Pediatric ddermatologyermatology Series Editor: Camila K. Janniger, MD A Brief Primer on Acne Therapy for Adolescents With Skin of Color Nanette B. Silverberg, MD Practice Points Acne in adolescents of color requires careful attention to skin care and hair care practices. Clues to pomade-exacerbated acne in adolescents of color are the presence of many lesions on the upper segment of the face with relative sparing of the cheeks and chin. Hyperpigmentation, erythema, and scarring, including keloids, are common sequelae in adolescents of color with moderate to severe acne. Therapy for acne in adolescents of color involves a combination of improved skin care, sun avoidance, and consistent therapeuticCUTIS management. ­­The­ majority­ of­ adolescents­ with­ skin­ of­ color­ in­ cne vulgaris is a chronic heritable skin dis- the­ United­ States­ and­ other­ westernized­ civiliza- order that can affect individuals of all races tions­ develop­ acne­ vulgaris.­ Indigenous­ popula- Aand ethnicities in westernized civilizations. tions­of­children­and­teenagers­with­skin­of­color­ In the United States, acne is the second most com- may­ not­ develop­ acne­ when­ raised­ on­ a­ paleo- mon diagnosis in black, Asian, and Hispanic patients lithicDo­diet,­suggesting­the ­WestNotern­diet­is­the­rudi- presenting Copy to dermatologists.1 Acne appears to be ment­ of­ acne­ vulgaris.­ Differences­ exist­ in­ the­ more prevalent in females with skin of color, espe- presentation­ of­ and­ therapy­ for­ acne­ in­ teenag- cially black women aged 10 to 70 years. In particular, ers­with­skin­of­color,­largely­due­to­the­increased­ dyspigmentation and atrophic scarring are more risk­ for­ hyperpigmentation,­ scarring,­ and­ keloid­ prevalent in black and Hispanic females with acne.2 formation,­as­well­as­style-­and­skin­care–related­ Acne is the fourth most common diagnosis in the exacerbating­ factors.­ The­ primary­ goal­ of­ acne­ pediatric population, and almost half of cases occur in therapy­ in­ adolescents­ with­ skin­ of­ color­ is­ the­ children with skin of color.3 This article reviews some prevention­ of­ long-term­ sequelae­ such­ as­ keloid­ of the concepts that affect identification, workup, and formation.­This­article­provides­a­brief­overview­of­ therapy in adolescent acne patients with skin of color. the­treatment­of­acne­vulgaris­in­adolescents­with­ skin­of­color.­ Puberty Cutis.­2013;92:20-26. Acne can start any time after the onset of adrenarche; in fact, acne is considered one of the first indicators of pubertal onset. In the United States, it is has been From the Department of Dermatology, St. Luke’s-Roosevelt Hospital observed that girls are beginning to enter puberty at Center, New York, New York, and Beth Israel Medical Center, an earlier age than they did 30 years ago.4 One study New York. identified a clear trend in earlier initial visits for acne Dr. Silverberg is an advisory board member for Galderma Laboratories, in all children from 1979 to 2007, further support- LP, and Stiefel, a GSK company. 5 Correspondence: Nanette B. Silverberg, MD, Department of ing earlier onset of puberty. In this study, the mean Dermatology, St. Luke’s-Roosevelt Hospital Center, 1090 Amsterdam age of black boys and girls at the time of acne visits Ave, Ste 11D, New York, NY 10025 ([email protected]). trended downward without significance5; however, 20 CUTIS® WWW.CUTIS.COM Copyright Cutis 2013. 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Pediatric Dermatology data already strongly support an early age of onset of Kitavan Islanders of Papua New Guinea, which sug- puberty for children with skin of color. gests that the Western diet may be contributory to In a study conducted in East Harlem, New York; the pathogenesis of acne and that a paleolithic diet metropolitan areas in Cincinnati, Ohio; and San may be a beneficial method of acne prevention, Francisco, California (N993), stage 2 or greater though perhaps not practical in the United States.15 breast development was noted by 7 to 8 years of age A study of teenagers and young adult males (age in 10.4% of white, 23.4% of black non-Hispanic, range, 15–25 years) in Australia demonstrated that and 14.9% of Hispanic girls.4 The earlier need for a low-glycemic diet may be beneficial for treatment treatment has resulted in a variety of new chal- of acne in overweight males16; however, the study lenges, including issues regarding the application of has not been repeated in a mixed ethnic population. acne products, which often are formulated for oily The benefits of dietary modification in children skin, on young dry faces, potentially causing greater with skin of color are unknown; however, a low- irritation and increasing the possibility of greater glycemic diet may induce weight loss and benefit cumulative scarring over the course of many more metabolic syndrome risks in overweight patients. years of acne. Furthermore, most acne products are approved by the US Food and Drug Administration