by race was evaluated for clinical characteristics, psychosocial impacts, perceptions, behaviors, and treatment satisfaction in facial AFA.

Methods
Study design. This was a cross-sectional, electronic web-based survey conducted with US participants from October to November 2011. The survey screened for participant-reported signs consistent with acne and captured data on sociodemographic and clinical characteristics, psychosocial impacts, perceptions, behaviors, and treatment satisfaction. Clinical experts contributed to development of the acne screening criteria, survey content, and selection of patient-reported outcome (PRO) measures. The study design and materials were approved by a central ethics review board. Additional details on study design and methodology are described elsewhere.[9]
Study population: recruitment and screening. All participants were recruited through the YouGov Polling Point Panel in the United States (Palo Alto, California) from a pool of registered panelists ?18 years of age. Eligible panelists were women between the ages of 25 and 45 years; had an active e-mail address at the time of study invitation; were able to read and understand English; had presence of self-reported acne, defined as ?25 visible facial lesions using survey-provided photographs at screening; and fulfilled one of the age and/or race/ethnicity strata targeted for the sample. Recruitment aimed to enroll a stratified sample based on age and race, with a minimum of 200 female participants with AFA. The stratification goals for age were 50 percent women ages 25 to 35 years and 50 percent women ages 36 to 45 years; the goals for race/ethnicity were 50 percent White/Caucasian women, 25 percent Black/African American women, and 25 percent Asian, Hispanic/Latina, or Other women. Further details about participant recruitment and screening methods have been described in a separate paper.[9]
Study variables. Sociodemographic and clinical data were collected to understand the characteristics of women with acne of different racial and ethnic backgrounds. Acne-related QoL was assessed using the Acne-specific Quality of Life questionnaire (Acne-QoL),[26] a 19-item PRO measure evaluating the impact of facial acne in the past week across the following four domains: self-perception, role-social, role-emotional, and acne symptoms, where higher scores (ranging from 0–30) indicate better QoL. Psychological status was assessed by the four-item Patient Health Questionnaire (PHQ-4),[27] a self-administered questionnaire assessing core depression and anxiety symptoms in the past two weeks; total scores can be interpreted as normal (0–2), mild (3–5), moderate (6–8), and severe (9–12) depression/anxiety. Perceptions about acne and behavior patterns of AFA were assessed by asking participants about the degree of troublesomeness for specific acne signs and acne overall, most important aspects of acne clearing, their feelings about acne, methods used to cope with acne, and myths or beliefs about acne. Participants who self-identified their racial background as a group other than White/Caucasian (i.e., Black/African American, Hispanic/Latina, Asian, and Other) were considered non-White women. Distinct acne needs for race, ethnicity, or skin type were assessed among non-White women, including preferences for acne treatments, healthcare professional with expertise/ specialty in non-White skin, and treatment effectiveness. Treatment expectations and satisfaction were assessed by overall level of acne clearing achieved in the past four weeks and acne treatment efficacy.
Statistical analyses. Descriptive statistics were used to evaluate survey data by racial groups (White/Caucasian vs. non-White/Caucasian women). For continuous variables, sample size, mean, standard deviation (SD), median, and minimum and maximum were examined. For categorical variables, frequencies were reported. Acne-QoL and PHQ-4 were scored based on guidelines set forth by the instrument developers. Student’s t-test and chi-square analyses were used to compare outcomes between racial groups. Results for the pooled survey sample have been described in a separate paper.[9]

Results
Sample characteristics. A flow diagram of study participants and eligibility by race is presented in Figure 1. A total of 7,245 female panelists were invited to participate in the survey, of which 3,702 responded to the e-mail invitation, provided consent, and completed eligibility screening. Among those screened, 208 were eligible and completed the survey. The final sample comprised 51.9 percent 25- to 35-year olds (n=108) and 51.4 percent White/Caucasian women (n=107). On average, surveys were completed within 25 minutes.
Sociodemographic and clinical characteristics. Sociodemographic (Table 1) and clinical characteristics (Table 2
and Table 2 continued) of the study sample were assessed. The sample was equally distributed between White/Caucasian (51.4%) and non-White/Caucasian women (48.6%). Non-White/Caucasian women comprised Black/African American (24.5%), Hispanic/Latina (11.1%), Asian (7.7%), and other ethnicities (5.3%). The average age of the sample was 35.4 years (SD=5.8), with no substantial difference in age between White/Caucasian and non-White/Caucasian women (p>0.05; Table 1). Both racial groups generally had similar sociodemographic characteristics (all p>0.05; “href=”https://jcadonline.com/wp-content/uploads/Callender_Tab1.jpg”>Table 1). More than 80 percent of women were covered by some type of health insurance and the majority (77.9%) had prescription drug coverage.
