Dermatological Conditions in Skin of Color— Clinical Considerations When Treating Acne Vulgaris in Skin of Color

J Clin Aesthet Dermatol. 2023;16(9 Suppl 2):S20–S21

by Archana M. Sangha, MMS, PA-C 

Ms. Sangha is a medical science liaison for Incyte in Wilmington, Delaware. Prior to that, she spent over a decade as a dermatology PA specializing in general, surgical, and cosmetic dermatology. She is a fellow of the American Academy of Physician Assistants in Alexandria, Virginia. She is also Immediate Past President of the Society of Dermatology Physician Assistants.

FUNDING: No funding was provided for this article.

DISCLOSURES: Ms. Sangha is an employee of Incyte in Wilmington, Delaware. 

Acne vulgaris affects nearly 10 percent of the world-wide population.1 In a study by Perkins et al, acne was found to be more prevalent in African Americans (37%) and Hispanics (32%), followed by Asians (30%), Caucasians (24%), and Continental Indians (23%).2 This article highlights five considerations when treating acne in patients with skin of color. 

Evaluate topical retinoid regimen

Topical retinoids are the mainstay of acne treatment and exert their effects by minimizing active lesions and inhibiting microcomedone formation.3 Higher doses of retinoids can cause skin irritation, thus increasing the risk of postinflammatory hyperpigmentation (PIH). Common side effects of topical retinoids include erythema, dryness, peeling, and irritation. These side effects are most common during the first few weeks of treatment initiation.4 To improve tolerability and patient adherence, consider the following: 

Retinoid concentration and vehicle formulation. Lower concentrations of topical retinoids have been shown to minimize the risk of PIH.5 Studies have shown that creams, microsphere, crystalline formulations, and aqueous gels are better tolerated in patients with skin of color.6

Short contact therapy. This method minimizes the length of exposure to the retinoid. Patients apply the topical retinoid for a specified amount of time (e.g., 30–60 minutes once daily) and then rinse it off their skin. In a study assessing tretinoin 0.05% cream applied in this manner for up to 32 weeks, results showed similar efficacy to its once-daily leave-on regimen, but with improved tolerability.7

Nondaily application. This method minimizes the frequency of exposure to the retinoid. Patients should apply the retinoid every other day. In a study comparing every other day tazarotene 0.1% gel to once-daily adapalene 0.1% gel, results showed that both formulations had similar efficacy and tolerability.8

Take a history of skincare regimen 

It is important to take a thorough history of a patient’s current skincare regimen. By doing so, you can learn if they are using products that may exacerbate potential side effects of a treatment regimen. Counsel patients to avoid toners and astringents, as they can excessively dry the skin and increase irritation.9 Recommend lipid-free cleansers, as they gently clean the skin and maintain epidermal integrity.10 Recommend noncomedogenic moisturizers as well. One study showed that adapalene used in combination with an anti-inflammatory moisturizer had greater efficacy and tolerability versus adapalene alone.11 Lastly, emphasize the importance of daily sunscreen use. Darker skin is naturally protected from ultraviolet B (UVB) light but susceptible to UVA and visible light. UVA has been shown to induce PIH in patients with acne.12 One study found that one of the most common reasons for sunscreen avoidance in skin of color populations was “dislike of greasiness;” thus, it is important to address this concern with patients and counsel them on the wide variety of sunscreen formulations available.13

Initiate isotretinoin gradually

For patients who require isotretinoin, they should be started on a low dosage, which is then increased gradually, as isotretinoin initiation can cause an initial acne flare. This initial flare can lead to subsequent PIH. Patients may also experience ashen or grayish facial skin secondary to the drug’s xerotic effects.14 

Inquire about haircare practices

Individuals of different ethnicities have varying haircare practices, and many frequently apply comedogenic oils to the hair and scalp. For example, a study by Nayak et al15 showed that Asian Indian male and female individuals applied coconut oil to the hair for moisturization. This practice often leads to pomade acne, which is characterized by numerous closed comedones over the forehead and temples.14 It is important to be aware of what products are being used on the hair so you can counsel patients appropriately. 