Presentation Nuances for children older than 12 years, leaving a paucity of The Table includes factors that should be considered approved products available for treatment of acne in when taking the history of adolescent acne patients young patients with skin of color. with skin of color. Presentation of acne in patients with skin of color is complicated by a few issues. First, Diet, Obesity, and Endocrinopathies Asian patients are more likely to experience erythema Obesity is increasingly prevalent in adolescents with after acne lesion clearance, while black and Hispanic skin of color, especially black female adolescents.6 patients are at a higher risk for dyspigmentation and Hidradenitis suppurativa is more common in indi- scarring, including keloid formation. Cystic acne is viduals with greater body mass indexes; however, more prevalent in blacks and Hispanics than in white data on the relationship between acne and weight patients. In a study of 313 patients with acne, Taylor are lacking in the literature.7 CUTISWhen obesity is noted et al17 noted hyperpigmentation in 65.3% of black in acne vulgaris patients, workup for metabolic syn- acne patients, 52.7% of Hispanic acne patients, and drome includes screening for insulin resistance in 47.4% of Asian acne patients. Hyperpigmentation males due to an increased risk for insulin resistance in often is more upsetting to the patient than the obese males with acne8 as well as screening for insulin original acne lesions. Erythema is a common sequela resistance and sex hormone irregularities in females. of acne in Asian teenagers. Keloids can form from It is especially important to consider that there is a inflammatory acne lesions in black patients and greaterDo prevalence of diabetes Notmellitus in black and other adolescentsCopy with skin of color. Pore size, sebum Hispanic patients in the United States with insulin production rates, and sebaceous gland size are known resistance as the rudiments in adolescence.9 Thus to be varied among adults of different races, but data when laboratory tests are ordered for females, glucose are lacking for adolescents.17 In teenagers with skin and insulin should be added to the panel, which of color, I look for acne that predominates across also may be the first abnormal tests in polycystic the upper forehead with minimal midfacial or chin ovary syndrome.10 lesions. If the patient has dozens of papules on the Congenital adrenal hyperplasia is more common forehead but less than 10 on the face below the eyes, in some groups of individuals with skin of color pomade acne is likely contributing to the severity of and should be considered in the workup of hirsute the patient’s disease. acne patients with menstrual irregularities. These variants may not be identified with newborn screen- Hairstyling and Skin Care Products ing.11,12 Screening questions for adolescent girls Any occlusive or thick product that is applied to with acne vulgaris include menstrual irregularities, the scalp (on the face or hair) may cause follicular excessive premenstrual symptoms, and hirsutism. occlusion and produce a monomorphic acne known For girls younger than 8 years and boys younger than as pomade acne or acne cosmetica. Lanolin, cocoa 10 years, endocrine referral may be needed. Early- butter, and petrolatum seem to be the leading agents onset acne (10 years of age) in girls of any ethnic- to cause this issue, and an alteration to silicone or ity confers a greater risk for disease severity.13 water-based gel agents is best for hair care. Care Cordain et al14 identified an absence of acne should be taken to differentiate traction folliculitis vulgaris in individuals from any age group among from aggressive hairpulling and pomade acne. In my ethnic Aché hunter-gatherers in Paraguay and experience treating teenagers with skin of color, the WWW.CUTIS.COM VOLUME 92, JULY 2013 21 Copyright Cutis 2013. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Pediatric Dermatology Consensus Data Complete Acne History in In May 2013, a consensus position paper from the Adolescents With Skin of Color American Acne & Rosacea Society was published regarding pediatric and adolescent acne. The article Location of acne (ie, face, chest, back, adds a variety of important pieces to the literature, shoulders, hairline) such as the need for endocrine screening in patients aged 1 to 7 years with acne.19 The treatment posi- Severity of lesions (ie, mild, moderate, severe, tion does not differ strongly from that of the Global dyspigmentation, scarring) Alliance to Improve Outcomes in Acne publication of 2003,20 and furthermore does not address the Frequency of outbreaks or flares and triggers particular issue of acne as it pertains to adolescents of color. Prior therapy (ie, over-the-counter, home remedies [eg, toothpaste], prescription agents) Nuances in Asian Patients A consensus group developed therapeutic guidelines Ingestion of medications or topical medicament for acne therapy in Asian patients.