How Is Acne Different in Darker Skin?

Skin pigmentation is one of the most variable and distinguishing factors in humans. With the ever-growing cultural diversity in the U.S., becoming familiar with skin conditions and their presentation of various skin pigmentation is key to this growing field of dermatology.

In the case of acne, it is reported to be one of the more prevalent dermatologic conditions in people of color. The causes of acne in darker skin does not differ from that in those with lighter skin;^[1] however, the question that should be asked is: How is acne different in darker skin?

Darker Pigmentation  

Darker skin has a greater production of melanin, synthesized by pigment producing cells in the epidermis known as melanocytes. Interestingly, there exists a direct correlation between the geographical distribution of UV radiation and skin pigmentation.^[2] A greater degree of melanin is a form of adaptation and serves as a natural form of sun protection.^[2] It turns out, people with darker skin seek dermatologists when they have changes in their skin that lead to skin conditions or changes with darker or lighter pigment.^[1]

Inflammation and Pigmentation

Acne is the consequence of various factors, such as increased production of oils from the skin’s oil glands (known as sebocytes), clogged pores, and bacterial overgrowth in the pores.^[3] Eventually, the body reacts to these “offending agents” by releasing inflammatory signals as a protective mechanism. The skin reacts to inflammation by producing more of the melanin pigment. The melanin is then either transferred to the surrounding cells or is lost to the dermal second layer of the skin, thus causing the darkened pigmentation (known as hyperpigmentation) in acne.^[4] As a result, dark spots known as post inflammatory hyperpigmentation (PIH) are often seen in areas of acne inflammation and is more common in darker skin types compared to Caucasian patients.^[5] 

PIH typically forms after an acne outbreak, although it is also seen along with active acne lesions. The healing process for PIH is somewhat unique to every individual but typically takes months to years to go away. It is described as blue-gray or dark brown lesions.^[6] Keloid scarring, although rarer, can develop in the African American population,^[7] due to excessive scarring that occurs after acne.

Acne Treatment Approach Is Different 

Special considerations must be taken during the treatment of acne in patients of darker skin tones. The steps for treating acne in those with darker skin are the following:

1. The first strategy is to treat any active lesions of acne.^[8] This step is similar in those with or without darker skin. Controlling the acne is an important first step. 
2. The second strategy is to reduce the formation of dark spots. This is accomplished by reducing the production of the melanin pigment. One example is the use of a topical medication known as azelaic acid. Topical azelaic acid 20% cream is FDA approved for the treatment of acne^[9] but also blocks the pigment-making enzyme tyrosine from making melanin.^[10]
3. The third strategy is to diligently protect the skin from ultraviolet light and sun exposure, both of which stimulate the production of the melanin pigment. For those with darker skin color and acne, sun and ultraviolet light exposure can lead to more post inflammatory hyperpigmentation (dark spots).

Pomade Acne

One variant of acne that is seen more commonly among the African American population is pomade acne. Pomade acne, typically found along the hairline areas of the African American population, is due to the common use of hair products (sometimes known as pomades).^[11] Pomades block and plug hair follicles, often causing acne along the hairline.^[12] Decreasing the use, or finding a less dense hair product, along with the management of acne, may reduce the severity and potential complications of this type of acne.