Clinical characteristics are described in Table 2 and Table 2 continued. The majority of White/Caucasian (82.2%) and non-White/Caucasian women (78.2%) had 25 to 49 visible facial lesions (referred to as “pimples”) at the time of survey completion (p>0.05). Overall, approximately two-thirds of White/Caucasian (63.6%) and non-White/Caucasian women (64.4%) reported having 25 to 49 visible facial lesions over the four weeks prior to the survey (p>0.05). Mean age of acne onset was significantly earlier for White/Caucasian (14.8 years, SD=5.3) than non-White/Caucasian women (17.0 years, SD=7.6; p<0.05), as was the age at which acne generally began to bother or concern them (White/Caucasian: 16.6±6.5 years vs. non-White/Caucasian: 19.3±8.6 years, p<0.05). Adult onset acne (?18 years) began around age 25 for both White/Caucasian (25.7 years, SD=6.1) and non-White/Caucasian women (25.4 years, SD=6.4; p>0.05). In terms of acne treatment, approximately half (White/Caucasian: 54.2% vs. non-White/Caucasian: 44.6%, p>0.05) had ever (in their lifetime) visited a healthcare professional (HCP) for acne and one-third (White/Caucasian: 36.4% vs. non-White/Caucasian: 30.7%, p>0.05) had previously been diagnosed with adult acne.
Overall patterns of facial acne locations were significantly different for White/Caucasian and non-White/Caucasian women (Figure 2). Facial acne for White/Caucasian women primarily presented on cheeks (30.8%) and chin (28.0%) versus the cheeks for non-White/Caucasian women (58.4%). Beyond the face, acne in the chest area was more common for White/Caucasian (46.7%) than non-White/Caucasian women (30.7%, p<0.05). Most women had experienced at least some erythema (referred to as “redness”) (White/Caucasian: 95.3% vs. non-White/Caucasian: 87.1%) or scarring (86.0% vs. 91.1%) from facial acne in the past four weeks (p>0.05 for both). Moderate to extensive erythema was slightly more common for White/Caucasian women (74.8% vs. non-White/Caucasian: 62.4%) and non-White/Caucasian women tended to report more scarring (72.3% vs. White: 54.2%). Non-White/Caucasian women reported substantially more PIH (referred to as “dark marks”) than White/Caucasian women (p<0.0001). Nearly half (49.5%) of non-White/Caucasian women reported experiencing “a lot” or “extensive” PIH, compared to one-fifth (22.5%) of White/Caucasian women.
Acne-QoL. All women reported low mean scores on each of the four Acne-QoL domains (mean scores ?15.0 out of 30 for self-perception, role-emotional, and acne symptoms; ?12.7 out of 24 for role-social), indicating that facial acne had negatively impacted their overall QoL in the past four weeks. Although White/Caucasian women had slightly higher scores (indicating better QoL), these differences between White/Caucasian and non-White/Caucasian women were not statistically significant. Acne Symptoms domain scores (White/Caucasian: 14.3 vs. non-White/Caucasian: 13.2, p>0.05) suggested active, progressive acne with limited improvement in acne signs. Scores from the Self-Perception domain (White/Caucasian: 10.8 vs. non-White/Caucasian: 10.7, p>0.05), indicated that acne had a negative impact on perception of appearance. Role-Emotional domain scores (White/Caucasian: 12.1 vs. non-White/Caucasian: 10.9, p>0.05) reflected negative emotions about having to deal with acne. Lastly, Role-Social domain scores (White/Caucasian: 12.7 vs. non-White/Caucasian: 10.8, p>0.05) suggested that acne negatively affected social functioning.
PHQ-4. The PHQ-4 indicated that participants had experienced symptoms of depression and/or anxiety within the past two weeks. The majority of White/Caucasian (71.0%) and non-White/Caucasian women (73.3%) reported symptoms reflecting mild, moderate, or severe levels of depression and anxiety (scores ?3; mean score 5.3±3.9 out of 12). Overall, no substantial difference between groups was observed. White/Caucasian women reported slightly more symptoms of anxiety (48.6% vs. 39.6% score ?3 on anxiety items, p>0.05) and depression (37.4% vs. 36.6% score ?3 on depression items, p>0.05) than non-White/Caucasian women.
