Dx Across the Skin Color Spectrum

Acne Vulgaris

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Acne vulgaris Photographs courtesy of Richard P. Usatine, MD.


A A 27-year-old Hispanic woman with comedonal and inflammatory acne. Erythema is prominent around the inflammatory lesions. Note the pustule on the cheek surrounded by pink color.

B A teenaged Black boy with acne papules and pustules on the face. There are comedones, hyperpigmented macules, and pustules on the cheek.

C A teenaged Black girl with pomade acne. The patient used various hair care products, which obstructed the pilosebaceous units on the forehead.


Acne is a leading dermatologic condition in individuals with skin of color in the United States.1

Key clinical features in people with darker skin tones include:

  • erythematous or hyperpigmented papules or comedones
  • hyperpigmented macules and postinflammatory hyperpigmentation (PIH)
  • increased risk for keloidal scars.2

Worth noting

  • Patients with darker skin tones may be more concerned with the dark marks (also referred to as scars or manchas in Spanish) than the acne itself. This PIH may be viewed by patients as the major problem.
  • Acne medications such as azelaic acid and some retinoids (when applied appropriately) can treat both acne and PIH.3
  • Irritation from topical acne medications, including retinoid dermatitis, may lead to more PIH. Using noncomedogenic moisturizers and applying medication appropriately (ie, a pea-sized amount of topical retinoid per application) may help limit irritation.4,5
  • One type of acne seen more commonly, although not exclusively, in Black patients is pomade acne, which principally appears on the forehead and is associated with use of hair care and styling products (Figure, C).

Health disparity highlight

Disparities in access to health care exist for those with dermatologic concerns. According to one study, African American (28.5%) and Hispanic patients (23.9%) were less likely to be seen by a dermatologist solely for the diagnosis of a dermatologic condition compared to Asian and Pacific Islander patients (36.7%) or White patients (43.2%).1

Noting that isotretinoin is the most potent systemic therapy for severe cystic acne vulgaris, Bell et al6 reported that Black patients had lower odds of receiving isotretinoin compared to White patients. Hispanic patients had lower odds of receiving a topical retinoid, tretinoin, than non-Hispanic patients.6

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