Discuss PIH 

Patients with skin of color are often equally or more bothered by PIH than active acne. Therefore, it is important to discuss how active acne leads to PIH and how a customized treatment plan treats both (e.g., consider treatment regimens that include topical retinoids and/or azelaic acid). Discuss with patients the anticipated timeline for improvement of both acne and PIH. Also, ask patients if they have treated their PIH in the past, and if so, with what products (e.g., hydroquinone, etc.). 

By understanding some of the unique challenges that impact patients with skin of color who have acne, you will be better equipped to achieve shared treatment goals. 


  1. Heng AHS, Chew FT. Systematic review of the epidemiology of acne vulgaris. Sci Rep. 2020;10(1):5754.
  2. Perkins AC, Cheng CE, Hillebrand GG, et al. Comparison of the epidemiology of acne vulgaris among Caucasian, Asian, Continental Indian and African American women. J Eur Acad Dermatol Venereol. 2011;25(9):1054–1060 
  3. Thielitz A, Abdel-Naser MB, Fluhr JW, et al. Topical retinoids in acne—an evidence-based overview. J Dtsch Dermatol Ges. 2008;6(12):1023–1031.
  4. Culp L, Moradi Tuchayi S, Alinia H, Feldman SR. Tolerability of topical retinoids: are there clinically meaningful differences among topical retinoids? J Cutan Med Surg. 2015;19(6):530–538.
  5. Alexis AF, Woolery-Lloyd H, Williams K, et al. Racial/ethnic variations in acne: implications for treatment and skin care recommendations for acne patients with skin of color. J Drugs Dermatol. 2021;20(7):716–725.
  6. Alexis AF, Barbosa VH. Skin of Color: A Practical Guide to Dermatologic Diagnosis and Treatment. Springer; 2012.
  7. Veraldi S, Barbareschi M, Benardon S, Schianchi R. Short contact therapy of acne with tretinoin. J Dermatolog Treat. 2013;24(5):374–376.
  8. Leyden J, Lowe N, Kakita L, Draelos Z. Comparison of treatment of acne vulgaris with alternate-day applications of tazarotene 0.1% gel and once-daily applications of adapalene 0.1% gel: a randomized trial. Cutis. 2001;67(6 Suppl):10–16.
  9. Callender VD, Baldwin H, Cook-Bolden FE, et al. Effects of topical retinoids on acne and post-inflammatory hyperpigmentation in patients with skin of color: a clinical review and implications for practice. Am J Clin Dermatol. 2022;23(1):69–81. 
  10. Levin J. The relationship of proper skin cleansing to pathophysiology, clinical benefits, and the concomitant use of prescription topical therapies in patients with acne vulgaris. Dermatol Clin. 2016;34(2):133–145. 
  11. Chularojanamontri L, Tuchinda P, Kulthanan K, et al. A double-blinded, randomized, vehicle-controlled study to access skin tolerability and efficacy of an anti-inflammatory moisturizer in treatment of acne with 0.1% adapalene gel. J Dermatolog Treat. 2016;27(2):140–145. 
  12. Poli F. Acne on pigmented skin. Int J Dermatol. 2007;46(Suppl 1):39–41.
  13. Mahler HIM. Reasons for using and failing to use sunscreen: comparison among Whites, Hispanics, and Asian/Pacific Islanders in Southern California. JAMA Dermatol. 2014;150(1):90–91.
  14. Davis EC, Callender VD. A review of acne in ethnic skin: pathogenesis, clinical manifestations, and management strategies. J Clin Aesthet Dermatol. 2010;3(4):24–38.
  15. Nayak BS, Ann CY, Azhar AB, et al. A study on scalp hair health and hair care practices among Malaysian medical students. Int J Trichology. 2017;9(2):58–62.