Perceptions and behaviors in AFA. Perceptions about acne and methods for coping with acne are described in Table 3. Sweating/perspiration was cited as an acne breakout trigger by more White/Caucasian (51.4%) than non-White/Caucasian women (29.7%, p<0.01). The majority of women attributed breakouts to hormones/menstrual cycle (White/Caucasian: 63.6% vs. non-White/Caucasian: 57.4%, p>0.05). Facial acne signs were troublesome for the majority of females; however, the overall experience with facial acne signs was described as troublesome by significantly more White/Caucasian than non-White/Caucasian women (88.8% vs. 76.2% yes, p<0.05). The most troublesome signs of facial acne were also different for White/Caucasian and non-White/Caucasian women ( Figure 3). White/Caucasian women ranked pustules (referred to as “bumps full of pus”) (41.1%) and papules (referred to as “bumps”) (20.6%) as their most troublesome acne signs, while PIH was rated as the most troublesome acne sign in non-White/Caucasian women (26.7%), followed by papules (15.8%) and pustules (15.8%). Erythema (referred to as “redness”) from facial acne was also a more troublesome acne sign for White/Caucasian women, with 43 percent describing erythema as “severely” or “very severely” troublesome compared to one-quarter (26.7%) of non-White/Caucasian women. PIH was severely troublesome for nearly half (48.5%) of non-White/Caucasian women.
In addition to being troublesome, acne was associated with negative self-perceptions. The majority (>75%) of women “agreed” or “strongly agreed” that acne made them feel less confident, more self-conscious around other people, frustrated, and embarrassed (Table 3). More White/Caucasian women felt self-conscious around other people (85.0%) than non-White/Caucasian women (68.3%, p<0.05). Whereas, more non-White/Caucasian than White/Caucasian women felt that non-acne sufferers could not relate to experiencing adult acne (66.3% vs. 57.9%, p<0.05).
White/Caucasian and non-White/Caucasian women generally used the same methods to cope with acne: using makeup (58.2%), “popping” or squeezing pimples (52.9%), and following a strict skin-cleaning routine (41.3%) (Figure 4). Using makeup to cope with acne was significantly more common for White/Caucasian women (67.3%) than non-White/Caucasian women (48.5%, p<0.05). About half of White/Caucasian (58.9%) and non-White/Caucasian women (46.5%) reported “popping” or squeezing pimples to cope with acne. White/Caucasian women felt less confident in their looks (p<0.05) and less attractive (p<0.001) without wearing makeup to cover acne than non-White/Caucasian women (Figure 5). More White/Caucasian women reported feeling “not at all” confident in their looks (42.1%) and “not at all” attractive (50.5%) without wearing makeup to conceal their acne, compared to approximately one-quarter of non-White/Caucasian women (24.8% for confidence, 26.7% for attractiveness).
Common beliefs or myths about acne were also assessed. Nearly all women believed that stress causes acne (White/Caucasian: 96.3% vs. non-White/Caucasian: 93.1%, p>0.05). Non-White/Caucasian women tended to have more misconceptions about acne. More non-White/Caucasian than White/Caucasian women believed that frequent face washing can help clear acne (38.6% vs. 17.8%, p<0.01); eating chocolate gives you acne (43.6% vs. 29.0%, p<0.05); makeup should not be worn if you have acne (50.5% vs. 30.8%, p<0.01); and that an over-the-counter (OTC) product (e.g., a good face cream or cleanser from a cosmetics counter) can effectively clear acne (59.4% vs. 44.9%, p<0.05). Also, more non-White/Caucasian women (64.4%) “strongly agreed” that a good acne medication should reduce PIH compared to White/Caucasian women (42.1%, p<0.05).
Acne in non-White/Caucasian women. Non-White/Caucasian women were asked about acne treatment preferences related to their race, ethnicity, or skin type and expressed a desire for treatments tailored for their skin’s distinct needs. Nearly 70 percent felt that their race/ethnicity/skin type required targeted attention and two-thirds (66.3%) desired an acne treatment that was designed to meet the needs of their skin. More than 75 percent would prefer to visit a healthcare professional who had experience treating acne in non-White/Caucasian women. In addition, the majority of non-White/Caucasian women (85.1%) would be interested in an acne treatment that had been proven effective in treating acne for their race, ethnicity, or skin type. The types of information considered most convincing in showing efficacy of an acne treatment were scientific data or statistics (33.7%), followed by a recommendation by a dermatologist (17.8%) or friend/family member (15.8%), photographs (13.9%), primary care physician recommendation (10.9%), and other types of information (8.0%).
Treatment satisfaction. Recent acne clearing and treatment expectations were assessed. Some differences were identified when women were asked to rank the importance of seven different acne signs with respect to acne clearing. More than half (57.9%) of White/Caucasian women indicated that lesion clearance was the most important aspect of acne clearing (p<0.001), compared to one-third (31.7%) of non-White/Caucasian women. Clearing PIH was most important for many non-White/Caucasian women (41.6%; p<0.0001); PIH was a lesser concern for White/Caucasian women (8.4%). Despite the importance of acne clearing, both White/Caucasian and non-White/Caucasian women equally (65.9%) reported having experienced minimal or no acne clearing in the past four weeks.
Women expected an effective acne treatment to have a quick onset and immediate results. The majority of White/Caucasian (68.2% and 70.1%) and non-White/Caucasian women (78.2% and 74.3%) expected to see results from an effective prescription or OTC acne medication within two weeks, respectively (p>0.05 for both). Furthermore, significantly more non-White/Caucasian than White/Caucasian women thought that they should see results even sooner; overnight improvement was expected for both prescription (18.8% vs. 6.5%, p<0.05) and OTC (14.9% vs. 3.7%, p<0.05) acne treatments. A variety of features were considered important in an effective acne treatment and these differed by race (Figure 6). Significantly more non-White/Caucasian than White/Caucasian women rated the following treatment features to be “very important”: few side effects, no bleaching/staining or skin dryness, and PIH efficacy (p<0.05 or lower).

Discussion
This was the first cross-sectional, web-based study collecting detailed participant-level information on the characteristics, perceptions, and needs for acne care and treatment for skin of color in AFA. This study provides a foundation for describing racial differences in clinical characteristics and examining burden of AFA as well as perceived treatment and distinct needs for acne in non-White/Caucasian women.
Findings from this survey emphasize the varying impact of AFA in White/Caucasian versus non-White/Caucasian women. Although acne has traditionally been treated homogeneously across all skin types, there is evidence that acne in non-White/Caucasian patients is clinically different and a targeted approach directed to characteristics of darker skin types could benefit patient care.[5,24] Previous research has demonstrated early onset of puberty in Black/African Americans compared to other ethnicities, corresponding to an earlier initial onset of acne.[28] These findings are contradictory to the results of this study, in which onset of acne in this sample reflected a significantly earlier acne onset in White/Caucasian women versus non-White/Caucasian women. With respect to self-reported clinical characteristics of acne, the location of facial acne in White/Caucasian women presented primarily on chin and cheek areas, while in non-White/Caucasian females, it presented on the cheeks, with more frequent PIH. This finding of greater PIH incidence in non-White/Caucasian women was consistent with previous research, which has shown that 65 to 75 percent of Black/African American women suffer from PIH; PIH can endure for several weeks to months.[5,20–22]
In this study sample, acne was shown to be burdensome and associated with low QoL and negative self-perceptions. Both White/Caucasian and non-White/Caucasian women with AFA exhibited low QoL specific to acne and symptoms of depression/anxiety. Poor QoL in acne patients has been documented in the literature. Levels of social and emotional problems in acne patients were similar to that of psoriasis patients,[29] and also comparable with that of patients with severe chronic disabling diseases, such as arthritis and diabetes.[13] Facial acne overall, as well as individual acne signs, were considered troublesome by most women. For White/Caucasian women, papules, pustules, and erythema were the most troublesome acne signs, while PIH was especially problematic for non-White/Caucasian women. The majority of women reported feelings of low self-confidence, high self-consciousness, frustration, and embarrassment as result of facial acne. White/Caucasian women generally felt both less self-confident and attractive without makeup and more self-conscious due to facial acne than non-White/Caucasian women. This finding in adult women may be related to racial differences in body image that have been observed in adolescent girls; Black/African American adolescent girls have reported greater body esteem and perceived sexual attractiveness than White/Caucasian female adolescents and more generally, adolescent girls with acne have lower body esteem scores than adolescents without acne.[30] In addition, more non-White/Caucasian women tended to endorse common lay perceptions about acne causation and treatment (e.g., frequent face washing/OTC treatment will clear acne; chocolate contributes to acne) that are generally unsupported by acne research, despite similarities in socioeconomic and educational status between the two groups. These beliefs are common among acne patients across different ages and gender.[31,32]
Important aspects of acne treatments and treatment expectations of AFA also varied with race. Clearing lesions was important in acne clearing for White/Caucasian women, while eliminating PIH was of primary importance for non-White/Caucasian women. All women expected to see results quickly (within 2 weeks) from an effective acne treatment, with rapid resolution of acne signs for prescription and OTC acne treatments alike. These unrealistic expectations for quick resolution of acne signs may indicate that further patient education and consultation on speed of treatment efficacy may be warranted.[24] The negative psychosocial impact and negative perceptions associated with facial AFA observed in this sample may contribute to their desire for acne treatments to produce results very quickly. Behaviors engaged in by participants to help cope with the presence of acne included makeup use (particularly among White/Caucasian women) as well as “popping” or squeezing lesions and instituting a strict skin cleansing regimen. The lower frequency of make-up use among non-White/Caucasian women observed in this study may relate to more limited make-up options for darker skin tones (particularly when concealing PIH is desired).
Consistent with the recent literature, this study demonstrates that there are racial differences in acne. Findings from the survey show that non-White/Caucasian women feel their acne requires targeted attention and expressed interest in acne treatments tailored to the unique needs of their skin. This finding was consistent with previous research that has emphasized the importance of considering race-related clinical characteristics when prescribing acne treatments for acne, such as focusing on treatments targeting PIH in people with skin of color.[22] Products used by non-White/Caucasian women may also contribute to the presence of acne, such as hair oil or pomade, and has been shown to be highly correlated with the presence of forehead acne in Black/African American women.[33]
The design of this study was unique in that it focused on a subpopulation of acne sufferers that has not been studied extensively, allowing for a more critical comparison of acne clinical characteristics, treatment preferences, and burden among different racial and ethnic groups. Additional advantages of this web-based study included stratified recruitment to generate data on a diverse sample of female participants of different ages and races. This approach also offered access to a large pool of US panelists, a high level of control in survey programming (e.g., pre-programmed skip patterns, automated data checks for quality control), and rapid data collection. Further details on the overall strengths and limitations of web-based surveys have been described elsewhere.[34]

Limitations
This study was not without limitations. The sample size for non-White/Caucasian women was limited by the pool of preregistered female panelists in the United States. Stratification of the sample into more granular race/ethnicity subgroups was not possible due to limited sample size. However, additional studies are planned that will allow further assessment of subgroups in a larger pool of non-White/Caucasian women. Additional limitations included selection bias due to web-based data collection methodology, use of self-reported clinical information (unconfirmed by physician records or diagnostic information), and potential response bias due to current acne severity (overall acne severity may have differed from time of screening). Lastly, enrollment was limited to women who self-reported ?25 visible facial lesions, thereby excluding milder cases with fewer lesions and limiting the conclusions that can be drawn about the AFA population as a whole or differences between women of different races.

Conclusion
In conclusion, AFA in skin of color are a unique and under-studied patient population. Acne therapies have typically not recognized the variation in clinical presentation and impact of acne as a function of race/ethnicity, gender, and age. The findings from this study emphasize the diversity in AFA and help to characterize AFA in non-White/Caucasian women. This study contributes to the body of knowledge about racial differences in AFA and highlights the multifaceted impacts of acne for White and non-White women. These findings may aid the clinical community in recognizing the substantial burden associated with acne. Informing clinicians about racial differences in clinical presentation of facial AFA and increasing awareness about the psychosocial impacts of AFA and specific needs of non-White women may help guide treatment recommendations for improving care in AFA populations.

Acknowledgment
The authors would like to acknowledge the following individuals for their contributions to the study: Emil A. Tanghetti (The Center for Dermatology and Laser Surgery) for his contributions to survey design; Karen Yeomans (UBC) for her contributions to survey design and execution; Krista A. Payne (UBC) for survey design; Ren Yu (Evidera) for data analysis and statistical support; Marielle Bassel, Sunning Tao, and Irene Pan (UBC) for project support; Sepideh F. Varon (Allergan) for strategy support in refocusing subject recruitment; Samantha Luks, Ashley Grosse, and Jason Cowden (YouGov) for web survey management and implementation; and Purvi Mody (Allergan) for editorial support in the preparation and styling of this manuscript.

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